Pancreatic cancer surgery: Difference between revisions

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:** The involvement of arteries such as the hepatic, celiac or superior mesenteric are contraindications to resection.<ref name="pmid22064622">{{cite journal |vauthors=Mollberg N, Rahbari NN, Koch M, Hartwig W, Hoeger Y, Büchler MW, Weitz J |title=Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis |journal=Ann. Surg. |volume=254 |issue=6 |pages=882–93 |year=2011 |pmid=22064622 |doi=10.1097/SLA.0b013e31823ac299 |url=}}</ref>  
:** The involvement of arteries such as the hepatic, celiac or superior mesenteric are contraindications to resection.<ref name="pmid22064622">{{cite journal |vauthors=Mollberg N, Rahbari NN, Koch M, Hartwig W, Hoeger Y, Büchler MW, Weitz J |title=Arterial resection during pancreatectomy for pancreatic cancer: a systematic review and meta-analysis |journal=Ann. Surg. |volume=254 |issue=6 |pages=882–93 |year=2011 |pmid=22064622 |doi=10.1097/SLA.0b013e31823ac299 |url=}}</ref>  
:*Extrapancreatic disease requires palliative therapy and curative resection is not performed in such patients.
:*Extrapancreatic disease requires palliative therapy and curative resection is not performed in such patients.
:*The European Society for Medical Oncology (ESMO) has certain guidelines on the treatment of metastatic pancreatic cancer:<ref name="pmid26314780">{{cite journal |vauthors=Ducreux M, Cuhna AS, Caramella C, Hollebecque A, Burtin P, Goéré D, Seufferlein T, Haustermans K, Van Laethem JL, Conroy T, Arnold D |title=Cancer of the pancreas: ESMO Clinical Practice Guidelines for diagnosis, treatment, and follow-up |journal=Ann. Oncol. |volume=26 Suppl 5 |issue= |pages=v56–68 |year=2015 |pmid=26314780 |doi=10.1093/annonc/mdv295 |url=}}</ref><ref name="pmid22997452">{{cite journal |vauthors=Seufferlein T, Bachet JB, Van Cutsem E, Rougier P |title=Pancreatic adenocarcinoma: ESMO-ESDO Clinical Practice Guidelines for diagnosis, treatment and follow-up |journal=Ann. Oncol. |volume=23 Suppl 7 |issue= |pages=vii33–40 |year=2012 |pmid=22997452 |doi=10.1093/annonc/mds224 |url=}}</ref><ref name="pmid26122369">{{cite journal |vauthors=Evans DB, George B, Tsai S |title=Non-metastatic Pancreatic Cancer: Resectable, Borderline Resectable, and Locally Advanced-Definitions of Increasing Importance for the Optimal Delivery of Multimodality Therapy |journal=Ann. Surg. Oncol. |volume=22 |issue=11 |pages=3409–13 |year=2015 |pmid=26122369 |doi=10.1245/s10434-015-4649-2 |url=}}</ref>
:*The European Society for Medical Oncology (ESMO) has certain guidelines on the treatment of pancreatic cancer:<ref name="pmid26314780">{{cite journal |vauthors=Ducreux M, Cuhna AS, Caramella C, Hollebecque A, Burtin P, Goéré D, Seufferlein T, Haustermans K, Van Laethem JL, Conroy T, Arnold D |title=Cancer of the pancreas: ESMO Clinical Practice Guidelines for diagnosis, treatment, and follow-up |journal=Ann. Oncol. |volume=26 Suppl 5 |issue= |pages=v56–68 |year=2015 |pmid=26314780 |doi=10.1093/annonc/mdv295 |url=}}</ref><ref name="pmid22997452">{{cite journal |vauthors=Seufferlein T, Bachet JB, Van Cutsem E, Rougier P |title=Pancreatic adenocarcinoma: ESMO-ESDO Clinical Practice Guidelines for diagnosis, treatment and follow-up |journal=Ann. Oncol. |volume=23 Suppl 7 |issue= |pages=vii33–40 |year=2012 |pmid=22997452 |doi=10.1093/annonc/mds224 |url=}}</ref><ref name="pmid26122369">{{cite journal |vauthors=Evans DB, George B, Tsai S |title=Non-metastatic Pancreatic Cancer: Resectable, Borderline Resectable, and Locally Advanced-Definitions of Increasing Importance for the Optimal Delivery of Multimodality Therapy |journal=Ann. Surg. Oncol. |volume=22 |issue=11 |pages=3409–13 |year=2015 |pmid=26122369 |doi=10.1245/s10434-015-4649-2 |url=}}</ref>
:**Chemotherapy not preferred.  
:**The only curative therapy for pancreatic cancer is surgical resection. 
:**Gemcitabine is preferred over 5 FU.  
:** The five year survival of patients with pancreatic cancer is 10 percent.
:**Treatment is symptomatic with bypass surgery or stent placement for gastric outlet obstruction or obstructive jaundice.
:** Patients with node-positive tumors have very poor long term survival.
:**Chemotherapy is not preferred metastatic cancer.  
:**Gemcitabine is preferred over 5 FU in case of metastasis.  
:**Treatment in case of metastatic cancer is symptomatic with bypass surgery or stent placement for gastric outlet obstruction or obstructive jaundice.
:*In case of locally advanced disease which is unresectable, the following methods of treatment are preferred:<ref name="pmid25524417">{{cite journal |vauthors=Rombouts SJ, Vogel JA, van Santvoort HC, van Lienden KP, van Hillegersberg R, Busch OR, Besselink MG, Molenaar IQ |title=Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer |journal=Br J Surg |volume=102 |issue=3 |pages=182–93 |year=2015 |pmid=25524417 |doi=10.1002/bjs.9716 |url=}}</ref><ref name="pmid25524417" />  
:*In case of locally advanced disease which is unresectable, the following methods of treatment are preferred:<ref name="pmid25524417">{{cite journal |vauthors=Rombouts SJ, Vogel JA, van Santvoort HC, van Lienden KP, van Hillegersberg R, Busch OR, Besselink MG, Molenaar IQ |title=Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer |journal=Br J Surg |volume=102 |issue=3 |pages=182–93 |year=2015 |pmid=25524417 |doi=10.1002/bjs.9716 |url=}}</ref><ref name="pmid25524417" />  
:**Microwave ablation
:**Microwave ablation
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* After removal of the above structures, the biliary and distal pancreatic ducts are anastomosed to the jejunum to facilitate surgical drainage.  
* After removal of the above structures, the biliary and distal pancreatic ducts are anastomosed to the jejunum to facilitate surgical drainage.  
* Biliary drainage may also be performed preoperatively.<ref name="pmid20071702">{{cite journal |vauthors=van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, Gerritsen JJ, Greve JW, Gerhards MF, de Hingh IH, Klinkenbijl JH, Nio CY, de Castro SM, Busch OR, van Gulik TM, Bossuyt PM, Gouma DJ |title=Preoperative biliary drainage for cancer of the head of the pancreas |journal=N. Engl. J. Med. |volume=362 |issue=2 |pages=129–37 |year=2010 |pmid=20071702 |doi=10.1056/NEJMoa0903230 |url=}}</ref>
* Biliary drainage may also be performed preoperatively.<ref name="pmid20071702">{{cite journal |vauthors=van der Gaag NA, Rauws EA, van Eijck CH, Bruno MJ, van der Harst E, Kubben FJ, Gerritsen JJ, Greve JW, Gerhards MF, de Hingh IH, Klinkenbijl JH, Nio CY, de Castro SM, Busch OR, van Gulik TM, Bossuyt PM, Gouma DJ |title=Preoperative biliary drainage for cancer of the head of the pancreas |journal=N. Engl. J. Med. |volume=362 |issue=2 |pages=129–37 |year=2010 |pmid=20071702 |doi=10.1056/NEJMoa0903230 |url=}}</ref>
This procedure is associated with several morbidities:<ref name="pmid17667503">{{cite journal |vauthors=McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF |title=Perioperative mortality for pancreatectomy: a national perspective |journal=Ann. Surg. |volume=246 |issue=2 |pages=246–53 |year=2007 |pmid=17667503 |pmc=1933570 |doi=10.1097/01.sla.0000259993.17350.3a |url=}}</ref><ref name="pmid17462460">{{cite journal |vauthors=Pawlik TM, Gleisner AL, Cameron JL, Winter JM, Assumpcao L, Lillemoe KD, Wolfgang C, Hruban RH, Schulick RD, Yeo CJ, Choti MA |title=Prognostic relevance of lymph node ratio following pancreaticoduodenectomy for pancreatic cancer |journal=Surgery |volume=141 |issue=5 |pages=610–8 |year=2007 |pmid=17462460 |doi=10.1016/j.surg.2006.12.013 |url=}}</ref><ref name="pmid17786531">{{cite journal |vauthors=House MG, Gönen M, Jarnagin WR, D'Angelica M, DeMatteo RP, Fong Y, Brennan MF, Allen PJ |title=Prognostic significance of pathologic nodal status in patients with resected pancreatic cancer |journal=J. Gastrointest. Surg. |volume=11 |issue=11 |pages=1549–55 |year=2007 |pmid=17786531 |doi=10.1007/s11605-007-0243-7 |url=}}</ref><ref name="pmid17592291">{{cite journal |vauthors=Raut CP, Tseng JF, Sun CC, Wang H, Wolff RA, Crane CH, Hwang R, Vauthey JN, Abdalla EK, Lee JE, Pisters PW, Evans DB |title=Impact of resection status on pattern of failure and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma |journal=Ann. Surg. |volume=246 |issue=1 |pages=52–60 |year=2007 |pmid=17592291 |pmc=1899216 |doi=10.1097/01.sla.0000259391.84304.2b |url=}}</ref><ref name="pmid8380315">{{cite journal |vauthors=Geer RJ, Brennan MF |title=Prognostic indicators for survival after resection of pancreatic adenocarcinoma |journal=Am. J. Surg. |volume=165 |issue=1 |pages=68–72; discussion 72–3 |year=1993 |pmid=8380315 |doi= |url=}}</ref><ref name="pmid10932371">{{cite journal |vauthors=Benassai G, Mastrorilli M, Quarto G, Cappiello A, Giani U, Mosella G |title=Survival after pancreaticoduodenectomy for ductal adenocarcinoma of the head of the pancreas |journal=Chir Ital |volume=52 |issue=3 |pages=263–70 |year=2000 |pmid=10932371 |doi= |url=}}</ref><ref name="pmid2322039">{{cite journal |vauthors=Trede M, Schwall G, Saeger HD |title=Survival after pancreatoduodenectomy. 118 consecutive resections without an operative mortality |journal=Ann. Surg. |volume=211 |issue=4 |pages=447–58 |year=1990 |pmid=2322039 |pmc=1358031 |doi= |url=}}</ref><ref name="pmid2742478">{{cite journal |vauthors=Pellegrini CA, Heck CF, Raper S, Way LW |title=An analysis of the reduced morbidity and mortality rates after pancreaticoduodenectomy |journal=Arch Surg |volume=124 |issue=7 |pages=778–81 |year=1989 |pmid=2742478 |doi= |url=}}</ref><ref name="pmid3632096">{{cite journal |vauthors=Crist DW, Sitzmann JV, Cameron JL |title=Improved hospital morbidity, mortality, and survival after the Whipple procedure |journal=Ann. Surg. |volume=206 |issue=3 |pages=358–65 |year=1987 |pmid=3632096 |pmc=1493175 |doi= |url=}}</ref><ref name="pmid22760965">{{cite journal |vauthors=Kneuertz PJ, Pitt HA, Bilimoria KY, Smiley JP, Cohen ME, Ko CY, Pawlik TM |title=Risk of morbidity and mortality following hepato-pancreato-biliary surgery |journal=J. Gastrointest. Surg. |volume=16 |issue=9 |pages=1727–35 |year=2012 |pmid=22760965 |doi=10.1007/s11605-012-1938-y |url=}}</ref><ref name="pmid11948273">{{cite journal |vauthors=Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, Welch HG, Wennberg DE |title=Hospital volume and surgical mortality in the United States |journal=N. Engl. J. Med. |volume=346 |issue=15 |pages=1128–37 |year=2002 |pmid=11948273 |doi=10.1056/NEJMsa012337 |url=}}</ref><ref name="pmid10455881">{{cite journal |vauthors=Birkmeyer JD, Warshaw AL, Finlayson SR, Grove MR, Tosteson AN |title=Relationship between hospital volume and late survival after pancreaticoduodenectomy |journal=Surgery |volume=126 |issue=2 |pages=178–83 |year=1999 |pmid=10455881 |doi= |url=}}</ref><ref name="pmid18926452">{{cite journal |vauthors=Bilimoria KY, Talamonti MS, Sener SF, Bilimoria MM, Stewart AK, Winchester DP, Ko CY, Bentrem DJ |title=Effect of hospital volume on margin status after pancreaticoduodenectomy for cancer |journal=J. Am. Coll. Surg. |volume=207 |issue=4 |pages=510–9 |year=2008 |pmid=18926452 |doi=10.1016/j.jamcollsurg.2008.04.033 |url=}}</ref><ref name="pmid14645640">{{cite journal |vauthors=Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL |title=Surgeon volume and operative mortality in the United States |journal=N. Engl. J. Med. |volume=349 |issue=22 |pages=2117–27 |year=2003 |pmid=14645640 |doi=10.1056/NEJMsa035205 |url=}}</ref><ref name="pmid21500187">{{cite journal |vauthors=Gooiker GA, van Gijn W, Wouters MW, Post PN, van de Velde CJ, Tollenaar RA |title=Systematic review and meta-analysis of the volume-outcome relationship in pancreatic surgery |journal=Br J Surg |volume=98 |issue=4 |pages=485–94 |year=2011 |pmid=21500187 |doi=10.1002/bjs.7413 |url=}}</ref>
Postoperative abcess
Wound infection<ref name="pmid17723881">{{cite journal |vauthors=Limongelli P, Pai M, Bansi D, Thiallinagram A, Tait P, Jackson J, Habib NA, Williamson RC, Jiao LR |title=Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery |journal=Surgery |volume=142 |issue=3 |pages=313–8 |year=2007 |pmid=17723881 |doi=10.1016/j.surg.2007.04.022 |url=}}</ref>
Anastomotic leak
Delay in gastric emptying<ref name="pmid17981197">{{cite journal |vauthors=Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Büchler MW |title=Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS) |journal=Surgery |volume=142 |issue=5 |pages=761–8 |year=2007 |pmid=17981197 |doi=10.1016/j.surg.2007.05.005 |url=}}</ref>
Pylorus sparing Whipple procedure:<ref name="pmid7908796">{{cite journal |vauthors=Tsao JI, Rossi RL, Lowell JA |title=Pylorus-preserving pancreatoduodenectomy. Is it an adequate cancer operation |journal=Arch Surg |volume=129 |issue=4 |pages=405–12 |year=1994 |pmid=7908796 |doi= |url=}}</ref>
The pylorus may be spared as a modification of Whipple procedure to decrease gastric emptying due to antrectomy. This significantly reduces the incidence of nutritional deficiencies arising from this surgery.


* Whipple procedure is associated with several morbidities that may increase patient mortality:<ref name="pmid17667503">{{cite journal |vauthors=McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF |title=Perioperative mortality for pancreatectomy: a national perspective |journal=Ann. Surg. |volume=246 |issue=2 |pages=246–53 |year=2007 |pmid=17667503 |pmc=1933570 |doi=10.1097/01.sla.0000259993.17350.3a |url=}}</ref><ref name="pmid17592291">{{cite journal |vauthors=Raut CP, Tseng JF, Sun CC, Wang H, Wolff RA, Crane CH, Hwang R, Vauthey JN, Abdalla EK, Lee JE, Pisters PW, Evans DB |title=Impact of resection status on pattern of failure and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma |journal=Ann. Surg. |volume=246 |issue=1 |pages=52–60 |year=2007 |pmid=17592291 |pmc=1899216 |doi=10.1097/01.sla.0000259391.84304.2b |url=}}</ref><ref name="pmid8380315">{{cite journal |vauthors=Geer RJ, Brennan MF |title=Prognostic indicators for survival after resection of pancreatic adenocarcinoma |journal=Am. J. Surg. |volume=165 |issue=1 |pages=68–72; discussion 72–3 |year=1993 |pmid=8380315 |doi= |url=}}</ref><ref name="pmid10932371">{{cite journal |vauthors=Benassai G, Mastrorilli M, Quarto G, Cappiello A, Giani U, Mosella G |title=Survival after pancreaticoduodenectomy for ductal adenocarcinoma of the head of the pancreas |journal=Chir Ital |volume=52 |issue=3 |pages=263–70 |year=2000 |pmid=10932371 |doi= |url=}}</ref><ref name="pmid2322039">{{cite journal |vauthors=Trede M, Schwall G, Saeger HD |title=Survival after pancreatoduodenectomy. 118 consecutive resections without an operative mortality |journal=Ann. Surg. |volume=211 |issue=4 |pages=447–58 |year=1990 |pmid=2322039 |pmc=1358031 |doi= |url=}}</ref><ref name="pmid2742478">{{cite journal |vauthors=Pellegrini CA, Heck CF, Raper S, Way LW |title=An analysis of the reduced morbidity and mortality rates after pancreaticoduodenectomy |journal=Arch Surg |volume=124 |issue=7 |pages=778–81 |year=1989 |pmid=2742478 |doi= |url=}}</ref><ref name="pmid3632096">{{cite journal |vauthors=Crist DW, Sitzmann JV, Cameron JL |title=Improved hospital morbidity, mortality, and survival after the Whipple procedure |journal=Ann. Surg. |volume=206 |issue=3 |pages=358–65 |year=1987 |pmid=3632096 |pmc=1493175 |doi= |url=}}</ref><ref name="pmid22760965">{{cite journal |vauthors=Kneuertz PJ, Pitt HA, Bilimoria KY, Smiley JP, Cohen ME, Ko CY, Pawlik TM |title=Risk of morbidity and mortality following hepato-pancreato-biliary surgery |journal=J. Gastrointest. Surg. |volume=16 |issue=9 |pages=1727–35 |year=2012 |pmid=22760965 |doi=10.1007/s11605-012-1938-y |url=}}</ref><ref name="pmid11948273">{{cite journal |vauthors=Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, Welch HG, Wennberg DE |title=Hospital volume and surgical mortality in the United States |journal=N. Engl. J. Med. |volume=346 |issue=15 |pages=1128–37 |year=2002 |pmid=11948273 |doi=10.1056/NEJMsa012337 |url=}}</ref><ref name="pmid10455881">{{cite journal |vauthors=Birkmeyer JD, Warshaw AL, Finlayson SR, Grove MR, Tosteson AN |title=Relationship between hospital volume and late survival after pancreaticoduodenectomy |journal=Surgery |volume=126 |issue=2 |pages=178–83 |year=1999 |pmid=10455881 |doi= |url=}}</ref><ref name="pmid18926452">{{cite journal |vauthors=Bilimoria KY, Talamonti MS, Sener SF, Bilimoria MM, Stewart AK, Winchester DP, Ko CY, Bentrem DJ |title=Effect of hospital volume on margin status after pancreaticoduodenectomy for cancer |journal=J. Am. Coll. Surg. |volume=207 |issue=4 |pages=510–9 |year=2008 |pmid=18926452 |doi=10.1016/j.jamcollsurg.2008.04.033 |url=}}</ref><ref name="pmid14645640">{{cite journal |vauthors=Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL |title=Surgeon volume and operative mortality in the United States |journal=N. Engl. J. Med. |volume=349 |issue=22 |pages=2117–27 |year=2003 |pmid=14645640 |doi=10.1056/NEJMsa035205 |url=}}</ref><ref name="pmid21500187">{{cite journal |vauthors=Gooiker GA, van Gijn W, Wouters MW, Post PN, van de Velde CJ, Tollenaar RA |title=Systematic review and meta-analysis of the volume-outcome relationship in pancreatic surgery |journal=Br J Surg |volume=98 |issue=4 |pages=485–94 |year=2011 |pmid=21500187 |doi=10.1002/bjs.7413 |url=}}</ref>
** Postoperative abcess
** Wound infection<ref name="pmid17723881">{{cite journal |vauthors=Limongelli P, Pai M, Bansi D, Thiallinagram A, Tait P, Jackson J, Habib NA, Williamson RC, Jiao LR |title=Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery |journal=Surgery |volume=142 |issue=3 |pages=313–8 |year=2007 |pmid=17723881 |doi=10.1016/j.surg.2007.04.022 |url=}}</ref>
** Anastomotic leak
** Delay in gastric emptying<ref name="pmid17981197">{{cite journal |vauthors=Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Büchler MW |title=Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS) |journal=Surgery |volume=142 |issue=5 |pages=761–8 |year=2007 |pmid=17981197 |doi=10.1016/j.surg.2007.05.005 |url=}}</ref>


The European Society for Medical Oncology states that the only curative therapy is surgical resection.  
==== Pylorus sparing Whipple procedure ====
Ten percent is the five year survival of patients with pancreatic cancer.
* The pylorus may be spared as a modification of Whipple procedure to decrease gastric emptying due to antrectomy.<ref name="pmid7908796">{{cite journal |vauthors=Tsao JI, Rossi RL, Lowell JA |title=Pylorus-preserving pancreatoduodenectomy. Is it an adequate cancer operation |journal=Arch Surg |volume=129 |issue=4 |pages=405–12 |year=1994 |pmid=7908796 |doi= |url=}}</ref>
Patients with node-positive tumors have very poor long term survival.
* Pylorus sparing surgery significantly reduces the incidence of nutritional deficiencies arising from this surgery.


Distal Pancreatectomy <ref name="pmid17667503">{{cite journal |vauthors=McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF |title=Perioperative mortality for pancreatectomy: a national perspective |journal=Ann. Surg. |volume=246 |issue=2 |pages=246–53 |year=2007 |pmid=17667503 |pmc=1933570 |doi=10.1097/01.sla.0000259993.17350.3a |url=}}</ref><ref name="pmid2910241">{{cite journal |vauthors=Sindelar WF |title=Clinical experience with regional pancreatectomy for adenocarcinoma of the pancreas |journal=Arch Surg |volume=124 |issue=1 |pages=127–32 |year=1989 |pmid=2910241 |doi= |url=}}</ref>This procedure has a limited use in curative resection of pancreatic cancer.
==== Distal Pancreatectomy ====
It is mainly performed for tumors located in:<ref name="pmid8402126">{{cite journal |vauthors=Johnson CD, Schwall G, Flechtenmacher J, Trede M |title=Resection for adenocarcinoma of the body and tail of the pancreas |journal=Br J Surg |volume=80 |issue=9 |pages=1177–9 |year=1993 |pmid=8402126 |doi= |url=}}</ref>
* This procedure has a limited use in curative resection of pancreatic cancer. <ref name="pmid17667503" /><ref name="pmid2910241">{{cite journal |vauthors=Sindelar WF |title=Clinical experience with regional pancreatectomy for adenocarcinoma of the pancreas |journal=Arch Surg |volume=124 |issue=1 |pages=127–32 |year=1989 |pmid=2910241 |doi= |url=}}</ref>  
Body of pancreas
* It is mainly performed for tumors located in:<ref name="pmid8402126">{{cite journal |vauthors=Johnson CD, Schwall G, Flechtenmacher J, Trede M |title=Resection for adenocarcinoma of the body and tail of the pancreas |journal=Br J Surg |volume=80 |issue=9 |pages=1177–9 |year=1993 |pmid=8402126 |doi= |url=}}</ref>
Tail of pancreas
** Body of pancreas
This form of surgery has fewer morbidities than the Whipple procedure.
** Tail of pancreas
* Distal Pancreatectomy involves the following components:
** Separation of the distal pancreas bearing the tumor from the normal tissue.
** Resection of the affected portion.
** Oversewing of the distal pancreatic duct.
* This form of surgery has fewer morbidities than the Whipple procedure.  
* This procedure is associated with the following morbidities:<ref name="pmid28406793">{{cite journal |vauthors=Elliott IA, Epelboym I, Winner M, Allendorf JD, Haigh PI |title=Population-Level Incidence and Predictors of Surgically Induced Diabetes and Exocrine Insufficiency after Partial Pancreatic Resection |journal=Perm J |volume=21 |issue= |pages= |year=2017 |pmid=28406793 |pmc=5391783 |doi=10.7812/TPP/16-095 |url=}}</ref><ref name="pmid28347869">{{cite journal |vauthors=Liu A, Carmichael KA, Schallom ME, Klinkenberg WD |title=Retrospective review of postoperative glycemic control in patients after distal pancreatectomy |journal=Int J Surg |volume=41 |issue= |pages=86–90 |year=2017 |pmid=28347869 |doi=10.1016/j.ijsu.2017.03.060 |url=}}</ref><ref name="pmid28272344">{{cite journal |vauthors=Gilliland TM, Villafane-Ferriol N, Shah KP, Shah RM, Tran Cao HS, Massarweh NN, Silberfein EJ, Choi EA, Hsu C, McElhany AL, Barakat O, Fisher W, Van Buren G |title=Nutritional and Metabolic Derangements in Pancreatic Cancer and Pancreatic Resection |journal=Nutrients |volume=9 |issue=3 |pages= |year=2017 |pmid=28272344 |pmc=5372906 |doi=10.3390/nu9030243 |url=}}</ref><ref name="pmid27763684">{{cite journal |vauthors=Strobel O, Brangs S, Hinz U, Pausch T, Hüttner FJ, Diener MK, Schneider L, Hackert T, Büchler MW |title=Incidence, risk factors and clinical implications of chyle leak after pancreatic surgery |journal=Br J Surg |volume=104 |issue=1 |pages=108–117 |year=2017 |pmid=27763684 |doi=10.1002/bjs.10316 |url=}}</ref>
** Pancreatic endocrine insufficiency
** Bleeding
** Leakage of pancreatic stump


==== Total Pancreatectomy ====
Distal Pancreatectomy involves the following components:
Features<ref name="pmid17667503" /><ref name="pmid18043098">{{cite journal |vauthors=Müller MW, Friess H, Kleeff J, Dahmen R, Wagner M, Hinz U, Breisch-Girbig D, Ceyhan GO, Büchler MW |title=Is there still a role for total pancreatectomy? |journal=Ann. Surg. |volume=246 |issue=6 |pages=966–74; discussion 974–5 |year=2007 |pmid=18043098 |doi=10.1097/SLA.0b013e31815c2ca3 |url=}}</ref><ref name="pmid2539061">{{cite journal |vauthors=Brooks JR, Brooks DC, Levine JD |title=Total pancreatectomy for ductal cell carcinoma of the pancreas. An update |journal=Ann. Surg. |volume=209 |issue=4 |pages=405–10 |year=1989 |pmid=2539061 |pmc=1493970 |doi= |url=}}</ref><ref name="pmid1867520">{{cite journal |vauthors=Dresler CM, Fortner JG, McDermott K, Bajorunas DR |title=Metabolic consequences of (regional) total pancreatectomy |journal=Ann. Surg. |volume=214 |issue=2 |pages=131–40 |year=1991 |pmid=1867520 |pmc=1358512 |doi= |url=}}</ref><ref name="pmid6639161">{{cite journal |vauthors=Andrén-Sandberg A, Ihse I |title=Factors influencing survival after total pancreatectomy in patients with pancreatic cancer |journal=Ann. Surg. |volume=198 |issue=5 |pages=605–10 |year=1983 |pmid=6639161 |pmc=1353132 |doi= |url=}}</ref><ref name="pmid11146775">{{cite journal |vauthors=Karpoff HM, Klimstra DS, Brennan MF, Conlon KC |title=Results of total pancreatectomy for adenocarcinoma of the pancreas |journal=Arch Surg |volume=136 |issue=1 |pages=44–7; discussion 48 |year=2001 |pmid=11146775 |doi= |url=}}</ref>
Separation of the distal pancreas bearing the tumor from the normal tissue
* Total pancreatectomy is the least preferred surgery due to high mortality rate.
Resection of the affected portion
* It is mainly performed for tumors located in:
Oversewing of the distal pancreatic duct
** Neck of the pancreas.
* Due to involvement of neck, patients develop insulin dependent DM.


This procedure is associated with several morbidities:<ref name="pmid28406793">{{cite journal |vauthors=Elliott IA, Epelboym I, Winner M, Allendorf JD, Haigh PI |title=Population-Level Incidence and Predictors of Surgically Induced Diabetes and Exocrine Insufficiency after Partial Pancreatic Resection |journal=Perm J |volume=21 |issue= |pages= |year=2017 |pmid=28406793 |pmc=5391783 |doi=10.7812/TPP/16-095 |url=}}</ref><ref name="pmid28347869">{{cite journal |vauthors=Liu A, Carmichael KA, Schallom ME, Klinkenberg WD |title=Retrospective review of postoperative glycemic control in patients after distal pancreatectomy |journal=Int J Surg |volume=41 |issue= |pages=86–90 |year=2017 |pmid=28347869 |doi=10.1016/j.ijsu.2017.03.060 |url=}}</ref><ref name="pmid28272344">{{cite journal |vauthors=Gilliland TM, Villafane-Ferriol N, Shah KP, Shah RM, Tran Cao HS, Massarweh NN, Silberfein EJ, Choi EA, Hsu C, McElhany AL, Barakat O, Fisher W, Van Buren G |title=Nutritional and Metabolic Derangements in Pancreatic Cancer and Pancreatic Resection |journal=Nutrients |volume=9 |issue=3 |pages= |year=2017 |pmid=28272344 |pmc=5372906 |doi=10.3390/nu9030243 |url=}}</ref><ref name="pmid27763684">{{cite journal |vauthors=Strobel O, Brangs S, Hinz U, Pausch T, Hüttner FJ, Diener MK, Schneider L, Hackert T, Büchler MW |title=Incidence, risk factors and clinical implications of chyle leak after pancreatic surgery |journal=Br J Surg |volume=104 |issue=1 |pages=108–117 |year=2017 |pmid=27763684 |doi=10.1002/bjs.10316 |url=}}</ref>
==== Lymphadnectomy ====
Pancreatic endocrine insufficiency
* Removal of positive nodes is preferrable, but some surgeons advocate extended as opposed to standard lymphadnectomy.<ref name="pmid12192322" /><ref name="pmid16269290" /><ref name="pmid25061003">{{cite journal |vauthors=Tol JA, Gouma DJ, Bassi C, Dervenis C, Montorsi M, Adham M, Andrén-Sandberg A, Asbun HJ, Bockhorn M, Büchler MW, Conlon KC, Fernández-Cruz L, Fingerhut A, Friess H, Hartwig W, Izbicki JR, Lillemoe KD, Milicevic MN, Neoptolemos JP, Shrikhande SV, Vollmer CM, Yeo CJ, Charnley RM |title=Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: a consensus statement by the International Study Group on Pancreatic Surgery (ISGPS) |journal=Surgery |volume=156 |issue=3 |pages=591–600 |year=2014 |pmid=25061003 |doi=10.1016/j.surg.2014.06.016 |url=}}</ref><ref name="pmid24368638">{{cite journal |vauthors=Jang JY, Kang MJ, Heo JS, Choi SH, Choi DW, Park SJ, Han SS, Yoon DS, Yu HC, Kang KJ, Kim SG, Kim SW |title=A prospective randomized controlled study comparing outcomes of standard resection and extended resection, including dissection of the nerve plexus and various lymph nodes, in patients with pancreatic head cancer |journal=Ann. Surg. |volume=259 |issue=4 |pages=656–64 |year=2014 |pmid=24368638 |doi=10.1097/SLA.0000000000000384 |url=}}</ref><ref name="pmid9790340">{{cite journal |vauthors=Pedrazzoli S, DiCarlo V, Dionigi R, Mosca F, Pederzoli P, Pasquali C, Klöppel G, Dhaene K, Michelassi F |title=Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy Study Group |journal=Ann. Surg. |volume=228 |issue=4 |pages=508–17 |year=1998 |pmid=9790340 |pmc=1191525 |doi= |url=}}</ref><ref name="pmid22038501">{{cite journal |vauthors=Nimura Y, Nagino M, Takao S, Takada T, Miyazaki K, Kawarada Y, Miyagawa S, Yamaguchi A, Ishiyama S, Takeda Y, Sakoda K, Kinoshita T, Yasui K, Shimada H, Katoh H |title=Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas: long-term results of a Japanese multicenter randomized controlled trial |journal=J Hepatobiliary Pancreat Sci |volume=19 |issue=3 |pages=230–41 |year=2012 |pmid=22038501 |doi=10.1007/s00534-011-0466-6 |url=}}</ref><ref name="pmid24419758">{{cite journal |vauthors=Kang MJ, Jang JY, Chang YR, Kwon W, Jung W, Kim SW |title=Revisiting the concept of lymph node metastases of pancreatic head cancer: number of metastatic lymph nodes and lymph node ratio according to N stage |journal=Ann. Surg. Oncol. |volume=21 |issue=5 |pages=1545–51 |year=2014 |pmid=24419758 |doi=10.1245/s10434-013-3473-9 |url=}}</ref><ref name="pmid17462460">{{cite journal |vauthors=Pawlik TM, Gleisner AL, Cameron JL, Winter JM, Assumpcao L, Lillemoe KD, Wolfgang C, Hruban RH, Schulick RD, Yeo CJ, Choti MA |title=Prognostic relevance of lymph node ratio following pancreaticoduodenectomy for pancreatic cancer |journal=Surgery |volume=141 |issue=5 |pages=610–8 |year=2007 |pmid=17462460 |doi=10.1016/j.surg.2006.12.013 |url=}}</ref><ref name="pmid17786531">{{cite journal |vauthors=House MG, Gönen M, Jarnagin WR, D'Angelica M, DeMatteo RP, Fong Y, Brennan MF, Allen PJ |title=Prognostic significance of pathologic nodal status in patients with resected pancreatic cancer |journal=J. Gastrointest. Surg. |volume=11 |issue=11 |pages=1549–55 |year=2007 |pmid=17786531 |doi=10.1007/s11605-007-0243-7 |url=}}</ref>
Bleeding
Leakage of pancreatic stump


Total Pancreatectomy<ref name="pmid17667503">{{cite journal |vauthors=McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF |title=Perioperative mortality for pancreatectomy: a national perspective |journal=Ann. Surg. |volume=246 |issue=2 |pages=246–53 |year=2007 |pmid=17667503 |pmc=1933570 |doi=10.1097/01.sla.0000259993.17350.3a |url=}}</ref><ref name="pmid18043098">{{cite journal |vauthors=Müller MW, Friess H, Kleeff J, Dahmen R, Wagner M, Hinz U, Breisch-Girbig D, Ceyhan GO, Büchler MW |title=Is there still a role for total pancreatectomy? |journal=Ann. Surg. |volume=246 |issue=6 |pages=966–74; discussion 974–5 |year=2007 |pmid=18043098 |doi=10.1097/SLA.0b013e31815c2ca3 |url=}}</ref><ref name="pmid2539061">{{cite journal |vauthors=Brooks JR, Brooks DC, Levine JD |title=Total pancreatectomy for ductal cell carcinoma of the pancreas. An update |journal=Ann. Surg. |volume=209 |issue=4 |pages=405–10 |year=1989 |pmid=2539061 |pmc=1493970 |doi= |url=}}</ref><ref name="pmid1867520">{{cite journal |vauthors=Dresler CM, Fortner JG, McDermott K, Bajorunas DR |title=Metabolic consequences of (regional) total pancreatectomy |journal=Ann. Surg. |volume=214 |issue=2 |pages=131–40 |year=1991 |pmid=1867520 |pmc=1358512 |doi= |url=}}</ref><ref name="pmid6639161">{{cite journal |vauthors=Andrén-Sandberg A, Ihse I |title=Factors influencing survival after total pancreatectomy in patients with pancreatic cancer |journal=Ann. Surg. |volume=198 |issue=5 |pages=605–10 |year=1983 |pmid=6639161 |pmc=1353132 |doi= |url=}}</ref><ref name="pmid11146775">{{cite journal |vauthors=Karpoff HM, Klimstra DS, Brennan MF, Conlon KC |title=Results of total pancreatectomy for adenocarcinoma of the pancreas |journal=Arch Surg |volume=136 |issue=1 |pages=44–7; discussion 48 |year=2001 |pmid=11146775 |doi= |url=}}</ref>
==== CA 19-9 level ====
 
* Elevated levels of CA 19-9 can help in the following ways:<ref name="pmid27049786">{{cite journal |vauthors=Bergquist JR, Puig CA, Shubert CR, Groeschl RT, Habermann EB, Kendrick ML, Nagorney DM, Smoot RL, Farnell MB, Truty MJ |title=Carbohydrate Antigen 19-9 Elevation in Anatomically Resectable, Early Stage Pancreatic Cancer Is Independently Associated with Decreased Overall Survival and an Indication for Neoadjuvant Therapy: A National Cancer Database Study |journal=J. Am. Coll. Surg. |volume=223 |issue=1 |pages=52–65 |year=2016 |pmid=27049786 |doi=10.1016/j.jamcollsurg.2016.02.009 |url=}}</ref>  
 
** Predicts the likelihood of complete resection  
It is the least preferred due to high mortality rate.
** Prognosis of patients with resectable disease  
It is mainly performed for tumors located in:
** Predicts the presence of occult metastases  
Neck of the pancreas.
* CA 19-9 levels are not used to dictate the initial strategy for treatment of pancreatic cancer.
Due to involvement of neck, patients develop insulin dependent DM.
 
Lymphadnectomy<ref name="pmid25061003">{{cite journal |vauthors=Tol JA, Gouma DJ, Bassi C, Dervenis C, Montorsi M, Adham M, Andrén-Sandberg A, Asbun HJ, Bockhorn M, Büchler MW, Conlon KC, Fernández-Cruz L, Fingerhut A, Friess H, Hartwig W, Izbicki JR, Lillemoe KD, Milicevic MN, Neoptolemos JP, Shrikhande SV, Vollmer CM, Yeo CJ, Charnley RM |title=Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: a consensus statement by the International Study Group on Pancreatic Surgery (ISGPS) |journal=Surgery |volume=156 |issue=3 |pages=591–600 |year=2014 |pmid=25061003 |doi=10.1016/j.surg.2014.06.016 |url=}}</ref><ref name="pmid24368638">{{cite journal |vauthors=Jang JY, Kang MJ, Heo JS, Choi SH, Choi DW, Park SJ, Han SS, Yoon DS, Yu HC, Kang KJ, Kim SG, Kim SW |title=A prospective randomized controlled study comparing outcomes of standard resection and extended resection, including dissection of the nerve plexus and various lymph nodes, in patients with pancreatic head cancer |journal=Ann. Surg. |volume=259 |issue=4 |pages=656–64 |year=2014 |pmid=24368638 |doi=10.1097/SLA.0000000000000384 |url=}}</ref><ref name="pmid12192322">{{cite journal |vauthors=Yeo CJ, Cameron JL, Lillemoe KD, Sohn TA, Campbell KA, Sauter PK, Coleman J, Abrams RA, Hruban RH |title=Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality |journal=Ann. Surg. |volume=236 |issue=3 |pages=355–66; discussion 366–8 |year=2002 |pmid=12192322 |pmc=1422589 |doi=10.1097/01.SLA.0000027272.08464.0B |url=}}</ref><ref name="pmid16269290">{{cite journal |vauthors=Farnell MB, Pearson RK, Sarr MG, DiMagno EP, Burgart LJ, Dahl TR, Foster N, Sargent DJ |title=A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma |journal=Surgery |volume=138 |issue=4 |pages=618–28; discussion 628–30 |year=2005 |pmid=16269290 |doi=10.1016/j.surg.2005.06.044 |url=}}</ref><ref name="pmid9790340">{{cite journal |vauthors=Pedrazzoli S, DiCarlo V, Dionigi R, Mosca F, Pederzoli P, Pasquali C, Klöppel G, Dhaene K, Michelassi F |title=Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy Study Group |journal=Ann. Surg. |volume=228 |issue=4 |pages=508–17 |year=1998 |pmid=9790340 |pmc=1191525 |doi= |url=}}</ref><ref name="pmid12192322">{{cite journal |vauthors=Yeo CJ, Cameron JL, Lillemoe KD, Sohn TA, Campbell KA, Sauter PK, Coleman J, Abrams RA, Hruban RH |title=Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality |journal=Ann. Surg. |volume=236 |issue=3 |pages=355–66; discussion 366–8 |year=2002 |pmid=12192322 |pmc=1422589 |doi=10.1097/01.SLA.0000027272.08464.0B |url=}}</ref><ref name="pmid16269290">{{cite journal |vauthors=Farnell MB, Pearson RK, Sarr MG, DiMagno EP, Burgart LJ, Dahl TR, Foster N, Sargent DJ |title=A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma |journal=Surgery |volume=138 |issue=4 |pages=618–28; discussion 628–30 |year=2005 |pmid=16269290 |doi=10.1016/j.surg.2005.06.044 |url=}}</ref><ref name="pmid22038501">{{cite journal |vauthors=Nimura Y, Nagino M, Takao S, Takada T, Miyazaki K, Kawarada Y, Miyagawa S, Yamaguchi A, Ishiyama S, Takeda Y, Sakoda K, Kinoshita T, Yasui K, Shimada H, Katoh H |title=Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas: long-term results of a Japanese multicenter randomized controlled trial |journal=J Hepatobiliary Pancreat Sci |volume=19 |issue=3 |pages=230–41 |year=2012 |pmid=22038501 |doi=10.1007/s00534-011-0466-6 |url=}}</ref><ref name="pmid24419758">{{cite journal |vauthors=Kang MJ, Jang JY, Chang YR, Kwon W, Jung W, Kim SW |title=Revisiting the concept of lymph node metastases of pancreatic head cancer: number of metastatic lymph nodes and lymph node ratio according to N stage |journal=Ann. Surg. Oncol. |volume=21 |issue=5 |pages=1545–51 |year=2014 |pmid=24419758 |doi=10.1245/s10434-013-3473-9 |url=}}</ref>
 
Removal of positive nodes is preferrable, but some surgeons advocate extended lymphadnectomy.
 
CA 19-9 level
 
Elevated levels of CA 19-9 can help in the following ways:<ref name="pmid27049786">{{cite journal |vauthors=Bergquist JR, Puig CA, Shubert CR, Groeschl RT, Habermann EB, Kendrick ML, Nagorney DM, Smoot RL, Farnell MB, Truty MJ |title=Carbohydrate Antigen 19-9 Elevation in Anatomically Resectable, Early Stage Pancreatic Cancer Is Independently Associated with Decreased Overall Survival and an Indication for Neoadjuvant Therapy: A National Cancer Database Study |journal=J. Am. Coll. Surg. |volume=223 |issue=1 |pages=52–65 |year=2016 |pmid=27049786 |doi=10.1016/j.jamcollsurg.2016.02.009 |url=}}</ref>
 
Predicts the likelihood of complete resection
 
Prognosis of patients with resectable disease
 
Predicts the presence of occult metastases
 
However, CA 19-9 levels are not used to dictate the initial strategy for treatment of pancreatic cancer.
 
PALLIATIVE THERAPY


=== Palliative Therapy===
=== Palliative Therapy===

Revision as of 19:41, 13 November 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

The mainstay of therapy for pancreatic cancer is surgery. The most common surgical treatment for cancer involving the pancreas is the Whipple procedure.

Surgery

  • In patients with pancreatic cancer, surgery is the primary modality of treatment.
  • Various methods of surgical resection may be employed and each of these has its own sets of risks and perioperative complications.
  • The benefits, risks and complications are discussed by the patient and surgical team before arriving at a well-informed decision. The method of surgical resection depends on the following features:[1][2][3]
    • Locally invasive characteristics of the neoplasm
    • Size
  • Surgical methods of curative resection include:
    • Distal Pancreatectomy
    • Total pancreatectomy
    • Pancreaticoduodenectomy, where pylorus may or may not be spared on an individual basis.
  • The National Comprehensive Cancer Network (NCCN) has recommended certain guidelines on resectability of pancreatic neoplasms based on a statement passed by the American pancreatic association:[4][5][6][7][8]
    • Patient selection is based on:
      • Resection margins
      • High probability of cure
      • Patient's age
      • Comorbidities
  • Curative resection is not contraindicated in all patients with vascular invasion.[9][10][11][12][13]
    • Involvement of the portal or superior mesenteric vein can be resected and reconstructed with the help of splenic, saphenous or internal jugular veins.[14][15][16][17]
    • The involvement of arteries such as the hepatic, celiac or superior mesenteric are contraindications to resection.[18]
  • Extrapancreatic disease requires palliative therapy and curative resection is not performed in such patients.
  • The European Society for Medical Oncology (ESMO) has certain guidelines on the treatment of pancreatic cancer:[19][20][21]
    • The only curative therapy for pancreatic cancer is surgical resection.
    • The five year survival of patients with pancreatic cancer is 10 percent.
    • Patients with node-positive tumors have very poor long term survival.
    • Chemotherapy is not preferred metastatic cancer.
    • Gemcitabine is preferred over 5 FU in case of metastasis.
    • Treatment in case of metastatic cancer is symptomatic with bypass surgery or stent placement for gastric outlet obstruction or obstructive jaundice.
  • In case of locally advanced disease which is unresectable, the following methods of treatment are preferred:[22][22]
    • Microwave ablation
    • Photodynamic therapy
    • Irreversible electroporation
    • Photodynamic therapy
    • High-intensity focused ultrasound (HIFU)
    • Iodine-125–cryosurgery
    • Iodine-125
    • Stereotactic body radiation therapy (SBRT)
    • Radiofrequency ablation (RFA)

Pancreaticoduodenectomy (Whipple Procedure)

Features[19][6][38][39][40][41][42][43]

  • It is mainly performed for tumors located in:[44][39][45]
    • Periampullary region
    • Duodenum
    • Bile duct (Cholangiocarcinoma)
    • Pancreatic duct
    • Head of pancreas
  • Whipple procedure involves removal of the following components due to common blood supply:
    • Stomach antrum
    • Gallbladder
    • Duodenum
    • Head of pancreas
  • After removal of the above structures, the biliary and distal pancreatic ducts are anastomosed to the jejunum to facilitate surgical drainage.
  • Biliary drainage may also be performed preoperatively.[46]

Pylorus sparing Whipple procedure

  • The pylorus may be spared as a modification of Whipple procedure to decrease gastric emptying due to antrectomy.[62]
  • Pylorus sparing surgery significantly reduces the incidence of nutritional deficiencies arising from this surgery.

Distal Pancreatectomy

  • This procedure has a limited use in curative resection of pancreatic cancer. [47][63]
  • It is mainly performed for tumors located in:[64]
    • Body of pancreas
    • Tail of pancreas
  • Distal Pancreatectomy involves the following components:
    • Separation of the distal pancreas bearing the tumor from the normal tissue.
    • Resection of the affected portion.
    • Oversewing of the distal pancreatic duct.
  • This form of surgery has fewer morbidities than the Whipple procedure.
  • This procedure is associated with the following morbidities:[65][66][67][68]
    • Pancreatic endocrine insufficiency
    • Bleeding
    • Leakage of pancreatic stump

Total Pancreatectomy

Features[47][69][70][71][72][73]

  • Total pancreatectomy is the least preferred surgery due to high mortality rate.
  • It is mainly performed for tumors located in:
    • Neck of the pancreas.
  • Due to involvement of neck, patients develop insulin dependent DM.

Lymphadnectomy

CA 19-9 level

  • Elevated levels of CA 19-9 can help in the following ways:[81]
    • Predicts the likelihood of complete resection
    • Prognosis of patients with resectable disease
    • Predicts the presence of occult metastases
  • CA 19-9 levels are not used to dictate the initial strategy for treatment of pancreatic cancer.

 Palliative Therapy

  • Pain:
    • There are various techniques for pain management as palliative therapy in patients:
    • Narcotic analgesics
    • Narcotic analgesics+ tricyclic antidepressants/ antiemetics
    • Endoscopic decompression with stent placement in patients with biliary or pancreatic duct obstruction
    • Radiation therapy
    • Neurolysis of the celiac ganglia by many approaches:
      • Intraoperative
      • Transgastric
      • Transthoracic
      • Transabdominal
  • Jaundice:
    • Obstructive jaundice can present with features of cholangitis:
      • Fever and chills
      • Nausea, vomiting
      • Clay-colored stools
      • Dark urine
      • Yellowish discoloration of skin
      • Pruritus
      • Right upper quadrant pain
      • Anorexia
      • Preferred treatment in patients: Endoscopic decompression with stent placement in patients with biliary obstruction
        • Techniques of biliary decompression:
          • Cholecystojejunostomy
          • Choledochojejunostomy
  • Types of stents:
    • Metal- costly, longer lifespan
    • Plastic- cheaper, need replacement every three months
  • Duodenal obstruction
    • Preferred treatment:
      • Endoscopic stenting of duodenal obstruction
      • Gastrojejunostomy

Pain There are various techniques for pain management as palliative therapy in patients:

Narcotic analgesics Narcotic analgesics+ tricyclic antidepressants/ antiemetics Endoscopic decompression with stent placement in patients with biliary or pancreatic duct obstruction Radiation therapy Neurolysis of the celiac ganglia by many approaches Intraoperative Transgastric Transthoracic Transabdominal

Jaundice Obstructive jaundice can present with features of cholangitis: Fever and chills Nausea, vomiting Clay-colored stools Dark urine Yellowish discoloration of skin Pruritus Right upper quadrant pain Anorexia Preferred treatment in patients: Endoscopic decompression with stent placement in patients with biliary obstruction Techniques of biliary decompression: Cholecystojejunostomy Choledochojejunostomy

Types of stents: Metal- costly, longer lifespan Plastic- cheaper, need replacement every three months

Duodenal obstruction Preferred treatment: Endoscopic stenting of duodenal obstruction Gastrojejunostomy

Treatment of pancreatic cancer depends on the stage of the cancer.[82] The Whipple procedure is the most common surgical treatment for cancers involving the head of the pancreas. It can only be performed if the patient is likely to survive major surgery and if the cancer is localised without invading local structures or metastasizing. It can therefore only be performed in the minority of cases.

Spleen-preserving distal pancreatectomy can also be used as a method to remove a cancer running through center of the pancreas; this is invasive surgery, resulting in loss of body and tail. Cancers of the t for pancreatic cancer uail of the pancreas can be resected using a procedure known as a distal pancreatectomy.[83] Recently, localized cancers of the pancreas have been resected using minimally invasive (laparoscopic) approaches.

Surgery can be performed for palliation, if the malignancy is invading or compressing the duodenum or colon. In that case, bypass surgery might overcome the obstruction and improve quality of life, but it is not intended as a cure.

Post-Operative Management

After surgery, adjuvant chemotherapy with gemcitabine may be offered to eliminate whatever cancerous tissue may remain in the body. This has been shown to increase 5-year survival rates. Addition of radiation therapy is a hotly debated topic, with groups in the US often favoring the use of adjuvant radiation therapy, while groups in Europe do not.[84]

Criteria for Unresectability

  • Tumor larger than 5 cm
  • Tumor invades adjacent tissue of organs (excluding duodenum)
  • Encasement, stenosis, or occlusion of the celiac artery, celiac artery branches, and/or SMA.
  • PV and/or SMV encasement (some centers will operate with venous invasion)
  • Hepatic metastases
  • Distant metastases (i.e. non regional lymph nodes)
  • Peritoneal carcinomatosis

References

References

  1. ↑ 1.0 1.1 Ryan DP, Hong TS, Bardeesy N (2014). "Pancreatic adenocarcinoma". N. Engl. J. Med. 371 (11): 1039–49. doi:10.1056/NEJMra1404198. PMID 25207767.
  2. ↑ Allen PJ, Kuk D, Castillo CF, Basturk O, Wolfgang CL, Cameron JL, Lillemoe KD, Ferrone CR, Morales-Oyarvide V, He J, Weiss MJ, Hruban RH, Gönen M, Klimstra DS, Mino-Kenudson M (2017). "Multi-institutional Validation Study of the American Joint Commission on Cancer (8th Edition) Changes for T and N Staging in Patients With Pancreatic Adenocarcinoma". Ann. Surg. 265 (1): 185–191. doi:10.1097/SLA.0000000000001763. PMID 27163957.
  3. ↑ Bilimoria KY, Bentrem DJ, Ko CY, Ritchey J, Stewart AK, Winchester DP, Talamonti MS (2007). "Validation of the 6th edition AJCC Pancreatic Cancer Staging System: report from the National Cancer Database". Cancer. 110 (4): 738–44. doi:10.1002/cncr.22852. PMID 17580363.
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  82. ↑ Pancreatic Cancer - Johns Hopkins Medicine: Surgical Treatment of Pancreatic Cancer
  83. ↑ Retrieved from http://pathology.jhu.edu/pancreas/TreatmentSurgery.php.
  84. ↑ Neoptolemos JP, Stocken DD, Friess H; et al. (2004). "A randomized trial of chemoradiotherapy and chemotherapy after resection of pancreatic cancer". N. Engl. J. Med. 350 (12): 1200–10. doi:10.1056/NEJMoa032295. PMID 15028824.


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