Pancreas—Pancreatic Cancer
Concept
90% of pts will be unresectable with mean survival of 3 months. Key is to determine who is a candidate for resec- tion. You will likely be given a pt you will need to explore to determine resectability.
Way Question May be Asked?
“61 y/o male comes to your office with recent weight loss and a CT scan ordered by his family doctor shows a mass in the head of the pancreas. What do you want to do?”
May present as just weight loss, obstructive jaundice, or examiners may be direct and get right into the thick of it.
How to Answer?
Be methodical!
History
Smoking Anorexia Alcohol use Weight loss
Back pain/abdominal pain (classic is painless jaundice)
Physical Exam
Mass in RUQ (liver or distended gallbladder)
Data
Full laboratory panel including LFTs, Albumin, CA19- 9, CEA
Routine pre-op studies (EKG, CXR)
CT scan—with thin section through pancreas
look for metastases, enlarged lymph nodes
→ don’t do percutaneous bx of possibly resectable tumor risk dissemination along
tract
ERCP—obtain biopsy/brushings/cytology Stent pt only if severely jaundiced, unrelenting
itching or abnormal L LFTs (especially coags) Angiogram with venous phase—look for encasement of
SMA, SMV, portal vein and r/o replaced right hepatic artery
Endoscopic U/S—not necessary but can help stage tumor and assess resectability
DDx
Remember other causes of obstructive jaundice if this is what you are presented with:
Stricture Stone
Extrinsic compression
Malignancy (duodenal, ampullary, cholangio)
Surgical Treatment
(1) Can laparoscope pt before you open to look for peritoneal implants
(a) if find, then do biliary and gastric bypass laparoscopically
(2) Chevron incision
(3) full abdominal exploration and evaluate for respectability (check for hepatic mets, lymph node mets outside of resection zone and liberal use of frozen section)
Clockwise Resection
(4) Cattell–Braasch maneuver ligate Middle colic vein exposing SMV
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(5) Extended Kocher maneuver ligate right gonadal vein (6) Portal dissection
ligate gastroduodenal dissect out gallbladder
Transect CHD just proximal to cystic duct (careful, a hepatic artery can course posterior to
portal vein) (7) Transect stomach
at level of third/fourth transverse vein on lesser curve and confluence of gastroepiploic veins on greater curve
+/− pylorus preserving (8) Transect jejunum
10 cm distal to ligament of Treitz (9) Transect pancreas at level of portal vein
if adherent, proximal and distal control and resect anterior wall and repair with vein patch frozen section to check pancreatic/biliary margins (10) Vagotomy
Counter-Clockwise Reconstruction
(11) End to side pancreaticojejunostomy 2 layers over a stent
(12) End to side choledochojejunostomy
(13) End to side gastrojejunostomy antecolic in two layers
(14) Gastrostomy (15) Jejunostomy (16) Lots of drains
Common Curveballs
Replaced right hepatic artery—what is its course?
Tumor invading portal vein (discovered during course of operation)
Can’t determine it is malignancy even with intra-op biopsies→“will you do a Whipple?”
Complications of Whipple
Leak at any of the anastomoses Abscess
Delayed gastric emptying Marginal ulcer
Pancreatic fistula Bile leak
Intra-op injury to middle colic vein
Peritoneal implants and asked what type of bypass operation you will perform
Tumor may be in tail of pancreas (→distal pancreatec- tomy)
May present as acute pancreatitis (change scenario) How to determine resectability?
Pt will be malnourished and asked to discuss TPN Asked when will you place biliary stent pre-op?
Strikeouts
Not performing adequate staging work-up to r/o unre- sectable disease
Not knowing how to describe Whipple operation Not knowing how to describe bypass operation Performing percutaneous biopsy of pancreatic mass in
potentially resectable lesions Performing total pancreatectomy
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