[Portal vein resection in the framework of surgical therapy of pancreatic head carcinoma: clarification of indication by improved preoperative diagnostic procedures?].

Tumor invasion of the portal vein by ductal adenocarcinoma of the pancreatic head is classically known as a criterion for inoperability. Despite improvement in operation techniques for portal vein resection during Whipple's procedure and acceptable mortality and morbidity, in the case of uncertain tumor infiltration vascular resection cannot be recommended in general. The problem is the preoperative detection of tumor infiltration of the portal vein. Often the surgeon is confronted with unsuspected macroscopic portal vein infiltration or tumor adhesion during the operation. Between 1986 and 1995 105 patients underwent Whipple's procedure for ductal adenocarcinoma of the pancreatic head in our department. In eight of these cases partial portal vein resection was performed because of macroscopic tumor infiltration or tumor adhesion. In all eight cases the preoperative diagnostic procedures with CT and portography did not show any suspicion of tumor infiltration. In four of the eight cases histological tumor infiltration of all vascular layers was found. In the others we found no or only adventitial tumor invasion. The patients without tumor infiltration of the portal vein showed a survival time after surgery of 27.78 months in contrast to 6.67 months in the group with histologically proven tumor infiltration. Endovascular, intraportal ultrasound (IPEUS), a new diagnostic procedure, can give helpful information regarding portal vein involvement. Although the IPEUS is not a standard diagnostic procedure it was shown to detect portal vein infiltration with high sensitivity and specificity. Our results indicate that in such cases where portal vein infiltration has been excluded by IPEUS, patients with macroscopic tumor adhesion do benefit from partial portal vein resection.