General Surgery
Perspective on Pancreatic Neoplasms (B)
Built from Maingot's Abdominal Operations
What’s inside
10 sections · 71 slides
Where pancreatic surgery stands
Forty years of change in how these tumours are found, judged and removed
- Scope of this perspective
- Terms used in this topic
- Parts of the pancreas and its ducts
- Duodenum, bile duct and pancreatic duct
- Advances of the last forty years
- 2–5%
- Operating without biopsy proof
- Ampullary neoplasms and negative biopsies
- Fine-needle aspiration smear from the pancreas
Limits of imaging and staging
What the best scans still cannot see, and how often they are wrong
- Absence of a screening test
- Staging with contrast-enhanced angio-CT
- Role of preoperative laparoscopy
- Staging sequence before resection
Preparing the patient
Draining the bile duct first, and whether to treat before operating
- Preoperative biliary stenting
- Arguments for neoadjuvant chemoradiation
- Evidence against a neoadjuvant benefit
- Adjuvant radiation after resection
Volume, margins and the retroperitoneal edge
Who operates, how completely, and what the pathologist finds at the cut edge
- Hospital and surgeon volume
- Components of the volume effect
- Positive retroperitoneal margins
- Pancreatic ductal adenocarcinoma under the microscope
- Celiac trunk and superior mesenteric artery
- Extended lymphadenectomy and intraoperative radiation
Choices inside the operation
Open or laparoscopic, pylorus in or out, and how far to go with the vessels
- Parts removed in a pancreaticoduodenectomy
- Reconstruction after pancreaticoduodenectomy
- Laparoscopic pancreatic resection
- Classic and pylorus-preserving resection
- Survival after either version
- 275 cc
- Experience at one high-volume unit
- “
- Vein resection and reconstruction
- Tumour contact with major vessels
- Arterial involvement
Leak at the pancreatic anastomosis
The commonest complication of the operation, and the one most likely to kill
- Pancreatic fistula after resection
- Gland texture and leak risk
- 13%
- Outcome of high-impact fistulas
- Sentinel bleed from a drain
- Sequence from leak to fatal haemorrhage
Cystic neoplasms of the pancreas
Fluid-filled tumours, mostly silent, now the commonest pancreatic growth in practice
- Rise in pancreatic cystic tumours
- 1 in 4
- Cystic lesion found on contrast CT
- Large fluid-filled mass in the upper abdomen
- Types of cystic lesion to tell apart
- Serous cystadenoma under the microscope
- Intraductal papillary mucinous neoplasm under the microscope
- Tests used to sort out a pancreatic cyst
- Cyst fluid carcinoembryonic antigen
- Accuracy of the diagnostic tests
Deciding to resect or to watch
Rules for a cyst that does not fit the picture of a pseudocyst
- Cysts that should be resected
- Dilated main pancreatic duct
- Mural nodule or solid component
- Cyst size in the Sendai consensus
- Watching a small asymptomatic cyst
- Resect or watch an undetermined cyst
- Magnetic resonance cholangiopancreatography
Extent of resection and follow-up
How much pancreas to take, and who needs watching afterwards
- Behaviour of small incidental cysts
- Balance of risk in mucinous cysts
- Cure rates for cystic carcinoma
- Segmental and local resections
- Pancreatic duct margin on frozen section
- Surveillance after resection
- Patients who do need surveillance
Points to carry away
The judgements this perspective keeps returning to
- Points to carry away: the cancer operation
- Points to carry away: cystic tumours
- References
- References (continued)
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition