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General Surgery
Perspective on Pancreatic Neoplasms (A)
Built from Maingot's Abdominal Operations
What’s inside
6 sections · 101 slides
Overview
- Scope of this perspective
- Anatomy of the pancreas that the argument rests on
- Exocrine and endocrine pancreas
- Why the topic has changed in one generation
Staging cancer of the pancreatic head
Reading the tumour-vessel relationship on CT, and deciding what to do first
- Purpose of preoperative staging
- Case for referral to a high-volume centre
- Endoscopic ultrasound-guided fine-needle biopsy of the pancreas
- Fine-needle aspiration cytology of pancreatic adenocarcinoma
- Arteries and veins that define resectability
- Celiac trunk and superior mesenteric artery around the pancreas
- Imaging features of early pancreatic ductal adenocarcinoma
- Pancreatic-region mass on contrast-enhanced abdominal CT
- Varadhachary CT-based classification
- Assumptions built into the Varadhachary definitions
- Varadhachary/Katz CT staging system for adenocarcinoma of the pancreatic head and uncinate process
- Reading the staging table
- Katz subtypes of borderline resectable disease
- Three forms of borderline resectable disease
- Type B: the biologic borderline patient
- Type C: the physiologic borderline patient
- What the Katz classification contributed
- AHPBA-SSO-SSAT consensus definition of resectable
- Two definitions of resectable compared
- Current consensus when surgery comes first
- Open questions in borderline resectable disease
- Regimens borrowed from metastatic disease
- Parts of the schedule that remain undefined
- ACOSOG Z5041 trial
Pancreaticoduodenectomy and local recurrence
The superior mesenteric artery dissection, and why the cancer comes back where it does
- Pancreaticoduodenectomy in outline
- Reconstruction after pancreaticoduodenectomy
- Exposing the superior mesenteric artery
- Pathophysiology of local recurrence
- How perineural spread produces local recurrence
- Consequence of better systemic therapy
Cystic neoplasms of the pancreas
Serous cystadenoma, mucinous cystic neoplasm and intraductal papillary mucinous neoplasm
- Three cystic neoplasms that dominate practice
- Growing importance of cystic lesions
- Large pancreatic cyst on abdominal CT
- Biology of serous cystadenoma
- Venous complications of serous cystadenoma
- Diagnosing serous cystadenoma
- Microcystic serous cystadenoma histology
- Role of EUS-guided aspiration in serous lesions
- Deciding on surgery for serous cystadenoma
- Observation policy for smaller serous lesions
- Diagnostic criterion for mucinous cystic neoplasm
- Mucinous cystic neoplasm with ovarian-type stroma
- Size and malignant potential in MCN
- Location of mucinous cystic neoplasms
- Worked example: a 3 cm mucinous lesion in the body
- Choice of operation for a body MCN
- Middle segment pancreatectomy as the preferred operation
- Sendai guidelines for intraductal papillary mucinous neoplasm
- Intraductal papillary mucinous neoplasm histology
- Rationale for observing low-risk IPMN
- Debate over enucleation and ablation in small IPMN
- Frozen-section assessment of the transection margin
- Limits of frozen-section expertise
- IPMN at the neck of the pancreas
- Margin planning in extended distal pancreatectomy
- Follow-up after resection for IPMN
Pancreatic neuroendocrine tumours
Biology that behaves quite unlike ductal cancer, and the operations it calls for
- Definition and nomenclature
- Pancreatic neuroendocrine tumour histology
- Behaviour of sporadic insulinoma
- Synchronous and metachronous metastases
- Size and metastatic risk in MEN1
- Observing small nonfunctioning pNETs in MEN1
- Zollinger-Ellison syndrome and the origin of gastrinoma
- Pancreatic gastrinoma
- Duodenal carcinoid tumours
- Well-differentiated neuroendocrine tumour of the duodenum
- Molecular origin of duodenal and pancreatic gastrinomas
- Causes of a raised serum gastrin level
- Distinguishing gastrinoma from parietal cell dysfunction
- Regional lymphadenectomy in neuroendocrine surgery
- Biochemical diagnosis of insulinoma
- The observed fast
- Interpreting the glucagon response
- Distribution of insulinoma within the pancreas
- Local recurrence after enucleation
- Technique of insulinoma enucleation
- Open versus laparoscopic enucleation
- Managing the pancreatic duct during enucleation
- Genetic testing and syndromic associations
- Timing surgery for MEN1 nonfunctional pNETs
- The Thompson procedure
- Completion total pancreatectomy in MEN1
- Targeted systemic therapy for metastatic pNETs
- Indolent metachronous recurrence and octreotide
- Multidisciplinary management of low-volume metastatic disease
- Selecting nonfunctioning pNETs for surgery
- Liver metastases: exocrine versus neuroendocrine
- Sequencing pancreas and liver surgery
- Portal vein embolization and staged hepatectomy
- Outlook for pancreatic neuroendocrine tumours
Take-home points
What to carry away from this perspective
- Take-home points on staging and sequencing
- Take-home points on cystic neoplasms
- Take-home points on neuroendocrine tumours
- References
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition