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Pancreatic carcinoma

  • 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

Adenocarcinoma of 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

CT showing a carcinoma in the head of the pancreas

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:
    • Slow release morphine

    • Coeliac nerve block

    • Thoracoscopic section of splanchnic nerves

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

Bibliography

Bailey I A,  Keating J,  Johnson C D.  Surgery offers the best palliation for carcinoma of the pancreas.  Ann R Coll Surg Eng 1991;  73:  243-247.

Carter D C.  Clinical features and management of carcinoma of the pancreas.  Br J Hosp Med 1995;  54:  459-464.

Cowling M G,  Adam A N.  Internal stenting of malignant biliary obstruction.  World J Surg 2001;  25:  355-361.

Gouma D J,  van Dijkum E J M, Obertop H.  The standard diagnostic and surgical treatment of pancreatic head tumours.  Eur J Surg Oncol 1999;  25:  113-123.

Lees W R.  Imaging diagnosis of pancreatic cancer.  Curr Pract Surg 1994;  6:  143-146.

Li D,  Xie K,  Wolff R et al.  Pancreatic cancer.  Lancet 2004;  363:  1049-1057.

Magee C J,  Shekouh A,  Ghaneh P,  Neoptolemos JP.  Update on pancreatic cancer.  Hosp Med 2002;  63:  200-206.

Neoptolemos J P,  Dunn J A,  Stocken D D et al.  Adjuvant chemoradiotherapy and chemotherapy in resectable pancreatic cancer:  a randomised controlled trial.  Lancet 2001;  358:  1576-1585.

Russell R C G.  Clinical presentation of carcinoma of the pancreas.  Curr Pract Surg 1994;  6:  136-142.

Tait I S.  Whipple's resection-proximal pancreaticoduodenectomy.  J R Coll Surg Ed 2002;  47:  528-540.

 

 
 

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