05 Apr, 2022
A 54-year-old school teacher from Noida, started experiencing some upper abdominal discomfort and feeling of fullness which did not improve with antacids. These symptoms persisted for a while and furthermore she noticed weight loss too. Finally, she was diagnosed with a large tumour in the pancreatic bodyin November 2021 which was involving the pancreatic bodyand extending to involve the celiac trunk (the artery that supplies blood to the entire upper gastrointestinal tract), and its branch the common hepatic artery (supplying blood to liver). It also involved adjacent adrenal gland and a 2 cm segment of portal vein (the vein which drains blood from entire intestine to the liver) and reaching quite close to the superior mesenteric artery (the artery that supplies blood to entire small bowel).
She then came to Max Super Specialty Hospital, Vaishali with hope that something could be done for her. The case was re-evaluated and after detailed discussion, she was planned for downstaging with chemotherapy prior to surgery followed by reassessment for surgery. She tolerated chemotherapy well with which the tumour shrunk slightly. On re-evaluation, by the Gastrointestinal and Hepatopancreatobiliary Surgical Oncology team, led by Dr Vivek Mangla, it was decided that the tumour could be taken out by a very rarely performed surgical procedure known as Appleby’s procedurealong with the removal of a segment of portal vein involved by the tumour and left adrenal gland. The extensive procedure entailed removal of a part of pancreas, the spleen, along with the involved arteries carefully preserving a branch supplying blood to the duodenum and pancreatic head. The blood supply of the liver is ensured by the naturally occurring collateral circulation from the area of pancreatic head. The procedure itself is quite challenging, and to add to the complexity, the case needed a segment of the portal vein be removed with the tumour and the blood flow restored by means of joining the two ends of the veins together, Dr Vivek said. Though challenging, this procedure was the patient’s only chance at having the tumour removed. (Ref. Diagram attached below).
The tumour was completely removed successfully in a surgery lasting around 7 hours performed by a team of doctors comprising surgeons, anesthesiologists, and radiologists led by Dr Vivek Mangla. The procedure, though a major surgery, is a safe operation, the safety of which is ensured by careful preservation of blood supply to liver and confirming it on an intra-operatively done ultrasound Doppler test. The patient was discharged from hospital about 9 days after surgery.
Pancreatic cancer is commonly seen, and quite often the early symptoms are non-specific. This usually leads to a delay in diagnosis resulting in tumours presenting at an advanced stage at time of diagnosis. Surgery combined with chemotherapy and radiotherapy if needed has an important role in the treatment of these cancers. Complete removal of the tumour is extremely important to prevent recurrence of cancer and sometimes entails resection and reconstruction of blood vessels as needed to preserve the blood supply to vital organs as in our patient.
Dr Vivek Mangla, who has more than 15 years of experience with advanced gastrointestinal and hepato-pancreato-biliary surgical procedures, further added that even though GI and HPB surgical oncology unit at Max Super Specialty hospital, Vaishali performs about 500 surgeries a year, and about 30-40 for pancreatic diseases, this was a first for them. He further added that this surgery has been done by very few centres in entire North India.