id
stringlengths 14
28
| title
stringclasses 18
values | content
stringlengths 2
999
| contents
stringlengths 19
1.02k
|
|---|---|---|---|
Surgery_Schwartz_9702 | Surgery_Schwartz | porcine mixed with bicarbonate granulesDigestive Care8000, 16,000UltresaEnteric-coated porcineAptalis13,800, 20,700, 23,000ViokaceTablet non-enteric-coated porcineAptalis10,440, 20,880Note: USP = United States Pharmacopeia, the standard for lipase content in the United States. An average meal requires roughly 90,000 USP units of lipase for fat digestion. Enzyme therapy of exocrine deficiency typically begins with a dose of 50,000 USP units per meal with subsequent adjustment.Reproduced with permission from Forsmark CE: Management of chronic pancreatitis, Gastroenterology. 2013 Jun;144(6):1282-1291.release.222 The somatostatin analogue octreotide acetate has therefore been investigated for pain relief in patients with chronic pancreatitis. In a double-blind, prospective, randomized 4-week trial, 65% of patients who received 200 μg of octreotide acetate subcutaneously three times daily reported pain relief, compared with 35% of placebo-treated subjects.223 Patients who had the best | Surgery_Schwartz. porcine mixed with bicarbonate granulesDigestive Care8000, 16,000UltresaEnteric-coated porcineAptalis13,800, 20,700, 23,000ViokaceTablet non-enteric-coated porcineAptalis10,440, 20,880Note: USP = United States Pharmacopeia, the standard for lipase content in the United States. An average meal requires roughly 90,000 USP units of lipase for fat digestion. Enzyme therapy of exocrine deficiency typically begins with a dose of 50,000 USP units per meal with subsequent adjustment.Reproduced with permission from Forsmark CE: Management of chronic pancreatitis, Gastroenterology. 2013 Jun;144(6):1282-1291.release.222 The somatostatin analogue octreotide acetate has therefore been investigated for pain relief in patients with chronic pancreatitis. In a double-blind, prospective, randomized 4-week trial, 65% of patients who received 200 μg of octreotide acetate subcutaneously three times daily reported pain relief, compared with 35% of placebo-treated subjects.223 Patients who had the best |
Surgery_Schwartz_9703 | Surgery_Schwartz | trial, 65% of patients who received 200 μg of octreotide acetate subcutaneously three times daily reported pain relief, compared with 35% of placebo-treated subjects.223 Patients who had the best results were patients with chronic abdominal pain, suggestive of obstructive pancreatopathy. However, in another trial that used a 3-day duration of treatment, no significant pain relief was observed.224 Anecdotal reports suggest that severe pain exacerbations in chronic pancreatitis can benefit from a combination of octreotide therapy and TPN, and a pilot study of the effectiveness of the sustained-release form of octreotide suggested that it was as effective as three-times-per-day admin-istration of the short-acting form of the drug.225Neurolytic Therapy. Celiac plexus neurolysis with alcohol injection has been an effective form of analgesic treatment in patients with pancreatic carcinoma. However, the use of radio-logically or endoscopically guided celiac plexus blockade in chronic | Surgery_Schwartz. trial, 65% of patients who received 200 μg of octreotide acetate subcutaneously three times daily reported pain relief, compared with 35% of placebo-treated subjects.223 Patients who had the best results were patients with chronic abdominal pain, suggestive of obstructive pancreatopathy. However, in another trial that used a 3-day duration of treatment, no significant pain relief was observed.224 Anecdotal reports suggest that severe pain exacerbations in chronic pancreatitis can benefit from a combination of octreotide therapy and TPN, and a pilot study of the effectiveness of the sustained-release form of octreotide suggested that it was as effective as three-times-per-day admin-istration of the short-acting form of the drug.225Neurolytic Therapy. Celiac plexus neurolysis with alcohol injection has been an effective form of analgesic treatment in patients with pancreatic carcinoma. However, the use of radio-logically or endoscopically guided celiac plexus blockade in chronic |
Surgery_Schwartz_9704 | Surgery_Schwartz | injection has been an effective form of analgesic treatment in patients with pancreatic carcinoma. However, the use of radio-logically or endoscopically guided celiac plexus blockade in chronic pancreatitis has been disappointing. Due to the risk of alcohol injury and the need for repeated injections, celiac plexus blockade in chronic pancreatitis has used short-acting analgesics or other drugs rather than 50% alcohol. A trial of EUS-guided celiac plexus blockade revealed successful pain relief in 55% of patients, but the benefit lasted beyond 6 months in only 10% of patients.226 The procedure therefore appears safe, but the effect is short lived in those patients who obtain pain relief.Endoscopic Management. The techniques of endoscopic treat-ment of pancreatic duct obstruction, stone disease, pseudocyst formation, pancreatic duct leak, and for the diagnosis and man-agement of associated pancreatic tumors have expanded greatly over the past 20 years. Newer endoscopes with expanded | Surgery_Schwartz. injection has been an effective form of analgesic treatment in patients with pancreatic carcinoma. However, the use of radio-logically or endoscopically guided celiac plexus blockade in chronic pancreatitis has been disappointing. Due to the risk of alcohol injury and the need for repeated injections, celiac plexus blockade in chronic pancreatitis has used short-acting analgesics or other drugs rather than 50% alcohol. A trial of EUS-guided celiac plexus blockade revealed successful pain relief in 55% of patients, but the benefit lasted beyond 6 months in only 10% of patients.226 The procedure therefore appears safe, but the effect is short lived in those patients who obtain pain relief.Endoscopic Management. The techniques of endoscopic treat-ment of pancreatic duct obstruction, stone disease, pseudocyst formation, pancreatic duct leak, and for the diagnosis and man-agement of associated pancreatic tumors have expanded greatly over the past 20 years. Newer endoscopes with expanded |
Surgery_Schwartz_9705 | Surgery_Schwartz | disease, pseudocyst formation, pancreatic duct leak, and for the diagnosis and man-agement of associated pancreatic tumors have expanded greatly over the past 20 years. Newer endoscopes with expanded thera-peutic capabilities have been introduced, and the role of EUS and EUS-guided needle and catheter insertion has expanded the abil-ity of the therapeutic endoscopist in the diagnosis and treatment of chronic pancreatitis and its complications.227Pancreatic duct stenting is used for treatment of proxi-mal pancreatic duct stenosis, decompression of a pancreatic duct leak, and for drainage of pancreatic pseudocysts that can be catheterized through the main pancreatic duct. Pancreatic duct stents can induce an inflammatory response within the Brunicardi_Ch33_p1429-p1516.indd 146901/03/19 6:45 PM 1470SPECIFIC CONSIDERATIONSPART IIMake a correct diagnosis • Appropriate history • Corroborating imaging tests • MRI/MRCP • EUS • CT • Functional tests if imaging tests equivocal • | Surgery_Schwartz. disease, pseudocyst formation, pancreatic duct leak, and for the diagnosis and man-agement of associated pancreatic tumors have expanded greatly over the past 20 years. Newer endoscopes with expanded thera-peutic capabilities have been introduced, and the role of EUS and EUS-guided needle and catheter insertion has expanded the abil-ity of the therapeutic endoscopist in the diagnosis and treatment of chronic pancreatitis and its complications.227Pancreatic duct stenting is used for treatment of proxi-mal pancreatic duct stenosis, decompression of a pancreatic duct leak, and for drainage of pancreatic pseudocysts that can be catheterized through the main pancreatic duct. Pancreatic duct stents can induce an inflammatory response within the Brunicardi_Ch33_p1429-p1516.indd 146901/03/19 6:45 PM 1470SPECIFIC CONSIDERATIONSPART IIMake a correct diagnosis • Appropriate history • Corroborating imaging tests • MRI/MRCP • EUS • CT • Functional tests if imaging tests equivocal • |
Surgery_Schwartz_9706 | Surgery_Schwartz | 6:45 PM 1470SPECIFIC CONSIDERATIONSPART IIMake a correct diagnosis • Appropriate history • Corroborating imaging tests • MRI/MRCP • EUS • CT • Functional tests if imaging tests equivocal • Tube-based secretin test • Endoscopic-based secretin test • Assess for alternative diseases and complications and treat if present • Pancreatic cancer or IPMN • Pseudocyst • Bile duct obstruction • Duodenal obstructionMedical therapy • Measure pain severity, character, and impact on QOL • Refer for formal structured smoking and alcohol cessation programs • Counsel on good nutrition and initiate supplementation with vitamin D and calcium • Baseline bone mineral density tasting • Provide information on local and national support groups • Initiate analgesics (starting with Tramadol) • Increase dose and potenay slowly as required • Initiate adjunctive agents in those with persistent pain or requiring higher dosages or potency of narcotics • Pregabalin, Gabapentin • SSRI • | Surgery_Schwartz. 6:45 PM 1470SPECIFIC CONSIDERATIONSPART IIMake a correct diagnosis • Appropriate history • Corroborating imaging tests • MRI/MRCP • EUS • CT • Functional tests if imaging tests equivocal • Tube-based secretin test • Endoscopic-based secretin test • Assess for alternative diseases and complications and treat if present • Pancreatic cancer or IPMN • Pseudocyst • Bile duct obstruction • Duodenal obstructionMedical therapy • Measure pain severity, character, and impact on QOL • Refer for formal structured smoking and alcohol cessation programs • Counsel on good nutrition and initiate supplementation with vitamin D and calcium • Baseline bone mineral density tasting • Provide information on local and national support groups • Initiate analgesics (starting with Tramadol) • Increase dose and potenay slowly as required • Initiate adjunctive agents in those with persistent pain or requiring higher dosages or potency of narcotics • Pregabalin, Gabapentin • SSRI • |
Surgery_Schwartz_9707 | Surgery_Schwartz | • Increase dose and potenay slowly as required • Initiate adjunctive agents in those with persistent pain or requiring higher dosages or potency of narcotics • Pregabalin, Gabapentin • SSRI • SSNRI • Tricyclic antidepressants • Assess for evidence of coexistent exocrine or endocrine insufficiency and treat if present • Fecal elastase or serum trypsin • HgB A1C or GTT • Initiate steroids if autoimmune pancreatitisInflammatory mass in pancreatic head • With or without dilated pancreatic duct • With or without duodenal or biliary obstructionSurgical therapy in ÿt patients • DPPHR • Berger operation • Frey operation • Berne operation • Whipple operationDiscuss options with patient, includingthat data supports superiority of surgery.Surgery remains an option for failure ofendoscopic therapy • Endoscopic therapy • Pancreatic and biliary sphincterotomy • Stricture dilation and stenting • Lithotripsy • Stone extraction • Surgical therapy • Modified Puestow or Frey | Surgery_Schwartz. • Increase dose and potenay slowly as required • Initiate adjunctive agents in those with persistent pain or requiring higher dosages or potency of narcotics • Pregabalin, Gabapentin • SSRI • SSNRI • Tricyclic antidepressants • Assess for evidence of coexistent exocrine or endocrine insufficiency and treat if present • Fecal elastase or serum trypsin • HgB A1C or GTT • Initiate steroids if autoimmune pancreatitisInflammatory mass in pancreatic head • With or without dilated pancreatic duct • With or without duodenal or biliary obstructionSurgical therapy in ÿt patients • DPPHR • Berger operation • Frey operation • Berne operation • Whipple operationDiscuss options with patient, includingthat data supports superiority of surgery.Surgery remains an option for failure ofendoscopic therapy • Endoscopic therapy • Pancreatic and biliary sphincterotomy • Stricture dilation and stenting • Lithotripsy • Stone extraction • Surgical therapy • Modified Puestow or Frey |
Surgery_Schwartz_9708 | Surgery_Schwartz | therapy • Endoscopic therapy • Pancreatic and biliary sphincterotomy • Stricture dilation and stenting • Lithotripsy • Stone extraction • Surgical therapy • Modified Puestow or Frey operation• Continued medical therapy• Surgical therapy • “V-plasty” • Total pancreatectomy, with islet cell autotransplantationDilated pancreatic duct (° 6 mm)Small duct disease (pancreatic duct˛ 6 mm)Treatment effective?Continue treatment with periodicreassessmentYesNoAssess anatomy of pancreas andpancreatic ductFigure 33-45. Management algorithm for chronic pancreatitis. IPMN = intraductal papillary mucinous neoplasm; QOL = quality of life; SSRI = selective serotonin reuptake inhibitor; SSNRI = selective serotonin-norepinephrine reuptake inhibitor; GTT = glucose tolerance test. (Reproduced with permission from Forsmark CE: Management of chronic pancreatitis, Gastroenterology. 2013 Jun;144(6):1282-1291.)Brunicardi_Ch33_p1429-p1516.indd 147001/03/19 6:45 PM 1471PANCREASCHAPTER 33duct, so | Surgery_Schwartz. therapy • Endoscopic therapy • Pancreatic and biliary sphincterotomy • Stricture dilation and stenting • Lithotripsy • Stone extraction • Surgical therapy • Modified Puestow or Frey operation• Continued medical therapy• Surgical therapy • “V-plasty” • Total pancreatectomy, with islet cell autotransplantationDilated pancreatic duct (° 6 mm)Small duct disease (pancreatic duct˛ 6 mm)Treatment effective?Continue treatment with periodicreassessmentYesNoAssess anatomy of pancreas andpancreatic ductFigure 33-45. Management algorithm for chronic pancreatitis. IPMN = intraductal papillary mucinous neoplasm; QOL = quality of life; SSRI = selective serotonin reuptake inhibitor; SSNRI = selective serotonin-norepinephrine reuptake inhibitor; GTT = glucose tolerance test. (Reproduced with permission from Forsmark CE: Management of chronic pancreatitis, Gastroenterology. 2013 Jun;144(6):1282-1291.)Brunicardi_Ch33_p1429-p1516.indd 147001/03/19 6:45 PM 1471PANCREASCHAPTER 33duct, so |
Surgery_Schwartz_9709 | Surgery_Schwartz | permission from Forsmark CE: Management of chronic pancreatitis, Gastroenterology. 2013 Jun;144(6):1282-1291.)Brunicardi_Ch33_p1429-p1516.indd 147001/03/19 6:45 PM 1471PANCREASCHAPTER 33duct, so prolonged stenting is usually avoided. Patients with sphincter of Oddi dyskinesia are at high risk for developing post-ERCP pancreatitis after biliary sphincterotomy, and the prophylactic placement of a pancreatic duct stent or the admin-istration of rectal indomethacin reduces the amylase level and development of pancreatitis after biliary sphincterotomy.33,228 Pancreatic duct leaks are seen in 37% of patients with acute pancreatitis, and pancreatic duct stenting appears to facilitate the resolution of the leak.229 Similarly, pancreatic duct stenting has been used to treat postsurgical pancreatic duct leaks and posttraumatic leaks.229-231Pancreas divisum (see Fig. 33-3) is thought to cause pain and chronic pancreatitis due to functional or mechanical obstruc-tion of the dorsal duct | Surgery_Schwartz. permission from Forsmark CE: Management of chronic pancreatitis, Gastroenterology. 2013 Jun;144(6):1282-1291.)Brunicardi_Ch33_p1429-p1516.indd 147001/03/19 6:45 PM 1471PANCREASCHAPTER 33duct, so prolonged stenting is usually avoided. Patients with sphincter of Oddi dyskinesia are at high risk for developing post-ERCP pancreatitis after biliary sphincterotomy, and the prophylactic placement of a pancreatic duct stent or the admin-istration of rectal indomethacin reduces the amylase level and development of pancreatitis after biliary sphincterotomy.33,228 Pancreatic duct leaks are seen in 37% of patients with acute pancreatitis, and pancreatic duct stenting appears to facilitate the resolution of the leak.229 Similarly, pancreatic duct stenting has been used to treat postsurgical pancreatic duct leaks and posttraumatic leaks.229-231Pancreas divisum (see Fig. 33-3) is thought to cause pain and chronic pancreatitis due to functional or mechanical obstruc-tion of the dorsal duct |
Surgery_Schwartz_9710 | Surgery_Schwartz | pancreatic duct leaks and posttraumatic leaks.229-231Pancreas divisum (see Fig. 33-3) is thought to cause pain and chronic pancreatitis due to functional or mechanical obstruc-tion of the dorsal duct draining exclusively, or predominantly, through the lesser papilla. A study from Marseille reported good long-term results in 24 patients after minor papilla sphinc-terotomy and dorsal duct stenting.232 The number of patients with chronic pain decreased from 83% before stenting to 29% after stenting, but pancreatitis or recurrent papillary stenosis occurred in 38%. Patients that responded best were those with intermittent pain, and this subset may be preferentially treated with endoscopic therapy. Patients with recurrent pain and a dilated dorsal duct may be candidates for internal drainage of the obstructed duct with either an extended Puestow procedure or a Frey procedure (see later in this section).Idiopathic pancreatitis patients have been treated with endoscopic stenting, pancreatic | Surgery_Schwartz. pancreatic duct leaks and posttraumatic leaks.229-231Pancreas divisum (see Fig. 33-3) is thought to cause pain and chronic pancreatitis due to functional or mechanical obstruc-tion of the dorsal duct draining exclusively, or predominantly, through the lesser papilla. A study from Marseille reported good long-term results in 24 patients after minor papilla sphinc-terotomy and dorsal duct stenting.232 The number of patients with chronic pain decreased from 83% before stenting to 29% after stenting, but pancreatitis or recurrent papillary stenosis occurred in 38%. Patients that responded best were those with intermittent pain, and this subset may be preferentially treated with endoscopic therapy. Patients with recurrent pain and a dilated dorsal duct may be candidates for internal drainage of the obstructed duct with either an extended Puestow procedure or a Frey procedure (see later in this section).Idiopathic pancreatitis patients have been treated with endoscopic stenting, pancreatic |
Surgery_Schwartz_9711 | Surgery_Schwartz | the obstructed duct with either an extended Puestow procedure or a Frey procedure (see later in this section).Idiopathic pancreatitis patients have been treated with endoscopic stenting, pancreatic duct sphincterotomy, and endo-scopic stone removal with good results. In a prospective ran-domized trial, 53% of idiopathic recurrent pancreatitis patients in the control group experienced continued episodes of pancre-atitis, although only 11% of the treated patients had continued symptoms.233Extracorporeal shock wave lithotripsy (ESWL) has been used for pancreatic duct stones, together with endoscopic stent-ing and stone removal.234 A single ESWL session was used in 35 patients with pancreatic duct stones, together with 86 ERCP sessions to complete the stone removal process. After 2.4 years, 80% of patients had significant relief of symptoms (Fig. 33-46). Also, endoscopic intraductal lithotripsy can now be performed in some specialized centers. However, due to the tendency for recurrent | Surgery_Schwartz. the obstructed duct with either an extended Puestow procedure or a Frey procedure (see later in this section).Idiopathic pancreatitis patients have been treated with endoscopic stenting, pancreatic duct sphincterotomy, and endo-scopic stone removal with good results. In a prospective ran-domized trial, 53% of idiopathic recurrent pancreatitis patients in the control group experienced continued episodes of pancre-atitis, although only 11% of the treated patients had continued symptoms.233Extracorporeal shock wave lithotripsy (ESWL) has been used for pancreatic duct stones, together with endoscopic stent-ing and stone removal.234 A single ESWL session was used in 35 patients with pancreatic duct stones, together with 86 ERCP sessions to complete the stone removal process. After 2.4 years, 80% of patients had significant relief of symptoms (Fig. 33-46). Also, endoscopic intraductal lithotripsy can now be performed in some specialized centers. However, due to the tendency for recurrent |
Surgery_Schwartz_9712 | Surgery_Schwartz | 80% of patients had significant relief of symptoms (Fig. 33-46). Also, endoscopic intraductal lithotripsy can now be performed in some specialized centers. However, due to the tendency for recurrent stone formation, the use of ESWL or endoscopic litho-tripsy for long-term management of calcific pancreatitis remains uncertain.Surgical Therapy Indications and History The traditional approach to surgi-cal treatment of chronic pancreatitis and its complications has maintained that surgery should be considered only when the medical therapy of symptoms has failed. Nealon and Thomp-son published a landmark study in 1993, however, that showed that the progression of chronic obstructive pancreatitis could be delayed or prevented by pancreatic duct decompression.235 No other therapy has been shown to prevent the progression of chronic pancreatitis, and this study demonstrated the role of surgery in the early management of the disease (Table 33-20). Small-duct disease or “minimal change chronic | Surgery_Schwartz. 80% of patients had significant relief of symptoms (Fig. 33-46). Also, endoscopic intraductal lithotripsy can now be performed in some specialized centers. However, due to the tendency for recurrent stone formation, the use of ESWL or endoscopic litho-tripsy for long-term management of calcific pancreatitis remains uncertain.Surgical Therapy Indications and History The traditional approach to surgi-cal treatment of chronic pancreatitis and its complications has maintained that surgery should be considered only when the medical therapy of symptoms has failed. Nealon and Thomp-son published a landmark study in 1993, however, that showed that the progression of chronic obstructive pancreatitis could be delayed or prevented by pancreatic duct decompression.235 No other therapy has been shown to prevent the progression of chronic pancreatitis, and this study demonstrated the role of surgery in the early management of the disease (Table 33-20). Small-duct disease or “minimal change chronic |
Surgery_Schwartz_9713 | Surgery_Schwartz | to prevent the progression of chronic pancreatitis, and this study demonstrated the role of surgery in the early management of the disease (Table 33-20). Small-duct disease or “minimal change chronic pancreatitis” are causes for uncertainty over the choice of operation, however. Major resections have a high complication rate, both early and late, in chronic alcoholic pancreatitis, and lesser procedures often result in symptomatic recurrence. Therefore, the choice of operation and the timing of surgery are based on each patient’s pancreatic anatomy, the likelihood (or lack thereof) that further ABFigure 33-46. Extracorporeal shock wave lithotripsy treatment of pancreatic duct stones. The endoscopic retrograde cholangiopancrea-tography images are shown (A) before and (B) after extracorporeal shock wave lithotripsy therapy of pancreatic duct obstruction due to calculus formation. (Reproduced with permission from Kozarek RA, Brandabur JJ, Ball TJ, et al. Clinical outcomes in patients who | Surgery_Schwartz. to prevent the progression of chronic pancreatitis, and this study demonstrated the role of surgery in the early management of the disease (Table 33-20). Small-duct disease or “minimal change chronic pancreatitis” are causes for uncertainty over the choice of operation, however. Major resections have a high complication rate, both early and late, in chronic alcoholic pancreatitis, and lesser procedures often result in symptomatic recurrence. Therefore, the choice of operation and the timing of surgery are based on each patient’s pancreatic anatomy, the likelihood (or lack thereof) that further ABFigure 33-46. Extracorporeal shock wave lithotripsy treatment of pancreatic duct stones. The endoscopic retrograde cholangiopancrea-tography images are shown (A) before and (B) after extracorporeal shock wave lithotripsy therapy of pancreatic duct obstruction due to calculus formation. (Reproduced with permission from Kozarek RA, Brandabur JJ, Ball TJ, et al. Clinical outcomes in patients who |
Surgery_Schwartz_9714 | Surgery_Schwartz | shock wave lithotripsy therapy of pancreatic duct obstruction due to calculus formation. (Reproduced with permission from Kozarek RA, Brandabur JJ, Ball TJ, et al. Clinical outcomes in patients who undergo extracorporeal shock wave lithotripsy for chronic calcific pancreatitis, Gastrointest Endosc. 2002 Oct;56(4):496-500.)Table 33-20Effect of surgical drainage on progression of chronic pancreatitisTREATMENT GROUP24-MONTH EVALUATIONOperated (n = 47)Mild to moderate 48 (87%); severe 6 (13%)Nonoperated (n = 36)Mild to moderate 8 (22%); severe 28 (78%)Eighty-three patients with chronic pancreatitis were evaluated by exocrine, endocrine, nutritional, and endoscopic retrograde cholangiopancreatography studies, and all had mild to moderate disease and dilated pancreatic ducts. A Puestow-type duct decompression procedure was performed in 47 patients, and all subjects were restaged by the same methods 24 months later.Reproduced with permission from Nealon WH, Thompson JC. Progressive loss of | Surgery_Schwartz. shock wave lithotripsy therapy of pancreatic duct obstruction due to calculus formation. (Reproduced with permission from Kozarek RA, Brandabur JJ, Ball TJ, et al. Clinical outcomes in patients who undergo extracorporeal shock wave lithotripsy for chronic calcific pancreatitis, Gastrointest Endosc. 2002 Oct;56(4):496-500.)Table 33-20Effect of surgical drainage on progression of chronic pancreatitisTREATMENT GROUP24-MONTH EVALUATIONOperated (n = 47)Mild to moderate 48 (87%); severe 6 (13%)Nonoperated (n = 36)Mild to moderate 8 (22%); severe 28 (78%)Eighty-three patients with chronic pancreatitis were evaluated by exocrine, endocrine, nutritional, and endoscopic retrograde cholangiopancreatography studies, and all had mild to moderate disease and dilated pancreatic ducts. A Puestow-type duct decompression procedure was performed in 47 patients, and all subjects were restaged by the same methods 24 months later.Reproduced with permission from Nealon WH, Thompson JC. Progressive loss of |
Surgery_Schwartz_9715 | Surgery_Schwartz | decompression procedure was performed in 47 patients, and all subjects were restaged by the same methods 24 months later.Reproduced with permission from Nealon WH, Thompson JC. Progressive loss of pancreatic function in chronic pancreatitis is delayed by main pancreatic duct decompression. A longitudinal prospective analysis of the modified puestow procedure, Ann Surg. 1993 May;217(5):458-466.Brunicardi_Ch33_p1429-p1516.indd 147101/03/19 6:45 PM 1472SPECIFIC CONSIDERATIONSPART IIFigure 33-47. Head-of-pancreas mass after Puestow procedure. The computed tomographic appearance of an inflammatory mass occupying the head of the pancreas, which developed 2 years after Puestow decompression of the body and tail of pancreas.medical and endoscopic therapy will halt the symptoms of the disease, and the chance that a good result will be obtained with the lowest risk of morbidity and mortality. Finally, preparation for surgery should include restoration of protein-caloric homeo-stasis, | Surgery_Schwartz. decompression procedure was performed in 47 patients, and all subjects were restaged by the same methods 24 months later.Reproduced with permission from Nealon WH, Thompson JC. Progressive loss of pancreatic function in chronic pancreatitis is delayed by main pancreatic duct decompression. A longitudinal prospective analysis of the modified puestow procedure, Ann Surg. 1993 May;217(5):458-466.Brunicardi_Ch33_p1429-p1516.indd 147101/03/19 6:45 PM 1472SPECIFIC CONSIDERATIONSPART IIFigure 33-47. Head-of-pancreas mass after Puestow procedure. The computed tomographic appearance of an inflammatory mass occupying the head of the pancreas, which developed 2 years after Puestow decompression of the body and tail of pancreas.medical and endoscopic therapy will halt the symptoms of the disease, and the chance that a good result will be obtained with the lowest risk of morbidity and mortality. Finally, preparation for surgery should include restoration of protein-caloric homeo-stasis, |
Surgery_Schwartz_9716 | Surgery_Schwartz | and the chance that a good result will be obtained with the lowest risk of morbidity and mortality. Finally, preparation for surgery should include restoration of protein-caloric homeo-stasis, abstinence from alcohol and tobacco, and a detailed review of the risks and likely outcomes to establish a bond of trust and commitment between the patient and the surgeon.Historically, the surgery for chronic pancreatitis before the second half of the 20th century was a true demonstration of trial and error.236 Obtaining good surgical outcomes before the avail-ability of CT scans and ERCP was either the result of serendip-ity or due to the skill and creativity of the surgeon. In 1911, Link described an operation he devised on the spot, when a laparot-omy in a young woman with abdominal pain revealed a fluctu-ant, obstructed pancreatic duct. After performing a dochotomy and evacuating multiple stones, he inserted a rubber tube, and exteriorized the pancreatostomy just above her navel.237 He | Surgery_Schwartz. and the chance that a good result will be obtained with the lowest risk of morbidity and mortality. Finally, preparation for surgery should include restoration of protein-caloric homeo-stasis, abstinence from alcohol and tobacco, and a detailed review of the risks and likely outcomes to establish a bond of trust and commitment between the patient and the surgeon.Historically, the surgery for chronic pancreatitis before the second half of the 20th century was a true demonstration of trial and error.236 Obtaining good surgical outcomes before the avail-ability of CT scans and ERCP was either the result of serendip-ity or due to the skill and creativity of the surgeon. In 1911, Link described an operation he devised on the spot, when a laparot-omy in a young woman with abdominal pain revealed a fluctu-ant, obstructed pancreatic duct. After performing a dochotomy and evacuating multiple stones, he inserted a rubber tube, and exteriorized the pancreatostomy just above her navel.237 He |
Surgery_Schwartz_9717 | Surgery_Schwartz | a fluctu-ant, obstructed pancreatic duct. After performing a dochotomy and evacuating multiple stones, he inserted a rubber tube, and exteriorized the pancreatostomy just above her navel.237 He later described the operation as having been a success for the next 30 years of the patient’s life, during which the patient managed the care of the drainage tube without apparent problems.238With the demonstration in 1942 by Priestley that total pancreatectomy was technically feasible,239 and the report in 1946 by Whipple that proximal pancreatic resection was ben-eficial in (three) patients with chronic pancreatitis,240 the option of surgical resection as treatment for chronic pancreatitis was established. By the mid 1950s, however, growing disappoint-ment with the high risk of resection and the lack of long-term benefit overshadowed the surgical treatment of chronic pancre-atitis. The choice of resection vs. drainage was largely based on surgeon preference until the 1970s, when the | Surgery_Schwartz. a fluctu-ant, obstructed pancreatic duct. After performing a dochotomy and evacuating multiple stones, he inserted a rubber tube, and exteriorized the pancreatostomy just above her navel.237 He later described the operation as having been a success for the next 30 years of the patient’s life, during which the patient managed the care of the drainage tube without apparent problems.238With the demonstration in 1942 by Priestley that total pancreatectomy was technically feasible,239 and the report in 1946 by Whipple that proximal pancreatic resection was ben-eficial in (three) patients with chronic pancreatitis,240 the option of surgical resection as treatment for chronic pancreatitis was established. By the mid 1950s, however, growing disappoint-ment with the high risk of resection and the lack of long-term benefit overshadowed the surgical treatment of chronic pancre-atitis. The choice of resection vs. drainage was largely based on surgeon preference until the 1970s, when the |
Surgery_Schwartz_9718 | Surgery_Schwartz | and the lack of long-term benefit overshadowed the surgical treatment of chronic pancre-atitis. The choice of resection vs. drainage was largely based on surgeon preference until the 1970s, when the widespread adoption of ERCP and CT scans provided the ability to pre-operatively diagnose obstructive and sclerotic disease, and this resulted in the rational selection of operative procedures. During this period, the major drawbacks to surgical therapy remained the recurrence of symptoms despite surgery, the correspond-ing development of an inflammatory (or malignant) mass in the undrained pancreatic head (Fig. 33-47), or the high morbidity and mortality of major resectional procedures that predisposed patients to a cascade of metabolic problems.241Sphincteroplasty The sphincter of Oddi and the pancreatic duct sphincter serve as gatekeepers for the passage of pancreatic juice into the duodenum (Fig. 33-48). Stenosis of either sphincter (scle-rosing papillitis), due to scarring from | Surgery_Schwartz. and the lack of long-term benefit overshadowed the surgical treatment of chronic pancre-atitis. The choice of resection vs. drainage was largely based on surgeon preference until the 1970s, when the widespread adoption of ERCP and CT scans provided the ability to pre-operatively diagnose obstructive and sclerotic disease, and this resulted in the rational selection of operative procedures. During this period, the major drawbacks to surgical therapy remained the recurrence of symptoms despite surgery, the correspond-ing development of an inflammatory (or malignant) mass in the undrained pancreatic head (Fig. 33-47), or the high morbidity and mortality of major resectional procedures that predisposed patients to a cascade of metabolic problems.241Sphincteroplasty The sphincter of Oddi and the pancreatic duct sphincter serve as gatekeepers for the passage of pancreatic juice into the duodenum (Fig. 33-48). Stenosis of either sphincter (scle-rosing papillitis), due to scarring from |
Surgery_Schwartz_9719 | Surgery_Schwartz | and the pancreatic duct sphincter serve as gatekeepers for the passage of pancreatic juice into the duodenum (Fig. 33-48). Stenosis of either sphincter (scle-rosing papillitis), due to scarring from pancreatitis or from the passage of gallstones, may result in obstruction of the pancreatic duct and chronic pain.242 As gallstone pancreatitis became a popu-lar diagnosis in the 1940s and 1950s, attention was focused on the ampullary region as a possible cause of chronic symptoms, and surgical sphincteroplasty was advocated. Although endoscopic techniques are now used routinely to perform sphincterotomy of either the common bile duct or pancreatic duct, a true (permanent) PancreasCommon bile ductDuodenal wallMajor papillaSphincter of ampullaMucosaSubmucosa Sphincter of pancreatic duct Pancreatic ductSphincter of common bile ductLongitudinal muscleof duodenal wallCircular muscle of duodenal wallFigure 33-48. Schematic diagram of the ampullary, biliary, and pancreatic duct sphincters. The | Surgery_Schwartz. and the pancreatic duct sphincter serve as gatekeepers for the passage of pancreatic juice into the duodenum (Fig. 33-48). Stenosis of either sphincter (scle-rosing papillitis), due to scarring from pancreatitis or from the passage of gallstones, may result in obstruction of the pancreatic duct and chronic pain.242 As gallstone pancreatitis became a popu-lar diagnosis in the 1940s and 1950s, attention was focused on the ampullary region as a possible cause of chronic symptoms, and surgical sphincteroplasty was advocated. Although endoscopic techniques are now used routinely to perform sphincterotomy of either the common bile duct or pancreatic duct, a true (permanent) PancreasCommon bile ductDuodenal wallMajor papillaSphincter of ampullaMucosaSubmucosa Sphincter of pancreatic duct Pancreatic ductSphincter of common bile ductLongitudinal muscleof duodenal wallCircular muscle of duodenal wallFigure 33-48. Schematic diagram of the ampullary, biliary, and pancreatic duct sphincters. The |
Surgery_Schwartz_9720 | Surgery_Schwartz | ductSphincter of common bile ductLongitudinal muscleof duodenal wallCircular muscle of duodenal wallFigure 33-48. Schematic diagram of the ampullary, biliary, and pancreatic duct sphincters. The point of merger of the bile duct and pancreatic duct is highly variable, and a true sphincter of the pancreatic duct may be poorly developed. (Reproduced with permission from Yamada T, Alpers DH, Kalloo AN, et al: Textbook of Gastroenterology, 5th ed. Oxford: Wiley-Blackwell; 2009.)Brunicardi_Ch33_p1429-p1516.indd 147201/03/19 6:45 PM 1473PANCREASCHAPTER 33Figure 33-49. Operative sphincteroplasty of the biliary and pan-creatic duct. The ampullary and bile duct sphincters are divided, as is the pancreatic duct sphincter, with suture apposition of the mucosal edges of the incision. sphincteroplasty can only be performed surgically. Transduode-nal sphincteroplasty with incision of the septum between the pan-creatic duct and common bile duct may offer significant relief for the rare patient | Surgery_Schwartz. ductSphincter of common bile ductLongitudinal muscleof duodenal wallCircular muscle of duodenal wallFigure 33-48. Schematic diagram of the ampullary, biliary, and pancreatic duct sphincters. The point of merger of the bile duct and pancreatic duct is highly variable, and a true sphincter of the pancreatic duct may be poorly developed. (Reproduced with permission from Yamada T, Alpers DH, Kalloo AN, et al: Textbook of Gastroenterology, 5th ed. Oxford: Wiley-Blackwell; 2009.)Brunicardi_Ch33_p1429-p1516.indd 147201/03/19 6:45 PM 1473PANCREASCHAPTER 33Figure 33-49. Operative sphincteroplasty of the biliary and pan-creatic duct. The ampullary and bile duct sphincters are divided, as is the pancreatic duct sphincter, with suture apposition of the mucosal edges of the incision. sphincteroplasty can only be performed surgically. Transduode-nal sphincteroplasty with incision of the septum between the pan-creatic duct and common bile duct may offer significant relief for the rare patient |
Surgery_Schwartz_9721 | Surgery_Schwartz | can only be performed surgically. Transduode-nal sphincteroplasty with incision of the septum between the pan-creatic duct and common bile duct may offer significant relief for the rare patient with a focal obstruction and inflammation isolated to this region (Fig. 33-49).Drainage Procedures After the early reports of success with pancreatostomy for the relief of symptoms of chronic pancreatitis,238 Cattell described pancreaticojejunostomy for relief of pain in unresectable pancreatic carcinoma.243 Shortly thereafter, Duval244 and, separately, Zollinger and associates245 described the caudal Roux-en-Y pancreaticojejunostomy for the treatment of chronic pancreatitis in 1954 (Fig. 33-50). The so-called Duval procedure was used for decades by some surgeons, but it almost invariably failed due to restenosis and segmental obstruction of the pancreas due to progressive scarring. In 1958, Puestow and Gillesby described these segmental narrowings and dilatations of the ductal system as a | Surgery_Schwartz. can only be performed surgically. Transduode-nal sphincteroplasty with incision of the septum between the pan-creatic duct and common bile duct may offer significant relief for the rare patient with a focal obstruction and inflammation isolated to this region (Fig. 33-49).Drainage Procedures After the early reports of success with pancreatostomy for the relief of symptoms of chronic pancreatitis,238 Cattell described pancreaticojejunostomy for relief of pain in unresectable pancreatic carcinoma.243 Shortly thereafter, Duval244 and, separately, Zollinger and associates245 described the caudal Roux-en-Y pancreaticojejunostomy for the treatment of chronic pancreatitis in 1954 (Fig. 33-50). The so-called Duval procedure was used for decades by some surgeons, but it almost invariably failed due to restenosis and segmental obstruction of the pancreas due to progressive scarring. In 1958, Puestow and Gillesby described these segmental narrowings and dilatations of the ductal system as a |
Surgery_Schwartz_9722 | Surgery_Schwartz | due to restenosis and segmental obstruction of the pancreas due to progressive scarring. In 1958, Puestow and Gillesby described these segmental narrowings and dilatations of the ductal system as a “chain of lakes,” and proposed a longitudinal decompression of the body and tail of the pancreas into a Roux limb of jejunum246 (Fig. 33-51). Four of Puestow and Gillesby’s 21 initial cases were side-to-side anastomoses, and 2 years after their report, Partington and Rochelle described a much simpler version of the longitudinal, or side-to-side Roux-en-Y pancreaticojejunostomy that became universally known as the Puestow procedure247 (Fig. 33-52).Successful pain relief after the Puestow-type decompres-sion procedure has been reported in 75% to 85% of patients for the first few years after surgery, but pain recurs in >20% of patients after 5 years due to progressive disease even in patients who are abstinent from alcohol.164Figure 33-50. Duval’s caudal pancreaticojejunostomy. (Reproduced | Surgery_Schwartz. due to restenosis and segmental obstruction of the pancreas due to progressive scarring. In 1958, Puestow and Gillesby described these segmental narrowings and dilatations of the ductal system as a “chain of lakes,” and proposed a longitudinal decompression of the body and tail of the pancreas into a Roux limb of jejunum246 (Fig. 33-51). Four of Puestow and Gillesby’s 21 initial cases were side-to-side anastomoses, and 2 years after their report, Partington and Rochelle described a much simpler version of the longitudinal, or side-to-side Roux-en-Y pancreaticojejunostomy that became universally known as the Puestow procedure247 (Fig. 33-52).Successful pain relief after the Puestow-type decompres-sion procedure has been reported in 75% to 85% of patients for the first few years after surgery, but pain recurs in >20% of patients after 5 years due to progressive disease even in patients who are abstinent from alcohol.164Figure 33-50. Duval’s caudal pancreaticojejunostomy. (Reproduced |
Surgery_Schwartz_9723 | Surgery_Schwartz | but pain recurs in >20% of patients after 5 years due to progressive disease even in patients who are abstinent from alcohol.164Figure 33-50. Duval’s caudal pancreaticojejunostomy. (Reproduced with permission from Greenlee HB: The role of surgery for chronic pancreatitis and its complications, Surg Annu. 1983;15:283-305.)Figure 33-51. Puestow and Gillesby’s longitudinal pancreatico-jejunostomy. Originally described as an invaginating anastomosis that drained the entire body and tail, the anastomosis was created after amputating the tail of the gland and opening the duct along the long axis of the gland. (Reproduced with permission from Greenlee HB: The role of surgery for chronic pancreatitis and its complica-tions, Surg Annu. 1983;15:283-305.)With the advent of therapeutic endoscopy and techniques for transluminal stone removal and lithotripsy, multiple series have reported the successful endoscopic treatment of pancreatic duct calculi, although the long-term outcomes of these | Surgery_Schwartz. but pain recurs in >20% of patients after 5 years due to progressive disease even in patients who are abstinent from alcohol.164Figure 33-50. Duval’s caudal pancreaticojejunostomy. (Reproduced with permission from Greenlee HB: The role of surgery for chronic pancreatitis and its complications, Surg Annu. 1983;15:283-305.)Figure 33-51. Puestow and Gillesby’s longitudinal pancreatico-jejunostomy. Originally described as an invaginating anastomosis that drained the entire body and tail, the anastomosis was created after amputating the tail of the gland and opening the duct along the long axis of the gland. (Reproduced with permission from Greenlee HB: The role of surgery for chronic pancreatitis and its complica-tions, Surg Annu. 1983;15:283-305.)With the advent of therapeutic endoscopy and techniques for transluminal stone removal and lithotripsy, multiple series have reported the successful endoscopic treatment of pancreatic duct calculi, although the long-term outcomes of these |
Surgery_Schwartz_9724 | Surgery_Schwartz | and techniques for transluminal stone removal and lithotripsy, multiple series have reported the successful endoscopic treatment of pancreatic duct calculi, although the long-term outcomes of these efforts has been uneven.248-251 Endoscopic removal of pancreatic duct stones is usually coupled to prolonged pancreatic duct stenting, Brunicardi_Ch33_p1429-p1516.indd 147301/03/19 6:45 PM 1474SPECIFIC CONSIDERATIONSPART IIABFigure 33-52. Longitudinal dochotomy in obstructing calcific pancreatitis. A longitudinal pancreatotomy typically discloses seg-mental stenosis of the pancreatic duct and the presence of intra-ductal calculi in a patient with chronic calcific pancreatitis (A). Following mobilization of a Roux limb of jejunum, a longitudinal pancreaticojejunostomy is performed to permit extensive drainage of the pancreatic duct system (B). This technique, described by Partington and Rochelle, is the typical method used for the Puestow procedure. which carries the risk of further | Surgery_Schwartz. and techniques for transluminal stone removal and lithotripsy, multiple series have reported the successful endoscopic treatment of pancreatic duct calculi, although the long-term outcomes of these efforts has been uneven.248-251 Endoscopic removal of pancreatic duct stones is usually coupled to prolonged pancreatic duct stenting, Brunicardi_Ch33_p1429-p1516.indd 147301/03/19 6:45 PM 1474SPECIFIC CONSIDERATIONSPART IIABFigure 33-52. Longitudinal dochotomy in obstructing calcific pancreatitis. A longitudinal pancreatotomy typically discloses seg-mental stenosis of the pancreatic duct and the presence of intra-ductal calculi in a patient with chronic calcific pancreatitis (A). Following mobilization of a Roux limb of jejunum, a longitudinal pancreaticojejunostomy is performed to permit extensive drainage of the pancreatic duct system (B). This technique, described by Partington and Rochelle, is the typical method used for the Puestow procedure. which carries the risk of further |
Surgery_Schwartz_9725 | Surgery_Schwartz | extensive drainage of the pancreatic duct system (B). This technique, described by Partington and Rochelle, is the typical method used for the Puestow procedure. which carries the risk of further inflammation.252,253 Despite the risk of perioperative complications, the surgical management of pancreatic duct stones and stenosis has been shown to be superior to endoscopic treatment in randomized clinical trials in which the long, side-to-side technique of pancreaticojejunos-tomy is used.254-256Resectional Procedures Distal Pancreatectomy For patients with focal inflammatory changes localized to the body and tail, or in whom no significant ductal dilatation exists, the technique of partial (40–80%) dis-tal pancreatectomy has been advocated (Fig. 33-53). Although distal pancreatectomy is less morbid than more extensive resec-tional procedures, the operation leaves untreated a major portion of the gland, and is therefore associated with a significant risk of symptomatic recurrence. It has | Surgery_Schwartz. extensive drainage of the pancreatic duct system (B). This technique, described by Partington and Rochelle, is the typical method used for the Puestow procedure. which carries the risk of further inflammation.252,253 Despite the risk of perioperative complications, the surgical management of pancreatic duct stones and stenosis has been shown to be superior to endoscopic treatment in randomized clinical trials in which the long, side-to-side technique of pancreaticojejunos-tomy is used.254-256Resectional Procedures Distal Pancreatectomy For patients with focal inflammatory changes localized to the body and tail, or in whom no significant ductal dilatation exists, the technique of partial (40–80%) dis-tal pancreatectomy has been advocated (Fig. 33-53). Although distal pancreatectomy is less morbid than more extensive resec-tional procedures, the operation leaves untreated a major portion of the gland, and is therefore associated with a significant risk of symptomatic recurrence. It has |
Surgery_Schwartz_9726 | Surgery_Schwartz | morbid than more extensive resec-tional procedures, the operation leaves untreated a major portion of the gland, and is therefore associated with a significant risk of symptomatic recurrence. It has been a more popular operation in British centers, where its success seems to be greater, perhaps due to the lower incidence of alcoholic chronic pancreatitis.257 However, long-term outcomes reveal good pain relief in only 60% of patients, with completion pancreatectomy required for pain relief in 13% of patients.Laparoscopic distal pancreatectomy has been shown to be feasible for the removal of focal lesions of the distal pancreas,258 but it is more difficult in the setting of chronic pancreatitis.Ninety-Five Percent Distal Pancreatectomy In 1965, Fry and Child proposed the more radical 95% distal pancreatectomy, which was intended for patients with sclerotic (small duct) disease and which attempted to avoid the morbidity of total pancreatectomy by preserving the rim of pancreas in the | Surgery_Schwartz. morbid than more extensive resec-tional procedures, the operation leaves untreated a major portion of the gland, and is therefore associated with a significant risk of symptomatic recurrence. It has been a more popular operation in British centers, where its success seems to be greater, perhaps due to the lower incidence of alcoholic chronic pancreatitis.257 However, long-term outcomes reveal good pain relief in only 60% of patients, with completion pancreatectomy required for pain relief in 13% of patients.Laparoscopic distal pancreatectomy has been shown to be feasible for the removal of focal lesions of the distal pancreas,258 but it is more difficult in the setting of chronic pancreatitis.Ninety-Five Percent Distal Pancreatectomy In 1965, Fry and Child proposed the more radical 95% distal pancreatectomy, which was intended for patients with sclerotic (small duct) disease and which attempted to avoid the morbidity of total pancreatectomy by preserving the rim of pancreas in the |
Surgery_Schwartz_9727 | Surgery_Schwartz | distal pancreatectomy, which was intended for patients with sclerotic (small duct) disease and which attempted to avoid the morbidity of total pancreatectomy by preserving the rim of pancreas in the pancreaticoduodenal groove, along with its associated blood vessels and distal common bile duct.241 The operation was found to be associated with pain relief in 60% to 77% of patients long term, but it is accompanied by a high risk of brittle diabetes, hypoglycemic coma, and malnutrition. Although the operation was the first attempt to resect the pancreatic head while preserving the duodenum and distal bile duct, the extensive degree of metabolic complications led to its failure as viable treatment for the symptoms of pancreatic sclerosis.Proximal Pancreatectomy In 1946, Whipple reported a series of five patients treated with either pancreaticoduodenectomy or total pancreatectomy for symptomatic chronic pancreatitis, with one operative death.240 Subsequently, proximal pancreatectomy or | Surgery_Schwartz. distal pancreatectomy, which was intended for patients with sclerotic (small duct) disease and which attempted to avoid the morbidity of total pancreatectomy by preserving the rim of pancreas in the pancreaticoduodenal groove, along with its associated blood vessels and distal common bile duct.241 The operation was found to be associated with pain relief in 60% to 77% of patients long term, but it is accompanied by a high risk of brittle diabetes, hypoglycemic coma, and malnutrition. Although the operation was the first attempt to resect the pancreatic head while preserving the duodenum and distal bile duct, the extensive degree of metabolic complications led to its failure as viable treatment for the symptoms of pancreatic sclerosis.Proximal Pancreatectomy In 1946, Whipple reported a series of five patients treated with either pancreaticoduodenectomy or total pancreatectomy for symptomatic chronic pancreatitis, with one operative death.240 Subsequently, proximal pancreatectomy or |
Surgery_Schwartz_9728 | Surgery_Schwartz | series of five patients treated with either pancreaticoduodenectomy or total pancreatectomy for symptomatic chronic pancreatitis, with one operative death.240 Subsequently, proximal pancreatectomy or pancreaticoduodenectomy, with or without pylorus preser-vation (Fig. 33-54), has been widely used for the treatment of chronic pancreatitis.259 In the three largest modern (circa 2000) series of the treatment of chronic pancreatitis by the Whipple Splenic arteryFigure 33-53. Distal (spleen-sparing) pancreatectomy. A distal pancreatectomy for chronic pancreatitis is usually performed with en bloc splenectomy, using either an open or laparoscopic tech-nique. In the presence of minimal inflammation, a spleen-sparing version can be performed, as shown here.Brunicardi_Ch33_p1429-p1516.indd 147401/03/19 6:45 PM 1475PANCREASCHAPTER 33procedure, pain relief 4 to 6 years after operation was found in 71% to 89% of patients. However, mortality ranged from 1.5% to 3%, and major complications | Surgery_Schwartz. series of five patients treated with either pancreaticoduodenectomy or total pancreatectomy for symptomatic chronic pancreatitis, with one operative death.240 Subsequently, proximal pancreatectomy or pancreaticoduodenectomy, with or without pylorus preser-vation (Fig. 33-54), has been widely used for the treatment of chronic pancreatitis.259 In the three largest modern (circa 2000) series of the treatment of chronic pancreatitis by the Whipple Splenic arteryFigure 33-53. Distal (spleen-sparing) pancreatectomy. A distal pancreatectomy for chronic pancreatitis is usually performed with en bloc splenectomy, using either an open or laparoscopic tech-nique. In the presence of minimal inflammation, a spleen-sparing version can be performed, as shown here.Brunicardi_Ch33_p1429-p1516.indd 147401/03/19 6:45 PM 1475PANCREASCHAPTER 33procedure, pain relief 4 to 6 years after operation was found in 71% to 89% of patients. However, mortality ranged from 1.5% to 3%, and major complications |
Surgery_Schwartz_9729 | Surgery_Schwartz | 6:45 PM 1475PANCREASCHAPTER 33procedure, pain relief 4 to 6 years after operation was found in 71% to 89% of patients. However, mortality ranged from 1.5% to 3%, and major complications occurred in 25% to 38% of patients at the Johns Hopkins Hospital,260 the Mayo Clinic,261 and the Massachusetts General Hospital.262 In follow-up, 25% to 48% of patients developed diabetes, and about the same per-centage required exocrine therapy. Advocates of the Whipple procedure as treatment for chronic pancreatitis suggest that the high rate of symptomatic relief outweighs the metabolic conse-quences and the mortality risk of the procedure, but increasingly this approach is being reserved for those patients with suspected occult malignancy.Total Pancreatectomy Priestley and associates first described successful total pancreatectomy in 1944 in a patient with hyperinsulinism,239 and two of Whipple’s original five cases of chronic pancreatitis reported in 1946 were treated with total | Surgery_Schwartz. 6:45 PM 1475PANCREASCHAPTER 33procedure, pain relief 4 to 6 years after operation was found in 71% to 89% of patients. However, mortality ranged from 1.5% to 3%, and major complications occurred in 25% to 38% of patients at the Johns Hopkins Hospital,260 the Mayo Clinic,261 and the Massachusetts General Hospital.262 In follow-up, 25% to 48% of patients developed diabetes, and about the same per-centage required exocrine therapy. Advocates of the Whipple procedure as treatment for chronic pancreatitis suggest that the high rate of symptomatic relief outweighs the metabolic conse-quences and the mortality risk of the procedure, but increasingly this approach is being reserved for those patients with suspected occult malignancy.Total Pancreatectomy Priestley and associates first described successful total pancreatectomy in 1944 in a patient with hyperinsulinism,239 and two of Whipple’s original five cases of chronic pancreatitis reported in 1946 were treated with total |
Surgery_Schwartz_9730 | Surgery_Schwartz | first described successful total pancreatectomy in 1944 in a patient with hyperinsulinism,239 and two of Whipple’s original five cases of chronic pancreatitis reported in 1946 were treated with total pancreatectomy.240 Subsequently, surgeons who used total pancreatectomy found that the operation produces no better pain relief for their patients than pancreaticoduodenectomy (about 80–85%). Moreover, the metabolic consequences of total pancreatectomy in the absence of islet cell transplantation can be profound and life-threatening. The patients have a “brittle” form of diabetes in which avoidance of hyperand hypoglycemia is problematic.263 In addition, lethal episodes of hypoglycemia are common in severe apancreatic diabetes. These are due to hypoglycemic unresponsiveness, due to the absence of pancreatic glucagon, and to hypoglycemia unawareness, despite an ongoing need to treat with exogenous insulin.177 In a series of >100 patients treated with total pancreatectomy, Gall and | Surgery_Schwartz. first described successful total pancreatectomy in 1944 in a patient with hyperinsulinism,239 and two of Whipple’s original five cases of chronic pancreatitis reported in 1946 were treated with total pancreatectomy.240 Subsequently, surgeons who used total pancreatectomy found that the operation produces no better pain relief for their patients than pancreaticoduodenectomy (about 80–85%). Moreover, the metabolic consequences of total pancreatectomy in the absence of islet cell transplantation can be profound and life-threatening. The patients have a “brittle” form of diabetes in which avoidance of hyperand hypoglycemia is problematic.263 In addition, lethal episodes of hypoglycemia are common in severe apancreatic diabetes. These are due to hypoglycemic unresponsiveness, due to the absence of pancreatic glucagon, and to hypoglycemia unawareness, despite an ongoing need to treat with exogenous insulin.177 In a series of >100 patients treated with total pancreatectomy, Gall and |
Surgery_Schwartz_9731 | Surgery_Schwartz | absence of pancreatic glucagon, and to hypoglycemia unawareness, despite an ongoing need to treat with exogenous insulin.177 In a series of >100 patients treated with total pancreatectomy, Gall and colleagues showed that half of all the late deaths after this operation were due to (iatrogenic) hypoglycemia.264 Despite newer forms of insulin, insulin delivery systems, and continuous blood glucose monitoring systems, severe pancreatogenic diabetes remains an adverse outcome, as complete prevention of the physiologic consequences of total pancreatectomy remains an unfulfilled goal. Even with the growing acceptance of islet auto-transplantation as an adjunct to the procedure (see later in CholedochojejunostomyGastrojejunostomyPancreaticojejunostomyCholedochojejunostomyDuodenojejunostomyPancreaticojejunostomyABFigure 33-54. The pancreaticoduodenectomy (Whipple procedure) can be performed either with the standard technique, which includes distal gastrectomy (A), or with preservation of the | Surgery_Schwartz. absence of pancreatic glucagon, and to hypoglycemia unawareness, despite an ongoing need to treat with exogenous insulin.177 In a series of >100 patients treated with total pancreatectomy, Gall and colleagues showed that half of all the late deaths after this operation were due to (iatrogenic) hypoglycemia.264 Despite newer forms of insulin, insulin delivery systems, and continuous blood glucose monitoring systems, severe pancreatogenic diabetes remains an adverse outcome, as complete prevention of the physiologic consequences of total pancreatectomy remains an unfulfilled goal. Even with the growing acceptance of islet auto-transplantation as an adjunct to the procedure (see later in CholedochojejunostomyGastrojejunostomyPancreaticojejunostomyCholedochojejunostomyDuodenojejunostomyPancreaticojejunostomyABFigure 33-54. The pancreaticoduodenectomy (Whipple procedure) can be performed either with the standard technique, which includes distal gastrectomy (A), or with preservation of the |
Surgery_Schwartz_9732 | Surgery_Schwartz | 33-54. The pancreaticoduodenectomy (Whipple procedure) can be performed either with the standard technique, which includes distal gastrectomy (A), or with preservation of the pylorus (B). The pylorus-sparing version of the procedure is used most commonly. (Repro-duced from Wu GY, Aziz K, Whalen GF: An Internist’s Illustrated Guide to Gastrointestinal Surgery. Totowa: Humana Press; 2003.)this section), total pancreatectomy itself is now used only rarely for the treatment of refractory chronic pancreatitis.Hybrid Procedures In 1980, Beger and associates described the Duodenum-preserving Pancreatic Head Resection or DPPHR265 (Fig. 33-55), and they published long-term results with DPPHR for the treatment of chronic pancreatitis in 1985266 and again in 1999.267 In 388 patients who were followed for an average of 6 years after DPPHR, pain relief was reportedly maintained in 91%, mortality was <1%, and diabetes developed in 21%, with 11% demonstrating a reversal of their preoperative | Surgery_Schwartz. 33-54. The pancreaticoduodenectomy (Whipple procedure) can be performed either with the standard technique, which includes distal gastrectomy (A), or with preservation of the pylorus (B). The pylorus-sparing version of the procedure is used most commonly. (Repro-duced from Wu GY, Aziz K, Whalen GF: An Internist’s Illustrated Guide to Gastrointestinal Surgery. Totowa: Humana Press; 2003.)this section), total pancreatectomy itself is now used only rarely for the treatment of refractory chronic pancreatitis.Hybrid Procedures In 1980, Beger and associates described the Duodenum-preserving Pancreatic Head Resection or DPPHR265 (Fig. 33-55), and they published long-term results with DPPHR for the treatment of chronic pancreatitis in 1985266 and again in 1999.267 In 388 patients who were followed for an average of 6 years after DPPHR, pain relief was reportedly maintained in 91%, mortality was <1%, and diabetes developed in 21%, with 11% demonstrating a reversal of their preoperative |
Surgery_Schwartz_9733 | Surgery_Schwartz | followed for an average of 6 years after DPPHR, pain relief was reportedly maintained in 91%, mortality was <1%, and diabetes developed in 21%, with 11% demonstrating a reversal of their preoperative diabetic sta-tus. These authors also compared the DPPHR procedure with the pylorus-sparing Whipple procedure in a randomized trial of 40 patients with chronic pancreatitis.268 The mortality was reportedly zero in both groups, and the morbidity was also com-parable. Pain relief (over 6 months) was seen in 94% of DPPHR patients, but in only 67% of Whipple patients. Furthermore, the insulin secretory capacity and glucose tolerance were noted to deteriorate in the Whipple group, but they actually improved in the DPPHR patients.The DPPHR requires the careful dissection of the gas-troduodenal artery and the creation of two anastomoses (Fig. 33-56), and it carries a similar complication risk as the Whipple procedure due to the risk of pancreatic leakage and intra-abdominal fluid collections.In | Surgery_Schwartz. followed for an average of 6 years after DPPHR, pain relief was reportedly maintained in 91%, mortality was <1%, and diabetes developed in 21%, with 11% demonstrating a reversal of their preoperative diabetic sta-tus. These authors also compared the DPPHR procedure with the pylorus-sparing Whipple procedure in a randomized trial of 40 patients with chronic pancreatitis.268 The mortality was reportedly zero in both groups, and the morbidity was also com-parable. Pain relief (over 6 months) was seen in 94% of DPPHR patients, but in only 67% of Whipple patients. Furthermore, the insulin secretory capacity and glucose tolerance were noted to deteriorate in the Whipple group, but they actually improved in the DPPHR patients.The DPPHR requires the careful dissection of the gas-troduodenal artery and the creation of two anastomoses (Fig. 33-56), and it carries a similar complication risk as the Whipple procedure due to the risk of pancreatic leakage and intra-abdominal fluid collections.In |
Surgery_Schwartz_9734 | Surgery_Schwartz | and the creation of two anastomoses (Fig. 33-56), and it carries a similar complication risk as the Whipple procedure due to the risk of pancreatic leakage and intra-abdominal fluid collections.In 1987, Frey and Smith described the local resection of the pancreatic head with longitudinal pancreaticojejunostomy (LR-LPJ), which included excavation of the pancreatic head, including the ductal structures in continuity with a long dochot-omy of the dorsal duct269 (Fig. 33-57). The Frey procedure pro-vides thorough decompression of the pancreatic head as well as the body and tail of the gland, and a long-term follow-up suggested that improved outcomes are associated with this more extensive decompressive procedure. Frey and Amikura reported their results in 50 patients followed for >7 years, and they found complete or substantial pain relief in 87% of patients. There was no operative mortality, but 22% of patients developed postop-erative complications.270Brunicardi_Ch33_p1429-p1516.indd | Surgery_Schwartz. and the creation of two anastomoses (Fig. 33-56), and it carries a similar complication risk as the Whipple procedure due to the risk of pancreatic leakage and intra-abdominal fluid collections.In 1987, Frey and Smith described the local resection of the pancreatic head with longitudinal pancreaticojejunostomy (LR-LPJ), which included excavation of the pancreatic head, including the ductal structures in continuity with a long dochot-omy of the dorsal duct269 (Fig. 33-57). The Frey procedure pro-vides thorough decompression of the pancreatic head as well as the body and tail of the gland, and a long-term follow-up suggested that improved outcomes are associated with this more extensive decompressive procedure. Frey and Amikura reported their results in 50 patients followed for >7 years, and they found complete or substantial pain relief in 87% of patients. There was no operative mortality, but 22% of patients developed postop-erative complications.270Brunicardi_Ch33_p1429-p1516.indd |
Surgery_Schwartz_9735 | Surgery_Schwartz | they found complete or substantial pain relief in 87% of patients. There was no operative mortality, but 22% of patients developed postop-erative complications.270Brunicardi_Ch33_p1429-p1516.indd 147501/03/19 6:45 PM 1476SPECIFIC CONSIDERATIONSPART IICommonbile ductPancreaticductPancreaticremnantABFigure 33-55. The duodenum-preserving pancreatic head resection described by Beger and colleagues. A. The completed resection after transection of the pancreatic neck, and subtotal removal of the pan-creatic head, with preservation of the distal common bile duct and duodenum. B. Completion of the reconstruction with anastomosis to the distal pancreas and to the proximal pancreatic rim by the same Roux limb of jejunum. (Reproduced with permission from Bell RH, Rikkers LF, Mulholland M: Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)Figure 33-56. Intraoperative view of the Beger procedure. The gastroduodenal artery is encircled by a vessel | Surgery_Schwartz. they found complete or substantial pain relief in 87% of patients. There was no operative mortality, but 22% of patients developed postop-erative complications.270Brunicardi_Ch33_p1429-p1516.indd 147501/03/19 6:45 PM 1476SPECIFIC CONSIDERATIONSPART IICommonbile ductPancreaticductPancreaticremnantABFigure 33-55. The duodenum-preserving pancreatic head resection described by Beger and colleagues. A. The completed resection after transection of the pancreatic neck, and subtotal removal of the pan-creatic head, with preservation of the distal common bile duct and duodenum. B. Completion of the reconstruction with anastomosis to the distal pancreas and to the proximal pancreatic rim by the same Roux limb of jejunum. (Reproduced with permission from Bell RH, Rikkers LF, Mulholland M: Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)Figure 33-56. Intraoperative view of the Beger procedure. The gastroduodenal artery is encircled by a vessel |
Surgery_Schwartz_9736 | Surgery_Schwartz | Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)Figure 33-56. Intraoperative view of the Beger procedure. The gastroduodenal artery is encircled by a vessel loop. Just below, the intrapancreatic portion of the common bile duct is exposed as it courses toward the ampulla. A rim of well-vascularized pancreatic tissue remains in the duodenal C-loop. Preservation of the posterior branch of the gastroduodenal artery is essential to preserve viability of these structures.Key steps in the performance of the LR-LPJ include pres-ervation of the pancreatic neck as well as the capsule of the posterior pancreatic head. In the pancreaticoduodenectomy and the DPPHR, the pancreatic neck is freed up from the portal and superior mesenteric vein confluence and divided. In the LR-LPJ, the neck of the pancreas is preserved intact as are the body and tail of the pancreas. Not having to divide the pancreatic neck, as in the pancreaticoduodenectomy or DPPHR, reduces | Surgery_Schwartz. Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)Figure 33-56. Intraoperative view of the Beger procedure. The gastroduodenal artery is encircled by a vessel loop. Just below, the intrapancreatic portion of the common bile duct is exposed as it courses toward the ampulla. A rim of well-vascularized pancreatic tissue remains in the duodenal C-loop. Preservation of the posterior branch of the gastroduodenal artery is essential to preserve viability of these structures.Key steps in the performance of the LR-LPJ include pres-ervation of the pancreatic neck as well as the capsule of the posterior pancreatic head. In the pancreaticoduodenectomy and the DPPHR, the pancreatic neck is freed up from the portal and superior mesenteric vein confluence and divided. In the LR-LPJ, the neck of the pancreas is preserved intact as are the body and tail of the pancreas. Not having to divide the pancreatic neck, as in the pancreaticoduodenectomy or DPPHR, reduces |
Surgery_Schwartz_9737 | Surgery_Schwartz | In the LR-LPJ, the neck of the pancreas is preserved intact as are the body and tail of the pancreas. Not having to divide the pancreatic neck, as in the pancreaticoduodenectomy or DPPHR, reduces the risk of the operation because it avoids intraoperative prob-lems with the venous structures lying posterior to the gland. To reduce the risk of penetrating the posterior capsule of the head, Frey recommended in his 1994 report that the posterior limit of resection be the back wall of the opened duct of Wirsung and duct to the uncinate (Fig. 33-58).Subsequent to Frey’s own modification of the technique, other surgeons have described modifications of the extent or technique of the LR-LPJ. Andersen and Topazian advocated performing the LR-LPJ as it was originally described, in which the entirety of the ducts are excised from the head (Fig. 33-59), and described the use of the ultrasonic aspirator and dissector for this purpose.271 This device permits precise removal of the ducts and adjacent | Surgery_Schwartz. In the LR-LPJ, the neck of the pancreas is preserved intact as are the body and tail of the pancreas. Not having to divide the pancreatic neck, as in the pancreaticoduodenectomy or DPPHR, reduces the risk of the operation because it avoids intraoperative prob-lems with the venous structures lying posterior to the gland. To reduce the risk of penetrating the posterior capsule of the head, Frey recommended in his 1994 report that the posterior limit of resection be the back wall of the opened duct of Wirsung and duct to the uncinate (Fig. 33-58).Subsequent to Frey’s own modification of the technique, other surgeons have described modifications of the extent or technique of the LR-LPJ. Andersen and Topazian advocated performing the LR-LPJ as it was originally described, in which the entirety of the ducts are excised from the head (Fig. 33-59), and described the use of the ultrasonic aspirator and dissector for this purpose.271 This device permits precise removal of the ducts and adjacent |
Surgery_Schwartz_9738 | Surgery_Schwartz | of the ducts are excised from the head (Fig. 33-59), and described the use of the ultrasonic aspirator and dissector for this purpose.271 This device permits precise removal of the ducts and adjacent tissue with good visualization and without complications. There is little pancreatic tissue behind these ducts, and the pancreatic capsule is continuously palpated as the dissection proceeds to ensure a safe margin of resection. The intrapancreatic portion of the common bile duct is usually exposed, and avoiding injury to it is enhanced by the ultrasonic aspirator. The majority of the parenchyma of the uncinate pro-cess is spared, and the excavation of the pancreatic head is made contiguous with a generous dochotomy of the dorsal duct. Whether merely unroofing as opposed to removal of the proximal ducts contributes to better pain relief is not known and awaits a randomized trial to compare the two versions of the LR-LPJ. Izbicki and colleagues at the University of Hamburg also recommend a | Surgery_Schwartz. of the ducts are excised from the head (Fig. 33-59), and described the use of the ultrasonic aspirator and dissector for this purpose.271 This device permits precise removal of the ducts and adjacent tissue with good visualization and without complications. There is little pancreatic tissue behind these ducts, and the pancreatic capsule is continuously palpated as the dissection proceeds to ensure a safe margin of resection. The intrapancreatic portion of the common bile duct is usually exposed, and avoiding injury to it is enhanced by the ultrasonic aspirator. The majority of the parenchyma of the uncinate pro-cess is spared, and the excavation of the pancreatic head is made contiguous with a generous dochotomy of the dorsal duct. Whether merely unroofing as opposed to removal of the proximal ducts contributes to better pain relief is not known and awaits a randomized trial to compare the two versions of the LR-LPJ. Izbicki and colleagues at the University of Hamburg also recommend a |
Surgery_Schwartz_9739 | Surgery_Schwartz | ducts contributes to better pain relief is not known and awaits a randomized trial to compare the two versions of the LR-LPJ. Izbicki and colleagues at the University of Hamburg also recommend a more extensive excavation of the pancreatic head, and they use a technique that they refer to as the Hamburg modification of the LR-LPJ272 (Fig. 33-60). This wider excavation of the pancreatic head is created in continu-ity with the dorsal dochotomy, and it is followed by a single, side-to-side pancreaticojejunostomy.In 2001, Ho and Frey subsequently described merely exca-vating the core of the pancreatic head and draining the exca-vation with a Roux-en-Y pancreaticojejunostomy, but without any effort to include the dorsal duct273,274 (Fig. 33-61). In 2003, Brunicardi_Ch33_p1429-p1516.indd 147601/03/19 6:45 PM 1477PANCREASCHAPTER 33Figure 33-57. Frey procedure. The local resection of the pancreatic head with longitudinal pancreaticojejunostomy (LR-LPJ) provides complete decompression of | Surgery_Schwartz. ducts contributes to better pain relief is not known and awaits a randomized trial to compare the two versions of the LR-LPJ. Izbicki and colleagues at the University of Hamburg also recommend a more extensive excavation of the pancreatic head, and they use a technique that they refer to as the Hamburg modification of the LR-LPJ272 (Fig. 33-60). This wider excavation of the pancreatic head is created in continu-ity with the dorsal dochotomy, and it is followed by a single, side-to-side pancreaticojejunostomy.In 2001, Ho and Frey subsequently described merely exca-vating the core of the pancreatic head and draining the exca-vation with a Roux-en-Y pancreaticojejunostomy, but without any effort to include the dorsal duct273,274 (Fig. 33-61). In 2003, Brunicardi_Ch33_p1429-p1516.indd 147601/03/19 6:45 PM 1477PANCREASCHAPTER 33Figure 33-57. Frey procedure. The local resection of the pancreatic head with longitudinal pancreaticojejunostomy (LR-LPJ) provides complete decompression of |
Surgery_Schwartz_9740 | Surgery_Schwartz | 6:45 PM 1477PANCREASCHAPTER 33Figure 33-57. Frey procedure. The local resection of the pancreatic head with longitudinal pancreaticojejunostomy (LR-LPJ) provides complete decompression of the entire pancreatic ductal system. Reconstruction is performed with a side-to-side Roux-en-Y pan-creaticojejunostomy. (Reproduced with permission from Bell RH, Rikkers LF, Mulholland M: Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)Figure 33-58. Operative view of excavated head of the pancreas during the Frey procedure. The main pancreatic duct is opened widely down to the level of the ampulla, and the head of the pan-creas is excavated in a conical fashion so as to allow complete decompression of the chronically obstructed and inflamed pancre-atic ducts. (Reproduced with permission from Aspelund G et al. Improved outcomes for benign disease with limited pancreatic head resection, J Gastrointest Surg. 2005 Mar;9(3):400-409.)Figure | Surgery_Schwartz. 6:45 PM 1477PANCREASCHAPTER 33Figure 33-57. Frey procedure. The local resection of the pancreatic head with longitudinal pancreaticojejunostomy (LR-LPJ) provides complete decompression of the entire pancreatic ductal system. Reconstruction is performed with a side-to-side Roux-en-Y pan-creaticojejunostomy. (Reproduced with permission from Bell RH, Rikkers LF, Mulholland M: Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)Figure 33-58. Operative view of excavated head of the pancreas during the Frey procedure. The main pancreatic duct is opened widely down to the level of the ampulla, and the head of the pan-creas is excavated in a conical fashion so as to allow complete decompression of the chronically obstructed and inflamed pancre-atic ducts. (Reproduced with permission from Aspelund G et al. Improved outcomes for benign disease with limited pancreatic head resection, J Gastrointest Surg. 2005 Mar;9(3):400-409.)Figure |
Surgery_Schwartz_9741 | Surgery_Schwartz | pancre-atic ducts. (Reproduced with permission from Aspelund G et al. Improved outcomes for benign disease with limited pancreatic head resection, J Gastrointest Surg. 2005 Mar;9(3):400-409.)Figure 33-59. Complete excavation of the pancreatic head and distal pancreatic dochotomy. A true excavation and removal of the proximal ductal system is combined with a distal pancreatic dochotomy. Reconstruction is performed with a single side-to-side Roux-en-Y pancreaticojejunostomy. (Reproduced with permission from Andersen DK, Topazian MD. Pancreatic head excavation: a variation on the theme of duodenum-preserving pancreatic head resection, Arch Surg. 2004 Apr;139(4):375-379.)Brunicardi_Ch33_p1429-p1516.indd 147701/03/19 6:46 PM 1478SPECIFIC CONSIDERATIONSPART IIFigure 33-60. The Hamburg modification of the local resection of the pancreatic head with longitudinal pancreaticojejunostomy. (Reproduced with permission from Shackelford RT, Yeo CJ, Peters JH: Shackelford’s Surgery of the | Surgery_Schwartz. pancre-atic ducts. (Reproduced with permission from Aspelund G et al. Improved outcomes for benign disease with limited pancreatic head resection, J Gastrointest Surg. 2005 Mar;9(3):400-409.)Figure 33-59. Complete excavation of the pancreatic head and distal pancreatic dochotomy. A true excavation and removal of the proximal ductal system is combined with a distal pancreatic dochotomy. Reconstruction is performed with a single side-to-side Roux-en-Y pancreaticojejunostomy. (Reproduced with permission from Andersen DK, Topazian MD. Pancreatic head excavation: a variation on the theme of duodenum-preserving pancreatic head resection, Arch Surg. 2004 Apr;139(4):375-379.)Brunicardi_Ch33_p1429-p1516.indd 147701/03/19 6:46 PM 1478SPECIFIC CONSIDERATIONSPART IIFigure 33-60. The Hamburg modification of the local resection of the pancreatic head with longitudinal pancreaticojejunostomy. (Reproduced with permission from Shackelford RT, Yeo CJ, Peters JH: Shackelford’s Surgery of the |
Surgery_Schwartz_9742 | Surgery_Schwartz | modification of the local resection of the pancreatic head with longitudinal pancreaticojejunostomy. (Reproduced with permission from Shackelford RT, Yeo CJ, Peters JH: Shackelford’s Surgery of the Alimentary Tract. New York, NY: Saunders/Elsevier; 2007.)Farkas and colleagues described a similar excavation of the cen-tral portion of the pancreatic head without any effort to include the duct of the body in the lateral pancreaticojejunostomy,275 and they reported excellent results with what they termed an organ-preserving pancreatic head resection (OPPHR) in a ran-domized comparison to the pylorus-preserving pancreaticoduo-denectomy (PPPD).276This approach was advocated by Gloor and associates in Bern as an alternative to the DPPHR procedure in patients with portal hypertension277 and was described as the Berne modifica-tion of the DPPHR (Fig. 33-62). Köninger and colleagues in Heidelberg subsequently published a randomized, controlled trial of the “Berne” version of the excavation | Surgery_Schwartz. modification of the local resection of the pancreatic head with longitudinal pancreaticojejunostomy. (Reproduced with permission from Shackelford RT, Yeo CJ, Peters JH: Shackelford’s Surgery of the Alimentary Tract. New York, NY: Saunders/Elsevier; 2007.)Farkas and colleagues described a similar excavation of the cen-tral portion of the pancreatic head without any effort to include the duct of the body in the lateral pancreaticojejunostomy,275 and they reported excellent results with what they termed an organ-preserving pancreatic head resection (OPPHR) in a ran-domized comparison to the pylorus-preserving pancreaticoduo-denectomy (PPPD).276This approach was advocated by Gloor and associates in Bern as an alternative to the DPPHR procedure in patients with portal hypertension277 and was described as the Berne modifica-tion of the DPPHR (Fig. 33-62). Köninger and colleagues in Heidelberg subsequently published a randomized, controlled trial of the “Berne” version of the excavation |
Surgery_Schwartz_9743 | Surgery_Schwartz | described as the Berne modifica-tion of the DPPHR (Fig. 33-62). Köninger and colleagues in Heidelberg subsequently published a randomized, controlled trial of the “Berne” version of the excavation method compared to the “classic” Beger procedure.278 Operative times and length of stay were shorter in the group undergoing excavation of the pancreatic head, while long-term outcomes and quality-of-life scores were identical over 2 years postoperatively.The common element of these variations on the theme of LR-LPJ remains the excavation or “coring out” of the central portion of the pancreatic head. It remains uncertain, however, whether and to what degree the dochotomy needs to be extended into the body and tail. The logical conclusion of all of these efforts is that the head of the pancreas is the nidus of the chronic inflammatory process in chronic pancreatitis and that removal of the central portion of the head of the gland is the key to the successful resolution of pain in the long | Surgery_Schwartz. described as the Berne modifica-tion of the DPPHR (Fig. 33-62). Köninger and colleagues in Heidelberg subsequently published a randomized, controlled trial of the “Berne” version of the excavation method compared to the “classic” Beger procedure.278 Operative times and length of stay were shorter in the group undergoing excavation of the pancreatic head, while long-term outcomes and quality-of-life scores were identical over 2 years postoperatively.The common element of these variations on the theme of LR-LPJ remains the excavation or “coring out” of the central portion of the pancreatic head. It remains uncertain, however, whether and to what degree the dochotomy needs to be extended into the body and tail. The logical conclusion of all of these efforts is that the head of the pancreas is the nidus of the chronic inflammatory process in chronic pancreatitis and that removal of the central portion of the head of the gland is the key to the successful resolution of pain in the long |
Surgery_Schwartz_9744 | Surgery_Schwartz | is the nidus of the chronic inflammatory process in chronic pancreatitis and that removal of the central portion of the head of the gland is the key to the successful resolution of pain in the long term.Complications Initial and long-term results of the LR-LPJ demonstrate pain relief that is equivalent to that of pancreati-coduodenectomy and the DPPHR.279,280 The observed mortal-ity rate has been virtually zero, and therefore, less than with the Whipple procedure. Major complications were less with the LR-LPJ (16%) than with pancreaticoduodenectomy (40%) or DPPHR (25%) in one single-site series, and the incidence of new postoperative diabetes after LR-LPJ was 8% with an aver-age follow-up of 3 years.1996Line of enterotomyJejunal limbsecured with 1strow of suturesNormal pancreatic ductPancreatic head cored outABFigure 33-61. Excavation of pancreatic head without longitudinal pancreaticojejunostomy. Comparisons of the Three Operative Procedures: Pancre-aticoduodenectomy (Whipple | Surgery_Schwartz. is the nidus of the chronic inflammatory process in chronic pancreatitis and that removal of the central portion of the head of the gland is the key to the successful resolution of pain in the long term.Complications Initial and long-term results of the LR-LPJ demonstrate pain relief that is equivalent to that of pancreati-coduodenectomy and the DPPHR.279,280 The observed mortal-ity rate has been virtually zero, and therefore, less than with the Whipple procedure. Major complications were less with the LR-LPJ (16%) than with pancreaticoduodenectomy (40%) or DPPHR (25%) in one single-site series, and the incidence of new postoperative diabetes after LR-LPJ was 8% with an aver-age follow-up of 3 years.1996Line of enterotomyJejunal limbsecured with 1strow of suturesNormal pancreatic ductPancreatic head cored outABFigure 33-61. Excavation of pancreatic head without longitudinal pancreaticojejunostomy. Comparisons of the Three Operative Procedures: Pancre-aticoduodenectomy (Whipple |
Surgery_Schwartz_9745 | Surgery_Schwartz | head cored outABFigure 33-61. Excavation of pancreatic head without longitudinal pancreaticojejunostomy. Comparisons of the Three Operative Procedures: Pancre-aticoduodenectomy (Whipple procedure), DPPHR (Beger procedure), and LR-LPJ (Frey procedure). There has been considerable interest to apply evidence-based methods to the study of the three operations currently advocated for the treat-ment of chronic pancreatitis. The best studies, or level 1 data by the Strength of Recommendation Taxonomy, are prospective, randomized controlled trials comparing two or more operations from a single or multi-institutional study. Retrospective, cohort-based studies are regarded as level 2 data by the Strength of Recommendation Taxonomy criteria.To date, ten published level 1 studies268,276,278-285 and three level 2 studies199,286,287 have examined various comparisons between these three operations. In the level 1 study of Klempa and colleagues281 and that of Buchler et al,288 DPPHR patients had a | Surgery_Schwartz. head cored outABFigure 33-61. Excavation of pancreatic head without longitudinal pancreaticojejunostomy. Comparisons of the Three Operative Procedures: Pancre-aticoduodenectomy (Whipple procedure), DPPHR (Beger procedure), and LR-LPJ (Frey procedure). There has been considerable interest to apply evidence-based methods to the study of the three operations currently advocated for the treat-ment of chronic pancreatitis. The best studies, or level 1 data by the Strength of Recommendation Taxonomy, are prospective, randomized controlled trials comparing two or more operations from a single or multi-institutional study. Retrospective, cohort-based studies are regarded as level 2 data by the Strength of Recommendation Taxonomy criteria.To date, ten published level 1 studies268,276,278-285 and three level 2 studies199,286,287 have examined various comparisons between these three operations. In the level 1 study of Klempa and colleagues281 and that of Buchler et al,288 DPPHR patients had a |
Surgery_Schwartz_9746 | Surgery_Schwartz | three level 2 studies199,286,287 have examined various comparisons between these three operations. In the level 1 study of Klempa and colleagues281 and that of Buchler et al,288 DPPHR patients had a shorter hospital stay, greater weight gain, less postopera-tive diabetes, and exocrine dysfunction than standard Whipple patients over a 3to 5-year follow-up. Pain control was similar between the two procedures. Similar results were observed in a Brunicardi_Ch33_p1429-p1516.indd 147801/03/19 6:46 PM 1479PANCREASCHAPTER 33Figure 33-62. The Berne modification of the local resection of the pancreatic head with longitudinal pancreaticojejunostomy.recent level 2 retrospective study of 123 patients287 and in the level 1 study by Keck et al.287In a level 1 study of 61 patients randomized to PPPD or LR-LPJ, Izbicki and colleagues found a lower postoperative complication rate associated with the Frey procedure (19%) compared to the PPPD group (53%), and better global quality-of-life scores (71% | Surgery_Schwartz. three level 2 studies199,286,287 have examined various comparisons between these three operations. In the level 1 study of Klempa and colleagues281 and that of Buchler et al,288 DPPHR patients had a shorter hospital stay, greater weight gain, less postopera-tive diabetes, and exocrine dysfunction than standard Whipple patients over a 3to 5-year follow-up. Pain control was similar between the two procedures. Similar results were observed in a Brunicardi_Ch33_p1429-p1516.indd 147801/03/19 6:46 PM 1479PANCREASCHAPTER 33Figure 33-62. The Berne modification of the local resection of the pancreatic head with longitudinal pancreaticojejunostomy.recent level 2 retrospective study of 123 patients287 and in the level 1 study by Keck et al.287In a level 1 study of 61 patients randomized to PPPD or LR-LPJ, Izbicki and colleagues found a lower postoperative complication rate associated with the Frey procedure (19%) compared to the PPPD group (53%), and better global quality-of-life scores (71% |
Surgery_Schwartz_9747 | Surgery_Schwartz | LR-LPJ, Izbicki and colleagues found a lower postoperative complication rate associated with the Frey procedure (19%) compared to the PPPD group (53%), and better global quality-of-life scores (71% vs. 43%, respectively).279 Both operations were equally effective in controlling pain over a 2-year follow-up. Similar results were seen in the study by Farkas and associates276 who employed a similar method of excavation of the pancreatic head that their group described as an organ-preserving pancreatic head resection (OPPHR) and found that OPPHR was associated with a shorter operating time, less postoperative morbidity, shorter hospital stay, and better quality of life than PPPD. The superior outcomes of the Frey procedure were found to be durable in a 15-year follow-up study by Bachmann et al285 who found that survival and function were superior after the Frey procedure.Late Morbidity and Mortality In 2005, Izbicki’s group reported on a level 1 study of 74 patients randomized to the | Surgery_Schwartz. LR-LPJ, Izbicki and colleagues found a lower postoperative complication rate associated with the Frey procedure (19%) compared to the PPPD group (53%), and better global quality-of-life scores (71% vs. 43%, respectively).279 Both operations were equally effective in controlling pain over a 2-year follow-up. Similar results were seen in the study by Farkas and associates276 who employed a similar method of excavation of the pancreatic head that their group described as an organ-preserving pancreatic head resection (OPPHR) and found that OPPHR was associated with a shorter operating time, less postoperative morbidity, shorter hospital stay, and better quality of life than PPPD. The superior outcomes of the Frey procedure were found to be durable in a 15-year follow-up study by Bachmann et al285 who found that survival and function were superior after the Frey procedure.Late Morbidity and Mortality In 2005, Izbicki’s group reported on a level 1 study of 74 patients randomized to the |
Surgery_Schwartz_9748 | Surgery_Schwartz | et al285 who found that survival and function were superior after the Frey procedure.Late Morbidity and Mortality In 2005, Izbicki’s group reported on a level 1 study of 74 patients randomized to the DPPHR or LR-LPJ who were then followed for an average of 8.5 years.286 There were no significant differences between the groups with regard to global quality of life, pain scores, late mortality, and exocrine or endocrine insufficiency. The level 1 study by Köninger, which compared the classic DPPHR with excavation of the pancreatic head, showed identical outcomes at 2 years after an initial reduction in morbidity associated with the excavation procedure.278 These results were echoed in the level 2 study by Aspelund and associates, which demonstrated fewer complications with both the DPPHR and LR-LPJ proce-dures compared to pancreaticoduodenectomy, a lower incidence of new diabetes (8%) for both DPPHR and LR-LPJ compared to the Whipple procedure (25%), but no significant differences in | Surgery_Schwartz. et al285 who found that survival and function were superior after the Frey procedure.Late Morbidity and Mortality In 2005, Izbicki’s group reported on a level 1 study of 74 patients randomized to the DPPHR or LR-LPJ who were then followed for an average of 8.5 years.286 There were no significant differences between the groups with regard to global quality of life, pain scores, late mortality, and exocrine or endocrine insufficiency. The level 1 study by Köninger, which compared the classic DPPHR with excavation of the pancreatic head, showed identical outcomes at 2 years after an initial reduction in morbidity associated with the excavation procedure.278 These results were echoed in the level 2 study by Aspelund and associates, which demonstrated fewer complications with both the DPPHR and LR-LPJ proce-dures compared to pancreaticoduodenectomy, a lower incidence of new diabetes (8%) for both DPPHR and LR-LPJ compared to the Whipple procedure (25%), but no significant differences in |
Surgery_Schwartz_9749 | Surgery_Schwartz | and LR-LPJ proce-dures compared to pancreaticoduodenectomy, a lower incidence of new diabetes (8%) for both DPPHR and LR-LPJ compared to the Whipple procedure (25%), but no significant differences in outcomes or pain relief between DPPHR and LR-LPJ.199 Finally, level 2 data support the efficacy of both DPPHR and LR-LPJ in patients with dilated as well as nondilated ducts.286,289,290Long-term exocrine and/or endocrine insufficiency in chronic pancreatitis patients treated surgically is a product of the surgical intervention as well as the progression of the underlying disease. Although the short-term (3-year) incidence of new diabe-tes after operation appears less with the LR-LPJ and DPPHR than with the PPPD, the late incidence of diabetes appears similar in all groups. After an average of 7 years of follow-up after LR-LPJ or PPPD, survival, pain relief, and pancreatic function were similar in both groups. The rate of diabetes was slightly lower after LR-LPJ (61%) than after PPPD | Surgery_Schwartz. and LR-LPJ proce-dures compared to pancreaticoduodenectomy, a lower incidence of new diabetes (8%) for both DPPHR and LR-LPJ compared to the Whipple procedure (25%), but no significant differences in outcomes or pain relief between DPPHR and LR-LPJ.199 Finally, level 2 data support the efficacy of both DPPHR and LR-LPJ in patients with dilated as well as nondilated ducts.286,289,290Long-term exocrine and/or endocrine insufficiency in chronic pancreatitis patients treated surgically is a product of the surgical intervention as well as the progression of the underlying disease. Although the short-term (3-year) incidence of new diabe-tes after operation appears less with the LR-LPJ and DPPHR than with the PPPD, the late incidence of diabetes appears similar in all groups. After an average of 7 years of follow-up after LR-LPJ or PPPD, survival, pain relief, and pancreatic function were similar in both groups. The rate of diabetes was slightly lower after LR-LPJ (61%) than after PPPD |
Surgery_Schwartz_9750 | Surgery_Schwartz | of 7 years of follow-up after LR-LPJ or PPPD, survival, pain relief, and pancreatic function were similar in both groups. The rate of diabetes was slightly lower after LR-LPJ (61%) than after PPPD (65%), but these had both more than doubled from their preoperative status.275-281 Therefore, although the limited pancreatic procedures of DPPHR and LR-LPJ have a lower initial rate of endocrine dysfunction, the long-term risk of diabetes is more related to the progression of the underlying disease than to the effects of operation.The level 1 studies confirm that the duodenum preserving options are associated with a lower immediate morbidity and mortality and therefore, in the absence of a mass or concerns about cancer, are better options than a Whipple procedure for chronic pancreatitis. The choice of LR-LPJ, DPPHR, or OPPHR depends largely on surgeon experience, and the LR-LPJ is most common in the United States.Total Pancreatectomy With Islet Auto-Transplantation Islet cell | Surgery_Schwartz. of 7 years of follow-up after LR-LPJ or PPPD, survival, pain relief, and pancreatic function were similar in both groups. The rate of diabetes was slightly lower after LR-LPJ (61%) than after PPPD (65%), but these had both more than doubled from their preoperative status.275-281 Therefore, although the limited pancreatic procedures of DPPHR and LR-LPJ have a lower initial rate of endocrine dysfunction, the long-term risk of diabetes is more related to the progression of the underlying disease than to the effects of operation.The level 1 studies confirm that the duodenum preserving options are associated with a lower immediate morbidity and mortality and therefore, in the absence of a mass or concerns about cancer, are better options than a Whipple procedure for chronic pancreatitis. The choice of LR-LPJ, DPPHR, or OPPHR depends largely on surgeon experience, and the LR-LPJ is most common in the United States.Total Pancreatectomy With Islet Auto-Transplantation Islet cell |
Surgery_Schwartz_9751 | Surgery_Schwartz | The choice of LR-LPJ, DPPHR, or OPPHR depends largely on surgeon experience, and the LR-LPJ is most common in the United States.Total Pancreatectomy With Islet Auto-Transplantation Islet cell transplantation for the treatment of diabetes is an attractive adjunct to pancreatic surgery in the treatment of benign pancre-atic disease. Despite the difficulties in recovering islets from a chronically inflamed gland, Najarian and associates demonstrated the utility of autotransplantation of islets in patients with chronic pancreatitis in 1980.291 Subsequently, through refinements in the methods of harvesting and gland preservation, and through standardization of the methods by which islets are infused into the portal venous circuit for intrahepatic engraftment, the suc-cess of total pancreatectomy combined with islet autotransplan-tation has steadily increased to achieve insulin independence in the majority of patients treated in recent series.292,293 Although 2 to 3 million islets are | Surgery_Schwartz. The choice of LR-LPJ, DPPHR, or OPPHR depends largely on surgeon experience, and the LR-LPJ is most common in the United States.Total Pancreatectomy With Islet Auto-Transplantation Islet cell transplantation for the treatment of diabetes is an attractive adjunct to pancreatic surgery in the treatment of benign pancre-atic disease. Despite the difficulties in recovering islets from a chronically inflamed gland, Najarian and associates demonstrated the utility of autotransplantation of islets in patients with chronic pancreatitis in 1980.291 Subsequently, through refinements in the methods of harvesting and gland preservation, and through standardization of the methods by which islets are infused into the portal venous circuit for intrahepatic engraftment, the suc-cess of total pancreatectomy combined with islet autotransplan-tation has steadily increased to achieve insulin independence in the majority of patients treated in recent series.292,293 Although 2 to 3 million islets are |
Surgery_Schwartz_9752 | Surgery_Schwartz | combined with islet autotransplan-tation has steadily increased to achieve insulin independence in the majority of patients treated in recent series.292,293 Although 2 to 3 million islets are required for successful engraftment in an allogeneic recipient, the auto-transplant recipient can usually achieve long-term, insulin-independent status after engraftment of only 300,000 to 400,000 islets (about one-third to one-half of the number of islets in the normal pancreas).294The ability to recover a sufficient quantity of islets from a sclerotic gland is dependent on the degree of fibrotic dis-ease present, so the selection of patients as candidates for autologous islet transplantation is important. The impressive improvement in quality of life measures and pain relief seen after total pancreatectomy with islet auto-transplantation (TP-IAT) indicate that it is a highly successful form of therapy for some patients (Fig. 33-63).295 The outcomes of TP-IAT are sig-nificantly better in | Surgery_Schwartz. combined with islet autotransplan-tation has steadily increased to achieve insulin independence in the majority of patients treated in recent series.292,293 Although 2 to 3 million islets are required for successful engraftment in an allogeneic recipient, the auto-transplant recipient can usually achieve long-term, insulin-independent status after engraftment of only 300,000 to 400,000 islets (about one-third to one-half of the number of islets in the normal pancreas).294The ability to recover a sufficient quantity of islets from a sclerotic gland is dependent on the degree of fibrotic dis-ease present, so the selection of patients as candidates for autologous islet transplantation is important. The impressive improvement in quality of life measures and pain relief seen after total pancreatectomy with islet auto-transplantation (TP-IAT) indicate that it is a highly successful form of therapy for some patients (Fig. 33-63).295 The outcomes of TP-IAT are sig-nificantly better in |
Surgery_Schwartz_9753 | Surgery_Schwartz | pancreatectomy with islet auto-transplantation (TP-IAT) indicate that it is a highly successful form of therapy for some patients (Fig. 33-63).295 The outcomes of TP-IAT are sig-nificantly better in pediatric patients than in adults, largely due to the prevalence of hereditary and idiopathic causes of chronic pancreatitis in pediatric patients.296 These studies suggest that further definition is needed regarding criteria for considering TP-IAT vs. hybrid or resectional procedures for patients with persistent symptoms. With the emerging evidence that hybrid procedures seem to offer better outcomes in patients with toxic etiologies of chronic pancreatitis, and that TP-IAT appears to Brunicardi_Ch33_p1429-p1516.indd 147901/03/19 6:46 PM 1480SPECIFIC CONSIDERATIONSPART II001224364860MonthsEffectNum DF1131252842994299Den DF0.26268.294.840.608<0.001<0.001F statisticP valueAgeTimeAge x TimePrevalence of narcotic use (%)72849610812020406080100Pediatric patientAdultFigure 33-63. Prevalence | Surgery_Schwartz. pancreatectomy with islet auto-transplantation (TP-IAT) indicate that it is a highly successful form of therapy for some patients (Fig. 33-63).295 The outcomes of TP-IAT are sig-nificantly better in pediatric patients than in adults, largely due to the prevalence of hereditary and idiopathic causes of chronic pancreatitis in pediatric patients.296 These studies suggest that further definition is needed regarding criteria for considering TP-IAT vs. hybrid or resectional procedures for patients with persistent symptoms. With the emerging evidence that hybrid procedures seem to offer better outcomes in patients with toxic etiologies of chronic pancreatitis, and that TP-IAT appears to Brunicardi_Ch33_p1429-p1516.indd 147901/03/19 6:46 PM 1480SPECIFIC CONSIDERATIONSPART II001224364860MonthsEffectNum DF1131252842994299Den DF0.26268.294.840.608<0.001<0.001F statisticP valueAgeTimeAge x TimePrevalence of narcotic use (%)72849610812020406080100Pediatric patientAdultFigure 33-63. Prevalence |
Surgery_Schwartz_9754 | Surgery_Schwartz | DF1131252842994299Den DF0.26268.294.840.608<0.001<0.001F statisticP valueAgeTimeAge x TimePrevalence of narcotic use (%)72849610812020406080100Pediatric patientAdultFigure 33-63. Prevalence of narcotic use after total pancreatectomy with islet auto-transplantation (TP-IAT) in adult and pediatric patients. (Reproduced with permission from Chinnakotla S, Beilman GJ, Dunn TB, et al. Factors Predicting Outcomes After a Total Pancreatectomy and Islet Autotransplantation Lessons Learned From Over 500 Cases, Ann Surg. 2015 Oct;262(4):610-622.)preferentially benefit patients with hereditary and idiopathic forms of the disease, the importance of the careful definition of the etiology of chronic pancreatitis, including genetic testing, is steadily increasing.PANCREATIC NEOPLASMSNeoplasms of the Endocrine PancreasNeoplasms of the endocrine pancreas are relatively uncommon but do occur with enough frequency (five cases per million population) that most surgeons will encounter them in an urban | Surgery_Schwartz. DF1131252842994299Den DF0.26268.294.840.608<0.001<0.001F statisticP valueAgeTimeAge x TimePrevalence of narcotic use (%)72849610812020406080100Pediatric patientAdultFigure 33-63. Prevalence of narcotic use after total pancreatectomy with islet auto-transplantation (TP-IAT) in adult and pediatric patients. (Reproduced with permission from Chinnakotla S, Beilman GJ, Dunn TB, et al. Factors Predicting Outcomes After a Total Pancreatectomy and Islet Autotransplantation Lessons Learned From Over 500 Cases, Ann Surg. 2015 Oct;262(4):610-622.)preferentially benefit patients with hereditary and idiopathic forms of the disease, the importance of the careful definition of the etiology of chronic pancreatitis, including genetic testing, is steadily increasing.PANCREATIC NEOPLASMSNeoplasms of the Endocrine PancreasNeoplasms of the endocrine pancreas are relatively uncommon but do occur with enough frequency (five cases per million population) that most surgeons will encounter them in an urban |
Surgery_Schwartz_9755 | Surgery_Schwartz | Endocrine PancreasNeoplasms of the endocrine pancreas are relatively uncommon but do occur with enough frequency (five cases per million population) that most surgeons will encounter them in an urban practice. The cells of the endocrine pancreas, or islet cells, origi-nate from neural crest cells, also referred to as amine precursor uptake and decarboxylation cells. Multiple endocrine neopla-sia (MEN) syndromes occur when these cells cause tumors in multiple sites. The MEN1 syndrome involves pituitary tumors, parathyroid hyperplasia, and pancreatic neoplasms. Although most pancreatic endocrine tumors are nonfunctional, some are functional, secreting peptide products that produce interesting clinical presentations. Neoplasms of the endocrine pancreas that are not associated with excess hormone levels and a recogniz-able clinical syndrome are considered nonfunctional. Special immunohistochemical stains allow pathologists to confirm the peptide products being produced within the cells of | Surgery_Schwartz. Endocrine PancreasNeoplasms of the endocrine pancreas are relatively uncommon but do occur with enough frequency (five cases per million population) that most surgeons will encounter them in an urban practice. The cells of the endocrine pancreas, or islet cells, origi-nate from neural crest cells, also referred to as amine precursor uptake and decarboxylation cells. Multiple endocrine neopla-sia (MEN) syndromes occur when these cells cause tumors in multiple sites. The MEN1 syndrome involves pituitary tumors, parathyroid hyperplasia, and pancreatic neoplasms. Although most pancreatic endocrine tumors are nonfunctional, some are functional, secreting peptide products that produce interesting clinical presentations. Neoplasms of the endocrine pancreas that are not associated with excess hormone levels and a recogniz-able clinical syndrome are considered nonfunctional. Special immunohistochemical stains allow pathologists to confirm the peptide products being produced within the cells of |
Surgery_Schwartz_9756 | Surgery_Schwartz | levels and a recogniz-able clinical syndrome are considered nonfunctional. Special immunohistochemical stains allow pathologists to confirm the peptide products being produced within the cells of a pancre-atic endocrine tumor. However, the histologic characteristics of these neoplasms do not predict their clinical behavior, and malignancy is usually determined by the presence of local inva-sion and lymph node or hepatic metastases. Unfortunately, most pancreatic endocrine tumors are malignant, but the course of the disease is far more favorable than that seen with pancreatic exo-crine cancer. The key to diagnosing these rare tumors is recogni-tion of the classic clinical syndrome; confirmation is achieved by measuring serum levels of the elevated hormone. Localiza-tion of the tumor can be a challenging step, but once accom-plished, the surgery is relatively straightforward. The goals of surgery range from complete resection, often accomplished with insulinomas, to controlling symptoms | Surgery_Schwartz. levels and a recogniz-able clinical syndrome are considered nonfunctional. Special immunohistochemical stains allow pathologists to confirm the peptide products being produced within the cells of a pancre-atic endocrine tumor. However, the histologic characteristics of these neoplasms do not predict their clinical behavior, and malignancy is usually determined by the presence of local inva-sion and lymph node or hepatic metastases. Unfortunately, most pancreatic endocrine tumors are malignant, but the course of the disease is far more favorable than that seen with pancreatic exo-crine cancer. The key to diagnosing these rare tumors is recogni-tion of the classic clinical syndrome; confirmation is achieved by measuring serum levels of the elevated hormone. Localiza-tion of the tumor can be a challenging step, but once accom-plished, the surgery is relatively straightforward. The goals of surgery range from complete resection, often accomplished with insulinomas, to controlling symptoms |
Surgery_Schwartz_9757 | Surgery_Schwartz | a challenging step, but once accom-plished, the surgery is relatively straightforward. The goals of surgery range from complete resection, often accomplished with insulinomas, to controlling symptoms with debulking proce-dures. Unresectable disease in the liver is often addressed with chemoembolization.As with pancreatic exocrine tumors, the initial diagnos-tic imaging test of choice for pancreatic endocrine tumors is a multidetector CT scan with four phases of contrast and fine cuts through the pancreas and liver. Neuroendocrine tumors of the pancreas often enhance with contrast. EUS can be superior to CT in localizing these tumors, which can produce dramatic symptoms despite their small (<1 cm) size. In contrast to pan-creatic exocrine tumors, many of the endocrine tumors have somatostatin receptors (SSTRs) that allow them to be detected by a radiolabeled octreotide scan. A radioactive somatostatin analogue is injected intravenously, followed by whole-body radionuclide scanning | Surgery_Schwartz. a challenging step, but once accom-plished, the surgery is relatively straightforward. The goals of surgery range from complete resection, often accomplished with insulinomas, to controlling symptoms with debulking proce-dures. Unresectable disease in the liver is often addressed with chemoembolization.As with pancreatic exocrine tumors, the initial diagnos-tic imaging test of choice for pancreatic endocrine tumors is a multidetector CT scan with four phases of contrast and fine cuts through the pancreas and liver. Neuroendocrine tumors of the pancreas often enhance with contrast. EUS can be superior to CT in localizing these tumors, which can produce dramatic symptoms despite their small (<1 cm) size. In contrast to pan-creatic exocrine tumors, many of the endocrine tumors have somatostatin receptors (SSTRs) that allow them to be detected by a radiolabeled octreotide scan. A radioactive somatostatin analogue is injected intravenously, followed by whole-body radionuclide scanning |
Surgery_Schwartz_9758 | Surgery_Schwartz | receptors (SSTRs) that allow them to be detected by a radiolabeled octreotide scan. A radioactive somatostatin analogue is injected intravenously, followed by whole-body radionuclide scanning (Fig. 33-64). The success of this modal-ity in localizing tumors and detecting metastases has decreased the use of older techniques such as angiography and selective venous sampling.InsulinomaInsulinomas are the most common functional pancreatic endocrine neoplasms and present with a typical clinical Brunicardi_Ch33_p1429-p1516.indd 148001/03/19 6:46 PM 1481PANCREASCHAPTER 33syndrome known as Whipple’s triad. The triad consists of symptomatic fasting hypoglycemia, a documented serum glucose level <50 mg/dL, and relief of symptoms with the administration of glucose. Patients can present with a profound syncopal episode or less severe symptoms that are averted by frequent eating. Common symptoms include palpitations, trembling, diaphoresis, confusion or obtundation, and seizure, and family | Surgery_Schwartz. receptors (SSTRs) that allow them to be detected by a radiolabeled octreotide scan. A radioactive somatostatin analogue is injected intravenously, followed by whole-body radionuclide scanning (Fig. 33-64). The success of this modal-ity in localizing tumors and detecting metastases has decreased the use of older techniques such as angiography and selective venous sampling.InsulinomaInsulinomas are the most common functional pancreatic endocrine neoplasms and present with a typical clinical Brunicardi_Ch33_p1429-p1516.indd 148001/03/19 6:46 PM 1481PANCREASCHAPTER 33syndrome known as Whipple’s triad. The triad consists of symptomatic fasting hypoglycemia, a documented serum glucose level <50 mg/dL, and relief of symptoms with the administration of glucose. Patients can present with a profound syncopal episode or less severe symptoms that are averted by frequent eating. Common symptoms include palpitations, trembling, diaphoresis, confusion or obtundation, and seizure, and family |
Surgery_Schwartz_9759 | Surgery_Schwartz | profound syncopal episode or less severe symptoms that are averted by frequent eating. Common symptoms include palpitations, trembling, diaphoresis, confusion or obtundation, and seizure, and family members may report that the patient has undergone a personality change.Routine laboratory studies will uncover a low blood sugar, the cause of all of these symptoms. Serum insulin levels are elevated. C-peptide levels should also be elevated and rule out the unusual case of surreptitious administration of insulin or oral hypoglycemic agents because excess endogenous insulin pro-duction leads to excess C-peptide. The diagnosis can be clinched with a monitored fast in which blood is sampled every 4 to 6 hours for glucose and insulin levels until the patient becomes symptomatic. However, this can be dangerous and must be done with close supervision.Insulinomas are usually localized with CT scanning and EUS. Technical advances in EUS have led to preoperative identification of >90% of | Surgery_Schwartz. profound syncopal episode or less severe symptoms that are averted by frequent eating. Common symptoms include palpitations, trembling, diaphoresis, confusion or obtundation, and seizure, and family members may report that the patient has undergone a personality change.Routine laboratory studies will uncover a low blood sugar, the cause of all of these symptoms. Serum insulin levels are elevated. C-peptide levels should also be elevated and rule out the unusual case of surreptitious administration of insulin or oral hypoglycemic agents because excess endogenous insulin pro-duction leads to excess C-peptide. The diagnosis can be clinched with a monitored fast in which blood is sampled every 4 to 6 hours for glucose and insulin levels until the patient becomes symptomatic. However, this can be dangerous and must be done with close supervision.Insulinomas are usually localized with CT scanning and EUS. Technical advances in EUS have led to preoperative identification of >90% of |
Surgery_Schwartz_9760 | Surgery_Schwartz | this can be dangerous and must be done with close supervision.Insulinomas are usually localized with CT scanning and EUS. Technical advances in EUS have led to preoperative identification of >90% of insulinomas.297 Visceral angiography with venous sampling is rarely required to accurately localize the tumor. Insulinomas are evenly distributed throughout the head, body, and tail of the pancreas.298 Unlike most endocrine pancreatic tumors, the majority (90%) of insulinomas are benign Figure 33-64. Radioactive octreotide scan demonstrating pancre-atic endocrine tumor in the body of the pancreas (arrow).and solitary, and only 10% are malignant. They are typically cured by simple enucleation. However, tumors located close to the main pancreatic duct and large (>2 cm) tumors may require a distal pancreatectomy or pancreaticoduodenectomy. Intraop-erative US is useful to determine the tumor’s relation to the main pancreatic duct and guides intraoperative decision making. Approximately 90% of | Surgery_Schwartz. this can be dangerous and must be done with close supervision.Insulinomas are usually localized with CT scanning and EUS. Technical advances in EUS have led to preoperative identification of >90% of insulinomas.297 Visceral angiography with venous sampling is rarely required to accurately localize the tumor. Insulinomas are evenly distributed throughout the head, body, and tail of the pancreas.298 Unlike most endocrine pancreatic tumors, the majority (90%) of insulinomas are benign Figure 33-64. Radioactive octreotide scan demonstrating pancre-atic endocrine tumor in the body of the pancreas (arrow).and solitary, and only 10% are malignant. They are typically cured by simple enucleation. However, tumors located close to the main pancreatic duct and large (>2 cm) tumors may require a distal pancreatectomy or pancreaticoduodenectomy. Intraop-erative US is useful to determine the tumor’s relation to the main pancreatic duct and guides intraoperative decision making. Approximately 90% of |
Surgery_Schwartz_9761 | Surgery_Schwartz | pancreatectomy or pancreaticoduodenectomy. Intraop-erative US is useful to determine the tumor’s relation to the main pancreatic duct and guides intraoperative decision making. Approximately 90% of insulinomas are sporadic, and 10% are associated with the MEN1 syndrome. Insulinomas associated with the MEN1 syndrome are more likely to be multifocal and have a higher rate of recurrence.Noninsulinoma Hyperinsulinemia Hypoglycemia SyndromeA syndrome of noninsulinoma pancreatogenous hypoglycemia was described by Service et al in 1999.299 The syndrome is asso-ciated with beta-cell hypertrophy, islet hyperplasia and increased beta-cell mass. When these findings are accompanied by ectopic islet tissue, multilobulated islets, and ductuloinsular complexes, the definition of nesideoblastosis is met. Nesideoblastosis accompanied by hyperinsulinism was previously considered a disease of neonates, where subtotal or total pancreatectomy was required to correct potentially fatal neonatal | Surgery_Schwartz. pancreatectomy or pancreaticoduodenectomy. Intraop-erative US is useful to determine the tumor’s relation to the main pancreatic duct and guides intraoperative decision making. Approximately 90% of insulinomas are sporadic, and 10% are associated with the MEN1 syndrome. Insulinomas associated with the MEN1 syndrome are more likely to be multifocal and have a higher rate of recurrence.Noninsulinoma Hyperinsulinemia Hypoglycemia SyndromeA syndrome of noninsulinoma pancreatogenous hypoglycemia was described by Service et al in 1999.299 The syndrome is asso-ciated with beta-cell hypertrophy, islet hyperplasia and increased beta-cell mass. When these findings are accompanied by ectopic islet tissue, multilobulated islets, and ductuloinsular complexes, the definition of nesideoblastosis is met. Nesideoblastosis accompanied by hyperinsulinism was previously considered a disease of neonates, where subtotal or total pancreatectomy was required to correct potentially fatal neonatal |
Surgery_Schwartz_9762 | Surgery_Schwartz | is met. Nesideoblastosis accompanied by hyperinsulinism was previously considered a disease of neonates, where subtotal or total pancreatectomy was required to correct potentially fatal neonatal hyperinsulinism. However, dozens of cases of nesideoblastosis associated with hyperinsulinism have now been reported in patients 2 to 5 years after Roux-en-Y gastric bypass for obesity.300 Many of these patients have undergone partial or total pancreatectomy to prevent potentially fatal hypoglycemia. The illness in former bariatric surgery patients appears to result from an idiosyncraticallyprolonged hypersecretion of the incretin hormones GIP and GLP-1 after the gastric bypass. GLP-1 is a potent stimulant of the expression of the transcription factor PDX-1, which nor-mally regulates beta-cell development and growth. The correct treatment of this condition to prevent episodes of hypoglycemia is conversion of the gastric bypass to a form of bariatric proce-dure that restores normal intestinal | Surgery_Schwartz. is met. Nesideoblastosis accompanied by hyperinsulinism was previously considered a disease of neonates, where subtotal or total pancreatectomy was required to correct potentially fatal neonatal hyperinsulinism. However, dozens of cases of nesideoblastosis associated with hyperinsulinism have now been reported in patients 2 to 5 years after Roux-en-Y gastric bypass for obesity.300 Many of these patients have undergone partial or total pancreatectomy to prevent potentially fatal hypoglycemia. The illness in former bariatric surgery patients appears to result from an idiosyncraticallyprolonged hypersecretion of the incretin hormones GIP and GLP-1 after the gastric bypass. GLP-1 is a potent stimulant of the expression of the transcription factor PDX-1, which nor-mally regulates beta-cell development and growth. The correct treatment of this condition to prevent episodes of hypoglycemia is conversion of the gastric bypass to a form of bariatric proce-dure that restores normal intestinal |
Surgery_Schwartz_9763 | Surgery_Schwartz | and growth. The correct treatment of this condition to prevent episodes of hypoglycemia is conversion of the gastric bypass to a form of bariatric proce-dure that restores normal intestinal flow of nutrients, such as the gastric sleeve, or the addition of a restriction element such as an adjustable gastric band. Pancreatic resection without conversion of the Roux-en-Y gastric bypass is not appropriate because this allows the abnormal enteroinsular relationship to continue and hyperinsulinemia persists or recurs after partial pancreatectomy.GastrinomaZollinger-Ellison syndrome (ZES) is caused by a gastrinoma, an endocrine tumor that secretes gastrin, leading to acid hyper-secretion and peptic ulceration. Many patients with ZES present with abdominal pain, peptic ulcer disease, and severe esopha-gitis. However, in the era of effective antacid therapy, the pre-sentation can be less dramatic. Although most of the ulcers are solitary, multiple ulcers in atypical locations that fail to | Surgery_Schwartz. and growth. The correct treatment of this condition to prevent episodes of hypoglycemia is conversion of the gastric bypass to a form of bariatric proce-dure that restores normal intestinal flow of nutrients, such as the gastric sleeve, or the addition of a restriction element such as an adjustable gastric band. Pancreatic resection without conversion of the Roux-en-Y gastric bypass is not appropriate because this allows the abnormal enteroinsular relationship to continue and hyperinsulinemia persists or recurs after partial pancreatectomy.GastrinomaZollinger-Ellison syndrome (ZES) is caused by a gastrinoma, an endocrine tumor that secretes gastrin, leading to acid hyper-secretion and peptic ulceration. Many patients with ZES present with abdominal pain, peptic ulcer disease, and severe esopha-gitis. However, in the era of effective antacid therapy, the pre-sentation can be less dramatic. Although most of the ulcers are solitary, multiple ulcers in atypical locations that fail to |
Surgery_Schwartz_9764 | Surgery_Schwartz | esopha-gitis. However, in the era of effective antacid therapy, the pre-sentation can be less dramatic. Although most of the ulcers are solitary, multiple ulcers in atypical locations that fail to respond to antacids should raise suspicion for ZES and prompt a work-up. At the time of diagnosis, 21% of patients with gastrinoma have diarrhea.The diagnosis of ZES is made by measuring the serum gastrin level. It is important that patients stop taking proton pump inhibitors for this test. In most patients with gastrinomas, the level is >1000 pg/mL. Gastrin levels can be elevated under conditions other than ZES. Common causes of hypergastrin-emia include pernicious anemia, treatment with proton pump inhibitors, renal failure, G-cell hyperplasia, atrophic gastritis, retained or excluded antrum, and gastric outlet obstruction. In equivocal cases, when the gastrin level is not markedly elevated, a secretin stimulation test is helpful.Brunicardi_Ch33_p1429-p1516.indd 148101/03/19 6:46 PM | Surgery_Schwartz. esopha-gitis. However, in the era of effective antacid therapy, the pre-sentation can be less dramatic. Although most of the ulcers are solitary, multiple ulcers in atypical locations that fail to respond to antacids should raise suspicion for ZES and prompt a work-up. At the time of diagnosis, 21% of patients with gastrinoma have diarrhea.The diagnosis of ZES is made by measuring the serum gastrin level. It is important that patients stop taking proton pump inhibitors for this test. In most patients with gastrinomas, the level is >1000 pg/mL. Gastrin levels can be elevated under conditions other than ZES. Common causes of hypergastrin-emia include pernicious anemia, treatment with proton pump inhibitors, renal failure, G-cell hyperplasia, atrophic gastritis, retained or excluded antrum, and gastric outlet obstruction. In equivocal cases, when the gastrin level is not markedly elevated, a secretin stimulation test is helpful.Brunicardi_Ch33_p1429-p1516.indd 148101/03/19 6:46 PM |
Surgery_Schwartz_9765 | Surgery_Schwartz | and gastric outlet obstruction. In equivocal cases, when the gastrin level is not markedly elevated, a secretin stimulation test is helpful.Brunicardi_Ch33_p1429-p1516.indd 148101/03/19 6:46 PM 1482SPECIFIC CONSIDERATIONSPART IIIn 70% to 90% of patients, the primary gastrinoma is found in Passaro’s triangle, an area defined by a triangle with points located at the junction of the cystic duct and common bile duct, the second and third portion of the duodenum, and the neck and body of the pancreas (Fig. 33-65). However, because gastri-nomas can be found almost anywhere, whole-body imaging is required. The test of choice is SSTR (octreotide) scintigraphy in combination with CT. The octreotide scan is more sensitive than CT, locating about 85% of gastrinomas and detecting tumors <1 cm. With the octreotide scan, the need for tedious and techni-cally demanding selective angiography and measurement of gas-trin gradients has declined. EUS is another modality that assists in the | Surgery_Schwartz. and gastric outlet obstruction. In equivocal cases, when the gastrin level is not markedly elevated, a secretin stimulation test is helpful.Brunicardi_Ch33_p1429-p1516.indd 148101/03/19 6:46 PM 1482SPECIFIC CONSIDERATIONSPART IIIn 70% to 90% of patients, the primary gastrinoma is found in Passaro’s triangle, an area defined by a triangle with points located at the junction of the cystic duct and common bile duct, the second and third portion of the duodenum, and the neck and body of the pancreas (Fig. 33-65). However, because gastri-nomas can be found almost anywhere, whole-body imaging is required. The test of choice is SSTR (octreotide) scintigraphy in combination with CT. The octreotide scan is more sensitive than CT, locating about 85% of gastrinomas and detecting tumors <1 cm. With the octreotide scan, the need for tedious and techni-cally demanding selective angiography and measurement of gas-trin gradients has declined. EUS is another modality that assists in the |
Surgery_Schwartz_9766 | Surgery_Schwartz | <1 cm. With the octreotide scan, the need for tedious and techni-cally demanding selective angiography and measurement of gas-trin gradients has declined. EUS is another modality that assists in the preoperative localization of gastrinomas. It is particularly helpful in localizing tumors in the pancreatic head or duodenal wall, where gastrinomas are usually <1 cm in size. A combina-tion of octreotide scan and EUS detects >90% of gastrinomas.It is important to rule out MEN1 syndrome by checking serum calcium levels before surgery because resection of the gastrinoma(s) in these patients rarely results in normalization of serum gastrin concentrations or a prolongation of survival. Only one-fourth of gastrinomas occur in association with the MEN1 syndrome. One-half of patients with gastrinomas will have soli-tary tumors while the remainder will have multiple gastrino-mas. Multiple tumors are more common in patients with MEN1 syndrome. Aggressive surgical treatment is justified in | Surgery_Schwartz. <1 cm. With the octreotide scan, the need for tedious and techni-cally demanding selective angiography and measurement of gas-trin gradients has declined. EUS is another modality that assists in the preoperative localization of gastrinomas. It is particularly helpful in localizing tumors in the pancreatic head or duodenal wall, where gastrinomas are usually <1 cm in size. A combina-tion of octreotide scan and EUS detects >90% of gastrinomas.It is important to rule out MEN1 syndrome by checking serum calcium levels before surgery because resection of the gastrinoma(s) in these patients rarely results in normalization of serum gastrin concentrations or a prolongation of survival. Only one-fourth of gastrinomas occur in association with the MEN1 syndrome. One-half of patients with gastrinomas will have soli-tary tumors while the remainder will have multiple gastrino-mas. Multiple tumors are more common in patients with MEN1 syndrome. Aggressive surgical treatment is justified in |
Surgery_Schwartz_9767 | Surgery_Schwartz | will have soli-tary tumors while the remainder will have multiple gastrino-mas. Multiple tumors are more common in patients with MEN1 syndrome. Aggressive surgical treatment is justified in patients with sporadic gastrinomas. If patients have MEN1 syndrome, the parathyroid hyperplasia is addressed with total parathyroid-ectomy and implantation of parathyroid tissue in the forearm.Approximately 50% of gastrinomas metastasize to lymph nodes or the liver and are therefore considered malignant. Patients who meet criteria for operability should undergo exploration for possible removal of the tumor. Although the tumors are submu-cosal, a full-thickness excision of the duodenal wall is performed if a duodenal gastrinoma is found. All lymph nodes in Passaro’s triangle are excised for pathologic analysis. If the gastrinoma is found in the pancreas and does not involve the main pancreatic duct, it is enucleated. Pancreatic resection is justified for solitary Figure 33-65. Passaro’s triangle. | Surgery_Schwartz. will have soli-tary tumors while the remainder will have multiple gastrino-mas. Multiple tumors are more common in patients with MEN1 syndrome. Aggressive surgical treatment is justified in patients with sporadic gastrinomas. If patients have MEN1 syndrome, the parathyroid hyperplasia is addressed with total parathyroid-ectomy and implantation of parathyroid tissue in the forearm.Approximately 50% of gastrinomas metastasize to lymph nodes or the liver and are therefore considered malignant. Patients who meet criteria for operability should undergo exploration for possible removal of the tumor. Although the tumors are submu-cosal, a full-thickness excision of the duodenal wall is performed if a duodenal gastrinoma is found. All lymph nodes in Passaro’s triangle are excised for pathologic analysis. If the gastrinoma is found in the pancreas and does not involve the main pancreatic duct, it is enucleated. Pancreatic resection is justified for solitary Figure 33-65. Passaro’s triangle. |
Surgery_Schwartz_9768 | Surgery_Schwartz | analysis. If the gastrinoma is found in the pancreas and does not involve the main pancreatic duct, it is enucleated. Pancreatic resection is justified for solitary Figure 33-65. Passaro’s triangle. The typical location of a gastrinoma is described by this anatomic region, including the head of the pancreas, duodenum, and the lymphatic bed posterior and superior to the duodenum, as originally described by E. Passaro. (Reproduced with permission from Stable BE, Morrow DJ, Passaro E: The gastrinoma triangle: operative implications, Am J Surg. 1984 Jan;147(1):25-31.)gastrinomas with no metastases. A highly selective vagotomy can be performed if unresectable disease is identified or if the gastrinoma cannot be localized. This may reduce the amount of expensive proton pump inhibitors required. In cases in which hepatic metastases are identified, resection is justified if the pri-mary gastrinoma is controlled and the metastases can be safely and completely removed. Debulking or incomplete | Surgery_Schwartz. analysis. If the gastrinoma is found in the pancreas and does not involve the main pancreatic duct, it is enucleated. Pancreatic resection is justified for solitary Figure 33-65. Passaro’s triangle. The typical location of a gastrinoma is described by this anatomic region, including the head of the pancreas, duodenum, and the lymphatic bed posterior and superior to the duodenum, as originally described by E. Passaro. (Reproduced with permission from Stable BE, Morrow DJ, Passaro E: The gastrinoma triangle: operative implications, Am J Surg. 1984 Jan;147(1):25-31.)gastrinomas with no metastases. A highly selective vagotomy can be performed if unresectable disease is identified or if the gastrinoma cannot be localized. This may reduce the amount of expensive proton pump inhibitors required. In cases in which hepatic metastases are identified, resection is justified if the pri-mary gastrinoma is controlled and the metastases can be safely and completely removed. Debulking or incomplete |
Surgery_Schwartz_9769 | Surgery_Schwartz | In cases in which hepatic metastases are identified, resection is justified if the pri-mary gastrinoma is controlled and the metastases can be safely and completely removed. Debulking or incomplete removal of multiple hepatic metastases is probably not helpful, especially in the setting of MEN1. The application of new modalities such as radiofrequency ablation seems reasonable, but data to sup-port this approach are limited.301 Postoperatively, patients are followed with fasting serum gastrin levels, secretin stimulation tests, octreotide scans, and CT scans. In patients found to have inoperable disease, chemotherapy with streptozocin, doxorubi-cin, and 5-fluorouracil (5-FU) is used. Other approaches such as somatostatin analogues, interferon, and chemoembolization also have been used in gastrinoma with some success.Unfortunately, a biochemical cure is achieved in only about one-third of the patients operated on for ZES. Despite the lack of success, long-term survival rates are good, | Surgery_Schwartz. In cases in which hepatic metastases are identified, resection is justified if the pri-mary gastrinoma is controlled and the metastases can be safely and completely removed. Debulking or incomplete removal of multiple hepatic metastases is probably not helpful, especially in the setting of MEN1. The application of new modalities such as radiofrequency ablation seems reasonable, but data to sup-port this approach are limited.301 Postoperatively, patients are followed with fasting serum gastrin levels, secretin stimulation tests, octreotide scans, and CT scans. In patients found to have inoperable disease, chemotherapy with streptozocin, doxorubi-cin, and 5-fluorouracil (5-FU) is used. Other approaches such as somatostatin analogues, interferon, and chemoembolization also have been used in gastrinoma with some success.Unfortunately, a biochemical cure is achieved in only about one-third of the patients operated on for ZES. Despite the lack of success, long-term survival rates are good, |
Surgery_Schwartz_9770 | Surgery_Schwartz | gastrinoma with some success.Unfortunately, a biochemical cure is achieved in only about one-third of the patients operated on for ZES. Despite the lack of success, long-term survival rates are good, even in patients with liver metastases. The 15-year survival rate for patients without liver metastases is about 80%, while the 5-year survival rate for patients with liver metastases is 20% to 50%. Pancreatic tumors are usually larger than tumors arising in the duodenum, and more often they have lymph node metastases. In gastrinomas, liver metastases decrease survival rates, but lymph node metastases do not. The best results are seen after complete excision of small sporadic tumors originating in the duodenum. Large tumors associated with liver metastases, located outside of Passaro’s triangle, have the worst prognosis.Vasoactive Intestinal Peptide-Secreting TumorIn 1958, Verner and Morrison first described the syndrome associated with a pancreatic neoplasm secreting VIP. The clas-sic | Surgery_Schwartz. gastrinoma with some success.Unfortunately, a biochemical cure is achieved in only about one-third of the patients operated on for ZES. Despite the lack of success, long-term survival rates are good, even in patients with liver metastases. The 15-year survival rate for patients without liver metastases is about 80%, while the 5-year survival rate for patients with liver metastases is 20% to 50%. Pancreatic tumors are usually larger than tumors arising in the duodenum, and more often they have lymph node metastases. In gastrinomas, liver metastases decrease survival rates, but lymph node metastases do not. The best results are seen after complete excision of small sporadic tumors originating in the duodenum. Large tumors associated with liver metastases, located outside of Passaro’s triangle, have the worst prognosis.Vasoactive Intestinal Peptide-Secreting TumorIn 1958, Verner and Morrison first described the syndrome associated with a pancreatic neoplasm secreting VIP. The clas-sic |
Surgery_Schwartz_9771 | Surgery_Schwartz | have the worst prognosis.Vasoactive Intestinal Peptide-Secreting TumorIn 1958, Verner and Morrison first described the syndrome associated with a pancreatic neoplasm secreting VIP. The clas-sic clinical syndrome associated with this pancreatic endocrine neoplasm consists of severe intermittent watery diarrhea leading to dehydration, and weakness from fluid and electrolyte losses. Large amounts of potassium are lost in the stool. The vasoac-tive intestinal peptide-secreting tumor (VIPoma) syndrome is also called WDHA syndrome due to the presence of watery diarrhea, hypokalemia, and achlorhydria. The massive (5 L/d) and episodic nature of the diarrhea associated with the appropriate electrolyte abnormalities should raise suspicion of the diagnosis. Serum VIP levels must be measured on multiple occasions because the excess secretion of VIP is episodic and single measurements might be normal and misleading. A CT scan localizes most VIPomas, although as with all islet cell tumors, EUS is | Surgery_Schwartz. have the worst prognosis.Vasoactive Intestinal Peptide-Secreting TumorIn 1958, Verner and Morrison first described the syndrome associated with a pancreatic neoplasm secreting VIP. The clas-sic clinical syndrome associated with this pancreatic endocrine neoplasm consists of severe intermittent watery diarrhea leading to dehydration, and weakness from fluid and electrolyte losses. Large amounts of potassium are lost in the stool. The vasoac-tive intestinal peptide-secreting tumor (VIPoma) syndrome is also called WDHA syndrome due to the presence of watery diarrhea, hypokalemia, and achlorhydria. The massive (5 L/d) and episodic nature of the diarrhea associated with the appropriate electrolyte abnormalities should raise suspicion of the diagnosis. Serum VIP levels must be measured on multiple occasions because the excess secretion of VIP is episodic and single measurements might be normal and misleading. A CT scan localizes most VIPomas, although as with all islet cell tumors, EUS is |
Surgery_Schwartz_9772 | Surgery_Schwartz | occasions because the excess secretion of VIP is episodic and single measurements might be normal and misleading. A CT scan localizes most VIPomas, although as with all islet cell tumors, EUS is the most sensitive imaging method. Electrolyte and fluid balance is sometimes dif-ficult to correct preoperatively and must be pursued aggressively. Somatostatin analogues are helpful in controlling the diarrhea and allowing replacement of fluid and electrolytes. VIPomas are more commonly located in the distal pancreas and most have spread outside the pancreas. Palliative debulking operations can some-times improve symptoms for a period, along with somatostatin analogues. Hepatic artery embolization also has been reported as a potentially beneficial treatment.302GlucagonomaDiabetes in association with dermatitis should raise the suspi-cion of a glucagonoma. The diabetes usually is mild. The classic necrolytic migratory erythema manifests as cyclic migrations of lesions with spreading margins | Surgery_Schwartz. occasions because the excess secretion of VIP is episodic and single measurements might be normal and misleading. A CT scan localizes most VIPomas, although as with all islet cell tumors, EUS is the most sensitive imaging method. Electrolyte and fluid balance is sometimes dif-ficult to correct preoperatively and must be pursued aggressively. Somatostatin analogues are helpful in controlling the diarrhea and allowing replacement of fluid and electrolytes. VIPomas are more commonly located in the distal pancreas and most have spread outside the pancreas. Palliative debulking operations can some-times improve symptoms for a period, along with somatostatin analogues. Hepatic artery embolization also has been reported as a potentially beneficial treatment.302GlucagonomaDiabetes in association with dermatitis should raise the suspi-cion of a glucagonoma. The diabetes usually is mild. The classic necrolytic migratory erythema manifests as cyclic migrations of lesions with spreading margins |
Surgery_Schwartz_9773 | Surgery_Schwartz | with dermatitis should raise the suspi-cion of a glucagonoma. The diabetes usually is mild. The classic necrolytic migratory erythema manifests as cyclic migrations of lesions with spreading margins and healing centers typically on Brunicardi_Ch33_p1429-p1516.indd 148201/03/19 6:46 PM 1483PANCREASCHAPTER 33the lower abdomen, perineum, perioral area, and feet. Patients also complain of an enlarged, sensitive tongue. The diagnosis is confirmed by measuring serum glucagon levels, which are usu-ally >500 pg/mL. Glucagon is a catabolic hormone, and most patients present with malnutrition. The rash associated with glucagonoma is thought to be caused by low levels of amino acids. Preoperative treatment usually includes control of the dia-betes, parenteral nutrition, and octreotide. Like VIPomas, glu-cagonomas are more often in the body and tail of the pancreas and tend to be large tumors with metastases. Again, debulking operations are recommended in good operative candidates to relieve | Surgery_Schwartz. with dermatitis should raise the suspi-cion of a glucagonoma. The diabetes usually is mild. The classic necrolytic migratory erythema manifests as cyclic migrations of lesions with spreading margins and healing centers typically on Brunicardi_Ch33_p1429-p1516.indd 148201/03/19 6:46 PM 1483PANCREASCHAPTER 33the lower abdomen, perineum, perioral area, and feet. Patients also complain of an enlarged, sensitive tongue. The diagnosis is confirmed by measuring serum glucagon levels, which are usu-ally >500 pg/mL. Glucagon is a catabolic hormone, and most patients present with malnutrition. The rash associated with glucagonoma is thought to be caused by low levels of amino acids. Preoperative treatment usually includes control of the dia-betes, parenteral nutrition, and octreotide. Like VIPomas, glu-cagonomas are more often in the body and tail of the pancreas and tend to be large tumors with metastases. Again, debulking operations are recommended in good operative candidates to relieve |
Surgery_Schwartz_9774 | Surgery_Schwartz | glu-cagonomas are more often in the body and tail of the pancreas and tend to be large tumors with metastases. Again, debulking operations are recommended in good operative candidates to relieve symptoms.SomatostatinomaBecause somatostatin inhibits pancreatic and biliary secretions, patients with a somatostatinoma present with gallstones due to bile stasis, diabetes due to inhibition of insulin secretion, and steatorrhea due to inhibition of pancreatic exocrine secretion and bile secretion. Most somatostatinomas originate in the proximal pancreas or the pancreatoduodenal groove, with the ampulla and periampullary area as the most common site (60%). The most common presentations are abdominal pain (25%), jaundice (25%), and cholelithiasis (19%).303 This rare type of pancreatic endocrine tumor is diagnosed by confirming elevated serum somatostatin levels, which are usually >10 ng/mL. Although most reported cases of somatostatinoma involve metastatic disease, an attempt at complete | Surgery_Schwartz. glu-cagonomas are more often in the body and tail of the pancreas and tend to be large tumors with metastases. Again, debulking operations are recommended in good operative candidates to relieve symptoms.SomatostatinomaBecause somatostatin inhibits pancreatic and biliary secretions, patients with a somatostatinoma present with gallstones due to bile stasis, diabetes due to inhibition of insulin secretion, and steatorrhea due to inhibition of pancreatic exocrine secretion and bile secretion. Most somatostatinomas originate in the proximal pancreas or the pancreatoduodenal groove, with the ampulla and periampullary area as the most common site (60%). The most common presentations are abdominal pain (25%), jaundice (25%), and cholelithiasis (19%).303 This rare type of pancreatic endocrine tumor is diagnosed by confirming elevated serum somatostatin levels, which are usually >10 ng/mL. Although most reported cases of somatostatinoma involve metastatic disease, an attempt at complete |
Surgery_Schwartz_9775 | Surgery_Schwartz | tumor is diagnosed by confirming elevated serum somatostatin levels, which are usually >10 ng/mL. Although most reported cases of somatostatinoma involve metastatic disease, an attempt at complete excision of the tumor and cholecystectomy is warranted in fit patients.Nonfunctioning Pancreatic Endocrine TumorsAlthough some pancreatic endocrine neoplasms secrete one or more hormones and are associated with interesting characteristic clinical syndromes, most are not associated with elevated serum hormone levels that cause symptoms. Pancreatic endocrine tumors are considered functional if they are associated with a clinical syndrome and nonfunctioning if not associated with clinical symptoms. The majority of pancreatic endocrine tumors (PET), also called pancreatic neuroendocrine tumors (pNET), are malignant because they have the potential for uncontrolled growth and metastasis. Immunohistochemical markers such as synaptophysin, chromogranin A (CgA), and neuron-specific enolase can be | Surgery_Schwartz. tumor is diagnosed by confirming elevated serum somatostatin levels, which are usually >10 ng/mL. Although most reported cases of somatostatinoma involve metastatic disease, an attempt at complete excision of the tumor and cholecystectomy is warranted in fit patients.Nonfunctioning Pancreatic Endocrine TumorsAlthough some pancreatic endocrine neoplasms secrete one or more hormones and are associated with interesting characteristic clinical syndromes, most are not associated with elevated serum hormone levels that cause symptoms. Pancreatic endocrine tumors are considered functional if they are associated with a clinical syndrome and nonfunctioning if not associated with clinical symptoms. The majority of pancreatic endocrine tumors (PET), also called pancreatic neuroendocrine tumors (pNET), are malignant because they have the potential for uncontrolled growth and metastasis. Immunohistochemical markers such as synaptophysin, chromogranin A (CgA), and neuron-specific enolase can be |
Surgery_Schwartz_9776 | Surgery_Schwartz | are malignant because they have the potential for uncontrolled growth and metastasis. Immunohistochemical markers such as synaptophysin, chromogranin A (CgA), and neuron-specific enolase can be helpful in the diagnosis, but the gross histology is not a reliable predictor of biologic behavior. CgA is used by some as a serum marker to monitor patients for disease recur-rence or response to treatment, but the test performs poorly for this purpose. Patients often present similar to patients with pancreatic adenocarcinoma with vague pain or weight loss, but pNETs are increasingly discovered incidentally when imaging is performed for another reason. The tumor frequently enhances with arterial contrast (Fig. 33-66). Sometimes a cystic compo-nent is seen due to central necrosis. Octreoscan (somatostatin receptor scintigraphy) can be helpful to stage the disease. Sur-gical resection is typically recommended in fit patients in the absence of metastatic disease. For patients with tumors in the | Surgery_Schwartz. are malignant because they have the potential for uncontrolled growth and metastasis. Immunohistochemical markers such as synaptophysin, chromogranin A (CgA), and neuron-specific enolase can be helpful in the diagnosis, but the gross histology is not a reliable predictor of biologic behavior. CgA is used by some as a serum marker to monitor patients for disease recur-rence or response to treatment, but the test performs poorly for this purpose. Patients often present similar to patients with pancreatic adenocarcinoma with vague pain or weight loss, but pNETs are increasingly discovered incidentally when imaging is performed for another reason. The tumor frequently enhances with arterial contrast (Fig. 33-66). Sometimes a cystic compo-nent is seen due to central necrosis. Octreoscan (somatostatin receptor scintigraphy) can be helpful to stage the disease. Sur-gical resection is typically recommended in fit patients in the absence of metastatic disease. For patients with tumors in the |
Surgery_Schwartz_9777 | Surgery_Schwartz | receptor scintigraphy) can be helpful to stage the disease. Sur-gical resection is typically recommended in fit patients in the absence of metastatic disease. For patients with tumors in the body and tail of the pancreas, this typically includes splenec-tomy. Enucleation and splenic preservation, although tempting in small tumors, fails to remove regional lymph nodes.With advances in imaging, small indolent pNETs are being discovered with increasing frequency, and some surgeons are considering observation in these cases.304 There are several argu-ments in favor of observation of small (<2 cm) nonfunctional pNETs, particularly in MEN-1 patients. Pancreatic resection has significant morbidity and mortality. In the setting of MEN-1, resection is rarely curative, and most patients require reopera-tion. Also, the survival of these patients, even with metastatic dis-ease, is generally excellent at least compared to pancreatic ductal adenocarcinoma. However, the 5-year survival with | Surgery_Schwartz. receptor scintigraphy) can be helpful to stage the disease. Sur-gical resection is typically recommended in fit patients in the absence of metastatic disease. For patients with tumors in the body and tail of the pancreas, this typically includes splenec-tomy. Enucleation and splenic preservation, although tempting in small tumors, fails to remove regional lymph nodes.With advances in imaging, small indolent pNETs are being discovered with increasing frequency, and some surgeons are considering observation in these cases.304 There are several argu-ments in favor of observation of small (<2 cm) nonfunctional pNETs, particularly in MEN-1 patients. Pancreatic resection has significant morbidity and mortality. In the setting of MEN-1, resection is rarely curative, and most patients require reopera-tion. Also, the survival of these patients, even with metastatic dis-ease, is generally excellent at least compared to pancreatic ductal adenocarcinoma. However, the 5-year survival with |
Surgery_Schwartz_9778 | Surgery_Schwartz | reopera-tion. Also, the survival of these patients, even with metastatic dis-ease, is generally excellent at least compared to pancreatic ductal adenocarcinoma. However, the 5-year survival with metastatic pNET is only 16% and radical surgery with curative intent is the standard of care, particularly in sporadic cases that are fit surgical candidates where the primary tumor can be completely excised.Adjuvant treatment after resection is withheld in the absence of radiographically demonstrable metastatic disease even if CgA levels remain elevated. Although these tumors have a slow growth pattern compared to pancreatic ductal adenocar-cinoma, many patients with pNETs will die of their disease even after an apparent complete resection, making surveillance after complete resection important. CT scan and or octreotide scan is recommended annually for 5 years after resection.ABCFigure 33-66. Pancreatic neuroendocrine tumor (PNET) demonstrating enhancement during arterial phase of computed | Surgery_Schwartz. reopera-tion. Also, the survival of these patients, even with metastatic dis-ease, is generally excellent at least compared to pancreatic ductal adenocarcinoma. However, the 5-year survival with metastatic pNET is only 16% and radical surgery with curative intent is the standard of care, particularly in sporadic cases that are fit surgical candidates where the primary tumor can be completely excised.Adjuvant treatment after resection is withheld in the absence of radiographically demonstrable metastatic disease even if CgA levels remain elevated. Although these tumors have a slow growth pattern compared to pancreatic ductal adenocar-cinoma, many patients with pNETs will die of their disease even after an apparent complete resection, making surveillance after complete resection important. CT scan and or octreotide scan is recommended annually for 5 years after resection.ABCFigure 33-66. Pancreatic neuroendocrine tumor (PNET) demonstrating enhancement during arterial phase of computed |
Surgery_Schwartz_9779 | Surgery_Schwartz | CT scan and or octreotide scan is recommended annually for 5 years after resection.ABCFigure 33-66. Pancreatic neuroendocrine tumor (PNET) demonstrating enhancement during arterial phase of computed tomography scan. Pancreatic head PNET seen in (left) sagital, (middle) coronal, and (right) lateral views of the abdomen.Brunicardi_Ch33_p1429-p1516.indd 148301/03/19 6:46 PM 1484SPECIFIC CONSIDERATIONSPART IIIncomplete resection (debulking) for locally advanced or metastatic pNETs of the pancreas is controversial because of the favorable survival duration of patients without surgery. How-ever, in carefully selected fit patients with a pNET in the head of the pancreas and minimal disease in the liver, a pancreaticoduo-denectomy with wedge resection of the liver metastasis might be appropriate because this avoids the morbidity of gastroin-testinal hemorrhage and biliary and gastric outlet obstruction before death from the metastatic disease. The role of cytoreduc-tive surgery in | Surgery_Schwartz. CT scan and or octreotide scan is recommended annually for 5 years after resection.ABCFigure 33-66. Pancreatic neuroendocrine tumor (PNET) demonstrating enhancement during arterial phase of computed tomography scan. Pancreatic head PNET seen in (left) sagital, (middle) coronal, and (right) lateral views of the abdomen.Brunicardi_Ch33_p1429-p1516.indd 148301/03/19 6:46 PM 1484SPECIFIC CONSIDERATIONSPART IIIncomplete resection (debulking) for locally advanced or metastatic pNETs of the pancreas is controversial because of the favorable survival duration of patients without surgery. How-ever, in carefully selected fit patients with a pNET in the head of the pancreas and minimal disease in the liver, a pancreaticoduo-denectomy with wedge resection of the liver metastasis might be appropriate because this avoids the morbidity of gastroin-testinal hemorrhage and biliary and gastric outlet obstruction before death from the metastatic disease. The role of cytoreduc-tive surgery in |
Surgery_Schwartz_9780 | Surgery_Schwartz | because this avoids the morbidity of gastroin-testinal hemorrhage and biliary and gastric outlet obstruction before death from the metastatic disease. The role of cytoreduc-tive surgery in metastatic pNET is controversial, but consensus guidelines agree that aggressive resection of the primary tumor, regional lymph nodes, and liver/distant metastases should be pursued if greater than 90% of the tumor burden can be resected, which is the case in only about 10% of patients with metastatic disease.Treatment of metastatic pancreatic neuroendocrine cancer requires a multidisciplinary approach often including a com-bination of cytoreductive surgery when appropriate, directed therapy for the treatment of liver metastases when possible, and systemic medical therapy. Local ablative therapies include radiofrequency ablation (RFA), cryotherapy, microwave coagu-lation, and ethanol injection, although RFA is the most popular and widely studied. These therapies can be performed percuta-neously or | Surgery_Schwartz. because this avoids the morbidity of gastroin-testinal hemorrhage and biliary and gastric outlet obstruction before death from the metastatic disease. The role of cytoreduc-tive surgery in metastatic pNET is controversial, but consensus guidelines agree that aggressive resection of the primary tumor, regional lymph nodes, and liver/distant metastases should be pursued if greater than 90% of the tumor burden can be resected, which is the case in only about 10% of patients with metastatic disease.Treatment of metastatic pancreatic neuroendocrine cancer requires a multidisciplinary approach often including a com-bination of cytoreductive surgery when appropriate, directed therapy for the treatment of liver metastases when possible, and systemic medical therapy. Local ablative therapies include radiofrequency ablation (RFA), cryotherapy, microwave coagu-lation, and ethanol injection, although RFA is the most popular and widely studied. These therapies can be performed percuta-neously or |
Surgery_Schwartz_9781 | Surgery_Schwartz | radiofrequency ablation (RFA), cryotherapy, microwave coagu-lation, and ethanol injection, although RFA is the most popular and widely studied. These therapies can be performed percuta-neously or during surgery via laparotomy or laparoscopy, can be repeated, and have been shown to complement resection of the primary tumor and amenable liver metastases; making pallia-tive surgery possible for patients that would otherwise not meet criteria. This approach often improves symptoms and 5-year survival is improved to 48%.305Transarterial chemoembolization (TACE) can be employed as palliative therapy in patients with liver metastases not amenable to surgical resection and/or ablation. It relies on the principle that metastatic tumor cells derive the majority of their oxygen supply from the hepatic artery as opposed to hepa-tocytes, which receive oxygen primarily from the portal vein. Performed via angiography, embolization may be performed alone (bland embolization) or in combination with | Surgery_Schwartz. radiofrequency ablation (RFA), cryotherapy, microwave coagu-lation, and ethanol injection, although RFA is the most popular and widely studied. These therapies can be performed percuta-neously or during surgery via laparotomy or laparoscopy, can be repeated, and have been shown to complement resection of the primary tumor and amenable liver metastases; making pallia-tive surgery possible for patients that would otherwise not meet criteria. This approach often improves symptoms and 5-year survival is improved to 48%.305Transarterial chemoembolization (TACE) can be employed as palliative therapy in patients with liver metastases not amenable to surgical resection and/or ablation. It relies on the principle that metastatic tumor cells derive the majority of their oxygen supply from the hepatic artery as opposed to hepa-tocytes, which receive oxygen primarily from the portal vein. Performed via angiography, embolization may be performed alone (bland embolization) or in combination with |
Surgery_Schwartz_9782 | Surgery_Schwartz | artery as opposed to hepa-tocytes, which receive oxygen primarily from the portal vein. Performed via angiography, embolization may be performed alone (bland embolization) or in combination with chemothera-peutic agents (chemoembolization). Radioembolization, the selective distribution of radioactive yttrium-90 microspheres into the peritumoral vasculature via branches of the hepatic artery, is another alternative.Somatostatin analogs can inhibit release of hormones from functional pNETS and reduce diarrhea in patients with VIPo-mas, glucagonomas, and somatostatinomas, and it can also help the rash of glucagonomas. Somatostatin analogs such as octreotide (Sandostatin LAR Depot), lanreotide (Somatuline Depot), and a new analog pasireotide (Sifnifor LAR) are also used to slow the growth of some functional and nonfunctional pNETS. Disease seen on an octreotide scan has somatostatin receptors and would be expected to respond. Patients with unre-sectable disease are often treated with | Surgery_Schwartz. artery as opposed to hepa-tocytes, which receive oxygen primarily from the portal vein. Performed via angiography, embolization may be performed alone (bland embolization) or in combination with chemothera-peutic agents (chemoembolization). Radioembolization, the selective distribution of radioactive yttrium-90 microspheres into the peritumoral vasculature via branches of the hepatic artery, is another alternative.Somatostatin analogs can inhibit release of hormones from functional pNETS and reduce diarrhea in patients with VIPo-mas, glucagonomas, and somatostatinomas, and it can also help the rash of glucagonomas. Somatostatin analogs such as octreotide (Sandostatin LAR Depot), lanreotide (Somatuline Depot), and a new analog pasireotide (Sifnifor LAR) are also used to slow the growth of some functional and nonfunctional pNETS. Disease seen on an octreotide scan has somatostatin receptors and would be expected to respond. Patients with unre-sectable disease are often treated with |
Surgery_Schwartz_9783 | Surgery_Schwartz | of some functional and nonfunctional pNETS. Disease seen on an octreotide scan has somatostatin receptors and would be expected to respond. Patients with unre-sectable disease are often treated with somatostatin analogs first before targeted therapy and cytotoxic chemotherapy are utilized because the side effects are minimal.Some targeted drugs can be helpful in treating advanced pNETs that progress despite somatostatin analogs. Sunitinib (Sutent) attacks new blood vessel growth and other targets that help cancer cells grow. Everolimus (Afinitor) works by block-ing a cell protein known as mammalian target of rapamycin (mTOR) and the VEGF pathway, which normally helps cells grow and divide. These targeted agents induce stabilization much more frequently than response, but they tend to carry fewer side effects than traditional cytotoxic chemotherapy. Cytotoxic chemotherapy for pNETS is usually reserved for large tumors or quickly growing tumors that are causing symptoms, or tumors that | Surgery_Schwartz. of some functional and nonfunctional pNETS. Disease seen on an octreotide scan has somatostatin receptors and would be expected to respond. Patients with unre-sectable disease are often treated with somatostatin analogs first before targeted therapy and cytotoxic chemotherapy are utilized because the side effects are minimal.Some targeted drugs can be helpful in treating advanced pNETs that progress despite somatostatin analogs. Sunitinib (Sutent) attacks new blood vessel growth and other targets that help cancer cells grow. Everolimus (Afinitor) works by block-ing a cell protein known as mammalian target of rapamycin (mTOR) and the VEGF pathway, which normally helps cells grow and divide. These targeted agents induce stabilization much more frequently than response, but they tend to carry fewer side effects than traditional cytotoxic chemotherapy. Cytotoxic chemotherapy for pNETS is usually reserved for large tumors or quickly growing tumors that are causing symptoms, or tumors that |
Surgery_Schwartz_9784 | Surgery_Schwartz | fewer side effects than traditional cytotoxic chemotherapy. Cytotoxic chemotherapy for pNETS is usually reserved for large tumors or quickly growing tumors that are causing symptoms, or tumors that progressed despite somatostatin analogs and targeted ther-apy. Platinum-based chemotherapy does, however, remain the standard of care for high-grade (poorly differentiated) pNET, yielding high response rates but typically short-lived benefit. The newer cytotoxic combination of capecitabine and temozolo-mide has shown activity in well-differentiated pNET.306Neoplasms of the Exocrine PancreasEpidemiology and Risk Factors. It is estimated that in 2017, 53,670 Americans will be diagnosed with pancreatic cancer and 43,090 will die from the disease. Overall, pancreatic cancer has the worst prognosis of all malignancies with a 5-year survival rate of only 7.2%.307 The incidence of pancreatic cancer continues to increase, perhaps related to the increased incidence of risk factors such as obesity | Surgery_Schwartz. fewer side effects than traditional cytotoxic chemotherapy. Cytotoxic chemotherapy for pNETS is usually reserved for large tumors or quickly growing tumors that are causing symptoms, or tumors that progressed despite somatostatin analogs and targeted ther-apy. Platinum-based chemotherapy does, however, remain the standard of care for high-grade (poorly differentiated) pNET, yielding high response rates but typically short-lived benefit. The newer cytotoxic combination of capecitabine and temozolo-mide has shown activity in well-differentiated pNET.306Neoplasms of the Exocrine PancreasEpidemiology and Risk Factors. It is estimated that in 2017, 53,670 Americans will be diagnosed with pancreatic cancer and 43,090 will die from the disease. Overall, pancreatic cancer has the worst prognosis of all malignancies with a 5-year survival rate of only 7.2%.307 The incidence of pancreatic cancer continues to increase, perhaps related to the increased incidence of risk factors such as obesity |
Surgery_Schwartz_9785 | Surgery_Schwartz | of all malignancies with a 5-year survival rate of only 7.2%.307 The incidence of pancreatic cancer continues to increase, perhaps related to the increased incidence of risk factors such as obesity and diabetes, and as a result, it is predicted that pancreatic cancer will become the leading cause of cancer deaths in the United States by 2050. Pancreatic cancer recently surpassed breast cancer and is now the third leading cause of cancer death behind lung and colorectal cancer. Despite its ubiquity, this dis-ease is extremely difficult to treat, and its exact cause is unknown. However, epidemiologic studies linking various environmental and host factors provide some clues. Recent discoveries using modern molecular biologic techniques have also improved our understanding of the causes of pancreatic cancer. The etiology of pancreatic cancer likely involves a complex interaction of genetic and environmental factors. These factors will become more fully understood as DNA sequencing is used | Surgery_Schwartz. of all malignancies with a 5-year survival rate of only 7.2%.307 The incidence of pancreatic cancer continues to increase, perhaps related to the increased incidence of risk factors such as obesity and diabetes, and as a result, it is predicted that pancreatic cancer will become the leading cause of cancer deaths in the United States by 2050. Pancreatic cancer recently surpassed breast cancer and is now the third leading cause of cancer death behind lung and colorectal cancer. Despite its ubiquity, this dis-ease is extremely difficult to treat, and its exact cause is unknown. However, epidemiologic studies linking various environmental and host factors provide some clues. Recent discoveries using modern molecular biologic techniques have also improved our understanding of the causes of pancreatic cancer. The etiology of pancreatic cancer likely involves a complex interaction of genetic and environmental factors. These factors will become more fully understood as DNA sequencing is used |
Surgery_Schwartz_9786 | Surgery_Schwartz | cancer. The etiology of pancreatic cancer likely involves a complex interaction of genetic and environmental factors. These factors will become more fully understood as DNA sequencing is used to screen populations at risk for developing pancreatic cancer.Pancreatic cancer is more common in older adults with most patients being 75 to 84 years old. Pancreatic cancer is more common in African Americans and slightly more com-mon in men than women. The risk of developing pancreatic cancer is two to three times higher if a parent or sibling had the disease. Another risk factor that is consistently linked to pan-creatic cancer is cigarette smoking. Smoking increases the risk of developing pancreatic cancer by at least twofold due to the carcinogens in cigarette smoke.308 Coffee and alcohol consump-tion have been investigated as possible risk factors, but the data are inconsistent. As in other GI cancers, diets high in fat and low in fiber, fruits, and vegetables are thought to be associated | Surgery_Schwartz. cancer. The etiology of pancreatic cancer likely involves a complex interaction of genetic and environmental factors. These factors will become more fully understood as DNA sequencing is used to screen populations at risk for developing pancreatic cancer.Pancreatic cancer is more common in older adults with most patients being 75 to 84 years old. Pancreatic cancer is more common in African Americans and slightly more com-mon in men than women. The risk of developing pancreatic cancer is two to three times higher if a parent or sibling had the disease. Another risk factor that is consistently linked to pan-creatic cancer is cigarette smoking. Smoking increases the risk of developing pancreatic cancer by at least twofold due to the carcinogens in cigarette smoke.308 Coffee and alcohol consump-tion have been investigated as possible risk factors, but the data are inconsistent. As in other GI cancers, diets high in fat and low in fiber, fruits, and vegetables are thought to be associated |
Surgery_Schwartz_9787 | Surgery_Schwartz | have been investigated as possible risk factors, but the data are inconsistent. As in other GI cancers, diets high in fat and low in fiber, fruits, and vegetables are thought to be associated with an increased risk of pancreatic cancer.Diabetes has been known to be associated with pancreatic cancer for many years. In fact, glucose intolerance is present in 80% of patients with pancreatic cancer, and approximately 20% have overt diabetes, a much greater incidence than would be expected to occur by chance. Preexisting type 2 diabetes increases the risk for development of pancreatic cancer by about twofold.309 The new onset of diabetes also can be an early mani-festation of otherwise occult pancreatic cancer. Thus, the new onset of diabetes, or a sudden increase in insulin requirement in an older adult patient with preexisting diabetes, should provoke concern for the presence of pancreatic cancer.Recent epidemiologic studies have confirmed the fact that patients with chronic | Surgery_Schwartz. have been investigated as possible risk factors, but the data are inconsistent. As in other GI cancers, diets high in fat and low in fiber, fruits, and vegetables are thought to be associated with an increased risk of pancreatic cancer.Diabetes has been known to be associated with pancreatic cancer for many years. In fact, glucose intolerance is present in 80% of patients with pancreatic cancer, and approximately 20% have overt diabetes, a much greater incidence than would be expected to occur by chance. Preexisting type 2 diabetes increases the risk for development of pancreatic cancer by about twofold.309 The new onset of diabetes also can be an early mani-festation of otherwise occult pancreatic cancer. Thus, the new onset of diabetes, or a sudden increase in insulin requirement in an older adult patient with preexisting diabetes, should provoke concern for the presence of pancreatic cancer.Recent epidemiologic studies have confirmed the fact that patients with chronic |
Surgery_Schwartz_9788 | Surgery_Schwartz | in an older adult patient with preexisting diabetes, should provoke concern for the presence of pancreatic cancer.Recent epidemiologic studies have confirmed the fact that patients with chronic pancreatitis, especially familial pan-creatitis, have an increased risk of developing pancreatic can-cer.124,196-198 Large, retrospective cohort studies of patients with pancreatitis have revealed up to a 20-fold increase in risk for pancreatic cancer. This increased risk seems to be independent of the type of pancreatitis, a finding consistent with the fact that most studies have shown little effect of alcohol ingestion per se Brunicardi_Ch33_p1429-p1516.indd 148401/03/19 6:46 PM 1485PANCREASCHAPTER 33on the risk of pancreatic carcinoma. The mechanisms involved in carcinogenesis in patients with preexisting pancreatitis are unknown. However, the mutated K-ras oncogene, which is pres-ent in most cases of pancreatic cancer, has been detected in the ductal epithelium of some patients with | Surgery_Schwartz. in an older adult patient with preexisting diabetes, should provoke concern for the presence of pancreatic cancer.Recent epidemiologic studies have confirmed the fact that patients with chronic pancreatitis, especially familial pan-creatitis, have an increased risk of developing pancreatic can-cer.124,196-198 Large, retrospective cohort studies of patients with pancreatitis have revealed up to a 20-fold increase in risk for pancreatic cancer. This increased risk seems to be independent of the type of pancreatitis, a finding consistent with the fact that most studies have shown little effect of alcohol ingestion per se Brunicardi_Ch33_p1429-p1516.indd 148401/03/19 6:46 PM 1485PANCREASCHAPTER 33on the risk of pancreatic carcinoma. The mechanisms involved in carcinogenesis in patients with preexisting pancreatitis are unknown. However, the mutated K-ras oncogene, which is pres-ent in most cases of pancreatic cancer, has been detected in the ductal epithelium of some patients with |
Surgery_Schwartz_9789 | Surgery_Schwartz | with preexisting pancreatitis are unknown. However, the mutated K-ras oncogene, which is pres-ent in most cases of pancreatic cancer, has been detected in the ductal epithelium of some patients with chronic pancreatitis.Genetics of Pancreatic Cancer. Pancreatic carcinogenesis probably involves multiple mutations that are inherited and acquired throughout aging. The K-ras oncogene is currently thought to be the most commonly mutated gene in pancreatic cancer, with approximately 90% of tumors having a mutation.310 This prevalent mutation is present in precursor lesions and is therefore thought to occur early and be essential to pancre-atic cancer development. K-ras mutations can be detected in DNA from serum, stool, pancreatic juice, and tissue aspirates of patients with pancreatic cancer, suggesting that the presence of this mutation or others may provide the basis for diagnostic testing in select individuals. The HER2/neu oncogene, homolo-gous to the epidermal growth factor receptor | Surgery_Schwartz. with preexisting pancreatitis are unknown. However, the mutated K-ras oncogene, which is pres-ent in most cases of pancreatic cancer, has been detected in the ductal epithelium of some patients with chronic pancreatitis.Genetics of Pancreatic Cancer. Pancreatic carcinogenesis probably involves multiple mutations that are inherited and acquired throughout aging. The K-ras oncogene is currently thought to be the most commonly mutated gene in pancreatic cancer, with approximately 90% of tumors having a mutation.310 This prevalent mutation is present in precursor lesions and is therefore thought to occur early and be essential to pancre-atic cancer development. K-ras mutations can be detected in DNA from serum, stool, pancreatic juice, and tissue aspirates of patients with pancreatic cancer, suggesting that the presence of this mutation or others may provide the basis for diagnostic testing in select individuals. The HER2/neu oncogene, homolo-gous to the epidermal growth factor receptor |
Surgery_Schwartz_9790 | Surgery_Schwartz | suggesting that the presence of this mutation or others may provide the basis for diagnostic testing in select individuals. The HER2/neu oncogene, homolo-gous to the epidermal growth factor receptor (EGFr), is over-expressed in pancreatic cancers.310 This receptor is involved in signal transduction pathways that lead to cellular proliferation. Multiple tumor-suppressor genes are deleted and/or mutated in pancreatic cancer, including p53, p16, and DPC4 (Smad 4), and in a minority of cases, BRCA2.311 Most pancreatic cancers have three or more of the aforementioned mutations.The genetic landscape of pancreatic adenocarcinoma has recently been investigated using exome capture technol-ogy combined with the SOLiD or Illumina next generation sequencing platforms and copy number analysis. Detailed analysis of 99 tumors reaffirmed the importance of the already known mutations such as KRAS, TP53, CDKN2A, SMAD4, MLL3, TGFBR2, ARID1A, and SF3B1 in pancreatic cancer and identified eight novel | Surgery_Schwartz. suggesting that the presence of this mutation or others may provide the basis for diagnostic testing in select individuals. The HER2/neu oncogene, homolo-gous to the epidermal growth factor receptor (EGFr), is over-expressed in pancreatic cancers.310 This receptor is involved in signal transduction pathways that lead to cellular proliferation. Multiple tumor-suppressor genes are deleted and/or mutated in pancreatic cancer, including p53, p16, and DPC4 (Smad 4), and in a minority of cases, BRCA2.311 Most pancreatic cancers have three or more of the aforementioned mutations.The genetic landscape of pancreatic adenocarcinoma has recently been investigated using exome capture technol-ogy combined with the SOLiD or Illumina next generation sequencing platforms and copy number analysis. Detailed analysis of 99 tumors reaffirmed the importance of the already known mutations such as KRAS, TP53, CDKN2A, SMAD4, MLL3, TGFBR2, ARID1A, and SF3B1 in pancreatic cancer and identified eight novel |
Surgery_Schwartz_9791 | Surgery_Schwartz | analysis of 99 tumors reaffirmed the importance of the already known mutations such as KRAS, TP53, CDKN2A, SMAD4, MLL3, TGFBR2, ARID1A, and SF3B1 in pancreatic cancer and identified eight novel significantly mutated genes involved in chromatin modification (EPC1 and ARID2), DNA dam-age repair (ATM) and other mechanisms (ZIM2, MAP2K4, NALCN, SLC16A4, and MAGEA6). Pathway-based analysis of recurrently altered genes also revealed the involvement of axon-guidance genes, particularly SLIT/ROBO signaling, in pancreatic carcinogenesis.312 Rapid and sensitive sequencing techniques will hopefully lead to better diagnostic and thera-peutic approaches for pancreatic cancer.It is estimated that up to 10% of pancreatic cancers occur as a result of an inherited genetic predisposition. A family his-tory of pancreatic cancer in a first-degree relative increases the risk of pancreatic cancer by about twofold. Rare familial cancer syndromes that are associated with an increased risk of pancreatic | Surgery_Schwartz. analysis of 99 tumors reaffirmed the importance of the already known mutations such as KRAS, TP53, CDKN2A, SMAD4, MLL3, TGFBR2, ARID1A, and SF3B1 in pancreatic cancer and identified eight novel significantly mutated genes involved in chromatin modification (EPC1 and ARID2), DNA dam-age repair (ATM) and other mechanisms (ZIM2, MAP2K4, NALCN, SLC16A4, and MAGEA6). Pathway-based analysis of recurrently altered genes also revealed the involvement of axon-guidance genes, particularly SLIT/ROBO signaling, in pancreatic carcinogenesis.312 Rapid and sensitive sequencing techniques will hopefully lead to better diagnostic and thera-peutic approaches for pancreatic cancer.It is estimated that up to 10% of pancreatic cancers occur as a result of an inherited genetic predisposition. A family his-tory of pancreatic cancer in a first-degree relative increases the risk of pancreatic cancer by about twofold. Rare familial cancer syndromes that are associated with an increased risk of pancreatic |
Surgery_Schwartz_9792 | Surgery_Schwartz | of pancreatic cancer in a first-degree relative increases the risk of pancreatic cancer by about twofold. Rare familial cancer syndromes that are associated with an increased risk of pancreatic cancer include BRCA2, the familial atypical multiple mole–melanoma syndrome, hereditary pancreati-tis, familial adenomatous polyposis (FAP), hereditary non-polyposis colorectal cancer, Peutz-Jeghers syndrome, and ataxia-telangiectasia.311Pathology. Pancreatic cancer probably arises through a stepwise progression of cellular changes, just as colon cancer progresses by stages from hyperplastic polyp to invasive cancer. Systematic histologic evaluation of areas surrounding pancreatic cancers has revealed the presence of precursor lesions that have been named pancreatic intraepithelial neoplasia (Fig. 33-67). Three stages of pancreatic intraepithelial neoplasia have been defined. These lesions demonstrate the same oncogene mutations and loss of tumor-suppressor genes found in invasive cancers, the | Surgery_Schwartz. of pancreatic cancer in a first-degree relative increases the risk of pancreatic cancer by about twofold. Rare familial cancer syndromes that are associated with an increased risk of pancreatic cancer include BRCA2, the familial atypical multiple mole–melanoma syndrome, hereditary pancreati-tis, familial adenomatous polyposis (FAP), hereditary non-polyposis colorectal cancer, Peutz-Jeghers syndrome, and ataxia-telangiectasia.311Pathology. Pancreatic cancer probably arises through a stepwise progression of cellular changes, just as colon cancer progresses by stages from hyperplastic polyp to invasive cancer. Systematic histologic evaluation of areas surrounding pancreatic cancers has revealed the presence of precursor lesions that have been named pancreatic intraepithelial neoplasia (Fig. 33-67). Three stages of pancreatic intraepithelial neoplasia have been defined. These lesions demonstrate the same oncogene mutations and loss of tumor-suppressor genes found in invasive cancers, the |
Surgery_Schwartz_9793 | Surgery_Schwartz | 33-67). Three stages of pancreatic intraepithelial neoplasia have been defined. These lesions demonstrate the same oncogene mutations and loss of tumor-suppressor genes found in invasive cancers, the frequency of these abnormalities increasing with progressive cellular atypia and architectural disarray.313 The ability to detect these precursor lesions in humans at a stage where the cancer can still be prevented or cured is an important goal of current pancreatic cancer research.About two-thirds of pancreatic adenocarcinomas arise within the head or uncinate process of the pancreas; 15% are in the body, and 10% are in the tail, with the remaining tumors demonstrating diffuse involvement of the gland. Tumors in the pancreatic body and tail are generally larger at the time of diagnosis, and therefore, less commonly resectable. Tumors in the head of the pancreas are typically diagnosed earlier because they cause obstructive jaundice. Ampullary carci-nomas, carcinomas of the distal bile | Surgery_Schwartz. 33-67). Three stages of pancreatic intraepithelial neoplasia have been defined. These lesions demonstrate the same oncogene mutations and loss of tumor-suppressor genes found in invasive cancers, the frequency of these abnormalities increasing with progressive cellular atypia and architectural disarray.313 The ability to detect these precursor lesions in humans at a stage where the cancer can still be prevented or cured is an important goal of current pancreatic cancer research.About two-thirds of pancreatic adenocarcinomas arise within the head or uncinate process of the pancreas; 15% are in the body, and 10% are in the tail, with the remaining tumors demonstrating diffuse involvement of the gland. Tumors in the pancreatic body and tail are generally larger at the time of diagnosis, and therefore, less commonly resectable. Tumors in the head of the pancreas are typically diagnosed earlier because they cause obstructive jaundice. Ampullary carci-nomas, carcinomas of the distal bile |
Surgery_Schwartz_9794 | Surgery_Schwartz | therefore, less commonly resectable. Tumors in the head of the pancreas are typically diagnosed earlier because they cause obstructive jaundice. Ampullary carci-nomas, carcinomas of the distal bile duct, and periampullary duodenal adenocarcinomas present in a similar fashion to pan-creatic head cancer but have a slightly better prognosis, prob-ably because early obstruction of the bile duct and jaundice leads to the diagnosis.In addition to ductal adenocarcinoma, which makes up about 75% of nonendocrine cancers of the pancreas, there are a variety of less common types of pancreatic cancer. Adenosquamous carcinoma is a variant that has both glandular and squamous differentiation. The biologic behavior of this lesion is unfortunately no better than the typical ductal adenocarcinoma.314 Acinar cell carcinoma is an uncommon type of pancreatic cancer that usually presents as a large tumor, often 10 cm in diameter or more, but the prognosis of patients with these tumors may be better than | Surgery_Schwartz. therefore, less commonly resectable. Tumors in the head of the pancreas are typically diagnosed earlier because they cause obstructive jaundice. Ampullary carci-nomas, carcinomas of the distal bile duct, and periampullary duodenal adenocarcinomas present in a similar fashion to pan-creatic head cancer but have a slightly better prognosis, prob-ably because early obstruction of the bile duct and jaundice leads to the diagnosis.In addition to ductal adenocarcinoma, which makes up about 75% of nonendocrine cancers of the pancreas, there are a variety of less common types of pancreatic cancer. Adenosquamous carcinoma is a variant that has both glandular and squamous differentiation. The biologic behavior of this lesion is unfortunately no better than the typical ductal adenocarcinoma.314 Acinar cell carcinoma is an uncommon type of pancreatic cancer that usually presents as a large tumor, often 10 cm in diameter or more, but the prognosis of patients with these tumors may be better than |
Surgery_Schwartz_9795 | Surgery_Schwartz | cell carcinoma is an uncommon type of pancreatic cancer that usually presents as a large tumor, often 10 cm in diameter or more, but the prognosis of patients with these tumors may be better than with ductal cancer.Diagnosis and Staging. Exact pathologic staging of pancre-atic cancer is important because it allows accurate quantitative assessment of results and comparisons between institutions. The tumor-node-metastasis (TNM) staging of pancreatic cancer was updated by the American Joint Committee on Cancer in 2017 (AJCC) (Table 33-21).The important changes in the staging include more stratification for tumor size and stratification for number of lymph nodes involved. In the new system, tumors ≤2 cm remain as T1 lesions but are subcategorized as T1a (≤0.5 cm), T1b (>0.5–>1 cm), and T1c (1–2 cm). Tumors that are >2–≤4 cm are categorized as T2, and tumors >4 cm are categorized as T3. Tumors that involve the celiac axis, superior mesenteric artery, and/or common hepatic artery are still | Surgery_Schwartz. cell carcinoma is an uncommon type of pancreatic cancer that usually presents as a large tumor, often 10 cm in diameter or more, but the prognosis of patients with these tumors may be better than with ductal cancer.Diagnosis and Staging. Exact pathologic staging of pancre-atic cancer is important because it allows accurate quantitative assessment of results and comparisons between institutions. The tumor-node-metastasis (TNM) staging of pancreatic cancer was updated by the American Joint Committee on Cancer in 2017 (AJCC) (Table 33-21).The important changes in the staging include more stratification for tumor size and stratification for number of lymph nodes involved. In the new system, tumors ≤2 cm remain as T1 lesions but are subcategorized as T1a (≤0.5 cm), T1b (>0.5–>1 cm), and T1c (1–2 cm). Tumors that are >2–≤4 cm are categorized as T2, and tumors >4 cm are categorized as T3. Tumors that involve the celiac axis, superior mesenteric artery, and/or common hepatic artery are still |
Surgery_Schwartz_9796 | Surgery_Schwartz | cm). Tumors that are >2–≤4 cm are categorized as T2, and tumors >4 cm are categorized as T3. Tumors that involve the celiac axis, superior mesenteric artery, and/or common hepatic artery are still categorized as T4 regardless of size. Metastasis in one to three regional lymph nodes is considered N1 disease, and involvement of ≥4 regional lymph nodes is N2. Patients without nodal involvement (N0) are stages IA, IB, and IIA based on tumor size (T1–T3, respectively). Patients with one to three regional lymph nodes involved (N2) are stage IIB regardless of tumor size. All patients with N2 disease without distant metastases are considered stage III regardless of tumor size. Patients with vascular involvement (T4) are stage III regardless of nodal involvement, and patients with distant metastases are, of course, stage IV.Ten percent of pancreas cancer cases are diagnosed while the cancer is still confined to the primary site (localized stage); 29% are diagnosed after the cancer has spread | Surgery_Schwartz. cm). Tumors that are >2–≤4 cm are categorized as T2, and tumors >4 cm are categorized as T3. Tumors that involve the celiac axis, superior mesenteric artery, and/or common hepatic artery are still categorized as T4 regardless of size. Metastasis in one to three regional lymph nodes is considered N1 disease, and involvement of ≥4 regional lymph nodes is N2. Patients without nodal involvement (N0) are stages IA, IB, and IIA based on tumor size (T1–T3, respectively). Patients with one to three regional lymph nodes involved (N2) are stage IIB regardless of tumor size. All patients with N2 disease without distant metastases are considered stage III regardless of tumor size. Patients with vascular involvement (T4) are stage III regardless of nodal involvement, and patients with distant metastases are, of course, stage IV.Ten percent of pancreas cancer cases are diagnosed while the cancer is still confined to the primary site (localized stage); 29% are diagnosed after the cancer has spread |
Surgery_Schwartz_9797 | Surgery_Schwartz | are, of course, stage IV.Ten percent of pancreas cancer cases are diagnosed while the cancer is still confined to the primary site (localized stage); 29% are diagnosed after the cancer has spread to regional lymph nodes or directly beyond the primary site; 52% are diagnosed after the cancer has already metastasized (distant stage); and for the remaining 9%, the staging information was unknown. The corresponding 5-year relative survival rates were 31.5% for localized, 11.5% for regional, 2.7% for distant, and 5.1% for unstaged. The overall 5-year relative survival rate for patients with pancreatic cancer for 2007 to 2013 from Surveillance, Epidemiology, and End Results (SEER) was 8.2%.3077Brunicardi_Ch33_p1429-p1516.indd 148501/03/19 6:46 PM 1486SPECIFIC CONSIDERATIONSPART IINormalPanIN-1APanIN-1BPanIN-2KI-67, Topo˜˜°, 14-3-3˛p53, DPC4, BRCA2Cyclin D1MesothelinMucin 1Mucin 1p16PSCA, Mucin5, FascinTelomere K-rasshorteningPanIN-3InvasionABCDFigure 33-67. Pancreatic | Surgery_Schwartz. are, of course, stage IV.Ten percent of pancreas cancer cases are diagnosed while the cancer is still confined to the primary site (localized stage); 29% are diagnosed after the cancer has spread to regional lymph nodes or directly beyond the primary site; 52% are diagnosed after the cancer has already metastasized (distant stage); and for the remaining 9%, the staging information was unknown. The corresponding 5-year relative survival rates were 31.5% for localized, 11.5% for regional, 2.7% for distant, and 5.1% for unstaged. The overall 5-year relative survival rate for patients with pancreatic cancer for 2007 to 2013 from Surveillance, Epidemiology, and End Results (SEER) was 8.2%.3077Brunicardi_Ch33_p1429-p1516.indd 148501/03/19 6:46 PM 1486SPECIFIC CONSIDERATIONSPART IINormalPanIN-1APanIN-1BPanIN-2KI-67, Topo˜˜°, 14-3-3˛p53, DPC4, BRCA2Cyclin D1MesothelinMucin 1Mucin 1p16PSCA, Mucin5, FascinTelomere K-rasshorteningPanIN-3InvasionABCDFigure 33-67. Pancreatic |
Surgery_Schwartz_9798 | Surgery_Schwartz | Topo˜˜°, 14-3-3˛p53, DPC4, BRCA2Cyclin D1MesothelinMucin 1Mucin 1p16PSCA, Mucin5, FascinTelomere K-rasshorteningPanIN-3InvasionABCDFigure 33-67. Pancreatic intraepithelial neoplasia (PanIN). Histology (top panel) showing grades PanIN-1A (A), PanIN-1B (B), PanIN-2 (C), and PanIN-3 (D), and schema of correlation of histology with mutational events (bottom panel) showing cumulative abnormalities of tumor-promoter and tumor suppressor factors such as kRAS, p53, etc, and their corresponding cellular phenotype. (Reproduced with permis-sion from Hruban RH, Takaori K, Klimstra DS, et al: An illustrated consensus on the classification of pancreatic intraepithelial neoplasia and intraductal papillary mucinous neoplasms, Am J Surg Pathol. 2004 Aug;28(8):977-987.)The most critical deficit in the ability to treat pancreatic cancer effectively is the lack of tools for early diagnosis. The pancreas is situated deep within the abdomen, and the early symptoms of pancreatic cancer often are too | Surgery_Schwartz. Topo˜˜°, 14-3-3˛p53, DPC4, BRCA2Cyclin D1MesothelinMucin 1Mucin 1p16PSCA, Mucin5, FascinTelomere K-rasshorteningPanIN-3InvasionABCDFigure 33-67. Pancreatic intraepithelial neoplasia (PanIN). Histology (top panel) showing grades PanIN-1A (A), PanIN-1B (B), PanIN-2 (C), and PanIN-3 (D), and schema of correlation of histology with mutational events (bottom panel) showing cumulative abnormalities of tumor-promoter and tumor suppressor factors such as kRAS, p53, etc, and their corresponding cellular phenotype. (Reproduced with permis-sion from Hruban RH, Takaori K, Klimstra DS, et al: An illustrated consensus on the classification of pancreatic intraepithelial neoplasia and intraductal papillary mucinous neoplasms, Am J Surg Pathol. 2004 Aug;28(8):977-987.)The most critical deficit in the ability to treat pancreatic cancer effectively is the lack of tools for early diagnosis. The pancreas is situated deep within the abdomen, and the early symptoms of pancreatic cancer often are too |
Surgery_Schwartz_9799 | Surgery_Schwartz | ability to treat pancreatic cancer effectively is the lack of tools for early diagnosis. The pancreas is situated deep within the abdomen, and the early symptoms of pancreatic cancer often are too vague to raise sus-picion of the disease. Ultimately, the majority of patients present with pain and jaundice. On physical examination, weight loss is evident and the skin is icteric; a distended gallbladder is palpa-ble in about one-fourth of patients. More fortunate patients have tumors situated such that biliary obstruction and jaundice occurs early and prompts diagnostic tests. Unfortunately, however, the vast majority of patients are not diagnosed until weight loss has occurred—a sign of advanced disease.Although it is often taught that carcinoma of the pancreas presents with painless jaundice (to help distinguish it from cho-ledocholithiasis), this aphorism is not accurate. Most patients do experience pain as part of the symptom complex of pancreatic cancer, and it is often the first | Surgery_Schwartz. ability to treat pancreatic cancer effectively is the lack of tools for early diagnosis. The pancreas is situated deep within the abdomen, and the early symptoms of pancreatic cancer often are too vague to raise sus-picion of the disease. Ultimately, the majority of patients present with pain and jaundice. On physical examination, weight loss is evident and the skin is icteric; a distended gallbladder is palpa-ble in about one-fourth of patients. More fortunate patients have tumors situated such that biliary obstruction and jaundice occurs early and prompts diagnostic tests. Unfortunately, however, the vast majority of patients are not diagnosed until weight loss has occurred—a sign of advanced disease.Although it is often taught that carcinoma of the pancreas presents with painless jaundice (to help distinguish it from cho-ledocholithiasis), this aphorism is not accurate. Most patients do experience pain as part of the symptom complex of pancreatic cancer, and it is often the first |
Surgery_Schwartz_9800 | Surgery_Schwartz | (to help distinguish it from cho-ledocholithiasis), this aphorism is not accurate. Most patients do experience pain as part of the symptom complex of pancreatic cancer, and it is often the first symptom. Therefore, awareness of the way pancreatic pain is perceived may help clinicians sus-pect pancreatic cancer. The pain associated with pancreatic can-cer is usually perceived in the epigastrium but can occur in any Brunicardi_Ch33_p1429-p1516.indd 148601/03/19 6:46 PM 1487PANCREASCHAPTER 33the serum of patients with pancreatic cancer. Serum levels are elevated in about 75% of patients with pancreatic cancer. How-ever, CA19-9 is also elevated in about 10% of patients with benign diseases of the pancreas, liver, and bile ducts.15 CA19-9 is thus neither sufficiently sensitive nor specific to allow an early diagnosis of pancreatic cancer. Despite the fact that many tumor markers such as CA19-9 have been studied, there are still no effective screening tests for pancreatic cancer. | Surgery_Schwartz. (to help distinguish it from cho-ledocholithiasis), this aphorism is not accurate. Most patients do experience pain as part of the symptom complex of pancreatic cancer, and it is often the first symptom. Therefore, awareness of the way pancreatic pain is perceived may help clinicians sus-pect pancreatic cancer. The pain associated with pancreatic can-cer is usually perceived in the epigastrium but can occur in any Brunicardi_Ch33_p1429-p1516.indd 148601/03/19 6:46 PM 1487PANCREASCHAPTER 33the serum of patients with pancreatic cancer. Serum levels are elevated in about 75% of patients with pancreatic cancer. How-ever, CA19-9 is also elevated in about 10% of patients with benign diseases of the pancreas, liver, and bile ducts.15 CA19-9 is thus neither sufficiently sensitive nor specific to allow an early diagnosis of pancreatic cancer. Despite the fact that many tumor markers such as CA19-9 have been studied, there are still no effective screening tests for pancreatic cancer. |
Surgery_Schwartz_9801 | Surgery_Schwartz | to allow an early diagnosis of pancreatic cancer. Despite the fact that many tumor markers such as CA19-9 have been studied, there are still no effective screening tests for pancreatic cancer. Research tak-ing advantage of recent advances in genomics, gene expression analysis, and proteomics has demonstrated thousands of genes and corresponding proteins that are differentially expressed in pancreatic tumors that have potential for early detection of pan-creatic cancer.316 Some of these proteins would be expected to be expressed at the cell surface or in pancreatic juice and may become useful as biomarkers for pancreatic cancer in the future.In patients presenting with jaundice, a reasonable first diagnostic imaging study is abdominal ultrasound. If bile duct dilation is not seen, hepatocellular disease is likely. Demonstra-tion of cholelithiasis and bile duct dilation suggests a diagnosis of choledocholithiasis, and the next logical step would be ERCP to clear the bile duct. In the | Surgery_Schwartz. to allow an early diagnosis of pancreatic cancer. Despite the fact that many tumor markers such as CA19-9 have been studied, there are still no effective screening tests for pancreatic cancer. Research tak-ing advantage of recent advances in genomics, gene expression analysis, and proteomics has demonstrated thousands of genes and corresponding proteins that are differentially expressed in pancreatic tumors that have potential for early detection of pan-creatic cancer.316 Some of these proteins would be expected to be expressed at the cell surface or in pancreatic juice and may become useful as biomarkers for pancreatic cancer in the future.In patients presenting with jaundice, a reasonable first diagnostic imaging study is abdominal ultrasound. If bile duct dilation is not seen, hepatocellular disease is likely. Demonstra-tion of cholelithiasis and bile duct dilation suggests a diagnosis of choledocholithiasis, and the next logical step would be ERCP to clear the bile duct. In the |
Subsets and Splits
No saved queries yet
Save your SQL queries to embed, download, and access them later. Queries will appear here once saved.