2. Introduction to pancreatic ca’s
• can arise from the endocrine or the exocrine parts of the pancreas
• 4th leading cause of cancer death on both male and female population
• Cigarette smoking is the leading risk factor for PDAC
• Obesity, high fat diet, diabetes, recurrent pancreatitis(hereditary) and
alcohol consumption are risk factors
• Commonly diagnosed in the 7th and 8th decade of life
3. Clinical presentations
• Depends on the location
• Pancreatic head and uncinate process cas present with jaundice with
associated pruritus, clay colored stool, dark urine and weight loss
• Epigastric pain radiating to the back if celiac plexus invasion.
• GOO can occur for large tumors obstructing duodenal loops
• PC has to be ruled out in Old age Patients presenting with pancreatitis
in absence of cholelithiasis and ethanol ingestion and also in new
onset diabetes
4. • Left supraclavicular adenopathy (Virchow node), periumbilical
adenopathy (Sister Mary Joseph node), or a firm circumferential
rim of tumor at the top of the rectum on digital rectal examination
(Blummer shelf from drop metastases) indicate late advanced tumor
• Ascites, hepatomegaly and palpable abdominal mass indicates
possible advanced tumor.
5. Investigations
• Lab investigations are non sensitive and specific.
• CBC may show anemia or leukopenia or leukocytosis if there is
overlying cholangitis
• Elevated bilirubin, liver enzymes i.e ALP and GGT
• CA 19-9 and CEA can be raised on PC but both are non sensitive and
specific and significance is for treatment response and recurrence.
6. • u/s is the initial investigations for most patients
• Pancreas protocol MDCT is the best modality for diagnosis and
staging
• EUS is becoming widely used and has advantage to detect small
tumors <2cm that can be missed by CT and better indicates venous
invasion only
• MRI is less sensitive except for small masses < 2cm and sub-
centrimetric liver metastasis
7. • CT scan shows hypo-attenuating
poorly defined mass in the arterial
phase
• One can also see desmoplastic
reaction.
• Can be iso-attenuating in delayed
phase of scanning
8. Diagnostic Biopsy
• If there is true diagnostic dilemma or neoadjuvant chemotherapy is
considered
• Mainly for locally advanced and metastatic
• EUS-FNAC is the recommendation
• U/S or CT guided biopsy from metastatic lesions
9.
10. Principles of management
Pancreatico-duodenectomy (whipples’ procedure) is the standard
surgery done with curative intent for pancreatic head cas and IPMN.
An article Six hundred fifty consecutive pancreaticoduodenectomies in
1990s: pathology complications and outcomes done by C J Yao et. Al
Ann surgery 1997
11.
12.
13.
14. Steps of pancreatico-duodenectomy
1. Recommended to make small incision and rule out metastasis to liver
and peritoneum. After that the incision can be lengthened
2. Then extensive kocherization is done and tumor attachment to SMA
is checked from ligament of Trietz side.
Alternatively the tumor can be palpated intraoperatively and
involvement of SMA can be checked.
15. 3. Lesser sac is entered. Can be done on two ways
A. Dividing the gastro-colic ligament
B. Lifting of the omentum from the transverse colon
Careful dissection to separate the hepatic flexure from the duodenum.
Identification of the plane between middle colic vein and gastroepiploic
vessels leads to identification of SMV
The confluence of SMV to portal vein should be palpated and plane has
to be developed
16.
17. 4.Cholecystectomy is done usually in a fundus down approach.
Care is usually mandatory to avoid injury to right hepatic artery
5. The fatty tissude anterior to porta hepatis is dissected and right
gastric artery is identified and ligated. CHA is identified.
Node of importance is an important clue to CHA and has prognostic
significance.
PHA and GDA is traced and GDA is ligated after checking
18.
19. 6. PV has to be identified and lymph-nodes located laterally should be
included in the specimen.
7. The antrum is divided in classic whipple and 2 cm from pylorus in
pylorus preserving whiplles
8. The Treitz ligament and adequate length of jejunum is divided.
20. 9. Penrose drain is placed around the pancreatic neck and hemostatic
stutures are placed over the superior and inferior border.
The pancreas is divided care given for pancreatic duct and to avoid
injury to SMV-PV confluence.
the specimen is carefully dissected off of the SMA
the surgeons non dominant hand hold the specimen and is dissected
with the dominant hand and specimen is removed
21. Lymphadenectomy
• Broadly classified in to three
A. Standard
B. Radical
C. Extended radical
Extended lymphadenectomy involves removal lymphnodes along the
aorta, CT, SMA and IMA
There is no survival benefit for extended radical lymphadenectomy but
increased morbidity.
22. Pancreatico-enteric anastomosisi
• Major site for leak
• Tension free anastomosis, good tissue perfusion, gentle tissue
handling and no distal obstruction are mandatory.
• Pancreas can be anatosmosed to stomach and jejunum with no
significant leak rate difference.
23. • A. pancreatico-jejunostomy
Can be of dunking type
Duct to mucosa
Duct to mucosa end to side is the commonly practiced anatomosis
27. Bilio-enteric anastomosis
• Constructed 6-8cm proximally from pancreatico-jejunostomy site
• Can be completed with 4-0 PDS/Vicryl in a continuous or interrupted
fashion
28. GI continuity
• Usually constructed 50 cm from hepaticojejunostomy site.
• Either gastro-jejunostomy ot duodeno-jejunostomy wherer classical
or PPWP
• Two options of retrocolic and anticolic
• some suggestions retrocolic predisposes to delayed gastric emptying
doe to edema
29. Distal pancreatectomy
• For tumors of the body and tail
• Usually Done to the left of SMV-PV confluence
The initial step is division of the gastro-colic ligament and dividing the
peritoneal attachment of the pancreas.
The peritoneal attachment between the spleen and splenic flexure
should be gently divided and short gastric vessels should be ligated
30. • The splenic artery and vein should be isolated. The splenorenal and
splenocolic attachments should be transected. Pancreas should be
transected at the desired place along with the spleen.
• The pancreatic duct should be identified and closed
• The parenchyma is closed in a horizontal matress fashion and drain is
left.
31.
32.
33.
34.
35.
36.
37. • Splenic preservation is not recommended in the case of pancreatic
adenocarcinoma i.e can affect oncologic clearance
38. Segmental pancreatectomy
• Done for benign and low grade malignant lesions located in the neck
of the pancreas
Prerequisites are
• 1. small lesions (<5 cm in diameter)
• 2. benign or low-grade malignant tumors
• 3. located in the neck
• 4. distal pancreas stump
of at least 5 cm in length
39. • Its done by closing the stump of the proximal segment and
anastomosing the distal segment as pancreatico-gastrostomy or Roux
en Y pancratico-jejunostomy
40. Total pancreatecomy
• Commenest indication is for IPMN involving the whole pancreatic
duct
• Causes endocrine and exocrine catastrophes on patients thus have
greatly increased morbidity and mortality.
41. • Survival after surgery depends on the margin and lymph node status
• GITSG showed adjuvant chemo-radiotherapy increases survival
• European Study Group for Pancreatic Cancer (ESPAC) showed
increased comparable survival in patients receiving concurrent
chemo-radiotherapy.
• Concluded concurrent chemo-radiotherapy is chosen because its
better tolerated.
42. • largest series of surgically resected cases of borderline and locally
unresectable tumors treated with a neoadjuvant regimen—
FOLFIRINOX (fluorouracil, leucovorin, oxaliplatin, and irinotecan)—
reporting a 92% R0 resection rate eventually (Ferrone, et al, 2015).
43. Palliative therapy
• Directed at relieving biliary obstructon, duodenal obstruction and
pain
• If patients tumor became unresectable intraoperatively palliative
bypasses should be done with gastrojejunostomy and
hepaticojejunostomy
• Celiac axis block is done for the pain
44. • New trials are showing palliative chemotherapy improves overall
survival, less anti pain use and weight gain.
45. Palliative care
• Aimed at relieving biliary obstruction, duodenal obstruction and pain.
• Relieving the biliary obstruction has the advantage of increased liver
function, less inflammatory cytokines in the circulation, and improved
nutrition status thus improved quality of life.
• Can be of endoscopic stenting, percutaneous or surgical drainage. All
have comparable efficacy of 80-100%
47. b. choledocho/hepatico
jejunostomy
Technically demanding but has
least risk of recurrent jaundice
Two options of side to side or end
to side anastomosis
Cholecystectomy s done first
The CBD/CHD is trnasected and
distal stump is closed wth vicryl 3-
0
48. • The posterior layer is completed
first followed by the anterior
layer.
49. • Side to side anastomosis is done by approximating the posterior wall
of CBD or CHD then anteriorly.
51. Pain palliaton
• Pain is initially managed by po NSAIDS or narcotics
• If there is inadequate response more aggressive approaches like
celiac axis block can be done
• Has the advantage of better palliation, less side effect and avoidance
of opoids.
• There is three approaches for celiac axis blockage
52. Percutaneous Celiac axis blockade
• Can be fluoroscopic, U/S guided or CT guided
• Has the benefit of long term pain blockage
53. Endoscopic Ultrasound–Guided Celiac Plexus
Block
• Endoscopic u/s with the injection of a mix of 1.5% lidocaine with 20ml
of 95% alcohol
• Provides a good long term care of pain
54. Celiac axis blockage with surgery
• This can be done by injecting 50% alcohol paravertebrally.
• It provides excellent long term pain control.
55. Pancreatic Neuroendocrine tumors
• Rare only accounting for <5% of total pancreatic tumors
• Most tumors are malignant
• Only 5% has familial syndromes predisposing to PNET
• Among the familial syndromes MEN 1 is the commonest.
• Functional PNEETS have a better prognosis than non functional
because they are detected early.
56. Insulinoma
• most common and characterized by Whipple’s triad
• Symptomatic fasting hypoglycemia
• A documented serum glucose level <40 mg/dL
• Relief of symptoms with the administration of glucose
56
57. • the majority (90%) of insulinomas are benign and
solitary, and only 10% are malignant
• 90% of insulinomas are sporadic, and 10% are
associated with the MEN1 syndrome
• Insulinomas associated with the MEN1 syndrome are more
likely to be multifocal thus have a higher rate of recurrence
57
58. Cont.
• Insulinomas are typically cured by simple enucleation
• However, tumors located close to the main pancreatic
duct and large (>2 cm) tumors may require a distal
pancreatectomy or pancreaticoduodenectomy
58
59. Gastrinoma
Tumor secretes gastrin, leading to
acid hypersecretion and peptic
ulceration –Zollinger-Ellison
syndrome
In 70% to 90% of patients, the
primary gastrinoma is found in
Passaro’s triangle,
59
60. Cont.
• Many patients with ZES present with abdominal pain, PUD, and
severe esophagitis
• Ulcers often fail to respond to antacids
• The diagnosis of ZES is made by measuring the serum gastrin level
plus imaging
• It is important to rule out MEN1
60
61. Glucagonoma
61
Diabetes in association with dermatitis
should raise the suspicion of a
glucagonoma
Usually large tumors of >6cm
Patients also complain of an enlarged,
sensitive tongue
62. Cont.
• The diagnosis is confirmed by measuring serum
glucagon levels
• Debulking operations are recommended in good
operative candidates to relieve symptoms
62
63. Somatostatinoma
• Most of these tumors originate in the proximal pancreas
or the pancreatoduodenal groove, with the ampulla and
periampullary area as the most common site (60%)
• Because somatostatin inhibits pancreatic and biliary
secretions, patients present with gallstones due to bile
stasis, diabetes due to inhibition of insulin secretion,
and steatorrhea due to inhibition of pancreatic exocrine
secretion and bile secretion
63
64. Cont.
• Diagnosis is confirmed by elevated serum somatostatin
levels
• Although most reported cases of somatostatinoma
involve metastatic disease, an attempt at complete
excision of the tumor and cholecystectomy is
warranted in fit patients
64
65. VIP-Secreting Tumor (VIPoma)
• A pancreatic endocrine neoplasm with severe intermittent watery
diarrhea leading to dehydration, and weakness from fluid and
electrolyte pancreatic cholera)
• Large amounts of potassium are lost in the stool
65
