Pankreas Kanserinde Vasküler Cerrahi
Özet
Pankreas duktal adenokanserinde vasküler invazyon varlığı, modern onkolojik ve cerrahi gelişmeler sayesinde mutlak bir kontrendikasyon olmaktan çıkmıştır. Tanı anında hastaların sadece küçük bir kısmına cerrahi uygulanabilse de, çoklu ajanlı kemoterapiler ve yüksek çözünürlüklü üç boyutlu görüntüleme teknikleri lokal ileri evre hastaları rezeksiyon yapılabilir duruma getirmektedir. Uluslararası kriterler doğrultusunda tümörün ana damarlarla ilişkisi rezektable, borderline rezektable ve unrezektable olarak sınıflandırılmaktadır. Portal ven ve superior mezenterik ven tutulumlarında uygulanan segmental rezeksiyonlar, venorafi veya sol renal ven ve safen ven gibi otolog greft uygulamaları, deneyimli merkezlerde morbidite ve mortaliteyi artırmadan sağ kalım oranlarına olumlu katkı sağlamaktadır. Çölyak trunkus veya superior mezenterik arter tutulmalarını içeren arteryal rezeksiyonlar ise teknik olarak daha kompleks süreçler barındırmakta olup, modifiye Appleby (DP-CAR) gibi özel prosedürlerle seçilmiş vakalarda negatif cerrahi sınır elde etmek amacıyla uygulanmaktadır. Sonuç olarak, multidisipliner yaklaşım ve ileri vasküler cerrahi tecrübesi, pankreas cerrahisinde rezektabilite sınırlarını genişleterek lokal ileri evre hastalar için küratif tedavi şansı sunmaktadır.
Vascular invasion in pancreatic ductal adenocarcinoma is no longer an absolute contraindication for surgery, thanks to advancing technological and oncological developments. Although only a small percentage of pancreatic cancer patients are eligible for immediate resection at diagnosis, modern multi-agent chemotherapies and high-resolution three-dimensional imaging enable locally advanced cases to become resectable. Based on international standards, tumor-vessel involvement is classified as resectable, borderline resectable, and unresectable. Segmental venous resections, venorrhaphy, or autologous grafting using the left renal vein or saphenous vein for portal vein and superior mesenteric vein involvement provide positive survival outcomes without increasing morbidity and mortality in specialized centers. Arterial resections involving the celiac axis or superior mesenteric artery present more complex challenges and are performed in highly selected cases via specialized procedures like DP-CAR to achieve negative surgical margins. Consequently, a multidisciplinary approach combined with advanced vascular surgery expertise expands the boundaries of resectability, offering successful curative treatment opportunities for locally advanced pancreatic cancers.
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