One of the rarely performed cancer surgeries – Appleby’s procedure – saved the life of a 54-year-old school teacher from Noida. She was diagnosed with a large tumor in the pancreatic body that had extended to nearby major blood vessels. Due to the complexity of the tumor position that engulfed several arteries and veins in the abdominal cavity, the challenging procedure took over seven hours. This feat was successfully achieved by a team of GI and HPB onco surgeons led by Dr Vivek Mangla, at Max Institute of Cancer Care, Vaishali.
Guneet (name changed to maintain confidentiality) initially started experiencing some discomfort in the upper abdomen, and complained of constant bloating that did not improve with antacids. Alongside, Ms Guneet also had sudden unexplained weight loss. She was eventually diagnosed with a large tumor in the pancreatic body in November 2021 which extended to 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 an adjacent adrenal gland and a 2 cm segment of portal vein (the vein which drains blood from entire intestine to the liver), reaching very close to the superior mesenteric artery (the artery that supplies blood to the entire small bowel).
Guneet then came to Max Institute of Cancer Care, Vaishali and her case was re-evaluated and after detailed discussion, planned for downstaging (of the bulky tumor) with chemotherapy. She tolerated chemotherapy well and her PET scans showed slight shrinking of the tumor. On further evaluation by the Gastrointestinal and Hepatopancreatobiliary Surgical Oncology team, led by Dr Vivek Mangla, it was decided that the tumor could be removed by a rarely performed procedure known as Appleby’s procedure along with removal of a segment of portal vein engulfed by the tumor and left adrenal gland.
“The procedure itself is quite challenging, and to add to the complexity, the case needed a segment of the portal vein to be removed with the tumor and the blood flow restored by means of joining the two ends of the veins together. Though challenging, this procedure was the patient’s only chance at having the tumor removed. The tumor could be completely removed successfully in a surgery lasting around seven hours performed by a team of doctors comprising surgeons, anesthesiologists, and radiologists, ”said Dr Vivek Mangla, Director (Gastrointestinal and HPB Surgical Oncology), Max Institute of Cancer Care, Max Hospital, Vaishali.
Appleby’s procedure is the last resort for such patients with large tumors in the pancreatic body. Though a major surgery, it is a safe operation where the safety is ensured by careful preservation of blood supply to the liver and confirming it on an intra-operatively done ultrasound Doppler test. Pancreatic cancer is commonly seen and quite often the early symptoms are non-specific. This usually leads to a delay in diagnosis resulting in most tumors presenting at an advanced stage at the 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 tumor 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 this case.