Pancreaticoduodenectomy for Cancer: Key Steps

Abstract

Pancreatic and periampullary cancer is a dreaded disease with poor prognosis. Cancer affecting the pancreatic head and periampullary area is often treated by pancreaticoduodenectomy (PD), a technically demanding procedure of a deep-seated “active” gland. This is compounded by the fact that several arterial anomalies of the hepatic arterial system are often encountered [1]. The preceding chapters have illustrated the basic anatomy of the area and the gradual evolution of surgical resection of pancreatic/periampullary cancer. A triple-phase pancreatic protocol contrast-enhanced computed tomography (CECT) enables precise delineation of the pancreatic tumor and its relation with the surrounding structures and vessels, namely, superior mesenteric artery (SMA) and superior mesenteric vein (SMV), splenic vein (SV), celiac axis (CA), common hepatic artery (CHA), hepatic artery (HA) proper, gastroduodenal artery (GDA), portal vein (PV) and inferior vena cava (IVC), and aorta (AO). Various classification systems have evolved based on tumor-vessel interface (TVI) as seen on CECT segregating tumors as resectable, borderline resectable, and locally advanced/irresectable [2]. Over the years pancreatic cancer surgery has come a long way, and there has been a considerable drop in mortality (<1%) in high-volume centers though the morbidity still remains high (40%) [3, 4].