The pancreas is surrounded by many critical arteries and veins, such as the portal vein, the superior mesenteric vein, the hepatic artery, and the superior mesenteric artery. This is precisely why pancreatic cancer often spreads toward such vascular structures and encases them. This phenomenon is also known as “vascular invasion.” As these veins and arteries are crucial for each patient’s life, many surgeons avoid approaching them. This is why all such pancreatic tumors are considered unresectable.  

Our team has been focused on the resection of such tumors (i.e., removing the tumor along with the affected part of the artery or the vein) since 2012. We were the first in Greece to perform such surgical procedures on tumors previously considered unresectable. We were also the first to collect our findings from patients in Greece and publish the first series of 24 cases in which the involved portal or mesenteric vein was resected. Our article was published in the Journal of Pancreatic Cancer in September 2019 (https://www.liebertpub.com/doi/10.1089/pancan.2019.0013). Our approach resulted in an almost fourfold increase in patients’ survival compared to the survival rate of patients who did not undergo surgical intervention as their tumor was initially considered unresectable. Now we have also advanced in the resection of involved/affected arteries. We were the first to perform the Appleby procedure (resection of the involved celiac artery or celiac axis) in Greece. Further details on this surgery were published in our article at the International Journal of Surgery in October 2020 (https://doi.org/10.1016/j.ijscr.2020.09.194).

The conversion of pancreatic cancer from an initially unresectable state to a resectable one requires a dedicated and highly experienced team of surgeons that performs such procedures frequently and has relevant credentials. Such credentials include: 

1. scientific publications in reputable scientific journals that have gone thorough checks and reviews and are held in high regard by internationally renowned pancreatic surgeons, and 
2. testimonials of patients who have been living for years after the resection of tumors that were generally considered “unresectable.”

Preoperative neoadjuvant chemotherapy must be administered prior to this surgical procedure. In some cases, radiation therapy is also administered preoperatively. Neoadjuvant chemotherapy is associated with CA 19-9 tumor marker decrease and potential tumor shrinkage, as seen in CT scans. Tumor shrinkage is not always achieved, but this is not our primary goal anyway. If tumor markers have decreased significantly after chemotherapy, we may move forward with surgery. It should be highlighted that the successful conversion of an unresectable tumor to a resectable one is the case in only one-third (1/3) of the patients. On the other hand, this fraction of patients (30%) would not exist if the process above had not been carefully followed.

When preparing for such a surgery, the pancreatic and vascular surgeon, along with the specialized pancreatic radiologist, study and analyze all CT and MRI scans together to plan and predict every step of the operation in terms of critical vessels, their involvement, and management. This surgery requires a highly experienced team of surgeons who use highly advanced surgical techniques. During surgery, the portal vein or the arteries are resected along with the tumor. The part of the portal vein that is removed is replaced with a biological graft (harvested from the patient) or a synthetic graft. The procedure lasts approximately 6-8 hours, and the total hospitalization time is 7-10 days. It should be noted that this surgery is highly advanced, complex, and technically challenging with critical technical details; it gives us a chance to convert pancreatic tumors that are considered “unresectable” by most surgeons worldwide (except for very few) to resectable ones. This procedure significantly improves the survival rates of pancreatic cancer patients. Due to its complexity, it is performed in a few Pancreatic Surgery Centers worldwide.