- Pancreatic carcinoma is the second commonest tumour of the digestive system
- The incidence is increasing in the Western world
- It is uncommon less than 45 years of age
- More than 80% of cases occur between 60 and 80 years of age
- Male : female ratio is 2 : 1
- Most tumours are adenocarcinomas
- More than 80% occur in the head of the pancreas
- Overall 5-year survival less than 5%
- Prognosis of ampullary tumours is much better
Clinical features
- 30% present with obstructive jaundice
- Classically described as 'painless jaundice'
- Most develop pain at some stage - 50% present with epigastric pain
- 90% develop anorexia and weight loss
- 75% have metastases at presentation
Pancreatic imaging
Ultrasound
- Abdominal ultrasound has sensitivity of about 80% for the
detection of pancreatic cancer
- Detects level of biliary obstruction, excludes gallstones and may
identify pancreatic mass
- Doppler ultrasound allows assessment of vascular invasion
Computerised tomography
- Spiral CT has improved on resolution of conventional CT
- Has sensitivity of greater than 95% for detection of pancreatic
tumours
- Contrast-enhanced triple-phase imaging is modality of choice
- Probably the most useful of staging investigations
- Both US and CT often fail to detect small (< 2 cms) hepatic
metastases
Laparoscopy
- Laparoscopy will identify liver or peritoneal metastases in 25%
of patients deemed resectable after conventional imaging
- Laparoscopic ultrasound has improved predictability of resection
- Mesenteric angiography is now considered obsolete
Resectional surgery
- Resection is the only hope of cure
- Only 15% tumours are deemed resectable
- Resectability assessed by:
- Tumour size (<4 cm)
- Invasion of SMA or portal vein
- Presence of ascites, nodal, peritoneal or liver metastases
- Pre-operative biliary drainage of unproven benefit
- Has not been shown to reduce post-operative morbidity or
mortality
Whipple's operation
- Involves a pancreatico-duodenal resection
- Initial assessment of resectability by dissection and
Kocherisation of the duodenum
- Head of pancreas and duodenum excised followed by:
- End to side pancreaticojejunostomy
- End to side hepaticojejunostomy
- Duodenojejunostomy
- Octreotide given for one week to reduce pancreatic secretion
- Operative mortality in experienced centres less than 5%
- In those suitable for resectional surgery 5-year survival still
only 30%
- Post-operative morbidity 30-50%
- 10% of patients develop diabetes
- 30% of patients require post-operative exocrine supplements
- Postoperative chemotherapy may improve survival
Complications
- Delayed gastric emptying
- Gastrointestinal haemorrhage
- Operative site haemorrhage
- Intra-abdominal abscess
- Pancreatic fistula
Pylorus-preserving proximal pancreaticoduodenectomy
- Preserves gastric antrum and pylorus
- Compared with Whipple's procedure
- Reduced morbidity
- Fewer post gastrectomy symptoms
- Less entero-gastric reflux
- Improved post-operative nutrition
- No difference in mortality
- May be associated with increased risk of local recurrence
Palliation of pancreatic cancer
- 85% of patients are not suitable for curative resection
- Palliation of symptoms can be achieved either surgically or
endoscopically
- Surgical palliation has initially higher complication rate
- Produces better long-term symptom control.
- Palliative treatment should achieve:
- Relief of jaundice by either endoscopic stenting or surgery
- Prevention of duodenal obstruction by gastrojejunostomy
- Relief of pain by coeliac plexus block
- External biliary drainage now rarely required
- Palliative chemotherapy (e.g. gemcitabine) controversial
Endoscopic stenting
- Achievable in over 95% of patients
- Complications include bleeding, perforation, pancreatitis
- Mortality less than 3%
- 20% develop duodenal obstruction
- Patency of plastic stents often only 3 to 4 months
- Can be improved with the use of self-expanding wall stents
Palliative surgery
- Biliary drainage can be achieved by choledocho- or
cholecystojejunostomy
- 10% will develop duodenal obstruction
- A 'triple bypass' involves a choledochojejunostomy,
gastrojejunostomy and entero-enterostomy
- Removes risk of duodenal obstruction and often avoid recurrent
jaundice
Analgesia
- Pain occurs in over 80% with advanced malignancy
- Can be palliated with:
Endocrine tumours of the pancreas
- Tumours of neuro-endocrine origin
- Often produce hormones causing defined clinical syndromes
- Hormones may be pancreatic or ectopic in origin
- Approximately 50% are non-functioning
- Non-functioning tumours have increased risk of malignancy
Insulinoma
- Commonest pancreatic neuro-endocrine tumour
- Presents with:
- Impaired consciousness
- Personality change
- Sweating and fainting attacks
- Fits occur in 30% of patients
- Associated with hypoglycaemia
- Symptoms are relieved by food
- Diagnosis confirmed by increased insulin and CRP
- 10% tumours are malignant
Gastrinoma
- Presents with Zollinger-Ellison syndrome
- Causes intractable peptic ulcer disease resistant to normal therapy
- Ulcers often occur at unusual or multiple sites
- 20% patients develop diarrhoea and weight loss
- Diagnosis confirmed by increased serum gastrin on secretin stimulation
- Also need to confirm gastric hypersecretion
- 60% tumours are malignant
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