Surgery
The Pancreas
Dr. Ali Ja’far
CARCINOMA OF THE PANCREA
Risk factors for the development of pancreatic cancer.
Demographic factors
Age (peak incidence 65–75 years), Male gender, Black ethnicity
Environment/lifestyle
Cigarette smoking
Genetic factors /medical conditions
Family history
Germline BRCA2 mutations in some rare high-risk families
Hereditary pancreatitis (50- to 70-fold increased risk)
Chronic pancreatitis (5- to 15-fold increased risk)
Lynch syndrome (HNPCC), Ataxia telangiectasia, Peutz–Jeghers syndrome
Familial breast–ovarian cancer syndrome, Familial atypical multiple mole melanoma
Familial adenomatous polyposis – risk of ampullary/duodenal carcinoma
Diabetes mellitus
Pathology of pancreatic tumours
85% ductal adenocarcinoma
Intense desmoplastic reaction (extensive fibrosis), difficult to differentiate from ch
pancreatitis
Spread; locally… nerve sheath, blood vessels and lymphatic
liver and peritoneal spread
Cystic tumours ; serous and mucinous
Serous : benign, old female, small and multiple
Mucinous : potential for malignant transformation, it is either Mucinous cystic neoplasm
(MCNs)
or intraductal papillary mucinous neoplasms (IPMNs)
Surgery
The Pancreas
Dr. Ali Ja’far
Adenomas of ampulla of Vater; premalignant lesion, may harbour invasive adenocarcinoma,
it is common in patients with FAP, need endoscopic surveillance
Ampullary adenocarcinoma
Ampullary neuroendocrine tumours
Clinical features
Painless jaundice, pruritus, dark urine, pale stool, steatorrhoea
Vague symptoms, weight loss , poor appitite
Recent onset DM over 50 with non specific symptms
Attacks of pancreatitis
Body and tail of pancreas tumours usually preset late as a big tumour with backache
Examination
; jaundice, weight loss, palpable liver and gall bladder, Courvoisier sign, sings
of advance disease (acites, supraclavicular LN, pelvic metastasis …etc)
Investigation
blood test; abnormal liver function test, anemia, tumour markers CA19-9
Ultrasound; dilated CBD, pancreatic mass liver metastasis, peritoneal mass
Contrast enhanced CT scan; site of tumour, relation to the arteries vein, duodenum, stomach,
bowel, peritoneum lymphnodes
MRI
ERCP; mainly therapeutic ( stenting)
EUS, tissue to confirm the Dx (ch. Pancreatitis, Mucinous tumours)
Diagnostic laparoscopy
Management
85% unrespectable at time of diagnosis palliative treatment
Operable surgical resection
1. head of pancreas and periampullary tumours: pancreaticoduodenectomy – whipple’s
operation ( resection of gastric antrum, duodenum, head of pancreas, CBD& gall bladder) or
pylorus preserving pancreaticodudenectomy
Surgery
The Pancreas
Dr. Ali Ja’far
2. body and tail of pancreas ; distal pancreatectomy and splenectomy
3. total pancreatectomy; a multifocal tumour (e.g. a main duct IPMN), or the body and tail of
the gland are too inflamed or too friable to achieve a safe anastomosis with the bowel.
Palliation of pancreatic cancer
Relieve jaundice and treat biliary sepsis: (Surgical biliary bypass, Stent placed at ERCP or
percutaneous transhepaticcholangiography).
Improve gastric emptying: (Surgical gastroenterostomy, Duodenal stent).
Pain relief (Stepwise escalation of analgesia, Coeliac plexus block, Transthoracic
splanchnicectomy)
Symptom relief and quality of life( Encourage normal activities, Enzyme replacement for
steatorrhoea, Treat diabetes).
Consider chemotherapy
Questions
Which of the following statements are true?
A Pancreatic injury is common following blunt abdominal trauma.
B Pancreatic injury is often accompanied by damage to the liver, spleen and duodenum.
C The serum amylase is raised in most cases of pancreatic injury.
D A CECT scan will delineate the damage.
E In doubtful cases, urgent ERCP is helpful.
BCDE
Which of the following statements is false?
A All patients with pancreatic trauma should undergo an exploratory laparotomy.
B Pancreatic duct disruption requires surgical exploration.
C Severe injury to the duodenum and the head of the pancreas requires
pancreatoduodenectomy.
D After conservative management for pancreatic injury, duct stricture and pseudocyst may
occur as complications.
Surgery
The Pancreas
Dr. Ali Ja’far
E During splenectomy, iatrogenic injury to the pancreatic tail can occur.
A
Which of the following statements are true with regard to complications in acute
pancreatitis?
A Patients with severe acute pancreatitis require a CECT scan to detect pancreatic necrosis.
B In severe acute pancreatitis, a laparotomy must be done in all cases of pancreatic
necrosis.
C Aneurysm of the superior mesenteric artery can occur.
D The vast majority of patients with peripancreatic sepsis can be treated conservatively.
E Pleural effusion is seen in 10–20 per cent of patients.
ACDE