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Surgery_Schwartz_9802 | Surgery_Schwartz | 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 absence of gallstones, malignant obstruction of the bile duct is likely, and a CT scan rather than ERCP would be the next logical step. For patients suspected of having pancreatic cancer who present without jaundice, a CT scan should be the first test.The current diagnostic and staging test of choice for pan-creatic cancer is a multidetector, dynamic, contrast-enhanced CT scan, and the techniques for obtaining high-quality images are constantly improving (Fig. 33-68). The accuracy of CT scan-ning for predicting unresectable disease is about 90% to 95%.317 In contrast, CT scanning is less accurate in predicting resect-able disease. CT scanning will miss small liver metastases, and predicting arterial involvement is sometimes difficult. CT find-ings that indicate a tumor is unresectable include | Surgery_Schwartz. 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 absence of gallstones, malignant obstruction of the bile duct is likely, and a CT scan rather than ERCP would be the next logical step. For patients suspected of having pancreatic cancer who present without jaundice, a CT scan should be the first test.The current diagnostic and staging test of choice for pan-creatic cancer is a multidetector, dynamic, contrast-enhanced CT scan, and the techniques for obtaining high-quality images are constantly improving (Fig. 33-68). The accuracy of CT scan-ning for predicting unresectable disease is about 90% to 95%.317 In contrast, CT scanning is less accurate in predicting resect-able disease. CT scanning will miss small liver metastases, and predicting arterial involvement is sometimes difficult. CT find-ings that indicate a tumor is unresectable include |
Surgery_Schwartz_9803 | Surgery_Schwartz | in predicting resect-able disease. CT scanning will miss small liver metastases, and predicting arterial involvement is sometimes difficult. CT find-ings that indicate a tumor is unresectable include involvement of ≥180° of the celiac axis, hepatic or superior mesenteric artery, enlarged lymph nodes outside the boundaries of resection, asci-tes, and distant metastases (e.g., liver). Invasion of the superior mesenteric vein or portal vein is not in itself a contraindication to resection as long as the veins are patent. Tumors are consid-ered “borderline resectable” if there is abutment of ≤180 degrees of the circumference of the SMA, celiac axis, or hepatic artery or if there is a short segment of vein occlusion. Also, patients with CT findings suspicious for metastatic disease, like 1 mm liver lesions too small to characterize or biopsy, are considered “borderline resectable” as are patients with multiple comorbidi-ties or marginal performance status. There is growing consensus that | Surgery_Schwartz. in predicting resect-able disease. CT scanning will miss small liver metastases, and predicting arterial involvement is sometimes difficult. CT find-ings that indicate a tumor is unresectable include involvement of ≥180° of the celiac axis, hepatic or superior mesenteric artery, enlarged lymph nodes outside the boundaries of resection, asci-tes, and distant metastases (e.g., liver). Invasion of the superior mesenteric vein or portal vein is not in itself a contraindication to resection as long as the veins are patent. Tumors are consid-ered “borderline resectable” if there is abutment of ≤180 degrees of the circumference of the SMA, celiac axis, or hepatic artery or if there is a short segment of vein occlusion. Also, patients with CT findings suspicious for metastatic disease, like 1 mm liver lesions too small to characterize or biopsy, are considered “borderline resectable” as are patients with multiple comorbidi-ties or marginal performance status. There is growing consensus that |
Surgery_Schwartz_9804 | Surgery_Schwartz | liver lesions too small to characterize or biopsy, are considered “borderline resectable” as are patients with multiple comorbidi-ties or marginal performance status. There is growing consensus that neoadjuvant treatment should be considered in all patients with any radiographic evidence of extension to adjacent vascu-lar structures.Currently, multidetector CT is probably the single most versatile and cost-effective tool for the diagnosis and staging of pancreatic cancer. Abdominal MRI provides essentially the same information as CT scanning. Positron emission tomog-raphy scanning in locally advanced lesions may help rule out distant metastases. EUS can be used to detect small pancreatic masses that could be missed by CT scanning and is commonly used when there is a high suspicion for pancreatic cancer but no mass is identified by the CT scan. EUS has the added advan-tage of providing the opportunity for transluminal biopsy of pancreatic masses, although a tissue diagnosis before | Surgery_Schwartz. liver lesions too small to characterize or biopsy, are considered “borderline resectable” as are patients with multiple comorbidi-ties or marginal performance status. There is growing consensus that neoadjuvant treatment should be considered in all patients with any radiographic evidence of extension to adjacent vascu-lar structures.Currently, multidetector CT is probably the single most versatile and cost-effective tool for the diagnosis and staging of pancreatic cancer. Abdominal MRI provides essentially the same information as CT scanning. Positron emission tomog-raphy scanning in locally advanced lesions may help rule out distant metastases. EUS can be used to detect small pancreatic masses that could be missed by CT scanning and is commonly used when there is a high suspicion for pancreatic cancer but no mass is identified by the CT scan. EUS has the added advan-tage of providing the opportunity for transluminal biopsy of pancreatic masses, although a tissue diagnosis before |
Surgery_Schwartz_9805 | Surgery_Schwartz | pancreatic cancer but no mass is identified by the CT scan. EUS has the added advan-tage of providing the opportunity for transluminal biopsy of pancreatic masses, although a tissue diagnosis before pancreati-coduodenectomy is not required. However, in specific patients a histologic diagnosis may be necessary such as for those in a part of the abdomen, and often, but not always, penetrates to the back. When questioned in retrospect, patients often recall mild and vague pain for many months before diagnosis. A low thresh-old for ordering a CT scan with “pancreatic protocol” should be maintained for elderly patients with unex-plained, persistent, although vague, abdominal pain. As men-tioned previously, new-onset diabetes in an elderly patient, especially if combined with vague abdominal pain, should prompt a search for pancreatic cancer.Unfortunately, at this time there is no sensitive and spe-cific serum marker to assist in the timely diagnosis of pan-creatic cancer. With jaundice, | Surgery_Schwartz. pancreatic cancer but no mass is identified by the CT scan. EUS has the added advan-tage of providing the opportunity for transluminal biopsy of pancreatic masses, although a tissue diagnosis before pancreati-coduodenectomy is not required. However, in specific patients a histologic diagnosis may be necessary such as for those in a part of the abdomen, and often, but not always, penetrates to the back. When questioned in retrospect, patients often recall mild and vague pain for many months before diagnosis. A low thresh-old for ordering a CT scan with “pancreatic protocol” should be maintained for elderly patients with unex-plained, persistent, although vague, abdominal pain. As men-tioned previously, new-onset diabetes in an elderly patient, especially if combined with vague abdominal pain, should prompt a search for pancreatic cancer.Unfortunately, at this time there is no sensitive and spe-cific serum marker to assist in the timely diagnosis of pan-creatic cancer. With jaundice, |
Surgery_Schwartz_9806 | Surgery_Schwartz | pain, should prompt a search for pancreatic cancer.Unfortunately, at this time there is no sensitive and spe-cific serum marker to assist in the timely diagnosis of pan-creatic cancer. With jaundice, direct hyperbilirubinemia and elevated alkaline phosphatase are expected but do not serve much of a diagnostic role other than to confirm the obvious. With long-standing biliary obstruction, the prothrombin time will be prolonged due to a depletion of vitamin K, a fat-soluble vitamin dependent on bile flow for absorption. CA19-9 is a mucin-associated carbohydrate antigen that can be detected in 8Table 33-21Staging of pancreatic cancerTumor (T)TXTumor cannot be assessedT1Tumor limited to the pancreas,* <2 cmT2Tumor limited to the pancreas,* 2–4 cmT3Tumor limited to the pancreas,* >4 cm; or tumor invading the duodenum or common bile ductT4Tumor invading adjacent organs (stomach, spleen, colon, adrenal gland) or the wall of large vessels (celiac axis or the superior mesenteric | Surgery_Schwartz. pain, should prompt a search for pancreatic cancer.Unfortunately, at this time there is no sensitive and spe-cific serum marker to assist in the timely diagnosis of pan-creatic cancer. With jaundice, direct hyperbilirubinemia and elevated alkaline phosphatase are expected but do not serve much of a diagnostic role other than to confirm the obvious. With long-standing biliary obstruction, the prothrombin time will be prolonged due to a depletion of vitamin K, a fat-soluble vitamin dependent on bile flow for absorption. CA19-9 is a mucin-associated carbohydrate antigen that can be detected in 8Table 33-21Staging of pancreatic cancerTumor (T)TXTumor cannot be assessedT1Tumor limited to the pancreas,* <2 cmT2Tumor limited to the pancreas,* 2–4 cmT3Tumor limited to the pancreas,* >4 cm; or tumor invading the duodenum or common bile ductT4Tumor invading adjacent organs (stomach, spleen, colon, adrenal gland) or the wall of large vessels (celiac axis or the superior mesenteric |
Surgery_Schwartz_9807 | Surgery_Schwartz | >4 cm; or tumor invading the duodenum or common bile ductT4Tumor invading adjacent organs (stomach, spleen, colon, adrenal gland) or the wall of large vessels (celiac axis or the superior mesenteric artery)Regional Lymph Node (N)NXRegional lymph nodes cannot be assessedN0No regional lymph node involvementN1Regional lymph node involvementDistant Metastasis (M)M0No distant metastasisM1Distant metastasis M1aMetastasis confined to liver M1bMetastases in at least one extrahepatic site (e.g., lung, ovary, nonregional lymph node, peritoneum, bone) M1cBoth hepatic and extrahepatic metastasesTUMORNODEMETASTASISSTAGET1N0M0IT2N0M0IIT3N0M0IIT4N0M0IIIAny TN1M0IIIAny TAny NM1IVUsed with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Brunicardi_Ch33_p1429-p1516.indd 148701/03/19 6:46 PM 1488SPECIFIC CONSIDERATIONSPART IIPortal veinStomachHepaticarteryCeliac axisSplenic veinDilated | Surgery_Schwartz. >4 cm; or tumor invading the duodenum or common bile ductT4Tumor invading adjacent organs (stomach, spleen, colon, adrenal gland) or the wall of large vessels (celiac axis or the superior mesenteric artery)Regional Lymph Node (N)NXRegional lymph nodes cannot be assessedN0No regional lymph node involvementN1Regional lymph node involvementDistant Metastasis (M)M0No distant metastasisM1Distant metastasis M1aMetastasis confined to liver M1bMetastases in at least one extrahepatic site (e.g., lung, ovary, nonregional lymph node, peritoneum, bone) M1cBoth hepatic and extrahepatic metastasesTUMORNODEMETASTASISSTAGET1N0M0IT2N0M0IIT3N0M0IIT4N0M0IIIAny TN1M0IIIAny TAny NM1IVUsed with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Brunicardi_Ch33_p1429-p1516.indd 148701/03/19 6:46 PM 1488SPECIFIC CONSIDERATIONSPART IIPortal veinStomachHepaticarteryCeliac axisSplenic veinDilated |
Surgery_Schwartz_9808 | Surgery_Schwartz | Manual, 8th Ed. Springer New York, 2017.Brunicardi_Ch33_p1429-p1516.indd 148701/03/19 6:46 PM 1488SPECIFIC CONSIDERATIONSPART IIPortal veinStomachHepaticarteryCeliac axisSplenic veinDilated pancreatic ductin body of pancreasGallbladderPortal veinPortal veinVena cavaDilated bile ductwith stentBody of pancreasGallbladderSplenoportalconfluenceDuodenumMass in headof pancreasMass in head,uncinate processof pancreasSMASMASMADuodenumBile duct stentFat plane between massin head of pancreasand portal veinFigure 33-68. Computed tomography scan demonstrating resectable pancreatic cancer. SMA = superior mesenteric artery.neoadjuvant clinical trial or before chemotherapy in advanced tumors. EUS is a sensitive test for portal/superior mesenteric vein invasion, although it is somewhat less effective at detect-ing superior mesenteric artery invasion. When all of the current staging modalities are used, their accuracy in predicting resect-ability has improved.As imaging continuously improves and | Surgery_Schwartz. Manual, 8th Ed. Springer New York, 2017.Brunicardi_Ch33_p1429-p1516.indd 148701/03/19 6:46 PM 1488SPECIFIC CONSIDERATIONSPART IIPortal veinStomachHepaticarteryCeliac axisSplenic veinDilated pancreatic ductin body of pancreasGallbladderPortal veinPortal veinVena cavaDilated bile ductwith stentBody of pancreasGallbladderSplenoportalconfluenceDuodenumMass in headof pancreasMass in head,uncinate processof pancreasSMASMASMADuodenumBile duct stentFat plane between massin head of pancreasand portal veinFigure 33-68. Computed tomography scan demonstrating resectable pancreatic cancer. SMA = superior mesenteric artery.neoadjuvant clinical trial or before chemotherapy in advanced tumors. EUS is a sensitive test for portal/superior mesenteric vein invasion, although it is somewhat less effective at detect-ing superior mesenteric artery invasion. When all of the current staging modalities are used, their accuracy in predicting resect-ability has improved.As imaging continuously improves and |
Surgery_Schwartz_9809 | Surgery_Schwartz | at detect-ing superior mesenteric artery invasion. When all of the current staging modalities are used, their accuracy in predicting resect-ability has improved.As imaging continuously improves and high-quality imag-ing is always obtained before surgery, the chance of bringing a patient to the operating room with the intent of a curative resec-tion and finding upon exploration that the patient has unresect-able disease is becoming increasingly uncommon.In an attempt to avoid such futile laparotomies, prelimi-nary laparoscopy has been advocated for patients with disease felt to be resectable by CT imaging (Fig. 33-69). Diagnostic laparoscopy with the use of US is reported to improve the accu-racy of predicting resectability to about 98%.318 The technique involves more than simple visualization with the scope and requires the placement of multiple ports and manipulation of the tissues. A general exploration of the peritoneal surfaces is carried out. The ligament of Treitz and the base | Surgery_Schwartz. at detect-ing superior mesenteric artery invasion. When all of the current staging modalities are used, their accuracy in predicting resect-ability has improved.As imaging continuously improves and high-quality imag-ing is always obtained before surgery, the chance of bringing a patient to the operating room with the intent of a curative resec-tion and finding upon exploration that the patient has unresect-able disease is becoming increasingly uncommon.In an attempt to avoid such futile laparotomies, prelimi-nary laparoscopy has been advocated for patients with disease felt to be resectable by CT imaging (Fig. 33-69). Diagnostic laparoscopy with the use of US is reported to improve the accu-racy of predicting resectability to about 98%.318 The technique involves more than simple visualization with the scope and requires the placement of multiple ports and manipulation of the tissues. A general exploration of the peritoneal surfaces is carried out. The ligament of Treitz and the base |
Surgery_Schwartz_9810 | Surgery_Schwartz | with the scope and requires the placement of multiple ports and manipulation of the tissues. A general exploration of the peritoneal surfaces is carried out. The ligament of Treitz and the base of the transverse mesocolon are examined for tumor. The gastrocolic ligament is incised, and the lesser sac is examined. The ultrasound probe is used to examine the liver, porta hepatis and the portal vein, the celiac axis, and the superior mesenteric artery.The percentage of patients in whom a positive laparoscopy helps avoid a nontherapeutic laparotomy varies from 10% to 30% in carcinoma of the head of the pancreas, but it may be as high as 50% in patients with tumors in the body and tail of the gland. Resection for pancreatic cancer is being approached laparoscopically, particularly for tumors in the body and tail of the pancreas thus eliminating the need for any separate stag-ing laparoscopy procedure. Also, as the quality of CT scanning has improved, the value of routine diagnostic | Surgery_Schwartz. with the scope and requires the placement of multiple ports and manipulation of the tissues. A general exploration of the peritoneal surfaces is carried out. The ligament of Treitz and the base of the transverse mesocolon are examined for tumor. The gastrocolic ligament is incised, and the lesser sac is examined. The ultrasound probe is used to examine the liver, porta hepatis and the portal vein, the celiac axis, and the superior mesenteric artery.The percentage of patients in whom a positive laparoscopy helps avoid a nontherapeutic laparotomy varies from 10% to 30% in carcinoma of the head of the pancreas, but it may be as high as 50% in patients with tumors in the body and tail of the gland. Resection for pancreatic cancer is being approached laparoscopically, particularly for tumors in the body and tail of the pancreas thus eliminating the need for any separate stag-ing laparoscopy procedure. Also, as the quality of CT scanning has improved, the value of routine diagnostic |
Surgery_Schwartz_9811 | Surgery_Schwartz | in the body and tail of the pancreas thus eliminating the need for any separate stag-ing laparoscopy procedure. Also, as the quality of CT scanning has improved, the value of routine diagnostic laparoscopy has decreased. The morbidity of diagnostic laparoscopy is less than that of laparotomy, and the procedure can be performed on an outpatient basis. Patients who are found to have unresectable disease recover more rapidly from a laparoscopy than a lapa-rotomy and can receive palliative chemotherapy and radiation sooner. The potential immunosuppressive effects of a major surgical procedure also are avoided, as well as the negative psy-chologic impact of a major painful operation with little benefit.Biliary obstruction can be relieved with an endoscopic approach in almost all cases. When large (10F) plastic stents are used, most patients do not require replacement for about 3 months. Metallic wall stents last about 5 months on average and usually fail only with tumor ingrowth.319 | Surgery_Schwartz. in the body and tail of the pancreas thus eliminating the need for any separate stag-ing laparoscopy procedure. Also, as the quality of CT scanning has improved, the value of routine diagnostic laparoscopy has decreased. The morbidity of diagnostic laparoscopy is less than that of laparotomy, and the procedure can be performed on an outpatient basis. Patients who are found to have unresectable disease recover more rapidly from a laparoscopy than a lapa-rotomy and can receive palliative chemotherapy and radiation sooner. The potential immunosuppressive effects of a major surgical procedure also are avoided, as well as the negative psy-chologic impact of a major painful operation with little benefit.Biliary obstruction can be relieved with an endoscopic approach in almost all cases. When large (10F) plastic stents are used, most patients do not require replacement for about 3 months. Metallic wall stents last about 5 months on average and usually fail only with tumor ingrowth.319 |
Surgery_Schwartz_9812 | Surgery_Schwartz | large (10F) plastic stents are used, most patients do not require replacement for about 3 months. Metallic wall stents last about 5 months on average and usually fail only with tumor ingrowth.319 Keeping in mind that patients with unresectable pancreatic cancer usually live <1 year, the requirement for numerous stent changes is unlikely.Diagnostic laparoscopy is possibly best applied to patients with pancreatic cancer on a selective basis. Diagnostic laparos-copy will have a higher yield in patients with large tumors (T3, Figure 33-69. Liver metastases identified at diagnostic laparoscopy.Brunicardi_Ch33_p1429-p1516.indd 148801/03/19 6:46 PM 1489PANCREASCHAPTER 33>4 cm), tumors located in the body or tail, patients with equivo-cal findings of metastasis or ascites on CT scan, and patients with other indications of advanced disease such as marked weight loss or markedly elevated CA19-9 (>1000 U/mL). An algorithm for the diagnosis, staging, and treatment of pan-creatic cancer is | Surgery_Schwartz. large (10F) plastic stents are used, most patients do not require replacement for about 3 months. Metallic wall stents last about 5 months on average and usually fail only with tumor ingrowth.319 Keeping in mind that patients with unresectable pancreatic cancer usually live <1 year, the requirement for numerous stent changes is unlikely.Diagnostic laparoscopy is possibly best applied to patients with pancreatic cancer on a selective basis. Diagnostic laparos-copy will have a higher yield in patients with large tumors (T3, Figure 33-69. Liver metastases identified at diagnostic laparoscopy.Brunicardi_Ch33_p1429-p1516.indd 148801/03/19 6:46 PM 1489PANCREASCHAPTER 33>4 cm), tumors located in the body or tail, patients with equivo-cal findings of metastasis or ascites on CT scan, and patients with other indications of advanced disease such as marked weight loss or markedly elevated CA19-9 (>1000 U/mL). An algorithm for the diagnosis, staging, and treatment of pan-creatic cancer is |
Surgery_Schwartz_9813 | Surgery_Schwartz | with other indications of advanced disease such as marked weight loss or markedly elevated CA19-9 (>1000 U/mL). An algorithm for the diagnosis, staging, and treatment of pan-creatic cancer is shown in Fig. 33-70. In practice, many of these patients are selected for neoadjuvant chemotherapy and then undergo restaging CT and staging laparoscopy prior to surgery.Palliative Surgery and Endoscopy. Most patients with pan-creatic cancer (85–90%) have disease that clearly precludes surgical resection. For these patients, appropriate and effective palliative treatment is critical to the quality of their remaining life. Because of the poor prognosis of the disease, it is not appro-priate to use invasive, toxic, and expensive regimens in patients with extremely advanced disease and poor performance status. When patients do desire antineoplastic therapy, it is important to encourage them to enroll in clinical trials so that therapeutic advances can be made. In general, there are three clinical | Surgery_Schwartz. with other indications of advanced disease such as marked weight loss or markedly elevated CA19-9 (>1000 U/mL). An algorithm for the diagnosis, staging, and treatment of pan-creatic cancer is shown in Fig. 33-70. In practice, many of these patients are selected for neoadjuvant chemotherapy and then undergo restaging CT and staging laparoscopy prior to surgery.Palliative Surgery and Endoscopy. Most patients with pan-creatic cancer (85–90%) have disease that clearly precludes surgical resection. For these patients, appropriate and effective palliative treatment is critical to the quality of their remaining life. Because of the poor prognosis of the disease, it is not appro-priate to use invasive, toxic, and expensive regimens in patients with extremely advanced disease and poor performance status. When patients do desire antineoplastic therapy, it is important to encourage them to enroll in clinical trials so that therapeutic advances can be made. In general, there are three clinical |
Surgery_Schwartz_9814 | Surgery_Schwartz | status. When patients do desire antineoplastic therapy, it is important to encourage them to enroll in clinical trials so that therapeutic advances can be made. In general, there are three clinical prob-lems in advanced pancreatic cancer that require palliation: pain, jaundice, and duodenal obstruction. The mainstay of pain con-trol is oral narcotics. Sustained-release preparations of morphine sulfate are frequently used. Invasion of retroperitoneal nerve trunks accounts for the severe pain experienced by patients with advanced pancreatic cancer. A celiac plexus nerve block can control pain effectively for a period of months, although the procedure sometimes needs to be repeated.320Jaundice is present in the majority of patients with pan-creatic cancer, and the most troublesome aspect for the patient is the accompanying pruritus. Biliary obstruction may also lead to cholangitis, coagulopathy, digestive symptoms, and hepato-cellular failure. In the past, surgeons traditionally | Surgery_Schwartz. status. When patients do desire antineoplastic therapy, it is important to encourage them to enroll in clinical trials so that therapeutic advances can be made. In general, there are three clinical prob-lems in advanced pancreatic cancer that require palliation: pain, jaundice, and duodenal obstruction. The mainstay of pain con-trol is oral narcotics. Sustained-release preparations of morphine sulfate are frequently used. Invasion of retroperitoneal nerve trunks accounts for the severe pain experienced by patients with advanced pancreatic cancer. A celiac plexus nerve block can control pain effectively for a period of months, although the procedure sometimes needs to be repeated.320Jaundice is present in the majority of patients with pan-creatic cancer, and the most troublesome aspect for the patient is the accompanying pruritus. Biliary obstruction may also lead to cholangitis, coagulopathy, digestive symptoms, and hepato-cellular failure. In the past, surgeons traditionally |
Surgery_Schwartz_9815 | Surgery_Schwartz | for the patient is the accompanying pruritus. Biliary obstruction may also lead to cholangitis, coagulopathy, digestive symptoms, and hepato-cellular failure. In the past, surgeons traditionally performed a biliary and enteric bypass when unresectable disease was found at laparotomy. This is an increasingly uncommon situation for the surgeon because locally advanced unresectable disease is now detected by high-quality preoperative imaging. Metastatic disease is also more reliably predicted by preoperative imaging and, in select cases, staging laparoscopy.In current practice, jaundice is usually palliated by an endoscopic biliary stent, often prior to surgical referral. Duo-denal obstruction is usually a late event in pancreatic cancer and occurs in only about 20% of patients.321 In cases of biliary and duodenal obstruction, several options need to be consid-ered. Endoscopic metallic duodenal stents are an option, but the patient’s poor prognosis, the cost, and the fact that duodenal | Surgery_Schwartz. for the patient is the accompanying pruritus. Biliary obstruction may also lead to cholangitis, coagulopathy, digestive symptoms, and hepato-cellular failure. In the past, surgeons traditionally performed a biliary and enteric bypass when unresectable disease was found at laparotomy. This is an increasingly uncommon situation for the surgeon because locally advanced unresectable disease is now detected by high-quality preoperative imaging. Metastatic disease is also more reliably predicted by preoperative imaging and, in select cases, staging laparoscopy.In current practice, jaundice is usually palliated by an endoscopic biliary stent, often prior to surgical referral. Duo-denal obstruction is usually a late event in pancreatic cancer and occurs in only about 20% of patients.321 In cases of biliary and duodenal obstruction, several options need to be consid-ered. Endoscopic metallic duodenal stents are an option, but the patient’s poor prognosis, the cost, and the fact that duodenal |
Surgery_Schwartz_9816 | Surgery_Schwartz | of biliary and duodenal obstruction, several options need to be consid-ered. Endoscopic metallic duodenal stents are an option, but the patient’s poor prognosis, the cost, and the fact that duodenal stents often do not result in ideal palliation has to be considered. The results of three RCTs examining endoscopic metallic stent-ing for malignant gastric outlet obstruction demonstrated that major and minor complications were comparable to gastrojeju-nostomy but time to tolerating oral intake and hospital stay was shorter.322 Robot-assisted laparoscopic biliary-enteric bypass is now available at many centers. Although this should result in similar palliation as an open bypass and may be associated with more rapid recovery, the potential complications, the patient’s life expectancy, and cost of this procedure must be considered. As many patients today already have a bile duct stent in place by the time of referral to a surgeon, it is not clear that operative biliary bypass is required. | Surgery_Schwartz. of biliary and duodenal obstruction, several options need to be consid-ered. Endoscopic metallic duodenal stents are an option, but the patient’s poor prognosis, the cost, and the fact that duodenal stents often do not result in ideal palliation has to be considered. The results of three RCTs examining endoscopic metallic stent-ing for malignant gastric outlet obstruction demonstrated that major and minor complications were comparable to gastrojeju-nostomy but time to tolerating oral intake and hospital stay was shorter.322 Robot-assisted laparoscopic biliary-enteric bypass is now available at many centers. Although this should result in similar palliation as an open bypass and may be associated with more rapid recovery, the potential complications, the patient’s life expectancy, and cost of this procedure must be considered. As many patients today already have a bile duct stent in place by the time of referral to a surgeon, it is not clear that operative biliary bypass is required. |
Surgery_Schwartz_9817 | Surgery_Schwartz | of this procedure must be considered. As many patients today already have a bile duct stent in place by the time of referral to a surgeon, it is not clear that operative biliary bypass is required. In patients with extensive metastases, an alternative short-term palliative option to consider in patients with gastric outlet obstruction is a percutaneous endoscopic gas-trostomy tube or gastrojejunal feeding tube that allows decom-pression of the stomach and feeding into the jejunum.If an operative bypass is performed, choledochojejunos-tomy is the preferred approach. Although an easy procedure to perform, choledochoduodenostomy is felt to be unwise because of the proximity of the duodenum to tumor. Some have discour-aged the use of the gallbladder for biliary bypass; however, it CT scanQuad phaseMultidetectorFine cutsUnresectablemassCT or EUSguided biopsyClinicaltrialResectable massNo mass butsuspicion remainsClinical trialDiagnosticlaparoscopy(selective)EUS | Surgery_Schwartz. of this procedure must be considered. As many patients today already have a bile duct stent in place by the time of referral to a surgeon, it is not clear that operative biliary bypass is required. In patients with extensive metastases, an alternative short-term palliative option to consider in patients with gastric outlet obstruction is a percutaneous endoscopic gas-trostomy tube or gastrojejunal feeding tube that allows decom-pression of the stomach and feeding into the jejunum.If an operative bypass is performed, choledochojejunos-tomy is the preferred approach. Although an easy procedure to perform, choledochoduodenostomy is felt to be unwise because of the proximity of the duodenum to tumor. Some have discour-aged the use of the gallbladder for biliary bypass; however, it CT scanQuad phaseMultidetectorFine cutsUnresectablemassCT or EUSguided biopsyClinicaltrialResectable massNo mass butsuspicion remainsClinical trialDiagnosticlaparoscopy(selective)EUS |
Surgery_Schwartz_9818 | Surgery_Schwartz | however, it CT scanQuad phaseMultidetectorFine cutsUnresectablemassCT or EUSguided biopsyClinicaltrialResectable massNo mass butsuspicion remainsClinical trialDiagnosticlaparoscopy(selective)EUS biopsydiagnosticlaparoscopyNeoadjuvantclinicaltrialERCP / EUSObserve/reimageWhippleprocedureFigure 33-70. Diagnostic and treatment algorithm for pancreatic cancer. If computed tomography (CT) scan demonstrates a potentially resectable tumor, patients are offered participation in a clinical trial after histologic confirmation by CT or endoscopic ultrasound (EUS)-guided biopsy. If CT scan demonstrates resectable disease, diagnostic laparoscopy is used selectively in patients with tumors in the body/tail, equivocal findings of metastasis or CT scan, ascites, high CA19-9, or marked weight loss. Patients also have diagnostic laparoscopy if they elect to participate in a neoadjuvant clinical trial. In cases where no mass is demonstrated on CT scan, but suspicion of cancer remains, EUS or endoscopic | Surgery_Schwartz. however, it CT scanQuad phaseMultidetectorFine cutsUnresectablemassCT or EUSguided biopsyClinicaltrialResectable massNo mass butsuspicion remainsClinical trialDiagnosticlaparoscopy(selective)EUS biopsydiagnosticlaparoscopyNeoadjuvantclinicaltrialERCP / EUSObserve/reimageWhippleprocedureFigure 33-70. Diagnostic and treatment algorithm for pancreatic cancer. If computed tomography (CT) scan demonstrates a potentially resectable tumor, patients are offered participation in a clinical trial after histologic confirmation by CT or endoscopic ultrasound (EUS)-guided biopsy. If CT scan demonstrates resectable disease, diagnostic laparoscopy is used selectively in patients with tumors in the body/tail, equivocal findings of metastasis or CT scan, ascites, high CA19-9, or marked weight loss. Patients also have diagnostic laparoscopy if they elect to participate in a neoadjuvant clinical trial. In cases where no mass is demonstrated on CT scan, but suspicion of cancer remains, EUS or endoscopic |
Surgery_Schwartz_9819 | Surgery_Schwartz | also have diagnostic laparoscopy if they elect to participate in a neoadjuvant clinical trial. In cases where no mass is demonstrated on CT scan, but suspicion of cancer remains, EUS or endoscopic retrograde cholangiopancreatography (ERCP) with brushings are performed, and the CT may be repeated after an interval of observation.Brunicardi_Ch33_p1429-p1516.indd 148901/03/19 6:46 PM 1490SPECIFIC CONSIDERATIONSPART IIis suitable as long as the cystic duct clearly enters the common duct well above the tumor. The jejunum is brought anterior to the colon, if possible, rather than retrocolic, where the tumor potentially would invade the bowel sooner. Some surgeons use a loop of jejunum with a jejunojejunostomy to divert the enteric stream away from the biliary-enteric anastomosis. Others use a Roux-en-Y limb with the gastrojejunostomy located 50 cm downstream from the hepaticojejunostomy (Fig. 33-71). Poten-tial advantages of the defunctionalized Roux-en-Y limb include the ease with | Surgery_Schwartz. also have diagnostic laparoscopy if they elect to participate in a neoadjuvant clinical trial. In cases where no mass is demonstrated on CT scan, but suspicion of cancer remains, EUS or endoscopic retrograde cholangiopancreatography (ERCP) with brushings are performed, and the CT may be repeated after an interval of observation.Brunicardi_Ch33_p1429-p1516.indd 148901/03/19 6:46 PM 1490SPECIFIC CONSIDERATIONSPART IIis suitable as long as the cystic duct clearly enters the common duct well above the tumor. The jejunum is brought anterior to the colon, if possible, rather than retrocolic, where the tumor potentially would invade the bowel sooner. Some surgeons use a loop of jejunum with a jejunojejunostomy to divert the enteric stream away from the biliary-enteric anastomosis. Others use a Roux-en-Y limb with the gastrojejunostomy located 50 cm downstream from the hepaticojejunostomy (Fig. 33-71). Poten-tial advantages of the defunctionalized Roux-en-Y limb include the ease with |
Surgery_Schwartz_9820 | Surgery_Schwartz | use a Roux-en-Y limb with the gastrojejunostomy located 50 cm downstream from the hepaticojejunostomy (Fig. 33-71). Poten-tial advantages of the defunctionalized Roux-en-Y limb include the ease with which it will reach up to the hepatic hilum, prob-able decreased risk of cholangitis, and easier management of biliary anastomotic leaks. If a gastrojejunostomy is performed, it should be placed dependently and posterior along the greater Figure 33-71. Biliary-enteric bypass to palliate unresectable pan-creatic cancer. (Reproduced with permission from Bell RH, Rikkers LF, Mulholland M: Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)Figure 33-72. Expandable metallic biliary stent. After ERCP cannulation of the distal bile duct (left) the stent is advanced over the cannula and placed across the obstruction in the distal bile duct (right).curvature to improve gastric emptying, and a vagotomy should not be performed. Endoscopic stents are | Surgery_Schwartz. use a Roux-en-Y limb with the gastrojejunostomy located 50 cm downstream from the hepaticojejunostomy (Fig. 33-71). Poten-tial advantages of the defunctionalized Roux-en-Y limb include the ease with which it will reach up to the hepatic hilum, prob-able decreased risk of cholangitis, and easier management of biliary anastomotic leaks. If a gastrojejunostomy is performed, it should be placed dependently and posterior along the greater Figure 33-71. Biliary-enteric bypass to palliate unresectable pan-creatic cancer. (Reproduced with permission from Bell RH, Rikkers LF, Mulholland M: Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)Figure 33-72. Expandable metallic biliary stent. After ERCP cannulation of the distal bile duct (left) the stent is advanced over the cannula and placed across the obstruction in the distal bile duct (right).curvature to improve gastric emptying, and a vagotomy should not be performed. Endoscopic stents are |
Surgery_Schwartz_9821 | Surgery_Schwartz | is advanced over the cannula and placed across the obstruction in the distal bile duct (right).curvature to improve gastric emptying, and a vagotomy should not be performed. Endoscopic stents are definitely not as dura-ble as a surgical bypass. Recurrent obstruction and cholangitis is more common with stents and results in inferior palliation. However, the endoscopic approach is associated with consider-ably less initial morbidity and mortality than surgical bypass. Expandable metallic wall stents have superior patency and pro-vide better palliation than plastic stents (Fig. 33-72).If an initial diagnostic laparoscopy reveals a contraindica-tion to the Whipple procedure, such as liver metastases, it is not appropriate to perform a laparotomy simply to create a biliary bypass. In such a patient, it is better to place an endoscopic stent. In contrast, in the uncommon scenario where a laparotomy has already been performed as part of the assessment of resectability and the Whipple | Surgery_Schwartz. is advanced over the cannula and placed across the obstruction in the distal bile duct (right).curvature to improve gastric emptying, and a vagotomy should not be performed. Endoscopic stents are definitely not as dura-ble as a surgical bypass. Recurrent obstruction and cholangitis is more common with stents and results in inferior palliation. However, the endoscopic approach is associated with consider-ably less initial morbidity and mortality than surgical bypass. Expandable metallic wall stents have superior patency and pro-vide better palliation than plastic stents (Fig. 33-72).If an initial diagnostic laparoscopy reveals a contraindica-tion to the Whipple procedure, such as liver metastases, it is not appropriate to perform a laparotomy simply to create a biliary bypass. In such a patient, it is better to place an endoscopic stent. In contrast, in the uncommon scenario where a laparotomy has already been performed as part of the assessment of resectability and the Whipple |
Surgery_Schwartz_9822 | Surgery_Schwartz | a patient, it is better to place an endoscopic stent. In contrast, in the uncommon scenario where a laparotomy has already been performed as part of the assessment of resectability and the Whipple procedure is not possible, a surgical bypass is usually performed. However, if the patient has a functioning endoscopic stent already in place, it may be reasonable to forego surgical bypass.Chemotherapy and Radiation for Locally Advanced/ Metastatic Disease. Patients with locally advanced unresectable disease are treated with chemotherapy and possibly radiation, and patients with stage IV metastatic disease are treated with systemic chemotherapy. The role of RT in unresectable, locoregionally advanced pancreas cancer remains controversial. RT may slow the progression of local disease and possibly alleviate or prevent symptoms including pain, biliary obstruction, bleeding, and bowel obstruction. However, the likelihood of micrometastatic distant disease is high, treatment is not expected to | Surgery_Schwartz. a patient, it is better to place an endoscopic stent. In contrast, in the uncommon scenario where a laparotomy has already been performed as part of the assessment of resectability and the Whipple procedure is not possible, a surgical bypass is usually performed. However, if the patient has a functioning endoscopic stent already in place, it may be reasonable to forego surgical bypass.Chemotherapy and Radiation for Locally Advanced/ Metastatic Disease. Patients with locally advanced unresectable disease are treated with chemotherapy and possibly radiation, and patients with stage IV metastatic disease are treated with systemic chemotherapy. The role of RT in unresectable, locoregionally advanced pancreas cancer remains controversial. RT may slow the progression of local disease and possibly alleviate or prevent symptoms including pain, biliary obstruction, bleeding, and bowel obstruction. However, the likelihood of micrometastatic distant disease is high, treatment is not expected to |
Surgery_Schwartz_9823 | Surgery_Schwartz | alleviate or prevent symptoms including pain, biliary obstruction, bleeding, and bowel obstruction. However, the likelihood of micrometastatic distant disease is high, treatment is not expected to be curative, and radiation can result in toxicity. Stereotactic body radiotherapy (SBRT) has been used to limit toxicity by targeting high-dose short-course radiation to enhance local response prior to surgery. In a phase 2 multi-institutional trial evaluating gemcitabine and SBRT in patients with locally advanced unresectable pancreatic cancer, 10% of patients with locally advanced disease who would not have been candidates for initial surgery were deemed to have resectable tumors following therapy, and 8% ultimately underwent R0 and node-negative resection.323 A number of chemotherapy regimens are available for pancreatic cancer, but the results are not impressive. Gemcitabine (Gemzar) was approved by the U.S. Food and Drug Administration (FDA) for use in pancreatic cancer in 1996. In | Surgery_Schwartz. alleviate or prevent symptoms including pain, biliary obstruction, bleeding, and bowel obstruction. However, the likelihood of micrometastatic distant disease is high, treatment is not expected to be curative, and radiation can result in toxicity. Stereotactic body radiotherapy (SBRT) has been used to limit toxicity by targeting high-dose short-course radiation to enhance local response prior to surgery. In a phase 2 multi-institutional trial evaluating gemcitabine and SBRT in patients with locally advanced unresectable pancreatic cancer, 10% of patients with locally advanced disease who would not have been candidates for initial surgery were deemed to have resectable tumors following therapy, and 8% ultimately underwent R0 and node-negative resection.323 A number of chemotherapy regimens are available for pancreatic cancer, but the results are not impressive. Gemcitabine (Gemzar) was approved by the U.S. Food and Drug Administration (FDA) for use in pancreatic cancer in 1996. In |
Surgery_Schwartz_9824 | Surgery_Schwartz | are available for pancreatic cancer, but the results are not impressive. Gemcitabine (Gemzar) was approved by the U.S. Food and Drug Administration (FDA) for use in pancreatic cancer in 1996. In patients with unresectable pancreatic cancer, gemcitabine results in symptomatic Brunicardi_Ch33_p1429-p1516.indd 149001/03/19 6:46 PM 1491PANCREASCHAPTER 33improvement, improved pain control and performance status, and weight gain.324 However, survival is improved by only 1 to 2 months. Prior to gemcitabine, 5-fluorouracil (5-FU) was used as the standard treatment for unresectable pancreatic cancer. Both of these drugs are still used today. 5-FU or capecitabine (Xeloda), a similar but orally administered drug, are frequently used as a radiosensitizer during radiation therapy. Single-agent gemcitabine is still commonly used in patients with a poor performance status.Erlotinib (Tarceva) was approved in 2005 based on very minimal improvement in overall survival in combination with | Surgery_Schwartz. are available for pancreatic cancer, but the results are not impressive. Gemcitabine (Gemzar) was approved by the U.S. Food and Drug Administration (FDA) for use in pancreatic cancer in 1996. In patients with unresectable pancreatic cancer, gemcitabine results in symptomatic Brunicardi_Ch33_p1429-p1516.indd 149001/03/19 6:46 PM 1491PANCREASCHAPTER 33improvement, improved pain control and performance status, and weight gain.324 However, survival is improved by only 1 to 2 months. Prior to gemcitabine, 5-fluorouracil (5-FU) was used as the standard treatment for unresectable pancreatic cancer. Both of these drugs are still used today. 5-FU or capecitabine (Xeloda), a similar but orally administered drug, are frequently used as a radiosensitizer during radiation therapy. Single-agent gemcitabine is still commonly used in patients with a poor performance status.Erlotinib (Tarceva) was approved in 2005 based on very minimal improvement in overall survival in combination with |
Surgery_Schwartz_9825 | Surgery_Schwartz | gemcitabine is still commonly used in patients with a poor performance status.Erlotinib (Tarceva) was approved in 2005 based on very minimal improvement in overall survival in combination with gemcitabine.325 The study showed that erlotinib in combination with gemcitabine results in a statistically significant improve-ment in overall survival in patients with advanced pancreatic cancer in the first-line setting. Although the absolute benefit in overall survival was modest with a median survival difference between the two arms of only 2 weeks.FOLFIRINOX, a combination of three chemotherapy drugs (5-FU/leucovorin, irinotecan, and oxaliplatin) is now commonly used as first-line treatment for metastatic pancreatic adenocarcinoma in patients with a relatively good performance status. In 2010, a Phase 3 clinical trial showed positive results for patients treated with FOLFIRINOX.326 The objective response rate was improved from 9% to 32%, and median overall survival of patients with | Surgery_Schwartz. gemcitabine is still commonly used in patients with a poor performance status.Erlotinib (Tarceva) was approved in 2005 based on very minimal improvement in overall survival in combination with gemcitabine.325 The study showed that erlotinib in combination with gemcitabine results in a statistically significant improve-ment in overall survival in patients with advanced pancreatic cancer in the first-line setting. Although the absolute benefit in overall survival was modest with a median survival difference between the two arms of only 2 weeks.FOLFIRINOX, a combination of three chemotherapy drugs (5-FU/leucovorin, irinotecan, and oxaliplatin) is now commonly used as first-line treatment for metastatic pancreatic adenocarcinoma in patients with a relatively good performance status. In 2010, a Phase 3 clinical trial showed positive results for patients treated with FOLFIRINOX.326 The objective response rate was improved from 9% to 32%, and median overall survival of patients with |
Surgery_Schwartz_9826 | Surgery_Schwartz | 2010, a Phase 3 clinical trial showed positive results for patients treated with FOLFIRINOX.326 The objective response rate was improved from 9% to 32%, and median overall survival of patients with metastatic pancreatic cancer improved from 7 to 11 months, but the improvement was associated with increased toxicity, so patient selection is important. Patients treated with FOLFIRINOX may experience more severe side effects than those treated with gemcitabine alone, so this combination is usu-ally reserved for patients with a good performance status.In 2013, another combination therapy was approved as first-line treatment for metastatic pancreatic adenocarcinoma.327 Albumin-bound paclitaxel (Abraxane) was approved to be used in combination with gemcitabine (Gemzar). The median overall survival was improved to 8.5 months in the nabpaclitaxel–gemcitabine group as compared with 6.7 months in the gemcitabine group. Progression-free survival and the response rate were also improved. Rates of | Surgery_Schwartz. 2010, a Phase 3 clinical trial showed positive results for patients treated with FOLFIRINOX.326 The objective response rate was improved from 9% to 32%, and median overall survival of patients with metastatic pancreatic cancer improved from 7 to 11 months, but the improvement was associated with increased toxicity, so patient selection is important. Patients treated with FOLFIRINOX may experience more severe side effects than those treated with gemcitabine alone, so this combination is usu-ally reserved for patients with a good performance status.In 2013, another combination therapy was approved as first-line treatment for metastatic pancreatic adenocarcinoma.327 Albumin-bound paclitaxel (Abraxane) was approved to be used in combination with gemcitabine (Gemzar). The median overall survival was improved to 8.5 months in the nabpaclitaxel–gemcitabine group as compared with 6.7 months in the gemcitabine group. Progression-free survival and the response rate were also improved. Rates of |
Surgery_Schwartz_9827 | Surgery_Schwartz | was improved to 8.5 months in the nabpaclitaxel–gemcitabine group as compared with 6.7 months in the gemcitabine group. Progression-free survival and the response rate were also improved. Rates of peripheral neuropathy and myelosuppression were increased, but this regimen is less toxic than FOLFIRINOX.In 2015, Irinotecan (ONIVYDE), in combination with 5-FU (fluorouracil) and leucovorin, was approved as treatment for met-astatic pancreatic adenocarcinoma that has progressed following treatment with a gemcitabine based therapy.328 The median over-all survival in patients assigned to nanoliposomal irinotecan plus fluorouracil and folinic acid was 6.1 months vs. 4.2 months with fluorouracil and folinic acid. Common side effects for this second-line therapy were neutropenia, diarrhea, vomiting, and fatigue.These results may warrant treatment in patients who understand the benefits and risks. However, the lack of signifi-cant survival advantage should encourage physicians to refer motivated | Surgery_Schwartz. was improved to 8.5 months in the nabpaclitaxel–gemcitabine group as compared with 6.7 months in the gemcitabine group. Progression-free survival and the response rate were also improved. Rates of peripheral neuropathy and myelosuppression were increased, but this regimen is less toxic than FOLFIRINOX.In 2015, Irinotecan (ONIVYDE), in combination with 5-FU (fluorouracil) and leucovorin, was approved as treatment for met-astatic pancreatic adenocarcinoma that has progressed following treatment with a gemcitabine based therapy.328 The median over-all survival in patients assigned to nanoliposomal irinotecan plus fluorouracil and folinic acid was 6.1 months vs. 4.2 months with fluorouracil and folinic acid. Common side effects for this second-line therapy were neutropenia, diarrhea, vomiting, and fatigue.These results may warrant treatment in patients who understand the benefits and risks. However, the lack of signifi-cant survival advantage should encourage physicians to refer motivated |
Surgery_Schwartz_9828 | Surgery_Schwartz | and fatigue.These results may warrant treatment in patients who understand the benefits and risks. However, the lack of signifi-cant survival advantage should encourage physicians to refer motivated patients for experimental protocols because it is only through continued clinical research that more meaningful treat-ments for pancreatic cancer will be developed.Ablation for Locally Advanced Unresectable Disease. Persistent arterial vascular encasement after neoadjuvant therapy contraindicates resection. Irreversible electroporation utilizes delivery of high-voltage millisecond electrical pulses resulting in permanent disruption of the cellular membranes and subsequent apoptosis. This process leads to cell death, but does not injure the extracellular matrix, thus allowing cellular tumor ablation while preserving structural components of tissues. Collagen-based structures such as vessels or the pancreatic duct are not disrupted. Furthermore, because IRE is not based on thermal damage of | Surgery_Schwartz. and fatigue.These results may warrant treatment in patients who understand the benefits and risks. However, the lack of signifi-cant survival advantage should encourage physicians to refer motivated patients for experimental protocols because it is only through continued clinical research that more meaningful treat-ments for pancreatic cancer will be developed.Ablation for Locally Advanced Unresectable Disease. Persistent arterial vascular encasement after neoadjuvant therapy contraindicates resection. Irreversible electroporation utilizes delivery of high-voltage millisecond electrical pulses resulting in permanent disruption of the cellular membranes and subsequent apoptosis. This process leads to cell death, but does not injure the extracellular matrix, thus allowing cellular tumor ablation while preserving structural components of tissues. Collagen-based structures such as vessels or the pancreatic duct are not disrupted. Furthermore, because IRE is not based on thermal damage of |
Surgery_Schwartz_9829 | Surgery_Schwartz | while preserving structural components of tissues. Collagen-based structures such as vessels or the pancreatic duct are not disrupted. Furthermore, because IRE is not based on thermal damage of cancer cells, the heat-sink phenomenon is not a concern, and even lesions abutting large vessels can be ablated with radical intent. Irreversible electroporation using the Nanoknife is reported to enable treatment of pancreatic tumors abutting vascular structures without compromise of the vessels or concern for the heat sink effect of nearby blood flow.329 Martin has created a registry and accumulated multi-institutional data on 200 patients with locally advanced pancreatic cancer showing OS of 28.3 months for patients with borderline resectable pancreatic cancer and 23.2 months in patients with unresectable pancreatic cancer. Those numbers compare favorably with the survival of patients treated with chemoradiation alone, which is 13 months in historical controls.330 This modality is new, but | Surgery_Schwartz. while preserving structural components of tissues. Collagen-based structures such as vessels or the pancreatic duct are not disrupted. Furthermore, because IRE is not based on thermal damage of cancer cells, the heat-sink phenomenon is not a concern, and even lesions abutting large vessels can be ablated with radical intent. Irreversible electroporation using the Nanoknife is reported to enable treatment of pancreatic tumors abutting vascular structures without compromise of the vessels or concern for the heat sink effect of nearby blood flow.329 Martin has created a registry and accumulated multi-institutional data on 200 patients with locally advanced pancreatic cancer showing OS of 28.3 months for patients with borderline resectable pancreatic cancer and 23.2 months in patients with unresectable pancreatic cancer. Those numbers compare favorably with the survival of patients treated with chemoradiation alone, which is 13 months in historical controls.330 This modality is new, but |
Surgery_Schwartz_9830 | Surgery_Schwartz | pancreatic cancer. Those numbers compare favorably with the survival of patients treated with chemoradiation alone, which is 13 months in historical controls.330 This modality is new, but these early reports indicate it may be safe in combination with chemotherapy and are of particular interest because of the potential to down stage and offer surgery to patients initially diagnosed with locally advanced unresectable disease. It is also important to understand that a significant learning curve exists to achieve safety and optimization of the technique. Proper patient selection, technical ability with intraoperative ultrasound to allow precise IRE electrode bracketing, and standardization of the IRE energy delivery is important. Randomized prospective trials are needed before adoption of this technique can be expanded.Surgical Resection: Pancreaticoduodenectomy. In a patient with appropriate clinical and/or imaging indications of pancreatic cancer, a tissue diagnosis before performing a | Surgery_Schwartz. pancreatic cancer. Those numbers compare favorably with the survival of patients treated with chemoradiation alone, which is 13 months in historical controls.330 This modality is new, but these early reports indicate it may be safe in combination with chemotherapy and are of particular interest because of the potential to down stage and offer surgery to patients initially diagnosed with locally advanced unresectable disease. It is also important to understand that a significant learning curve exists to achieve safety and optimization of the technique. Proper patient selection, technical ability with intraoperative ultrasound to allow precise IRE electrode bracketing, and standardization of the IRE energy delivery is important. Randomized prospective trials are needed before adoption of this technique can be expanded.Surgical Resection: Pancreaticoduodenectomy. In a patient with appropriate clinical and/or imaging indications of pancreatic cancer, a tissue diagnosis before performing a |
Surgery_Schwartz_9831 | Surgery_Schwartz | technique can be expanded.Surgical Resection: Pancreaticoduodenectomy. In a patient with appropriate clinical and/or imaging indications of pancreatic cancer, a tissue diagnosis before performing a pancreaticoduo-denectomy is not essential. Although percutaneous CT-guided biopsy is usually safe, complications such as hemorrhage, pan-creatitis, fistula, and abscess can occur. Tumor seeding along the subcutaneous tract of the needle is uncommon. Likewise, FNA under EUS guidance is safe and well tolerated. The prob-lem with preoperative or even intraoperative biopsy is that many pancreatic cancers are not very cellular and contain a significant amount of fibrous tissue, so a biopsy may be misinterpreted as showing chronic pancreatitis if it does not contain malignant glandular cells. In the face of clinical and radiologic preoperative indications of pancreatic cancer, a negative biopsy should not preclude resection. In patients who are not candidates for resec-tion because of metastatic | Surgery_Schwartz. technique can be expanded.Surgical Resection: Pancreaticoduodenectomy. In a patient with appropriate clinical and/or imaging indications of pancreatic cancer, a tissue diagnosis before performing a pancreaticoduo-denectomy is not essential. Although percutaneous CT-guided biopsy is usually safe, complications such as hemorrhage, pan-creatitis, fistula, and abscess can occur. Tumor seeding along the subcutaneous tract of the needle is uncommon. Likewise, FNA under EUS guidance is safe and well tolerated. The prob-lem with preoperative or even intraoperative biopsy is that many pancreatic cancers are not very cellular and contain a significant amount of fibrous tissue, so a biopsy may be misinterpreted as showing chronic pancreatitis if it does not contain malignant glandular cells. In the face of clinical and radiologic preoperative indications of pancreatic cancer, a negative biopsy should not preclude resection. In patients who are not candidates for resec-tion because of metastatic |
Surgery_Schwartz_9832 | Surgery_Schwartz | face of clinical and radiologic preoperative indications of pancreatic cancer, a negative biopsy should not preclude resection. In patients who are not candidates for resec-tion because of metastatic disease, biopsy for a tissue diagnosis becomes important because these patients may be candidates for palliative chemotherapy trials. It is especially important to make an aggressive attempt at tissue diagnosis before surgery in patients whose clinical presentation and imaging studies are more suggestive of alternative diagnoses such as pancreatic lym-phoma or pancreatic islet cell tumors. These patients might avoid surgery altogether in the case of lymphoma or warrant an aggres-sive approach in the case of islet cell carcinoma.Pancreaticoduodenectomy can be performed through a midline incision from xiphoid to umbilicus or through a bilat-eral subcostal incision. The initial portion of the procedure is an assessment of resectability. The liver and visceral and parietal peritoneal surfaces | Surgery_Schwartz. face of clinical and radiologic preoperative indications of pancreatic cancer, a negative biopsy should not preclude resection. In patients who are not candidates for resec-tion because of metastatic disease, biopsy for a tissue diagnosis becomes important because these patients may be candidates for palliative chemotherapy trials. It is especially important to make an aggressive attempt at tissue diagnosis before surgery in patients whose clinical presentation and imaging studies are more suggestive of alternative diagnoses such as pancreatic lym-phoma or pancreatic islet cell tumors. These patients might avoid surgery altogether in the case of lymphoma or warrant an aggres-sive approach in the case of islet cell carcinoma.Pancreaticoduodenectomy can be performed through a midline incision from xiphoid to umbilicus or through a bilat-eral subcostal incision. The initial portion of the procedure is an assessment of resectability. The liver and visceral and parietal peritoneal surfaces |
Surgery_Schwartz_9833 | Surgery_Schwartz | from xiphoid to umbilicus or through a bilat-eral subcostal incision. The initial portion of the procedure is an assessment of resectability. The liver and visceral and parietal peritoneal surfaces are thoroughly assessed. The gastrohepatic omentum is opened, and the celiac axis area is examined for enlarged lymph nodes. The base of the transverse mesocolon is examined for tumor involvement.The ascending and hepatic flexure of the colon are mobi-lized off the duodenum and head of the pancreas and reflected medially. A Kocher maneuver is performed by dissecting behind Brunicardi_Ch33_p1429-p1516.indd 149101/03/19 6:46 PM 1492SPECIFIC CONSIDERATIONSPART IIthe head of the pancreas. The superior mesenteric vein is identi-fied early in the case and dissected up toward the inferior border of the neck of the pancreas. The gastroepiploic vein and artery are ligated to prevent any traction injury. Often, the middle colic vein and right gastroepiploic vein share a common trunk before | Surgery_Schwartz. from xiphoid to umbilicus or through a bilat-eral subcostal incision. The initial portion of the procedure is an assessment of resectability. The liver and visceral and parietal peritoneal surfaces are thoroughly assessed. The gastrohepatic omentum is opened, and the celiac axis area is examined for enlarged lymph nodes. The base of the transverse mesocolon is examined for tumor involvement.The ascending and hepatic flexure of the colon are mobi-lized off the duodenum and head of the pancreas and reflected medially. A Kocher maneuver is performed by dissecting behind Brunicardi_Ch33_p1429-p1516.indd 149101/03/19 6:46 PM 1492SPECIFIC CONSIDERATIONSPART IIthe head of the pancreas. The superior mesenteric vein is identi-fied early in the case and dissected up toward the inferior border of the neck of the pancreas. The gastroepiploic vein and artery are ligated to prevent any traction injury. Often, the middle colic vein and right gastroepiploic vein share a common trunk before |
Surgery_Schwartz_9834 | Surgery_Schwartz | of the neck of the pancreas. The gastroepiploic vein and artery are ligated to prevent any traction injury. Often, the middle colic vein and right gastroepiploic vein share a common trunk before entering into the superior mesenteric vein. Knowledge of this anatomy helps reduce injury to the veins and unnecessary blood loss. The relation of the tumor to the superior mesenteric vein and artery cannot be accurately assessed by palpation at this point and is not completely determined until later in the opera-tion when the neck of the pancreas is divided and the surgeon is committed to resection. Mesenteric vascular involvement is best determined by a high quality preoperative CT scan.It is important to assess for an aberrant right hepatic artery, which is present in 20% of patients. The aberrant artery com-monly arises from the superior mesenteric artery posterior to the pancreas and ascends parallel and adjacent to the superior mesenteric and portal veins. The presence of an aberrant | Surgery_Schwartz. of the neck of the pancreas. The gastroepiploic vein and artery are ligated to prevent any traction injury. Often, the middle colic vein and right gastroepiploic vein share a common trunk before entering into the superior mesenteric vein. Knowledge of this anatomy helps reduce injury to the veins and unnecessary blood loss. The relation of the tumor to the superior mesenteric vein and artery cannot be accurately assessed by palpation at this point and is not completely determined until later in the opera-tion when the neck of the pancreas is divided and the surgeon is committed to resection. Mesenteric vascular involvement is best determined by a high quality preoperative CT scan.It is important to assess for an aberrant right hepatic artery, which is present in 20% of patients. The aberrant artery com-monly arises from the superior mesenteric artery posterior to the pancreas and ascends parallel and adjacent to the superior mesenteric and portal veins. The presence of an aberrant |
Surgery_Schwartz_9835 | Surgery_Schwartz | artery com-monly arises from the superior mesenteric artery posterior to the pancreas and ascends parallel and adjacent to the superior mesenteric and portal veins. The presence of an aberrant right hepatic artery should be apparent on the preoperative CT scan and can be identified intraoperatively by palpation on the back side of the hepatoduodenal ligament, where a prominent pulse will be felt posterior and to the right of the portal vein.The porta hepatis is examined. Enlarged or firm lymph nodes that can be swept down toward the head of the pancreas with the specimen do not preclude resection. If the assessment phase reveals no contraindications to the Whipple procedure (Table 33-22), the resection phase commences.If the pylorus is to be preserved, the stomach and proximal duodenum are mobilized off the pancreas, preserving the gastroepiploic vessels down to the pylorus. The proximal hepatic artery is identified usually by removing a lymph node that commonly lies just anterior to | Surgery_Schwartz. artery com-monly arises from the superior mesenteric artery posterior to the pancreas and ascends parallel and adjacent to the superior mesenteric and portal veins. The presence of an aberrant right hepatic artery should be apparent on the preoperative CT scan and can be identified intraoperatively by palpation on the back side of the hepatoduodenal ligament, where a prominent pulse will be felt posterior and to the right of the portal vein.The porta hepatis is examined. Enlarged or firm lymph nodes that can be swept down toward the head of the pancreas with the specimen do not preclude resection. If the assessment phase reveals no contraindications to the Whipple procedure (Table 33-22), the resection phase commences.If the pylorus is to be preserved, the stomach and proximal duodenum are mobilized off the pancreas, preserving the gastroepiploic vessels down to the pylorus. The proximal hepatic artery is identified usually by removing a lymph node that commonly lies just anterior to |
Surgery_Schwartz_9836 | Surgery_Schwartz | mobilized off the pancreas, preserving the gastroepiploic vessels down to the pylorus. The proximal hepatic artery is identified usually by removing a lymph node that commonly lies just anterior to the artery. The hepatic artery is dissected and traced toward the porta hepatis. The gastroduodenal branch of the hepatic artery is identified. A test clamping is performed to ensure that a strong pulse remains in the proper hepatic artery before division of the gastroduodenal artery. In cases of celiac occlusion, flow comes from the superior mesenteric artery and retrograde through the gastroduodenal artery to the proper hepatic artery. Ligation of the gastroduodenal in this case would be equivalent to hepatic artery ligation. A bypass to the hepatic artery would be required. Once the test clamping is negative and the gastroduodenal artery is divided, the hepatic artery is retracted medially, and the common bile duct is retracted laterally to reveal the anterior surface of the portal vein | Surgery_Schwartz. mobilized off the pancreas, preserving the gastroepiploic vessels down to the pylorus. The proximal hepatic artery is identified usually by removing a lymph node that commonly lies just anterior to the artery. The hepatic artery is dissected and traced toward the porta hepatis. The gastroduodenal branch of the hepatic artery is identified. A test clamping is performed to ensure that a strong pulse remains in the proper hepatic artery before division of the gastroduodenal artery. In cases of celiac occlusion, flow comes from the superior mesenteric artery and retrograde through the gastroduodenal artery to the proper hepatic artery. Ligation of the gastroduodenal in this case would be equivalent to hepatic artery ligation. A bypass to the hepatic artery would be required. Once the test clamping is negative and the gastroduodenal artery is divided, the hepatic artery is retracted medially, and the common bile duct is retracted laterally to reveal the anterior surface of the portal vein |
Surgery_Schwartz_9837 | Surgery_Schwartz | is negative and the gastroduodenal artery is divided, the hepatic artery is retracted medially, and the common bile duct is retracted laterally to reveal the anterior surface of the portal vein behind them. Dissection is performed only on the anterior surface of the vein. If there is no tumor involvement, the neck of the Table 33-22Findings at explorationFindings contraindicating resection Liver metastases (any size) Celiac lymph node involvement Peritoneal implants Hepatic hilar lymph node involvementFindings not contraindicating resection Invasion at duodenum or distal stomach Involved peripancreatic lymph nodes Involved lymph nodes along the porta hepatis that can be swept down with the specimenpancreas will separate from the vein easily. A large, blunt-tipped clamp is a safe instrument to use for this dissection. The tunnel under the neck of the pancreas can then be completed mostly under direct vision from inferior and superior.The gallbladder is then mobilized from the liver, | Surgery_Schwartz. is negative and the gastroduodenal artery is divided, the hepatic artery is retracted medially, and the common bile duct is retracted laterally to reveal the anterior surface of the portal vein behind them. Dissection is performed only on the anterior surface of the vein. If there is no tumor involvement, the neck of the Table 33-22Findings at explorationFindings contraindicating resection Liver metastases (any size) Celiac lymph node involvement Peritoneal implants Hepatic hilar lymph node involvementFindings not contraindicating resection Invasion at duodenum or distal stomach Involved peripancreatic lymph nodes Involved lymph nodes along the porta hepatis that can be swept down with the specimenpancreas will separate from the vein easily. A large, blunt-tipped clamp is a safe instrument to use for this dissection. The tunnel under the neck of the pancreas can then be completed mostly under direct vision from inferior and superior.The gallbladder is then mobilized from the liver, |
Surgery_Schwartz_9838 | Surgery_Schwartz | to use for this dissection. The tunnel under the neck of the pancreas can then be completed mostly under direct vision from inferior and superior.The gallbladder is then mobilized from the liver, the cystic duct and artery are ligated, and the gallbladder is removed. The common hepatic duct is circumferentially dissected. Either the duodenum is divided 2 cm distal to the pylorus (which defines the procedure as a pylorus-preserving pancreaticoduodenectomy, or PPPD) or the antrum is divided, as classically described by Whipple. The jejunum is divided beyond the ligament of Treitz, and the mesentery is ligated until the jejunum can be delivered posterior to the superior mesenteric vessels from left to right.The common hepatic duct is then divided usually just above the entrance of the cystic duct, and the bile duct is dis-sected down to the superior margin of the duodenum. Inferior traction on the distal bile duct opens the plane to make visible the anterior portion of the portal vein. | Surgery_Schwartz. to use for this dissection. The tunnel under the neck of the pancreas can then be completed mostly under direct vision from inferior and superior.The gallbladder is then mobilized from the liver, the cystic duct and artery are ligated, and the gallbladder is removed. The common hepatic duct is circumferentially dissected. Either the duodenum is divided 2 cm distal to the pylorus (which defines the procedure as a pylorus-preserving pancreaticoduodenectomy, or PPPD) or the antrum is divided, as classically described by Whipple. The jejunum is divided beyond the ligament of Treitz, and the mesentery is ligated until the jejunum can be delivered posterior to the superior mesenteric vessels from left to right.The common hepatic duct is then divided usually just above the entrance of the cystic duct, and the bile duct is dis-sected down to the superior margin of the duodenum. Inferior traction on the distal bile duct opens the plane to make visible the anterior portion of the portal vein. |
Surgery_Schwartz_9839 | Surgery_Schwartz | duct, and the bile duct is dis-sected down to the superior margin of the duodenum. Inferior traction on the distal bile duct opens the plane to make visible the anterior portion of the portal vein. The pancreatic neck is divided anterior to the portal vein (Fig. 33-73). The use of cau-tery is avoided in the area of the pancreatic duct. The pancreatic head and uncinate process then are dissected off of the right lateral aspect of the superior mesenteric vein, ligating the fragile branches draining the head and uncinate process into the portal vein (Fig. 33-74). The uncinate process is then dissected off of the posterior and lateral aspect of the superior mesenteric artery. This can be the most tedious portion of the operation, Figure 33-73. Division of the pancreatic neck. The pancreatic neck is separated from the anterior surface of the portal vein and then divided. If there is no tumor involvement, the neck of the pan-creas will separate from the vein easily. A large, blunt-tipped | Surgery_Schwartz. duct, and the bile duct is dis-sected down to the superior margin of the duodenum. Inferior traction on the distal bile duct opens the plane to make visible the anterior portion of the portal vein. The pancreatic neck is divided anterior to the portal vein (Fig. 33-73). The use of cau-tery is avoided in the area of the pancreatic duct. The pancreatic head and uncinate process then are dissected off of the right lateral aspect of the superior mesenteric vein, ligating the fragile branches draining the head and uncinate process into the portal vein (Fig. 33-74). The uncinate process is then dissected off of the posterior and lateral aspect of the superior mesenteric artery. This can be the most tedious portion of the operation, Figure 33-73. Division of the pancreatic neck. The pancreatic neck is separated from the anterior surface of the portal vein and then divided. If there is no tumor involvement, the neck of the pan-creas will separate from the vein easily. A large, blunt-tipped |
Surgery_Schwartz_9840 | Surgery_Schwartz | neck is separated from the anterior surface of the portal vein and then divided. If there is no tumor involvement, the neck of the pan-creas will separate from the vein easily. A large, blunt-tipped clamp is a safe instrument to use for this dissection. (Reproduced with per-mission from Bell RH, Rikkers LF, Mulholland M: Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)Brunicardi_Ch33_p1429-p1516.indd 149201/03/19 6:46 PM 1493PANCREASCHAPTER 33Figure 33-74. Dissection of the pancreatic head and uncinate pro-cess. The pancreatic head and uncinate process are dissected off of the right lateral aspect of the superior mesenteric vein and portal vein by ligating the fragile venous branches. (Reproduced with per-mission from Bell RH, Rikkers LF, Mulholland M: Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)but thoroughly clearing all tissue from the mesenteric vessels helps avoid | Surgery_Schwartz. neck is separated from the anterior surface of the portal vein and then divided. If there is no tumor involvement, the neck of the pan-creas will separate from the vein easily. A large, blunt-tipped clamp is a safe instrument to use for this dissection. (Reproduced with per-mission from Bell RH, Rikkers LF, Mulholland M: Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)Brunicardi_Ch33_p1429-p1516.indd 149201/03/19 6:46 PM 1493PANCREASCHAPTER 33Figure 33-74. Dissection of the pancreatic head and uncinate pro-cess. The pancreatic head and uncinate process are dissected off of the right lateral aspect of the superior mesenteric vein and portal vein by ligating the fragile venous branches. (Reproduced with per-mission from Bell RH, Rikkers LF, Mulholland M: Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)but thoroughly clearing all tissue from the mesenteric vessels helps avoid |
Surgery_Schwartz_9841 | Surgery_Schwartz | Rikkers LF, Mulholland M: Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)but thoroughly clearing all tissue from the mesenteric vessels helps avoid incomplete resection. The wound is irrigated and meticulous hemostasis is assured at this point because the view of the portal vein area and retroperitoneum is more difficult after the reconstruction phase is completed.The reconstruction involves anastomoses of the pancreas first, then the bile duct, and, finally, the duodenum or stomach. There are various techniques for the pancreatic anastomoses. After the pancreatic anastomosis is completed, the choledocho-jejunostomy is performed about 10 cm down the jejunal limb from the pancreatic anastomosis. This is usually performed in an end-to-side fashion with one layer of interrupted sutures. The duodenojejunostomy or gastrojejunostomy is performed another 10 to 15 cm downstream from the biliary anastomosis, using a two-layer | Surgery_Schwartz. Rikkers LF, Mulholland M: Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott Williams & Wilkins; 1996.)but thoroughly clearing all tissue from the mesenteric vessels helps avoid incomplete resection. The wound is irrigated and meticulous hemostasis is assured at this point because the view of the portal vein area and retroperitoneum is more difficult after the reconstruction phase is completed.The reconstruction involves anastomoses of the pancreas first, then the bile duct, and, finally, the duodenum or stomach. There are various techniques for the pancreatic anastomoses. After the pancreatic anastomosis is completed, the choledocho-jejunostomy is performed about 10 cm down the jejunal limb from the pancreatic anastomosis. This is usually performed in an end-to-side fashion with one layer of interrupted sutures. The duodenojejunostomy or gastrojejunostomy is performed another 10 to 15 cm downstream from the biliary anastomosis, using a two-layer |
Surgery_Schwartz_9842 | Surgery_Schwartz | an end-to-side fashion with one layer of interrupted sutures. The duodenojejunostomy or gastrojejunostomy is performed another 10 to 15 cm downstream from the biliary anastomosis, using a two-layer technique.Pancreaticoduodenectomy With Vascular Resection. Accurate staging of pancreatic cancer with a high-quality pre-operative CT scan is extremely important. Involvement of the superior mesenteric artery, the celiac axis, or hepatic artery indicate a T4/stage 3 tumor that is locally advanced and unre-sectable. However, involvement of the portal vein or superior mesenteric vein does not necessarily preclude resection as long as there is a patent superior mesenteric vein-portal vein conflu-ence. Reconstruction can often be accomplished with a primary anastomosis of the vein. When resection of more than 2 cm of vein is required, an interposition graft such as the internal jugu-lar vein can be used for a tension-free reconstruction.In a systematic review of 28 retrospective studies from | Surgery_Schwartz. an end-to-side fashion with one layer of interrupted sutures. The duodenojejunostomy or gastrojejunostomy is performed another 10 to 15 cm downstream from the biliary anastomosis, using a two-layer technique.Pancreaticoduodenectomy With Vascular Resection. Accurate staging of pancreatic cancer with a high-quality pre-operative CT scan is extremely important. Involvement of the superior mesenteric artery, the celiac axis, or hepatic artery indicate a T4/stage 3 tumor that is locally advanced and unre-sectable. However, involvement of the portal vein or superior mesenteric vein does not necessarily preclude resection as long as there is a patent superior mesenteric vein-portal vein conflu-ence. Reconstruction can often be accomplished with a primary anastomosis of the vein. When resection of more than 2 cm of vein is required, an interposition graft such as the internal jugu-lar vein can be used for a tension-free reconstruction.In a systematic review of 28 retrospective studies from |
Surgery_Schwartz_9843 | Surgery_Schwartz | of more than 2 cm of vein is required, an interposition graft such as the internal jugu-lar vein can be used for a tension-free reconstruction.In a systematic review of 28 retrospective studies from high-volume pancreas centers, the morbidity, mortality, and survival outcome after undertaking extended pancreaticoduodenectomy with vascular resection for pancreatic cancer with venous involvement and/or limited arterial involvement was acceptable.331 Another more recent report from five teaching hospitals demonstrated that the Whipple procedure combined with vascular resection and reconstruction could achieve complete removal of tumors without significantly increasing the mortality rate, and the median survival time was higher than that of patients who underwent palliative treatment.332 However, contrary to the findings of analyses from expert pancreas centers, a retrospective cohort analysis using the National Surgical Quality Improvement Program data from 2005 to 2009 demonstrated | Surgery_Schwartz. of more than 2 cm of vein is required, an interposition graft such as the internal jugu-lar vein can be used for a tension-free reconstruction.In a systematic review of 28 retrospective studies from high-volume pancreas centers, the morbidity, mortality, and survival outcome after undertaking extended pancreaticoduodenectomy with vascular resection for pancreatic cancer with venous involvement and/or limited arterial involvement was acceptable.331 Another more recent report from five teaching hospitals demonstrated that the Whipple procedure combined with vascular resection and reconstruction could achieve complete removal of tumors without significantly increasing the mortality rate, and the median survival time was higher than that of patients who underwent palliative treatment.332 However, contrary to the findings of analyses from expert pancreas centers, a retrospective cohort analysis using the National Surgical Quality Improvement Program data from 2005 to 2009 demonstrated |
Surgery_Schwartz_9844 | Surgery_Schwartz | However, contrary to the findings of analyses from expert pancreas centers, a retrospective cohort analysis using the National Surgical Quality Improvement Program data from 2005 to 2009 demonstrated increased 30-day postoperative morbidity and mortality in pancreaticoduodenectomy with vein resection when compared with pancreaticoduodenectomy alone.333 These data indicate that pancreaticoduodenectomy with vascular resection is only a reasonable option when it is performed after neoadjuvant therapy and at very-high-volume centers where the morbidity of the operation can be kept to a minimum.Minimally Invasive Pancreatectomy. Laparoscopic distal pancreatectomy has been proven to be safe and is appropriate for essentially all indications for pancreatectomy. This approach is associated with decreased blood loss and quicker recovery. Centrally located lesions near the splenoportal confluence must be approached laparoscopically with caution. Robotic technology may make dissection and | Surgery_Schwartz. However, contrary to the findings of analyses from expert pancreas centers, a retrospective cohort analysis using the National Surgical Quality Improvement Program data from 2005 to 2009 demonstrated increased 30-day postoperative morbidity and mortality in pancreaticoduodenectomy with vein resection when compared with pancreaticoduodenectomy alone.333 These data indicate that pancreaticoduodenectomy with vascular resection is only a reasonable option when it is performed after neoadjuvant therapy and at very-high-volume centers where the morbidity of the operation can be kept to a minimum.Minimally Invasive Pancreatectomy. Laparoscopic distal pancreatectomy has been proven to be safe and is appropriate for essentially all indications for pancreatectomy. This approach is associated with decreased blood loss and quicker recovery. Centrally located lesions near the splenoportal confluence must be approached laparoscopically with caution. Robotic technology may make dissection and |
Surgery_Schwartz_9845 | Surgery_Schwartz | with decreased blood loss and quicker recovery. Centrally located lesions near the splenoportal confluence must be approached laparoscopically with caution. Robotic technology may make dissection and control of major vessels in this area easier and perhaps safer. Interest in laparoscopic pancreaticoduodenectomy is increasing throughout the United States with some early adopters reporting excellent outcomes comparable to the open procedure.334 Early results indicate this technique is feasible, but considerable expertise is required in both open pancreatic resection as well as advanced laparoscopic techniques to achieve these outcomes. Whether the advantages seen in other areas of minimally invasive surgery apply to the Whipple procedure is an area of current investigation.Variations and Controversies. The preservation of the pylorus has several theoretical advantages, including preven-tion of reflux of pancreaticobiliary secretions into the stomach, decreased incidence of marginal | Surgery_Schwartz. with decreased blood loss and quicker recovery. Centrally located lesions near the splenoportal confluence must be approached laparoscopically with caution. Robotic technology may make dissection and control of major vessels in this area easier and perhaps safer. Interest in laparoscopic pancreaticoduodenectomy is increasing throughout the United States with some early adopters reporting excellent outcomes comparable to the open procedure.334 Early results indicate this technique is feasible, but considerable expertise is required in both open pancreatic resection as well as advanced laparoscopic techniques to achieve these outcomes. Whether the advantages seen in other areas of minimally invasive surgery apply to the Whipple procedure is an area of current investigation.Variations and Controversies. The preservation of the pylorus has several theoretical advantages, including preven-tion of reflux of pancreaticobiliary secretions into the stomach, decreased incidence of marginal |
Surgery_Schwartz_9846 | Surgery_Schwartz | Controversies. The preservation of the pylorus has several theoretical advantages, including preven-tion of reflux of pancreaticobiliary secretions into the stomach, decreased incidence of marginal ulceration, normal gastric acid secretion and hormone release, and improved gastric function. Patients with pylorus-preserving resections have appeared to regain weight better than historic controls in some studies. Return of gastric emptying in the immediate postoperative period may take longer after the pylorus-preserving operation, and it is controversial whether there is any significant improve-ment in long-term quality of life with pyloric preservation.335-336Techniques for the pancreaticojejunostomy include end-to-side or end-to-end and duct-to-mucosa sutures or invagination (Fig. 33-75). Pancreaticogastrostomy has also been investigated.Some surgeons use stents, glue to seal the anastomosis, or octreotide to decrease pancreatic secretions. No matter what com-bination of these | Surgery_Schwartz. Controversies. The preservation of the pylorus has several theoretical advantages, including preven-tion of reflux of pancreaticobiliary secretions into the stomach, decreased incidence of marginal ulceration, normal gastric acid secretion and hormone release, and improved gastric function. Patients with pylorus-preserving resections have appeared to regain weight better than historic controls in some studies. Return of gastric emptying in the immediate postoperative period may take longer after the pylorus-preserving operation, and it is controversial whether there is any significant improve-ment in long-term quality of life with pyloric preservation.335-336Techniques for the pancreaticojejunostomy include end-to-side or end-to-end and duct-to-mucosa sutures or invagination (Fig. 33-75). Pancreaticogastrostomy has also been investigated.Some surgeons use stents, glue to seal the anastomosis, or octreotide to decrease pancreatic secretions. No matter what com-bination of these |
Surgery_Schwartz_9847 | Surgery_Schwartz | 33-75). Pancreaticogastrostomy has also been investigated.Some surgeons use stents, glue to seal the anastomosis, or octreotide to decrease pancreatic secretions. No matter what com-bination of these techniques is used, the clinically significant pan-creatic leakage rate is always about 10%. Therefore, the choice of techniques depends more on the surgeon’s personal experience.Traditionally, most surgeons place drains around the pan-creatic and biliary anastomoses because disruption of the pan-creaticojejunostomy cannot be avoided in one out of 10 patients. Brunicardi_Ch33_p1429-p1516.indd 149301/03/19 6:46 PM 1494SPECIFIC CONSIDERATIONSPART IIThis complication can lead to the development of an upper abdominal abscess or can present as an external pancreatic fis-tula. Usually, a pure pancreatic leak is controlled by the drains and will eventually seal spontaneously. Combined pancreatic and biliary leaks are cause for concern because bile will activate the pancreatic enzymes. In its | Surgery_Schwartz. 33-75). Pancreaticogastrostomy has also been investigated.Some surgeons use stents, glue to seal the anastomosis, or octreotide to decrease pancreatic secretions. No matter what com-bination of these techniques is used, the clinically significant pan-creatic leakage rate is always about 10%. Therefore, the choice of techniques depends more on the surgeon’s personal experience.Traditionally, most surgeons place drains around the pan-creatic and biliary anastomoses because disruption of the pan-creaticojejunostomy cannot be avoided in one out of 10 patients. Brunicardi_Ch33_p1429-p1516.indd 149301/03/19 6:46 PM 1494SPECIFIC CONSIDERATIONSPART IIThis complication can lead to the development of an upper abdominal abscess or can present as an external pancreatic fis-tula. Usually, a pure pancreatic leak is controlled by the drains and will eventually seal spontaneously. Combined pancreatic and biliary leaks are cause for concern because bile will activate the pancreatic enzymes. In its |
Surgery_Schwartz_9848 | Surgery_Schwartz | leak is controlled by the drains and will eventually seal spontaneously. Combined pancreatic and biliary leaks are cause for concern because bile will activate the pancreatic enzymes. In its most virulent form, disruption leads to necrotizing retroperitoneal infection, which can erode major arteries and veins of the upper abdomen, including the exposed portal vein and its branches or the stump of the gastro-duodenal artery. Impending catastrophe is often preceded by a small herald bleed from the drain site. Depending on the clinical situation, such an event is an indication to perform an angio-gram or return the patient to the operating room to widely drain the pancreaticojejunostomy and to repair the involved blood vessel. Open packing may be necessary to control diffuse necro-sis and infection. Some studies have questioned the practice of routine drain placement after pancreatectomy with reliance on postoperative percutaneous drainage when leaks occur.337 How-ever, a randomized, | Surgery_Schwartz. leak is controlled by the drains and will eventually seal spontaneously. Combined pancreatic and biliary leaks are cause for concern because bile will activate the pancreatic enzymes. In its most virulent form, disruption leads to necrotizing retroperitoneal infection, which can erode major arteries and veins of the upper abdomen, including the exposed portal vein and its branches or the stump of the gastro-duodenal artery. Impending catastrophe is often preceded by a small herald bleed from the drain site. Depending on the clinical situation, such an event is an indication to perform an angio-gram or return the patient to the operating room to widely drain the pancreaticojejunostomy and to repair the involved blood vessel. Open packing may be necessary to control diffuse necro-sis and infection. Some studies have questioned the practice of routine drain placement after pancreatectomy with reliance on postoperative percutaneous drainage when leaks occur.337 How-ever, a randomized, |
Surgery_Schwartz_9849 | Surgery_Schwartz | infection. Some studies have questioned the practice of routine drain placement after pancreatectomy with reliance on postoperative percutaneous drainage when leaks occur.337 How-ever, a randomized, controlled, multicenter trial showed that patients who develop a leak after pancreaticoduodenectomy are ABCDEFigure 33-75. Techniques for pancreaticojejunostomy. A to D. Duct-to-mucosa, end-to-side E. Intraoperative photographs of end-to-side pancreaticojejunostomy. F to J. End-to-end invagination. K to O. End-to-side invagination.Brunicardi_Ch33_p1429-p1516.indd 149401/03/19 6:46 PM 1495PANCREASCHAPTER 33FGHIJFigure 33-75. (Continued)at a substantially increased risk of mortality if a drain was not placed at the time of resection.337 In contrast, the outcome does not seem to be as dramatically affected by drain placement in the setting of distal pancreatectomy.338 In the absence of a fis-tula, drains should be removed early in the postoperative period, preferably by postoperative day | Surgery_Schwartz. infection. Some studies have questioned the practice of routine drain placement after pancreatectomy with reliance on postoperative percutaneous drainage when leaks occur.337 How-ever, a randomized, controlled, multicenter trial showed that patients who develop a leak after pancreaticoduodenectomy are ABCDEFigure 33-75. Techniques for pancreaticojejunostomy. A to D. Duct-to-mucosa, end-to-side E. Intraoperative photographs of end-to-side pancreaticojejunostomy. F to J. End-to-end invagination. K to O. End-to-side invagination.Brunicardi_Ch33_p1429-p1516.indd 149401/03/19 6:46 PM 1495PANCREASCHAPTER 33FGHIJFigure 33-75. (Continued)at a substantially increased risk of mortality if a drain was not placed at the time of resection.337 In contrast, the outcome does not seem to be as dramatically affected by drain placement in the setting of distal pancreatectomy.338 In the absence of a fis-tula, drains should be removed early in the postoperative period, preferably by postoperative day |
Surgery_Schwartz_9850 | Surgery_Schwartz | affected by drain placement in the setting of distal pancreatectomy.338 In the absence of a fis-tula, drains should be removed early in the postoperative period, preferably by postoperative day 5.339Many patients with pancreatic cancer are malnourished preoperatively and suffer from gastroparesis in the immedi-ate postoperative period. Routine placement of a feeding jeju-nostomy tube and gastrostomy tube has become less common, and most surgeons use these tubes selectively. Gastrostomy tubes may decrease the length of stay in patients who might Brunicardi_Ch33_p1429-p1516.indd 149501/03/19 6:46 PM 1496SPECIFIC CONSIDERATIONSPART IIKLNOMFigure 33-75. (Continued)be predicted to have severe gastroparesis. Jejunostomy tubes are certainly not benign and can result in leaks and intestinal obstruction. However, parenteral nutrition is also associated with serious complications such as line sepsis, loss of gut muco-sal integrity, and hepatic dysfunction. Enteric tubes should be considered | Surgery_Schwartz. affected by drain placement in the setting of distal pancreatectomy.338 In the absence of a fis-tula, drains should be removed early in the postoperative period, preferably by postoperative day 5.339Many patients with pancreatic cancer are malnourished preoperatively and suffer from gastroparesis in the immedi-ate postoperative period. Routine placement of a feeding jeju-nostomy tube and gastrostomy tube has become less common, and most surgeons use these tubes selectively. Gastrostomy tubes may decrease the length of stay in patients who might Brunicardi_Ch33_p1429-p1516.indd 149501/03/19 6:46 PM 1496SPECIFIC CONSIDERATIONSPART IIKLNOMFigure 33-75. (Continued)be predicted to have severe gastroparesis. Jejunostomy tubes are certainly not benign and can result in leaks and intestinal obstruction. However, parenteral nutrition is also associated with serious complications such as line sepsis, loss of gut muco-sal integrity, and hepatic dysfunction. Enteric tubes should be considered |
Surgery_Schwartz_9851 | Surgery_Schwartz | However, parenteral nutrition is also associated with serious complications such as line sepsis, loss of gut muco-sal integrity, and hepatic dysfunction. Enteric tubes should be considered in patients at risk such as malnourished patients who have received neoadjuvant chemotherapy.Because of the high incidence of direct retroperitoneal invasion and regional lymph node metastasis at the time of surgery, trails of more extended resections including extension of the pancreatic resection to the middle body of the pancreas, segmental resection of the portal vein, if necessary, resection of retroperitoneal tissue along the right perinephric area, and lymphadenectomy to the region of the celiac plexus were exam-ined. In the hands of experienced surgeons, these techniques are associated with greater blood loss but no increase in mortality. However, improved survival has not been demonstrated. Total pancreatectomy has also been considered in the past. Although pancreatic leaks are eliminated, | Surgery_Schwartz. However, parenteral nutrition is also associated with serious complications such as line sepsis, loss of gut muco-sal integrity, and hepatic dysfunction. Enteric tubes should be considered in patients at risk such as malnourished patients who have received neoadjuvant chemotherapy.Because of the high incidence of direct retroperitoneal invasion and regional lymph node metastasis at the time of surgery, trails of more extended resections including extension of the pancreatic resection to the middle body of the pancreas, segmental resection of the portal vein, if necessary, resection of retroperitoneal tissue along the right perinephric area, and lymphadenectomy to the region of the celiac plexus were exam-ined. In the hands of experienced surgeons, these techniques are associated with greater blood loss but no increase in mortality. However, improved survival has not been demonstrated. Total pancreatectomy has also been considered in the past. Although pancreatic leaks are eliminated, |
Surgery_Schwartz_9852 | Surgery_Schwartz | blood loss but no increase in mortality. However, improved survival has not been demonstrated. Total pancreatectomy has also been considered in the past. Although pancreatic leaks are eliminated, major morbidity from brittle diabetes and exocrine insufficiency outweigh any theoretical benefit.Pancreatic cancer can recur locally after pancreaticoduo-denectomy. Intraoperative radiotherapy (IORT) delivers radia-tion to the operative bed at the time of resection. Radiation to Brunicardi_Ch33_p1429-p1516.indd 149601/03/19 6:46 PM 1497PANCREASCHAPTER 33surrounding normal areas is minimized, but the radiation is delivered all in one setting, rather than in fractionated doses over time. Favorable results were recently reported among a series of patients with locally advanced unresectable or border-line-resectable PDAC who received intensive neoadjuvant treat-ment followed by exploratory laparotomy and IORT.340Complications of Pancreaticoduodenectomy. The operative mortality rate for | Surgery_Schwartz. blood loss but no increase in mortality. However, improved survival has not been demonstrated. Total pancreatectomy has also been considered in the past. Although pancreatic leaks are eliminated, major morbidity from brittle diabetes and exocrine insufficiency outweigh any theoretical benefit.Pancreatic cancer can recur locally after pancreaticoduo-denectomy. Intraoperative radiotherapy (IORT) delivers radia-tion to the operative bed at the time of resection. Radiation to Brunicardi_Ch33_p1429-p1516.indd 149601/03/19 6:46 PM 1497PANCREASCHAPTER 33surrounding normal areas is minimized, but the radiation is delivered all in one setting, rather than in fractionated doses over time. Favorable results were recently reported among a series of patients with locally advanced unresectable or border-line-resectable PDAC who received intensive neoadjuvant treat-ment followed by exploratory laparotomy and IORT.340Complications of Pancreaticoduodenectomy. The operative mortality rate for |
Surgery_Schwartz_9853 | Surgery_Schwartz | or border-line-resectable PDAC who received intensive neoadjuvant treat-ment followed by exploratory laparotomy and IORT.340Complications of Pancreaticoduodenectomy. The operative mortality rate for pancreaticoduodenectomy has decreased to <5% in high-volume centers (where individual surgeons perform more than 15 cases per year), suggesting that patients in rural areas would benefit from referral to large urban centers.341-342 The most common causes of death are sepsis, hemorrhage, and cardiovascular events. Postoperative complications are unfortunately still very common and include delayed gastric emptying, pancreatic fistula, and hemorrhage.Delayed gastric emptying is common after pancreatico-duodenectomy and is treated conservatively as long as complete gastric outlet obstruction is ruled out by a contrast study. In the acute phase, intravenous erythromycin may help, but the prob-lem usually improves with time.Considerable attention has been focused on the preven-tion of | Surgery_Schwartz. or border-line-resectable PDAC who received intensive neoadjuvant treat-ment followed by exploratory laparotomy and IORT.340Complications of Pancreaticoduodenectomy. The operative mortality rate for pancreaticoduodenectomy has decreased to <5% in high-volume centers (where individual surgeons perform more than 15 cases per year), suggesting that patients in rural areas would benefit from referral to large urban centers.341-342 The most common causes of death are sepsis, hemorrhage, and cardiovascular events. Postoperative complications are unfortunately still very common and include delayed gastric emptying, pancreatic fistula, and hemorrhage.Delayed gastric emptying is common after pancreatico-duodenectomy and is treated conservatively as long as complete gastric outlet obstruction is ruled out by a contrast study. In the acute phase, intravenous erythromycin may help, but the prob-lem usually improves with time.Considerable attention has been focused on the preven-tion of |
Surgery_Schwartz_9854 | Surgery_Schwartz | is ruled out by a contrast study. In the acute phase, intravenous erythromycin may help, but the prob-lem usually improves with time.Considerable attention has been focused on the preven-tion of pancreatic leak after pancreas resection. Modifications of the anastomotic technique (end-to-side or end-to-end, duct-to-mucosa, or invaginated), the use of jejunum or the stomach for drainage, the use of pancreatic duct stents, the use of octreotide, and various sealants have all been evaluated.Long-acting synthetic analogues of somatostatin have been evaluated as a pharmacologic therapy to reduce pancreatic secretion and the rate of pancreatic fistula after pancreatic resec-tion. Some European studies supported benefit particularly in selected higher risk patients, while previous North American tri-als concluded there was no benefit.343-349 A recent single-center, randomized trial with pasireotide (a newer analog) suggested potential benefit.350Many technical modifications to the classic | Surgery_Schwartz. is ruled out by a contrast study. In the acute phase, intravenous erythromycin may help, but the prob-lem usually improves with time.Considerable attention has been focused on the preven-tion of pancreatic leak after pancreas resection. Modifications of the anastomotic technique (end-to-side or end-to-end, duct-to-mucosa, or invaginated), the use of jejunum or the stomach for drainage, the use of pancreatic duct stents, the use of octreotide, and various sealants have all been evaluated.Long-acting synthetic analogues of somatostatin have been evaluated as a pharmacologic therapy to reduce pancreatic secretion and the rate of pancreatic fistula after pancreatic resec-tion. Some European studies supported benefit particularly in selected higher risk patients, while previous North American tri-als concluded there was no benefit.343-349 A recent single-center, randomized trial with pasireotide (a newer analog) suggested potential benefit.350Many technical modifications to the classic |
Surgery_Schwartz_9855 | Surgery_Schwartz | tri-als concluded there was no benefit.343-349 A recent single-center, randomized trial with pasireotide (a newer analog) suggested potential benefit.350Many technical modifications to the classic pancreaticodu-odenectomy have been described. However, numerous technical variations to the pancreaticoenteric anastomosis have not clearly demonstrated an objective method to consistently decrease the rate of clinically significant postoperative pancreatic fistula, which in most series is about 10%. Yeo compared the incidence of pancreatic fistula in patients who had a pancreaticoduode-nectomy with reconstruction via a pancreaticogastrostomy or pancreaticojejunostomy.351 There was no significant difference between the two techniques in the incidence of pancreatic fis-tula. A recent meta-analysis summarized the results of 16 trials comparing pancreaticogastrostomy to pancreaticojejunostomy. All of the observational clinical studies reported superiority of pancreaticogastrostomy over | Surgery_Schwartz. tri-als concluded there was no benefit.343-349 A recent single-center, randomized trial with pasireotide (a newer analog) suggested potential benefit.350Many technical modifications to the classic pancreaticodu-odenectomy have been described. However, numerous technical variations to the pancreaticoenteric anastomosis have not clearly demonstrated an objective method to consistently decrease the rate of clinically significant postoperative pancreatic fistula, which in most series is about 10%. Yeo compared the incidence of pancreatic fistula in patients who had a pancreaticoduode-nectomy with reconstruction via a pancreaticogastrostomy or pancreaticojejunostomy.351 There was no significant difference between the two techniques in the incidence of pancreatic fis-tula. A recent meta-analysis summarized the results of 16 trials comparing pancreaticogastrostomy to pancreaticojejunostomy. All of the observational clinical studies reported superiority of pancreaticogastrostomy over |
Surgery_Schwartz_9856 | Surgery_Schwartz | summarized the results of 16 trials comparing pancreaticogastrostomy to pancreaticojejunostomy. All of the observational clinical studies reported superiority of pancreaticogastrostomy over pancreaticojejunostomy, most likely influenced by publication bias. In contrast, all random-ized prospective trials failed to show advantage of a particular technique, suggesting both techniques provide equally good results.352Other options to consider when performing the pancre-atic anastomosis are the duct-to-mucosa vs. the invagination techniques. Some surgeons choose the technique at the time of operation, depending on the size of the pancreatic duct and the texture of pancreas favoring invagination when the duct is small and the pancreatic texture is soft.353 Other surgeons use the same technique every time. The duct-to-mucosa anastomosis results in a low pancreatic fistula rate, particularly in patients with a large pancreatic duct and a fibrotic pancreas.354Use of a pancreatic duct stent | Surgery_Schwartz. summarized the results of 16 trials comparing pancreaticogastrostomy to pancreaticojejunostomy. All of the observational clinical studies reported superiority of pancreaticogastrostomy over pancreaticojejunostomy, most likely influenced by publication bias. In contrast, all random-ized prospective trials failed to show advantage of a particular technique, suggesting both techniques provide equally good results.352Other options to consider when performing the pancre-atic anastomosis are the duct-to-mucosa vs. the invagination techniques. Some surgeons choose the technique at the time of operation, depending on the size of the pancreatic duct and the texture of pancreas favoring invagination when the duct is small and the pancreatic texture is soft.353 Other surgeons use the same technique every time. The duct-to-mucosa anastomosis results in a low pancreatic fistula rate, particularly in patients with a large pancreatic duct and a fibrotic pancreas.354Use of a pancreatic duct stent |
Surgery_Schwartz_9857 | Surgery_Schwartz | every time. The duct-to-mucosa anastomosis results in a low pancreatic fistula rate, particularly in patients with a large pancreatic duct and a fibrotic pancreas.354Use of a pancreatic duct stent across the anastomosis has been suggested as a means of preventing a pancreatic leak and as an aid in technical precision. Both internal stenting as well as external stenting have been practiced. A recent Cochrane analysis of eight randomized, controlled trials failed to iden-tify any convincing evidence of benefit with internal or external pancreatic duct stents.355 Some previous studies indicated that stents might be harmful. A recent multicenter randomized trial comparing external to internal pancreatic duct stents during pan-creaticoduodenectomy showed a lower rate of pancreatic fistula with internal stents, so this controversy is likely to continue.356Reconstruction with an isolated Roux-en-Y pancreatico-enteric anastomosis has been suggested as a method do decrease postoperative | Surgery_Schwartz. every time. The duct-to-mucosa anastomosis results in a low pancreatic fistula rate, particularly in patients with a large pancreatic duct and a fibrotic pancreas.354Use of a pancreatic duct stent across the anastomosis has been suggested as a means of preventing a pancreatic leak and as an aid in technical precision. Both internal stenting as well as external stenting have been practiced. A recent Cochrane analysis of eight randomized, controlled trials failed to iden-tify any convincing evidence of benefit with internal or external pancreatic duct stents.355 Some previous studies indicated that stents might be harmful. A recent multicenter randomized trial comparing external to internal pancreatic duct stents during pan-creaticoduodenectomy showed a lower rate of pancreatic fistula with internal stents, so this controversy is likely to continue.356Reconstruction with an isolated Roux-en-Y pancreatico-enteric anastomosis has been suggested as a method do decrease postoperative |
Surgery_Schwartz_9858 | Surgery_Schwartz | with internal stents, so this controversy is likely to continue.356Reconstruction with an isolated Roux-en-Y pancreatico-enteric anastomosis has been suggested as a method do decrease postoperative pancreatic leak.357-358 The logic behind this tech-nical modification is that the use of separate Roux-en-Y limbs for biliary and pancreatic secretions may protect the pancreatic anastomosis from activated pancreatic enzymes. However, data is limited, and this is not a common practice.Avoiding the pancreatic anastomosis altogether by ductal ligation or occlusion has also been evaluated as a potential technique to reduce the rate of postoperative pancreatic fistula.359-360 Ductal occlusion with neoprene or prolamine, which are nonresorbable glues, has been abandoned due to pancreatic atrophy and loss of exocrine function. Duct occlusion in pancreaticojejunostomy significantly increases the risk of endocrine insufficiency without a decrease in the postoperative complication rate. To avoid | Surgery_Schwartz. with internal stents, so this controversy is likely to continue.356Reconstruction with an isolated Roux-en-Y pancreatico-enteric anastomosis has been suggested as a method do decrease postoperative pancreatic leak.357-358 The logic behind this tech-nical modification is that the use of separate Roux-en-Y limbs for biliary and pancreatic secretions may protect the pancreatic anastomosis from activated pancreatic enzymes. However, data is limited, and this is not a common practice.Avoiding the pancreatic anastomosis altogether by ductal ligation or occlusion has also been evaluated as a potential technique to reduce the rate of postoperative pancreatic fistula.359-360 Ductal occlusion with neoprene or prolamine, which are nonresorbable glues, has been abandoned due to pancreatic atrophy and loss of exocrine function. Duct occlusion in pancreaticojejunostomy significantly increases the risk of endocrine insufficiency without a decrease in the postoperative complication rate. To avoid |
Surgery_Schwartz_9859 | Surgery_Schwartz | and loss of exocrine function. Duct occlusion in pancreaticojejunostomy significantly increases the risk of endocrine insufficiency without a decrease in the postoperative complication rate. To avoid long-term loss of function, absorbable glues, such as fibrin glue, have been evaluated to limit the action of pancreatic enzymes until the anastomosis is healed. Fibrin glue has been used for both duct occlusion and has also been applied to the surface of the pancreatic stump and anastomotic site without clear improvement in pancreatic fistula rate. The effect of BioGlue applied to the anastomotic surface after the Whipple procedure and pancreatic stump after distal pancreatectomy was evaluated in a retrospective cohort study. There were no statistically significant differences in the incidence or severity grades of postoperative pancreatic fistulas.361 A randomized prospective trial of application of fibrin glue to the surface of the pancreaticojejunostomy in high-risk patients did not | Surgery_Schwartz. and loss of exocrine function. Duct occlusion in pancreaticojejunostomy significantly increases the risk of endocrine insufficiency without a decrease in the postoperative complication rate. To avoid long-term loss of function, absorbable glues, such as fibrin glue, have been evaluated to limit the action of pancreatic enzymes until the anastomosis is healed. Fibrin glue has been used for both duct occlusion and has also been applied to the surface of the pancreatic stump and anastomotic site without clear improvement in pancreatic fistula rate. The effect of BioGlue applied to the anastomotic surface after the Whipple procedure and pancreatic stump after distal pancreatectomy was evaluated in a retrospective cohort study. There were no statistically significant differences in the incidence or severity grades of postoperative pancreatic fistulas.361 A randomized prospective trial of application of fibrin glue to the surface of the pancreaticojejunostomy in high-risk patients did not |
Surgery_Schwartz_9860 | Surgery_Schwartz | or severity grades of postoperative pancreatic fistulas.361 A randomized prospective trial of application of fibrin glue to the surface of the pancreaticojejunostomy in high-risk patients did not reduce the incidence of pancreatic fistula or total complications after pancreaticoduodenectomy.362If not combined with a biliary leak, pancreatic fistula, although serious, can usually be managed conservatively. In about 95% of cases, reoperation is not indicated, and prolonged drainage, using drains placed in the original operation or percu-taneously after resection, results in spontaneous closure of the fistula.363Hemorrhage can occur either intraoperatively or postop-eratively. Intraoperative hemorrhage typically occurs during the dissection of the portal vein. A major laceration of the portal vein can occur at a point in the operation at which the portal vein is not yet exposed. Temporary control of hemorrhage is gener-ally possible in this situation by compressing the portal vein and | Surgery_Schwartz. or severity grades of postoperative pancreatic fistulas.361 A randomized prospective trial of application of fibrin glue to the surface of the pancreaticojejunostomy in high-risk patients did not reduce the incidence of pancreatic fistula or total complications after pancreaticoduodenectomy.362If not combined with a biliary leak, pancreatic fistula, although serious, can usually be managed conservatively. In about 95% of cases, reoperation is not indicated, and prolonged drainage, using drains placed in the original operation or percu-taneously after resection, results in spontaneous closure of the fistula.363Hemorrhage can occur either intraoperatively or postop-eratively. Intraoperative hemorrhage typically occurs during the dissection of the portal vein. A major laceration of the portal vein can occur at a point in the operation at which the portal vein is not yet exposed. Temporary control of hemorrhage is gener-ally possible in this situation by compressing the portal vein and |
Surgery_Schwartz_9861 | Surgery_Schwartz | vein can occur at a point in the operation at which the portal vein is not yet exposed. Temporary control of hemorrhage is gener-ally possible in this situation by compressing the portal vein and superior mesenteric vein against the tumor with the surgeon’s left hand behind the head of the pancreas. An experienced assis-tant is needed to divide the neck of the pancreas to the left of the portal vein and achieve proximal and distal control. Sometimes, the vein can be sutured closed with minimal narrowing. Other times, a segmental resection and interposition graft (internal jugular vein) may be needed.Postoperative hemorrhage can occur from inadequate liga-ture of any one of numerous blood vessels during the procedure. Brunicardi_Ch33_p1429-p1516.indd 149701/03/19 6:46 PM 1498SPECIFIC CONSIDERATIONSPART IIHemorrhage can also occur due to digestion of retroperitoneal blood vessels due to a combined biliary-pancreatic leak. Uncom-monly, a stress ulcer, or later, a marginal ulcer, can | Surgery_Schwartz. vein can occur at a point in the operation at which the portal vein is not yet exposed. Temporary control of hemorrhage is gener-ally possible in this situation by compressing the portal vein and superior mesenteric vein against the tumor with the surgeon’s left hand behind the head of the pancreas. An experienced assis-tant is needed to divide the neck of the pancreas to the left of the portal vein and achieve proximal and distal control. Sometimes, the vein can be sutured closed with minimal narrowing. Other times, a segmental resection and interposition graft (internal jugular vein) may be needed.Postoperative hemorrhage can occur from inadequate liga-ture of any one of numerous blood vessels during the procedure. Brunicardi_Ch33_p1429-p1516.indd 149701/03/19 6:46 PM 1498SPECIFIC CONSIDERATIONSPART IIHemorrhage can also occur due to digestion of retroperitoneal blood vessels due to a combined biliary-pancreatic leak. Uncom-monly, a stress ulcer, or later, a marginal ulcer, can |
Surgery_Schwartz_9862 | Surgery_Schwartz | can also occur due to digestion of retroperitoneal blood vessels due to a combined biliary-pancreatic leak. Uncom-monly, a stress ulcer, or later, a marginal ulcer, can result in GI hemorrhage. Typically, a vagotomy is not performed when pan-creaticoduodenectomy is performed for pancreatic cancer, but patients are placed on proton pump inhibitors.Outcome and Value of Pancreaticoduodenectomy for Cancer. Survival figures indicate that perhaps few patients are cured indefinitely of pancreatic cancer with pancreaticoduode-nectomy. This has led to a nihilistic view toward patients with this disease which has further contributed to poor outcomes. Using the National Cancer Data Base (1995–2004), Bilimoria reported on 9559 patients with early stage potentially resect-able tumors (pretreatment clinical Stage I: T1N0M0 and T2N0M0).364 Multivariate models were employed to identify factors predicting failure to undergo surgery and assess the impact of pancreatectomy on survival. This study | Surgery_Schwartz. can also occur due to digestion of retroperitoneal blood vessels due to a combined biliary-pancreatic leak. Uncom-monly, a stress ulcer, or later, a marginal ulcer, can result in GI hemorrhage. Typically, a vagotomy is not performed when pan-creaticoduodenectomy is performed for pancreatic cancer, but patients are placed on proton pump inhibitors.Outcome and Value of Pancreaticoduodenectomy for Cancer. Survival figures indicate that perhaps few patients are cured indefinitely of pancreatic cancer with pancreaticoduode-nectomy. This has led to a nihilistic view toward patients with this disease which has further contributed to poor outcomes. Using the National Cancer Data Base (1995–2004), Bilimoria reported on 9559 patients with early stage potentially resect-able tumors (pretreatment clinical Stage I: T1N0M0 and T2N0M0).364 Multivariate models were employed to identify factors predicting failure to undergo surgery and assess the impact of pancreatectomy on survival. This study |
Surgery_Schwartz_9863 | Surgery_Schwartz | clinical Stage I: T1N0M0 and T2N0M0).364 Multivariate models were employed to identify factors predicting failure to undergo surgery and assess the impact of pancreatectomy on survival. This study identified a striking underuse of pancreatectomy in the United States. Of clinical stage I patients, 71.4% (6823/9559) did not undergo surgery; 6.4% (616/9559) were excluded due to comorbidi-ties; 4.2% (403/9559) refused surgery; 9.1% (869/9559) were excluded due to age; and 38.2% (3644/9559) with potentially resectable cancers were not offered surgery. Patients were less likely to undergo surgery if they were older than 65 years, were black, were on Medicare or Medicaid, had pancreatic head lesions, earned lower annual incomes, or had less education. Patients were less likely to receive surgery at low-volume and community centers. Patients who were not offered surgery had worse survival than patients who underwent resection. Over-all survival from PDAC would significantly increase if more | Surgery_Schwartz. clinical Stage I: T1N0M0 and T2N0M0).364 Multivariate models were employed to identify factors predicting failure to undergo surgery and assess the impact of pancreatectomy on survival. This study identified a striking underuse of pancreatectomy in the United States. Of clinical stage I patients, 71.4% (6823/9559) did not undergo surgery; 6.4% (616/9559) were excluded due to comorbidi-ties; 4.2% (403/9559) refused surgery; 9.1% (869/9559) were excluded due to age; and 38.2% (3644/9559) with potentially resectable cancers were not offered surgery. Patients were less likely to undergo surgery if they were older than 65 years, were black, were on Medicare or Medicaid, had pancreatic head lesions, earned lower annual incomes, or had less education. Patients were less likely to receive surgery at low-volume and community centers. Patients who were not offered surgery had worse survival than patients who underwent resection. Over-all survival from PDAC would significantly increase if more |
Surgery_Schwartz_9864 | Surgery_Schwartz | at low-volume and community centers. Patients who were not offered surgery had worse survival than patients who underwent resection. Over-all survival from PDAC would significantly increase if more patients with stage I tumors were identified and offered surgery at high-volume centers (Fig. 33-76).Although pancreaticoduodenectomy may be performed with the hope of the rare cure in mind, the operation more importantly provides better palliation than any other treatment, and it is the only modality that offers any meaningful improve-ment in survival. If the procedure is performed without major complications, many months of palliation are usually achieved. However, it is the surgeon’s duty to make sure patients and their families have a realistic understanding of the true goals of pan-creaticoduodenectomy in the setting of pancreatic cancer.Adjuvant Chemotherapy and Radiation. Small studies in the 1980s suggested that adjuvant chemotherapy with 5-FU combined with radiation improves | Surgery_Schwartz. at low-volume and community centers. Patients who were not offered surgery had worse survival than patients who underwent resection. Over-all survival from PDAC would significantly increase if more patients with stage I tumors were identified and offered surgery at high-volume centers (Fig. 33-76).Although pancreaticoduodenectomy may be performed with the hope of the rare cure in mind, the operation more importantly provides better palliation than any other treatment, and it is the only modality that offers any meaningful improve-ment in survival. If the procedure is performed without major complications, many months of palliation are usually achieved. However, it is the surgeon’s duty to make sure patients and their families have a realistic understanding of the true goals of pan-creaticoduodenectomy in the setting of pancreatic cancer.Adjuvant Chemotherapy and Radiation. Small studies in the 1980s suggested that adjuvant chemotherapy with 5-FU combined with radiation improves |
Surgery_Schwartz_9865 | Surgery_Schwartz | in the setting of pancreatic cancer.Adjuvant Chemotherapy and Radiation. Small studies in the 1980s suggested that adjuvant chemotherapy with 5-FU combined with radiation improves survival by about 9 months after pancreatic resection for pancreatic adenocarcinoma.365 Subsequent, noncontrolled studies have reinforced that concept; however, the data have been criticized due to the low number of patients and low dose of radiation therapy that was given. In addition, gemcitabine has replaced 5-FU as standard therapy in pancreatic cancer but is thought to be too toxic when given with radiotherapy without dose reduction. A recent large European multicenter trial concluded that there was no value to chemo-radiotherapy, although the study suggested the possibility that chemotherapy alone might have survival benefit.366 Random-ized trials have failed to resolve the debate regarding the role of adjuvant radiation therapy in resectable pancreas cancer. A reasonable consideration in a disease | Surgery_Schwartz. in the setting of pancreatic cancer.Adjuvant Chemotherapy and Radiation. Small studies in the 1980s suggested that adjuvant chemotherapy with 5-FU combined with radiation improves survival by about 9 months after pancreatic resection for pancreatic adenocarcinoma.365 Subsequent, noncontrolled studies have reinforced that concept; however, the data have been criticized due to the low number of patients and low dose of radiation therapy that was given. In addition, gemcitabine has replaced 5-FU as standard therapy in pancreatic cancer but is thought to be too toxic when given with radiotherapy without dose reduction. A recent large European multicenter trial concluded that there was no value to chemo-radiotherapy, although the study suggested the possibility that chemotherapy alone might have survival benefit.366 Random-ized trials have failed to resolve the debate regarding the role of adjuvant radiation therapy in resectable pancreas cancer. A reasonable consideration in a disease |
Surgery_Schwartz_9866 | Surgery_Schwartz | have survival benefit.366 Random-ized trials have failed to resolve the debate regarding the role of adjuvant radiation therapy in resectable pancreas cancer. A reasonable consideration in a disease with high rates of distant metastases is to begin with adjuvant chemotherapy, followed by radiation therapy in patients who do not progress, particularly in patients where there may be increased concern about local recurrence such as in patients with close margins.Remarkable results in adjuvant therapy were reported by the Virginia Mason Clinic with combination 5-FU, cisplatinum, interferon-〈, and external beam radiation.367 Although the toxic-ity was high (42% hospitalized for GI toxicity), the promising results prompted larger confirmatory studies. Unfortunately, one such study was stopped due to toxicity, and this protocol has not been widely adopted. More recent results with FOLFIRINOX in the setting of metastatic disease have encouraged clinical tri-als using this regimen in the | Surgery_Schwartz. have survival benefit.366 Random-ized trials have failed to resolve the debate regarding the role of adjuvant radiation therapy in resectable pancreas cancer. A reasonable consideration in a disease with high rates of distant metastases is to begin with adjuvant chemotherapy, followed by radiation therapy in patients who do not progress, particularly in patients where there may be increased concern about local recurrence such as in patients with close margins.Remarkable results in adjuvant therapy were reported by the Virginia Mason Clinic with combination 5-FU, cisplatinum, interferon-〈, and external beam radiation.367 Although the toxic-ity was high (42% hospitalized for GI toxicity), the promising results prompted larger confirmatory studies. Unfortunately, one such study was stopped due to toxicity, and this protocol has not been widely adopted. More recent results with FOLFIRINOX in the setting of metastatic disease have encouraged clinical tri-als using this regimen in the |
Surgery_Schwartz_9867 | Surgery_Schwartz | due to toxicity, and this protocol has not been widely adopted. More recent results with FOLFIRINOX in the setting of metastatic disease have encouraged clinical tri-als using this regimen in the adjuvant setting, which are cur-rently underway (ClinicalTrials.gov identifier: NCT02172976). Nevertheless, pending further study, it is typical in the United States for patients with acceptable functional status to receive some form of adjuvant chemotherapy and sometimes chemora-diotherapy after surgery.Neoadjuvant Treatment. There are several potential advan-tages to the use of chemotherapy or chemoradiation before an attempt at surgical resection. For example, it avoids the risk that adjuvant treatment is delayed by complications of surgery. Neoadjuvant treatment also may decrease the tumor burden at operation, increasing the rate of resectability and killing some tumor cells before they can be spread intraoperatively. Another potential advantage is that it allows patients with occult | Surgery_Schwartz. due to toxicity, and this protocol has not been widely adopted. More recent results with FOLFIRINOX in the setting of metastatic disease have encouraged clinical tri-als using this regimen in the adjuvant setting, which are cur-rently underway (ClinicalTrials.gov identifier: NCT02172976). Nevertheless, pending further study, it is typical in the United States for patients with acceptable functional status to receive some form of adjuvant chemotherapy and sometimes chemora-diotherapy after surgery.Neoadjuvant Treatment. There are several potential advan-tages to the use of chemotherapy or chemoradiation before an attempt at surgical resection. For example, it avoids the risk that adjuvant treatment is delayed by complications of surgery. Neoadjuvant treatment also may decrease the tumor burden at operation, increasing the rate of resectability and killing some tumor cells before they can be spread intraoperatively. Another potential advantage is that it allows patients with occult |
Surgery_Schwartz_9868 | Surgery_Schwartz | burden at operation, increasing the rate of resectability and killing some tumor cells before they can be spread intraoperatively. Another potential advantage is that it allows patients with occult meta-static disease to avoid the morbidity of pancreatic resection. As many as 20% of patients treated with neoadjuvant chemoradia-tion develop metastatic disease detected by restaging CT and do not go on to surgery. This approach may separate patients into a subset likely to benefit from resection and a subset in whom sur-gery would be unlikely to provide clinical benefit. Preoperative chemoradiation has been shown not to increase the periopera-tive morbidity or mortality of pancreaticoduodenectomy. It may even decrease the incidence of pancreatic fistula. Prospective randomized trials investigating this concept are ongoing but are difficult to complete due to the high number of patients who fail to complete or receive a full course of either therapy. Studies have shown that neoadjuvant | Surgery_Schwartz. burden at operation, increasing the rate of resectability and killing some tumor cells before they can be spread intraoperatively. Another potential advantage is that it allows patients with occult meta-static disease to avoid the morbidity of pancreatic resection. As many as 20% of patients treated with neoadjuvant chemoradia-tion develop metastatic disease detected by restaging CT and do not go on to surgery. This approach may separate patients into a subset likely to benefit from resection and a subset in whom sur-gery would be unlikely to provide clinical benefit. Preoperative chemoradiation has been shown not to increase the periopera-tive morbidity or mortality of pancreaticoduodenectomy. It may even decrease the incidence of pancreatic fistula. Prospective randomized trials investigating this concept are ongoing but are difficult to complete due to the high number of patients who fail to complete or receive a full course of either therapy. Studies have shown that neoadjuvant |
Surgery_Schwartz_9869 | Surgery_Schwartz | this concept are ongoing but are difficult to complete due to the high number of patients who fail to complete or receive a full course of either therapy. Studies have shown that neoadjuvant therapy is associated with a lower rate of lymph node positivity and improved survival is achieved among the patients who do not develop disease progression dur-ing neoadjuvant therapy and go on to resection. Neoadjuvant therapy should be considered an acceptable alternative to sur-gery first followed by adjuvant therapy for resectable pancre-atic cancer. Patients should be encouraged to consider available 000.20.40.6Cause-specific survival0.81.0Performed, med. survival = 36 months (N = 724)Refused, med. survival = 7 months (N = 82)1020304050Months60708090Figure 33-76. Effect of surgery on survival in early stage pan-creas cancer. Survival comparison for cases (combined stages IA and IB) for which resection was recommended, and resection was either performed or refused. (Reproduced with | Surgery_Schwartz. this concept are ongoing but are difficult to complete due to the high number of patients who fail to complete or receive a full course of either therapy. Studies have shown that neoadjuvant therapy is associated with a lower rate of lymph node positivity and improved survival is achieved among the patients who do not develop disease progression dur-ing neoadjuvant therapy and go on to resection. Neoadjuvant therapy should be considered an acceptable alternative to sur-gery first followed by adjuvant therapy for resectable pancre-atic cancer. Patients should be encouraged to consider available 000.20.40.6Cause-specific survival0.81.0Performed, med. survival = 36 months (N = 724)Refused, med. survival = 7 months (N = 82)1020304050Months60708090Figure 33-76. Effect of surgery on survival in early stage pan-creas cancer. Survival comparison for cases (combined stages IA and IB) for which resection was recommended, and resection was either performed or refused. (Reproduced with |
Surgery_Schwartz_9870 | Surgery_Schwartz | in early stage pan-creas cancer. Survival comparison for cases (combined stages IA and IB) for which resection was recommended, and resection was either performed or refused. (Reproduced with permission from Chiari ST, Kelly K, Hollingsworth MA, et al. Early detection of sporadic pancreatic cancer: summative review, Pancreas. 2015 Jul;44(5):693-712.)Brunicardi_Ch33_p1429-p1516.indd 149801/03/19 6:46 PM 1499PANCREASCHAPTER 33clinical trials of neoadjuvant therapy for resectable pancreatic cancer.368 Unfortunately, a recent trial attempting to random-ize patients with resectable pancreatic cancer to neoadjuvant versus adjuvant therapy failed to demonstrate an advantage for the neoadjuvant approach. However, the study was inconclu-sive because it was stopped after 73 of a planned 254 patients due to slow accrual, with only 66 eligible for analysis. Other trials are ongoing. The NEOPA trial (ClinicalTrials.gov iden-tifier: NCT01900327) is a prospectively randomized phase 3 trial of | Surgery_Schwartz. in early stage pan-creas cancer. Survival comparison for cases (combined stages IA and IB) for which resection was recommended, and resection was either performed or refused. (Reproduced with permission from Chiari ST, Kelly K, Hollingsworth MA, et al. Early detection of sporadic pancreatic cancer: summative review, Pancreas. 2015 Jul;44(5):693-712.)Brunicardi_Ch33_p1429-p1516.indd 149801/03/19 6:46 PM 1499PANCREASCHAPTER 33clinical trials of neoadjuvant therapy for resectable pancreatic cancer.368 Unfortunately, a recent trial attempting to random-ize patients with resectable pancreatic cancer to neoadjuvant versus adjuvant therapy failed to demonstrate an advantage for the neoadjuvant approach. However, the study was inconclu-sive because it was stopped after 73 of a planned 254 patients due to slow accrual, with only 66 eligible for analysis. Other trials are ongoing. The NEOPA trial (ClinicalTrials.gov iden-tifier: NCT01900327) is a prospectively randomized phase 3 trial of |
Surgery_Schwartz_9871 | Surgery_Schwartz | due to slow accrual, with only 66 eligible for analysis. Other trials are ongoing. The NEOPA trial (ClinicalTrials.gov iden-tifier: NCT01900327) is a prospectively randomized phase 3 trial of patients receiving neoadjuvant chemoradiation followed by curative surgery vs. primary surgery followed by adjuvant therapy with a primary endpoint of 3-year overall survival.369Most pancreatic surgeons agree that neoadjuvant chemo-therapy, and perhaps chemoradiotherapy, should be offered to patients with locally advanced but resectable disease (vein involvement) and to patients with “borderline resectable dis-ease” (abutment of ≤180 degrees of the circumference of the SMA, celiac axis, or hepatic artery or if there is a short segment of vein occlusion, CT findings suspicious for metastatic disease, like 1 mm liver lesions too small to characterize or biopsy, and patients with multiple comorbidities or marginal performance status). This strategy acknowledges the fact that these patients are at | Surgery_Schwartz. due to slow accrual, with only 66 eligible for analysis. Other trials are ongoing. The NEOPA trial (ClinicalTrials.gov iden-tifier: NCT01900327) is a prospectively randomized phase 3 trial of patients receiving neoadjuvant chemoradiation followed by curative surgery vs. primary surgery followed by adjuvant therapy with a primary endpoint of 3-year overall survival.369Most pancreatic surgeons agree that neoadjuvant chemo-therapy, and perhaps chemoradiotherapy, should be offered to patients with locally advanced but resectable disease (vein involvement) and to patients with “borderline resectable dis-ease” (abutment of ≤180 degrees of the circumference of the SMA, celiac axis, or hepatic artery or if there is a short segment of vein occlusion, CT findings suspicious for metastatic disease, like 1 mm liver lesions too small to characterize or biopsy, and patients with multiple comorbidities or marginal performance status). This strategy acknowledges the fact that these patients are at |
Surgery_Schwartz_9872 | Surgery_Schwartz | like 1 mm liver lesions too small to characterize or biopsy, and patients with multiple comorbidities or marginal performance status). This strategy acknowledges the fact that these patients are at high risk of early distant recurrence and/or R1 resection with early local recurrence. Neoadjuvant treatment helps select the right patients for surgery and may reduce the incidence of a margin positive resection.Postoperative Surveillance. Recurrence after successful resection usually manifests as hepatic metastases. Adjuvant che-motherapy with or without radiation is usually administered for 6 months. During this time period, patients are monitored with frequent physical examinations and laboratory tests, including CA19-9. CT scans are typically ordered every 3 months in the first 2 years after resection or when a rising CA19-9 or new symptoms suggest recurrence. Surgical therapy for recurrent disease is usually reserved only for select patients with lim-ited disease who remain reasonable | Surgery_Schwartz. like 1 mm liver lesions too small to characterize or biopsy, and patients with multiple comorbidities or marginal performance status). This strategy acknowledges the fact that these patients are at high risk of early distant recurrence and/or R1 resection with early local recurrence. Neoadjuvant treatment helps select the right patients for surgery and may reduce the incidence of a margin positive resection.Postoperative Surveillance. Recurrence after successful resection usually manifests as hepatic metastases. Adjuvant che-motherapy with or without radiation is usually administered for 6 months. During this time period, patients are monitored with frequent physical examinations and laboratory tests, including CA19-9. CT scans are typically ordered every 3 months in the first 2 years after resection or when a rising CA19-9 or new symptoms suggest recurrence. Surgical therapy for recurrent disease is usually reserved only for select patients with lim-ited disease who remain reasonable |
Surgery_Schwartz_9873 | Surgery_Schwartz | resection or when a rising CA19-9 or new symptoms suggest recurrence. Surgical therapy for recurrent disease is usually reserved only for select patients with lim-ited disease who remain reasonable operative candidates who develop symptomatic gastric outlet or bowel obstruction.Ampullary and Periampullary Cancer. Ampullary cancers need to be distinguished from periampullary cancers. The ampulla is the junction of the biliary and pancreatic ducts within the duodenum. Periampullary cancer includes tumors arising from the distal bile duct, duodenal mucosa, or pancreas just adjacent to the ampulla, and the ampulla can be overgrown by cancers that arise from these adjacent areas, making it impos-sible to determine the true site of origin. Clinically, the term periampullary cancer is, therefore, a nonspecific term used to refer to a variety of tumors arising at the intersection of these four sites. The term ampullary cancer is more specific and is reserved for tumors that arise at the | Surgery_Schwartz. resection or when a rising CA19-9 or new symptoms suggest recurrence. Surgical therapy for recurrent disease is usually reserved only for select patients with lim-ited disease who remain reasonable operative candidates who develop symptomatic gastric outlet or bowel obstruction.Ampullary and Periampullary Cancer. Ampullary cancers need to be distinguished from periampullary cancers. The ampulla is the junction of the biliary and pancreatic ducts within the duodenum. Periampullary cancer includes tumors arising from the distal bile duct, duodenal mucosa, or pancreas just adjacent to the ampulla, and the ampulla can be overgrown by cancers that arise from these adjacent areas, making it impos-sible to determine the true site of origin. Clinically, the term periampullary cancer is, therefore, a nonspecific term used to refer to a variety of tumors arising at the intersection of these four sites. The term ampullary cancer is more specific and is reserved for tumors that arise at the |
Surgery_Schwartz_9874 | Surgery_Schwartz | a nonspecific term used to refer to a variety of tumors arising at the intersection of these four sites. The term ampullary cancer is more specific and is reserved for tumors that arise at the ampulla. Based on their location, ampullary cancers are usually detected relatively early due to the appearance of jaundice and have a more favorable prognosis. The ampulla of Vater is lined by an epithelial layer that transitions from pancreatic and biliary ductal epithelium to duodenal mucosal epithelium. Ampullary adenocarcinomas can therefore have an intestinal and/or pancreaticobiliary his-tologic morphology, with the former having a better progno-sis. Patients with ampullary cancer have a 10-year survival of about 35%, which is a much better prognosis than patients with pancreatic adenocarcinoma. The difference in survival is not entirely explained by an earlier presentation and lower inci-dence of lymph node metastases. There are biologic, particularly molecular, differences between | Surgery_Schwartz. a nonspecific term used to refer to a variety of tumors arising at the intersection of these four sites. The term ampullary cancer is more specific and is reserved for tumors that arise at the ampulla. Based on their location, ampullary cancers are usually detected relatively early due to the appearance of jaundice and have a more favorable prognosis. The ampulla of Vater is lined by an epithelial layer that transitions from pancreatic and biliary ductal epithelium to duodenal mucosal epithelium. Ampullary adenocarcinomas can therefore have an intestinal and/or pancreaticobiliary his-tologic morphology, with the former having a better progno-sis. Patients with ampullary cancer have a 10-year survival of about 35%, which is a much better prognosis than patients with pancreatic adenocarcinoma. The difference in survival is not entirely explained by an earlier presentation and lower inci-dence of lymph node metastases. There are biologic, particularly molecular, differences between |
Surgery_Schwartz_9875 | Surgery_Schwartz | The difference in survival is not entirely explained by an earlier presentation and lower inci-dence of lymph node metastases. There are biologic, particularly molecular, differences between ampullary and pancreatic adenocarcinoma of the pancreas.370 Intestinal type ampullary cancers have a lower incidence of EGFr and mutant p53 over-expression, and fewer activating K-ras mutations. These tumors are more likely to have genetic changes similar to colon cancer such as microsatellite instability and adenomatous polyposis coli mutations.Management of Periampullary Adenomas. Benign tumors such as ampullary adenomas can also originate at the ampulla. The accuracy of endoscopic biopsy in distinguishing ampullary cancer from benign adenoma is poor, with false-negative rates from 25% to 56% even if sphincterotomy precedes the biopsy. However, benign villous adenomas of the ampullary region can be excised locally. This technique is applicable only for small tumors (approximately 2 cm or less) | Surgery_Schwartz. The difference in survival is not entirely explained by an earlier presentation and lower inci-dence of lymph node metastases. There are biologic, particularly molecular, differences between ampullary and pancreatic adenocarcinoma of the pancreas.370 Intestinal type ampullary cancers have a lower incidence of EGFr and mutant p53 over-expression, and fewer activating K-ras mutations. These tumors are more likely to have genetic changes similar to colon cancer such as microsatellite instability and adenomatous polyposis coli mutations.Management of Periampullary Adenomas. Benign tumors such as ampullary adenomas can also originate at the ampulla. The accuracy of endoscopic biopsy in distinguishing ampullary cancer from benign adenoma is poor, with false-negative rates from 25% to 56% even if sphincterotomy precedes the biopsy. However, benign villous adenomas of the ampullary region can be excised locally. This technique is applicable only for small tumors (approximately 2 cm or less) |
Surgery_Schwartz_9876 | Surgery_Schwartz | if sphincterotomy precedes the biopsy. However, benign villous adenomas of the ampullary region can be excised locally. This technique is applicable only for small tumors (approximately 2 cm or less) with no evidence of malig-nancy upon biopsy. EUS may help to accurately determine if there is invasion into the duodenal wall. In the absence of inva-sion, adenomas may be amenable to an endoscopic or trans-duodenal excision. A longitudinal duodenotomy is made and the tumor is excised with a 2to 3-mm margin of normal duo-denal mucosa. In some centers, small periampullary adenomas can also be removed endoscopically. A preoperative diagnosis of cancer is a contraindication to transduodenal excision, and pancreaticoduodenectomy should be performed. Likewise, if final pathologic examination of a locally excised tumor reveals invasive cancer, the patient should be returned to the operat-ing room for a pancreaticoduodenectomy. An important sub-set of patients are those with FAP who develop | Surgery_Schwartz. if sphincterotomy precedes the biopsy. However, benign villous adenomas of the ampullary region can be excised locally. This technique is applicable only for small tumors (approximately 2 cm or less) with no evidence of malig-nancy upon biopsy. EUS may help to accurately determine if there is invasion into the duodenal wall. In the absence of inva-sion, adenomas may be amenable to an endoscopic or trans-duodenal excision. A longitudinal duodenotomy is made and the tumor is excised with a 2to 3-mm margin of normal duo-denal mucosa. In some centers, small periampullary adenomas can also be removed endoscopically. A preoperative diagnosis of cancer is a contraindication to transduodenal excision, and pancreaticoduodenectomy should be performed. Likewise, if final pathologic examination of a locally excised tumor reveals invasive cancer, the patient should be returned to the operat-ing room for a pancreaticoduodenectomy. An important sub-set of patients are those with FAP who develop |
Surgery_Schwartz_9877 | Surgery_Schwartz | a locally excised tumor reveals invasive cancer, the patient should be returned to the operat-ing room for a pancreaticoduodenectomy. An important sub-set of patients are those with FAP who develop periampullary or duodenal adenomas. These lesions have a high incidence of harboring carcinoma and frequently recur unless the mucosa at risk is resected. A standard (not pylorus-sparing) Whipple is the procedure of choice in FAP patients with periampullary lesions.Cystic Neoplasms of the Pancreas. A cystic neoplasm needs to be considered when a patient presents with a fluid-containing pancreatic lesion. Asymptomatic cystic neoplasms of the pancreas may be more frequent than previously recognized and are being identified with increasing frequency as the use of abdominal CT scanning and MRI has increased. Pancreatic cysts are now thought to be present in about 9% of the popula-tion age 80 and older.371 When symptoms are clearly attributable to a pancreatic cyst, resection is indicated in | Surgery_Schwartz. a locally excised tumor reveals invasive cancer, the patient should be returned to the operat-ing room for a pancreaticoduodenectomy. An important sub-set of patients are those with FAP who develop periampullary or duodenal adenomas. These lesions have a high incidence of harboring carcinoma and frequently recur unless the mucosa at risk is resected. A standard (not pylorus-sparing) Whipple is the procedure of choice in FAP patients with periampullary lesions.Cystic Neoplasms of the Pancreas. A cystic neoplasm needs to be considered when a patient presents with a fluid-containing pancreatic lesion. Asymptomatic cystic neoplasms of the pancreas may be more frequent than previously recognized and are being identified with increasing frequency as the use of abdominal CT scanning and MRI has increased. Pancreatic cysts are now thought to be present in about 9% of the popula-tion age 80 and older.371 When symptoms are clearly attributable to a pancreatic cyst, resection is indicated in |
Surgery_Schwartz_9878 | Surgery_Schwartz | increased. Pancreatic cysts are now thought to be present in about 9% of the popula-tion age 80 and older.371 When symptoms are clearly attributable to a pancreatic cyst, resection is indicated in patients who are fit candidates for surgery. However, management of asymp-tomatic pancreatic cysts is nuanced and can trigger significant anxiety for patients and their surgeons. Invasive surveillance and aggressive surgical intervention can cause harm, decrease quality of life, and increase costs. While the overall risk that an incidental pancreatic cyst is malignant is very low (about 1 in 10,000), the risks of surgery are very significant with a 2% to 5% mortality and 30% to 40% morbidity. However, some of these neoplasms slowly undergo malignant transformation and thus represent an opportunity for surgical cure, which is uncom-mon after transformation to invasive pancreatic adenocarci-noma. The dilemma for the surgeon is to identify the minority of cysts that pose a significant risk and | Surgery_Schwartz. increased. Pancreatic cysts are now thought to be present in about 9% of the popula-tion age 80 and older.371 When symptoms are clearly attributable to a pancreatic cyst, resection is indicated in patients who are fit candidates for surgery. However, management of asymp-tomatic pancreatic cysts is nuanced and can trigger significant anxiety for patients and their surgeons. Invasive surveillance and aggressive surgical intervention can cause harm, decrease quality of life, and increase costs. While the overall risk that an incidental pancreatic cyst is malignant is very low (about 1 in 10,000), the risks of surgery are very significant with a 2% to 5% mortality and 30% to 40% morbidity. However, some of these neoplasms slowly undergo malignant transformation and thus represent an opportunity for surgical cure, which is uncom-mon after transformation to invasive pancreatic adenocarci-noma. The dilemma for the surgeon is to identify the minority of cysts that pose a significant risk and |
Surgery_Schwartz_9879 | Surgery_Schwartz | for surgical cure, which is uncom-mon after transformation to invasive pancreatic adenocarci-noma. The dilemma for the surgeon is to identify the minority of cysts that pose a significant risk and provide individual patients with an accurate assessment of their unique risk-benefit ratio of resection vs. surveillance.Surveillance programs are of questionable value in patients who are not candidates for surgery due to age and or multiple comorbidities and limited life expectancy. Surgeons also need to clearly explain to the patient the risks and benefits of surveil-lance itself. MRI is the preferred surveillance imaging modality Brunicardi_Ch33_p1429-p1516.indd 149901/03/19 6:46 PM 1500SPECIFIC CONSIDERATIONSPART IIover computed tomography because MRI does not expose the patient to radiation and better demonstrates the structural rela-tionship between the pancreatic duct and associated cyst. Also, MRI is less invasive than EUS. EUS is therefore reserved for further evaluation of | Surgery_Schwartz. for surgical cure, which is uncom-mon after transformation to invasive pancreatic adenocarci-noma. The dilemma for the surgeon is to identify the minority of cysts that pose a significant risk and provide individual patients with an accurate assessment of their unique risk-benefit ratio of resection vs. surveillance.Surveillance programs are of questionable value in patients who are not candidates for surgery due to age and or multiple comorbidities and limited life expectancy. Surgeons also need to clearly explain to the patient the risks and benefits of surveil-lance itself. MRI is the preferred surveillance imaging modality Brunicardi_Ch33_p1429-p1516.indd 149901/03/19 6:46 PM 1500SPECIFIC CONSIDERATIONSPART IIover computed tomography because MRI does not expose the patient to radiation and better demonstrates the structural rela-tionship between the pancreatic duct and associated cyst. Also, MRI is less invasive than EUS. EUS is therefore reserved for further evaluation of |
Surgery_Schwartz_9880 | Surgery_Schwartz | and better demonstrates the structural rela-tionship between the pancreatic duct and associated cyst. Also, MRI is less invasive than EUS. EUS is therefore reserved for further evaluation of higher risk cysts. Another problem to con-front is when to stop surveillance in a cyst that has been stable during observation. Some clinicians stop following after 5 years but data is lacking to guide this decision. In addition, patients who have undergone resection of a pancreatic cystic neoplasm with high grade dysplasia may warrant continued surveillance after surgery particularly when there is a possible field effect such as in IPMN or concern that all of the disease has not been resected. Individualized decision-making and multidisciplinary input is ideal.372Pseudocysts. The most common cystic lesion of the pancreas is the pseudocyst, which, of course, has no epithelial lining and is a nonneoplastic complication of pancreatitis or pancreatic duct injury. As discussed in “Complications of | Surgery_Schwartz. and better demonstrates the structural rela-tionship between the pancreatic duct and associated cyst. Also, MRI is less invasive than EUS. EUS is therefore reserved for further evaluation of higher risk cysts. Another problem to con-front is when to stop surveillance in a cyst that has been stable during observation. Some clinicians stop following after 5 years but data is lacking to guide this decision. In addition, patients who have undergone resection of a pancreatic cystic neoplasm with high grade dysplasia may warrant continued surveillance after surgery particularly when there is a possible field effect such as in IPMN or concern that all of the disease has not been resected. Individualized decision-making and multidisciplinary input is ideal.372Pseudocysts. The most common cystic lesion of the pancreas is the pseudocyst, which, of course, has no epithelial lining and is a nonneoplastic complication of pancreatitis or pancreatic duct injury. As discussed in “Complications of |
Surgery_Schwartz_9881 | Surgery_Schwartz | lesion of the pancreas is the pseudocyst, which, of course, has no epithelial lining and is a nonneoplastic complication of pancreatitis or pancreatic duct injury. As discussed in “Complications of Chronic Pancreatitis,” the diagnosis is usually straightforward from the clinical history. Although not usually necessary, analysis of pseudocyst fluid would reveal a high amylase content. The danger comes in mistaking a cystic pancreatic neoplasm for a pseudocyst and incorrectly draining a cystic neoplasm into the GI tract rather than resecting the neoplasm. For this reason, biopsy of the pseudocyst wall is a requirement in the management of pancreatic pseudocysts.Cystadenoma. Serous cystadenomas are essentially considered benign tumors without malignant potential. Serous cystadenocarcinoma has been reported very rarely (<1%). Therefore, malignant potential should not be used as an argument for surgical resection, and the majority of these lesions can be safely observed in the absence of | Surgery_Schwartz. lesion of the pancreas is the pseudocyst, which, of course, has no epithelial lining and is a nonneoplastic complication of pancreatitis or pancreatic duct injury. As discussed in “Complications of Chronic Pancreatitis,” the diagnosis is usually straightforward from the clinical history. Although not usually necessary, analysis of pseudocyst fluid would reveal a high amylase content. The danger comes in mistaking a cystic pancreatic neoplasm for a pseudocyst and incorrectly draining a cystic neoplasm into the GI tract rather than resecting the neoplasm. For this reason, biopsy of the pseudocyst wall is a requirement in the management of pancreatic pseudocysts.Cystadenoma. Serous cystadenomas are essentially considered benign tumors without malignant potential. Serous cystadenocarcinoma has been reported very rarely (<1%). Therefore, malignant potential should not be used as an argument for surgical resection, and the majority of these lesions can be safely observed in the absence of |
Surgery_Schwartz_9882 | Surgery_Schwartz | been reported very rarely (<1%). Therefore, malignant potential should not be used as an argument for surgical resection, and the majority of these lesions can be safely observed in the absence of symptoms due to mass effect or rapid growth. The average rate of growth is about 0.5 cm per year. About 50% of cystadenomas are asymptomatic and detected as an incidental finding. Most symptomatic patients have mild upper abdominal pain, epigastric fullness, or moderate weight loss. Occasionally, cystadenomas can grow to a size capable of producing jaundice or GI obstruction due to mass effect (Fig. 33-77). For symptomatic patients with serous cystadenoma, surgical resection is indicated. For lesions in the tail, splenectomy is not necessary, given the benign nature of the tumor. In appropriate candidates, a laparoscopic approach to distal pancreatectomy with or without splenic preservation can be considered. These cysts are frequently found in older women in which pancreatic resection for | Surgery_Schwartz. been reported very rarely (<1%). Therefore, malignant potential should not be used as an argument for surgical resection, and the majority of these lesions can be safely observed in the absence of symptoms due to mass effect or rapid growth. The average rate of growth is about 0.5 cm per year. About 50% of cystadenomas are asymptomatic and detected as an incidental finding. Most symptomatic patients have mild upper abdominal pain, epigastric fullness, or moderate weight loss. Occasionally, cystadenomas can grow to a size capable of producing jaundice or GI obstruction due to mass effect (Fig. 33-77). For symptomatic patients with serous cystadenoma, surgical resection is indicated. For lesions in the tail, splenectomy is not necessary, given the benign nature of the tumor. In appropriate candidates, a laparoscopic approach to distal pancreatectomy with or without splenic preservation can be considered. These cysts are frequently found in older women in which pancreatic resection for |
Surgery_Schwartz_9883 | Surgery_Schwartz | candidates, a laparoscopic approach to distal pancreatectomy with or without splenic preservation can be considered. These cysts are frequently found in older women in which pancreatic resection for a benign neoplasm should be avoided in the absence of significant symptoms. All regions of the pancreas are affected, with half in the head/uncinate process, and half in the neck, body, or tail of the pancreas. They have a spongy appearance, and multiple small cysts (microcystic) are more common than larger cysts (macrocystic or oligocystic). These lesions contain thin serous fluid that does not stain positive for mucin and is low in CEA (<200 ng/mL). Typical imaging characteristics include a well-circumscribed cystic mass, small septations, fluid close to water density, and sometimes, a central scar with calcification. If a conservative management is adopted, it is important to be sure of the diagnosis. EUS-FNA should yield nonviscous fluid with low CEA and amylase levels, and if cells | Surgery_Schwartz. candidates, a laparoscopic approach to distal pancreatectomy with or without splenic preservation can be considered. These cysts are frequently found in older women in which pancreatic resection for a benign neoplasm should be avoided in the absence of significant symptoms. All regions of the pancreas are affected, with half in the head/uncinate process, and half in the neck, body, or tail of the pancreas. They have a spongy appearance, and multiple small cysts (microcystic) are more common than larger cysts (macrocystic or oligocystic). These lesions contain thin serous fluid that does not stain positive for mucin and is low in CEA (<200 ng/mL). Typical imaging characteristics include a well-circumscribed cystic mass, small septations, fluid close to water density, and sometimes, a central scar with calcification. If a conservative management is adopted, it is important to be sure of the diagnosis. EUS-FNA should yield nonviscous fluid with low CEA and amylase levels, and if cells |
Surgery_Schwartz_9884 | Surgery_Schwartz | scar with calcification. If a conservative management is adopted, it is important to be sure of the diagnosis. EUS-FNA should yield nonviscous fluid with low CEA and amylase levels, and if cells are obtained, which is rare, they are cuboidal and have a clear cytoplasm.Mucinous Cystadenoma and Cystadenocarcinoma. Muci-nous cystic neoplasms (MCNs) encompass a spectrum ranging from benign but potentially malignant to carcinoma with a very aggressive behavior (Table 33-23). There is often heterogene-ity within the lesions with benign and malignant-appearing regions, making it impossible to exclude malignancy with biopsy. MCNs are commonly seen in perimenopausal women, and about two-thirds are located in the body or tail of the pan-creas. Like cystadenomas, most MCNs are now incidental find-ings identified during imaging performed for other reasons. When symptoms are present, they are usually nonspecific and include upper abdominal discomfort or pain, early satiety, and weight loss. On | Surgery_Schwartz. scar with calcification. If a conservative management is adopted, it is important to be sure of the diagnosis. EUS-FNA should yield nonviscous fluid with low CEA and amylase levels, and if cells are obtained, which is rare, they are cuboidal and have a clear cytoplasm.Mucinous Cystadenoma and Cystadenocarcinoma. Muci-nous cystic neoplasms (MCNs) encompass a spectrum ranging from benign but potentially malignant to carcinoma with a very aggressive behavior (Table 33-23). There is often heterogene-ity within the lesions with benign and malignant-appearing regions, making it impossible to exclude malignancy with biopsy. MCNs are commonly seen in perimenopausal women, and about two-thirds are located in the body or tail of the pan-creas. Like cystadenomas, most MCNs are now incidental find-ings identified during imaging performed for other reasons. When symptoms are present, they are usually nonspecific and include upper abdominal discomfort or pain, early satiety, and weight loss. On |
Surgery_Schwartz_9885 | Surgery_Schwartz | identified during imaging performed for other reasons. When symptoms are present, they are usually nonspecific and include upper abdominal discomfort or pain, early satiety, and weight loss. On imaging studies, the cysts have thick walls and do not communicate with the main pancreatic duct (Fig. 33-78). There may be nodules or calcifications within the wall of the cyst. The cysts are lined by tall columnar epithelium that fills the cyst with viscous mucin. The submucosal layer consists of a highly cellular stroma of spindle cells with elongated nuclei similar to the “ovarian stroma,” which is a key pathologic feature distinguishing these lesions. Elevated CEA levels in the fluid (≥200 ng/mL) are consistent with mucinous lesions and may suggest malignant transformation.373 Solid areas may con-tain atypical cells or invasive cancer, and extensive sampling of the specimen is necessary to accurately predict prognosis. Figure 33-77. Mucinous cystic neoplasm in tail of pancreas.Table | Surgery_Schwartz. identified during imaging performed for other reasons. When symptoms are present, they are usually nonspecific and include upper abdominal discomfort or pain, early satiety, and weight loss. On imaging studies, the cysts have thick walls and do not communicate with the main pancreatic duct (Fig. 33-78). There may be nodules or calcifications within the wall of the cyst. The cysts are lined by tall columnar epithelium that fills the cyst with viscous mucin. The submucosal layer consists of a highly cellular stroma of spindle cells with elongated nuclei similar to the “ovarian stroma,” which is a key pathologic feature distinguishing these lesions. Elevated CEA levels in the fluid (≥200 ng/mL) are consistent with mucinous lesions and may suggest malignant transformation.373 Solid areas may con-tain atypical cells or invasive cancer, and extensive sampling of the specimen is necessary to accurately predict prognosis. Figure 33-77. Mucinous cystic neoplasm in tail of pancreas.Table |
Surgery_Schwartz_9886 | Surgery_Schwartz | may con-tain atypical cells or invasive cancer, and extensive sampling of the specimen is necessary to accurately predict prognosis. Figure 33-77. Mucinous cystic neoplasm in tail of pancreas.Table 33-23World Health Organization classification of primary tumors of the exocrine pancreas A. Benign 1. Serous cystadenoma (16%) 2. Mucinous cystadenoma (45%) 3. Intraductal papillary-mucinous adenoma (32%) 4. Mature cystic teratoma B. Borderline 1. Mucinous cystic tumor with moderate dysplasia 2. Intraductal papillary mucinous tumor with moderate dysplasia 3. Solid pseudopapillary tumor C. Malignant 1. Ductal adenocarcinoma 2. Serous/mucinous cystadenocarcinoma (29%) 3. Intraductal mucinous papillary tumorBrunicardi_Ch33_p1429-p1516.indd 150001/03/19 6:46 PM 1501PANCREASCHAPTER 33NoYes<1 cm1–2 cm2–3 cm>3 cmNoNoa. Pancreatitis may be an indication for surgery for relief of symptoms.b. Differential diagnosis includes mucin. Mucin can move with change in patient position, may be dislodged | Surgery_Schwartz. may con-tain atypical cells or invasive cancer, and extensive sampling of the specimen is necessary to accurately predict prognosis. Figure 33-77. Mucinous cystic neoplasm in tail of pancreas.Table 33-23World Health Organization classification of primary tumors of the exocrine pancreas A. Benign 1. Serous cystadenoma (16%) 2. Mucinous cystadenoma (45%) 3. Intraductal papillary-mucinous adenoma (32%) 4. Mature cystic teratoma B. Borderline 1. Mucinous cystic tumor with moderate dysplasia 2. Intraductal papillary mucinous tumor with moderate dysplasia 3. Solid pseudopapillary tumor C. Malignant 1. Ductal adenocarcinoma 2. Serous/mucinous cystadenocarcinoma (29%) 3. Intraductal mucinous papillary tumorBrunicardi_Ch33_p1429-p1516.indd 150001/03/19 6:46 PM 1501PANCREASCHAPTER 33NoYes<1 cm1–2 cm2–3 cm>3 cmNoNoa. Pancreatitis may be an indication for surgery for relief of symptoms.b. Differential diagnosis includes mucin. Mucin can move with change in patient position, may be dislodged |
Surgery_Schwartz_9887 | Surgery_Schwartz | cm2–3 cm>3 cmNoNoa. Pancreatitis may be an indication for surgery for relief of symptoms.b. Differential diagnosis includes mucin. Mucin can move with change in patient position, may be dislodged oncyst lavage and does not have Doppler ’ow. Features of true tumor nodule include lack of mobility, presence ofDoppler ’ow and FNA of nodule showing tumor tissuec. Presence of any one of thickened walls, intraductal mucin or mural nodules is suggestive of main ductinvolvement. In their absence main duct involvement is inconclusive.d. Studies from Japan suggest that on follow-up of subjects with suspected BD-IPMN there is increased incidenceof pancreatic ductal adenocarcinoma unrelated to malignant transformation of the BD-IPMN(s) being followed.However, it is unclear if imaging surveillance can detect early ductal adenocarcinoma, and, if so, at what intervalsurveillance imaging should be performed.Are any of the following high-risk stigmata of malignancy present?i) obstructive jaundice in a | Surgery_Schwartz. cm2–3 cm>3 cmNoNoa. Pancreatitis may be an indication for surgery for relief of symptoms.b. Differential diagnosis includes mucin. Mucin can move with change in patient position, may be dislodged oncyst lavage and does not have Doppler ’ow. Features of true tumor nodule include lack of mobility, presence ofDoppler ’ow and FNA of nodule showing tumor tissuec. Presence of any one of thickened walls, intraductal mucin or mural nodules is suggestive of main ductinvolvement. In their absence main duct involvement is inconclusive.d. Studies from Japan suggest that on follow-up of subjects with suspected BD-IPMN there is increased incidenceof pancreatic ductal adenocarcinoma unrelated to malignant transformation of the BD-IPMN(s) being followed.However, it is unclear if imaging surveillance can detect early ductal adenocarcinoma, and, if so, at what intervalsurveillance imaging should be performed.Are any of the following high-risk stigmata of malignancy present?i) obstructive jaundice in a |
Surgery_Schwartz_9888 | Surgery_Schwartz | detect early ductal adenocarcinoma, and, if so, at what intervalsurveillance imaging should be performed.Are any of the following high-risk stigmata of malignancy present?i) obstructive jaundice in a patient with cystic lesion of the head of the pancreas,ii) enhancing solid component within cyst, iii) main pancreatic duct ‰10 mm in sizeAre any of the following worrisome features present?Clinical: PancreatitisaImaging: i) cyst ‰3 cm, ii) thickened/enhancing cyst walls, iii) main duct size 5–9 mm, iii) non-enhancingmural nodule iv) abrupt change in caliber of pancreatic duct with distal pancreatic atrophy.What is the size of largest cyst?InconclusiveIf yes, perform endoscopic ultrasoundConsidersurgery,if clinicallyappropriateAre any of these features present?i) Deÿnite mural nodule(s)bii) Main duct features suspicious for involvementciii) Cytology: suspicious or positive for malignancyCT/MRIin 2–3 yearsdCT/MRIyearly × 2 years,then lengthenintervalif no changedEUS in 3–6 months, | Surgery_Schwartz. detect early ductal adenocarcinoma, and, if so, at what intervalsurveillance imaging should be performed.Are any of the following high-risk stigmata of malignancy present?i) obstructive jaundice in a patient with cystic lesion of the head of the pancreas,ii) enhancing solid component within cyst, iii) main pancreatic duct ‰10 mm in sizeAre any of the following worrisome features present?Clinical: PancreatitisaImaging: i) cyst ‰3 cm, ii) thickened/enhancing cyst walls, iii) main duct size 5–9 mm, iii) non-enhancingmural nodule iv) abrupt change in caliber of pancreatic duct with distal pancreatic atrophy.What is the size of largest cyst?InconclusiveIf yes, perform endoscopic ultrasoundConsidersurgery,if clinicallyappropriateAre any of these features present?i) Deÿnite mural nodule(s)bii) Main duct features suspicious for involvementciii) Cytology: suspicious or positive for malignancyCT/MRIin 2–3 yearsdCT/MRIyearly × 2 years,then lengthenintervalif no changedEUS in 3–6 months, |
Surgery_Schwartz_9889 | Surgery_Schwartz | Main duct features suspicious for involvementciii) Cytology: suspicious or positive for malignancyCT/MRIin 2–3 yearsdCT/MRIyearly × 2 years,then lengthenintervalif no changedEUS in 3–6 months, thenlengthen interval alternating MRIwith EUS as appropriate.dConsider surgery in young,ÿt patients with need forprolonged surveillanceClose surveillance alternatingMRI with EUS every 3–6 months.Strongly consider surgery in young,ÿt patientsYesFigure 33-78. Algorithm for management of pancreatic cystic neoplasms. CEA = carcinoembryonic antigen; CT = computed tomography; ERCP = endoscopic retrograde cholangiopancreatography; EUS = endoscopic ultrasound; FNA = fine-needle aspiration; Hx = history; IPMN = intraductal papillary mucinous neoplasm of the pancreas; MCN = mucinous cystic neoplasm; MRCP = magnetic resonance cholangiopancreatography. (Reproduced with permission from Tanaka M, Adsay V, Chari S, et al. International consensus guidelines 2012 for the management of IPMN and MCN of the | Surgery_Schwartz. Main duct features suspicious for involvementciii) Cytology: suspicious or positive for malignancyCT/MRIin 2–3 yearsdCT/MRIyearly × 2 years,then lengthenintervalif no changedEUS in 3–6 months, thenlengthen interval alternating MRIwith EUS as appropriate.dConsider surgery in young,ÿt patients with need forprolonged surveillanceClose surveillance alternatingMRI with EUS every 3–6 months.Strongly consider surgery in young,ÿt patientsYesFigure 33-78. Algorithm for management of pancreatic cystic neoplasms. CEA = carcinoembryonic antigen; CT = computed tomography; ERCP = endoscopic retrograde cholangiopancreatography; EUS = endoscopic ultrasound; FNA = fine-needle aspiration; Hx = history; IPMN = intraductal papillary mucinous neoplasm of the pancreas; MCN = mucinous cystic neoplasm; MRCP = magnetic resonance cholangiopancreatography. (Reproduced with permission from Tanaka M, Adsay V, Chari S, et al. International consensus guidelines 2012 for the management of IPMN and MCN of the |
Surgery_Schwartz_9890 | Surgery_Schwartz | = magnetic resonance cholangiopancreatography. (Reproduced with permission from Tanaka M, Adsay V, Chari S, et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas, Pancreatology. 2012 May-Jun;12(3):183-197.)Resection is the treatment of choice for most mucin-producing cystic tumors. Malignancy cannot be ruled out without removal and extensive sampling of the entire tumor. Malignancy has been reported in 6% to 36% of MCNs. Current thinking is that all of these tumors will eventually evolve into cancer if left untreated. However, for individual patients, the surgeon is often faced with a difficult decision. The risk of pancreas surgery in an older patient with multiple comorbidities and a relatively short life expectancy regardless of their pancreatic cyst is frequently weighed against the potential future risk that the cyst, particularly a small cyst, will transform into an incurable invasive cancer.The utility of detailed DNA analysis of | Surgery_Schwartz. = magnetic resonance cholangiopancreatography. (Reproduced with permission from Tanaka M, Adsay V, Chari S, et al. International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas, Pancreatology. 2012 May-Jun;12(3):183-197.)Resection is the treatment of choice for most mucin-producing cystic tumors. Malignancy cannot be ruled out without removal and extensive sampling of the entire tumor. Malignancy has been reported in 6% to 36% of MCNs. Current thinking is that all of these tumors will eventually evolve into cancer if left untreated. However, for individual patients, the surgeon is often faced with a difficult decision. The risk of pancreas surgery in an older patient with multiple comorbidities and a relatively short life expectancy regardless of their pancreatic cyst is frequently weighed against the potential future risk that the cyst, particularly a small cyst, will transform into an incurable invasive cancer.The utility of detailed DNA analysis of |
Surgery_Schwartz_9891 | Surgery_Schwartz | cyst is frequently weighed against the potential future risk that the cyst, particularly a small cyst, will transform into an incurable invasive cancer.The utility of detailed DNA analysis of pancreatic cyst fluid to diagnose mucinous and malignant cysts has been evalu-ated in the PANDA study.374 The study concluded that cyst fluid K-ras mutation was helpful in the diagnosis of mucinous cysts with a 96% specificity. Components of DNA analysis detect-ing malignant cysts included allelic loss amplitude over 82% and high DNA amount. The criteria of high amplitude K-ras mutation followed by allelic loss showed maximum specificity (96%) for malignancy. However, this test lacks sensitivity. In clinical practice, the surgeon must take all of these complemen-tary factors into consideration when determining the malignant potential of a pancreatic cystic neoplasm.Because most MCNs are located in the body and tail of the pancreas, distal pancreatectomy is the most common treatment. For small | Surgery_Schwartz. cyst is frequently weighed against the potential future risk that the cyst, particularly a small cyst, will transform into an incurable invasive cancer.The utility of detailed DNA analysis of pancreatic cyst fluid to diagnose mucinous and malignant cysts has been evalu-ated in the PANDA study.374 The study concluded that cyst fluid K-ras mutation was helpful in the diagnosis of mucinous cysts with a 96% specificity. Components of DNA analysis detect-ing malignant cysts included allelic loss amplitude over 82% and high DNA amount. The criteria of high amplitude K-ras mutation followed by allelic loss showed maximum specificity (96%) for malignancy. However, this test lacks sensitivity. In clinical practice, the surgeon must take all of these complemen-tary factors into consideration when determining the malignant potential of a pancreatic cystic neoplasm.Because most MCNs are located in the body and tail of the pancreas, distal pancreatectomy is the most common treatment. For small |
Surgery_Schwartz_9892 | Surgery_Schwartz | determining the malignant potential of a pancreatic cystic neoplasm.Because most MCNs are located in the body and tail of the pancreas, distal pancreatectomy is the most common treatment. For small lesions, it may be appropriate to preserve the spleen, but splenectomy ensures removal of the lymph node basin that can potentially be involved. It is very important not to rupture the cyst during resection, and the tumor should be removed intact, not morselized. Therefore, a laparoscopic approach may not be appropriate for larger lesions. Completely resected MCNs without atypia are usually cured especially if small (<3 cm). Even patients with moderate dysplasia or carcinoma in situ are usually cured by complete resection. Noninvasive MCNs require no surveillance after resection. For MCNs with an associated invasive carcinoma, prognosis depends on the extent of the invasive component, tumor stage, and resectability. The 2-year survival rate and 5-year survival rate of patients with | Surgery_Schwartz. determining the malignant potential of a pancreatic cystic neoplasm.Because most MCNs are located in the body and tail of the pancreas, distal pancreatectomy is the most common treatment. For small lesions, it may be appropriate to preserve the spleen, but splenectomy ensures removal of the lymph node basin that can potentially be involved. It is very important not to rupture the cyst during resection, and the tumor should be removed intact, not morselized. Therefore, a laparoscopic approach may not be appropriate for larger lesions. Completely resected MCNs without atypia are usually cured especially if small (<3 cm). Even patients with moderate dysplasia or carcinoma in situ are usually cured by complete resection. Noninvasive MCNs require no surveillance after resection. For MCNs with an associated invasive carcinoma, prognosis depends on the extent of the invasive component, tumor stage, and resectability. The 2-year survival rate and 5-year survival rate of patients with |
Surgery_Schwartz_9893 | Surgery_Schwartz | with an associated invasive carcinoma, prognosis depends on the extent of the invasive component, tumor stage, and resectability. The 2-year survival rate and 5-year survival rate of patients with Brunicardi_Ch33_p1429-p1516.indd 150101/03/19 6:46 PM 1502SPECIFIC CONSIDERATIONSPART IIresected MCN with an associated invasive carcinoma are about 67% and 50%, respectively.375Intraductal Papillary Mucinous Neoplasm. Intraductal papillary mucinous neoplasms (IPMNs) usually occur within the head of the pancreas and arise within the pancreatic ducts. The ductal epithelium forms a papillary projection into the duct, and mucin production causes intraluminal cystic dilation of the pancreatic ducts (Fig. 33-79). Imaging studies demonstrate diffuse dilation of the pancreatic duct, and the pancreatic parenchyma is often atrophic due to chronic duct obstruction. However, classic features of chronic pancreatitis, such as calcification and a beaded appearance of the duct, are not present. At | Surgery_Schwartz. with an associated invasive carcinoma, prognosis depends on the extent of the invasive component, tumor stage, and resectability. The 2-year survival rate and 5-year survival rate of patients with Brunicardi_Ch33_p1429-p1516.indd 150101/03/19 6:46 PM 1502SPECIFIC CONSIDERATIONSPART IIresected MCN with an associated invasive carcinoma are about 67% and 50%, respectively.375Intraductal Papillary Mucinous Neoplasm. Intraductal papillary mucinous neoplasms (IPMNs) usually occur within the head of the pancreas and arise within the pancreatic ducts. The ductal epithelium forms a papillary projection into the duct, and mucin production causes intraluminal cystic dilation of the pancreatic ducts (Fig. 33-79). Imaging studies demonstrate diffuse dilation of the pancreatic duct, and the pancreatic parenchyma is often atrophic due to chronic duct obstruction. However, classic features of chronic pancreatitis, such as calcification and a beaded appearance of the duct, are not present. At |
Surgery_Schwartz_9894 | Surgery_Schwartz | parenchyma is often atrophic due to chronic duct obstruction. However, classic features of chronic pancreatitis, such as calcification and a beaded appearance of the duct, are not present. At ERCP, mucin can be seen extruding from the ampulla of Vater, a so-called fish-eye lesion that is virtually diagnostic of IPMN (Fig. 33-80). Initial reports suggested a male predominance, but more recent series indicate an equal distribution. Patients are usually in their seventh to eighth decade of life and present with abdominal pain or recurrent pancreatitis, thought to be caused by obstruction of the pancreatic duct by thick mucin. Some patients 9Figure 33-79. Computed tomography appearance of massive mul-tiseptated serous cystadenoma in head of pancreas with central stel-late scar (left) and resected specimen (right).Figure 33-80. Intraductal papillary mucinous neoplasm histology. Papillary projections of ductal epithelium resemble villous morphology and contain mucin-filled vesicles. | Surgery_Schwartz. parenchyma is often atrophic due to chronic duct obstruction. However, classic features of chronic pancreatitis, such as calcification and a beaded appearance of the duct, are not present. At ERCP, mucin can be seen extruding from the ampulla of Vater, a so-called fish-eye lesion that is virtually diagnostic of IPMN (Fig. 33-80). Initial reports suggested a male predominance, but more recent series indicate an equal distribution. Patients are usually in their seventh to eighth decade of life and present with abdominal pain or recurrent pancreatitis, thought to be caused by obstruction of the pancreatic duct by thick mucin. Some patients 9Figure 33-79. Computed tomography appearance of massive mul-tiseptated serous cystadenoma in head of pancreas with central stel-late scar (left) and resected specimen (right).Figure 33-80. Intraductal papillary mucinous neoplasm histology. Papillary projections of ductal epithelium resemble villous morphology and contain mucin-filled vesicles. |
Surgery_Schwartz_9895 | Surgery_Schwartz | resected specimen (right).Figure 33-80. Intraductal papillary mucinous neoplasm histology. Papillary projections of ductal epithelium resemble villous morphology and contain mucin-filled vesicles. (Reproduced with permission from Asiyanbola B, Andersen DK. IPMN. Editorial Update. accesssurgery.com McGraw-Hill Education; 2008.)(5–10%) have steatorrhea, diabetes, and weight loss secondary to pancreatic insufficiency.Some IPMNs primarily involve the main pancreatic duct, while others involve the branch ducts. The mean fre-quency of malignancy in main duct IPMN (MD-IPMN) is 62% (Fig. 33-81). Considering this high incidence of malignant lesions and the low 5-year survival rates (31–54%), interna-tional consensus guidelines recommend resection for all surgi-cally fit patients with MD-IPMN.372 If the margin is positive for high-grade dysplasia, additional resection should be attempted to obtain at least moderate-grade dysplasia at the surgical margin.The surgical management of IPMNs is | Surgery_Schwartz. resected specimen (right).Figure 33-80. Intraductal papillary mucinous neoplasm histology. Papillary projections of ductal epithelium resemble villous morphology and contain mucin-filled vesicles. (Reproduced with permission from Asiyanbola B, Andersen DK. IPMN. Editorial Update. accesssurgery.com McGraw-Hill Education; 2008.)(5–10%) have steatorrhea, diabetes, and weight loss secondary to pancreatic insufficiency.Some IPMNs primarily involve the main pancreatic duct, while others involve the branch ducts. The mean fre-quency of malignancy in main duct IPMN (MD-IPMN) is 62% (Fig. 33-81). Considering this high incidence of malignant lesions and the low 5-year survival rates (31–54%), interna-tional consensus guidelines recommend resection for all surgi-cally fit patients with MD-IPMN.372 If the margin is positive for high-grade dysplasia, additional resection should be attempted to obtain at least moderate-grade dysplasia at the surgical margin.The surgical management of IPMNs is |
Surgery_Schwartz_9896 | Surgery_Schwartz | If the margin is positive for high-grade dysplasia, additional resection should be attempted to obtain at least moderate-grade dysplasia at the surgical margin.The surgical management of IPMNs is complicated by the fact that the lesion itself is small and preoperative imaging stud-ies show a dilated pancreatic duct but not necessarily the mass. Mucus can dilate the duct proximal and distal to the lesion. Fur-thermore, these lesions can spread microscopically along the duct, and there can be skip areas of normal duct between the diseased portions. Therefore, thorough preoperative imaging including EUS, MRCP, or ERCP, and sometimes pancreatic ductoscopy, which can also be repeated intraoperatively, is use-ful (see Fig. 33-80). The surgeon needs to be prepared to extend the resection, if necessary, based on intraoperative findings and frozen section of the margin. Extending the resection to the point of total pancreatectomy is controversial due to the mor-bidity of this operation. Like | Surgery_Schwartz. If the margin is positive for high-grade dysplasia, additional resection should be attempted to obtain at least moderate-grade dysplasia at the surgical margin.The surgical management of IPMNs is complicated by the fact that the lesion itself is small and preoperative imaging stud-ies show a dilated pancreatic duct but not necessarily the mass. Mucus can dilate the duct proximal and distal to the lesion. Fur-thermore, these lesions can spread microscopically along the duct, and there can be skip areas of normal duct between the diseased portions. Therefore, thorough preoperative imaging including EUS, MRCP, or ERCP, and sometimes pancreatic ductoscopy, which can also be repeated intraoperatively, is use-ful (see Fig. 33-80). The surgeon needs to be prepared to extend the resection, if necessary, based on intraoperative findings and frozen section of the margin. Extending the resection to the point of total pancreatectomy is controversial due to the mor-bidity of this operation. Like |
Surgery_Schwartz_9897 | Surgery_Schwartz | based on intraoperative findings and frozen section of the margin. Extending the resection to the point of total pancreatectomy is controversial due to the mor-bidity of this operation. Like MCNs, the IPMNs require careful histologic examination of the entire specimen for an invasive cancer (Fig. 33-82).Survival of patients with IPMN, even when malignant and invasive, can be quite good. As with MCN, patients with bor-derline tumors or carcinoma in situ are usually cured. For this reason, if recurrence occurs in the remaining pancreas, further resection is warranted because several series have shown that some of these cases are salvageable. Patients with IPMN are also at risk for other malignancies and should undergo colonos-copy and close surveillance.Branch-duct type IPMNs (BD-IPMN) are often found in the uncinate process, are sometimes asymptomatic, and are less frequently associated with malignant transformation (6–46%). Asymptomatic, small suspected BD-IPMNs are frequently | Surgery_Schwartz. based on intraoperative findings and frozen section of the margin. Extending the resection to the point of total pancreatectomy is controversial due to the mor-bidity of this operation. Like MCNs, the IPMNs require careful histologic examination of the entire specimen for an invasive cancer (Fig. 33-82).Survival of patients with IPMN, even when malignant and invasive, can be quite good. As with MCN, patients with bor-derline tumors or carcinoma in situ are usually cured. For this reason, if recurrence occurs in the remaining pancreas, further resection is warranted because several series have shown that some of these cases are salvageable. Patients with IPMN are also at risk for other malignancies and should undergo colonos-copy and close surveillance.Branch-duct type IPMNs (BD-IPMN) are often found in the uncinate process, are sometimes asymptomatic, and are less frequently associated with malignant transformation (6–46%). Asymptomatic, small suspected BD-IPMNs are frequently |
Surgery_Schwartz_9898 | Surgery_Schwartz | are often found in the uncinate process, are sometimes asymptomatic, and are less frequently associated with malignant transformation (6–46%). Asymptomatic, small suspected BD-IPMNs are frequently Brunicardi_Ch33_p1429-p1516.indd 150201/03/19 6:47 PM 1503PANCREASCHAPTER 33ABCFigure 33-81. Intraductal papillary mucinous neoplasm (IPMN). A. Examples of “fish-eye deformity” of IPMN. Mucin is seen extruding from the ampulla. B. Mucin coming from pancreatic duct when neck of pancreas is transected during Whipple procedure (left). Intraoperative pancreatic ductoscopy to assess the pancreatic tail (right). C. Views of pancreatic duct during ductoscopy; normal (left) and IPMN (right).Brunicardi_Ch33_p1429-p1516.indd 150301/03/19 6:47 PM 1504SPECIFIC CONSIDERATIONSPART IIobserved with serial imaging. High-risk features such as mural nodules, a dilated main duct, positive cytology or cyst fluid CEA >200 need to be ruled out. In the absence of these fea-tures, continued observation with | Surgery_Schwartz. are often found in the uncinate process, are sometimes asymptomatic, and are less frequently associated with malignant transformation (6–46%). Asymptomatic, small suspected BD-IPMNs are frequently Brunicardi_Ch33_p1429-p1516.indd 150201/03/19 6:47 PM 1503PANCREASCHAPTER 33ABCFigure 33-81. Intraductal papillary mucinous neoplasm (IPMN). A. Examples of “fish-eye deformity” of IPMN. Mucin is seen extruding from the ampulla. B. Mucin coming from pancreatic duct when neck of pancreas is transected during Whipple procedure (left). Intraoperative pancreatic ductoscopy to assess the pancreatic tail (right). C. Views of pancreatic duct during ductoscopy; normal (left) and IPMN (right).Brunicardi_Ch33_p1429-p1516.indd 150301/03/19 6:47 PM 1504SPECIFIC CONSIDERATIONSPART IIobserved with serial imaging. High-risk features such as mural nodules, a dilated main duct, positive cytology or cyst fluid CEA >200 need to be ruled out. In the absence of these fea-tures, continued observation with |
Surgery_Schwartz_9899 | Surgery_Schwartz | imaging. High-risk features such as mural nodules, a dilated main duct, positive cytology or cyst fluid CEA >200 need to be ruled out. In the absence of these fea-tures, continued observation with serial imaging is appropriate, especially in patients who are not ideal operative candidates. The mean frequency of invasive cancer in resected BD-IPMN is 18%. BD-IPMN mostly occurs in elderly patients, and the annual malignancy rate is only 2% to 3%. These factors support conservative management with follow-up in patients who do not have any symptoms or risk factors predicting malignancy such as mural nodule, rapidly increasing cyst size, and high-grade atypia in cytology. There is insufficient data to support immediate resection for all BD-IPMNs <3 cm without “high-risk stigmata” and “worrisome features.” Branch-duct IPMNs ≥3 cm should be resected.372Four histologic subtypes of IPMNs have been character-ized: gastric, intestinal, pancreatobiliary, and oncocytic. Most of BD-IPMNs are | Surgery_Schwartz. imaging. High-risk features such as mural nodules, a dilated main duct, positive cytology or cyst fluid CEA >200 need to be ruled out. In the absence of these fea-tures, continued observation with serial imaging is appropriate, especially in patients who are not ideal operative candidates. The mean frequency of invasive cancer in resected BD-IPMN is 18%. BD-IPMN mostly occurs in elderly patients, and the annual malignancy rate is only 2% to 3%. These factors support conservative management with follow-up in patients who do not have any symptoms or risk factors predicting malignancy such as mural nodule, rapidly increasing cyst size, and high-grade atypia in cytology. There is insufficient data to support immediate resection for all BD-IPMNs <3 cm without “high-risk stigmata” and “worrisome features.” Branch-duct IPMNs ≥3 cm should be resected.372Four histologic subtypes of IPMNs have been character-ized: gastric, intestinal, pancreatobiliary, and oncocytic. Most of BD-IPMNs are |
Surgery_Schwartz_9900 | Surgery_Schwartz | features.” Branch-duct IPMNs ≥3 cm should be resected.372Four histologic subtypes of IPMNs have been character-ized: gastric, intestinal, pancreatobiliary, and oncocytic. Most of BD-IPMNs are composed of gastric-type epithelium. However, intestinal type is more common in MD-IPMN. In a recent report, the four subtypes of IPMNs were associated with significant dif-ferences in survival.376 Patients with gastric-type IPMN had the best prognosis, whereas those with intestinal and pancreatobili-ary type had a bad prognosis.Workup of Asymptomatic Pancreatic Cystic NeoplasmsIncidentally discovered asymptomatic pancreatic cystic neo-plasms are evaluated by MRI with MRCP to check for “high-risk stigmata or worrisome features.” An enhancing solid component or main pancreatic duct (MPD) dilation ≥10 mm are considered “high-risk stigmata.” Cysts ≥3 cm, thickened enhancing cyst walls, nonenhancing mural nodules, MPD size of 5 to 9 mm, abrupt change in the MPD caliber with distal pancreatic atrophy, | Surgery_Schwartz. features.” Branch-duct IPMNs ≥3 cm should be resected.372Four histologic subtypes of IPMNs have been character-ized: gastric, intestinal, pancreatobiliary, and oncocytic. Most of BD-IPMNs are composed of gastric-type epithelium. However, intestinal type is more common in MD-IPMN. In a recent report, the four subtypes of IPMNs were associated with significant dif-ferences in survival.376 Patients with gastric-type IPMN had the best prognosis, whereas those with intestinal and pancreatobili-ary type had a bad prognosis.Workup of Asymptomatic Pancreatic Cystic NeoplasmsIncidentally discovered asymptomatic pancreatic cystic neo-plasms are evaluated by MRI with MRCP to check for “high-risk stigmata or worrisome features.” An enhancing solid component or main pancreatic duct (MPD) dilation ≥10 mm are considered “high-risk stigmata.” Cysts ≥3 cm, thickened enhancing cyst walls, nonenhancing mural nodules, MPD size of 5 to 9 mm, abrupt change in the MPD caliber with distal pancreatic atrophy, |
Surgery_Schwartz_9901 | Surgery_Schwartz | are considered “high-risk stigmata.” Cysts ≥3 cm, thickened enhancing cyst walls, nonenhancing mural nodules, MPD size of 5 to 9 mm, abrupt change in the MPD caliber with distal pancreatic atrophy, and lymphadenopathy are considered “worrisome features.” All cysts with high risk stigmata are resected. All cysts with wor-risome features and cysts > 3 cm without worrisome features are further evaluated with EUS. If EUS shows a definite mural nodule, main duct features suspicious for involvement or the cytology is positive or suspicious for malignancy, then resection is recommended. In the absence of worrisome features, no fur-ther initial work-up is recommended, but surveillance is still required.The interval between surveillance imaging is based on the size of the cyst with a lengthening of the interval once sta-bility is established. Patients with noninvasive MCNs require no surveillance after resection, but patients with IPMNs need surveillance after resection. In the absence of | Surgery_Schwartz. are considered “high-risk stigmata.” Cysts ≥3 cm, thickened enhancing cyst walls, nonenhancing mural nodules, MPD size of 5 to 9 mm, abrupt change in the MPD caliber with distal pancreatic atrophy, and lymphadenopathy are considered “worrisome features.” All cysts with high risk stigmata are resected. All cysts with wor-risome features and cysts > 3 cm without worrisome features are further evaluated with EUS. If EUS shows a definite mural nodule, main duct features suspicious for involvement or the cytology is positive or suspicious for malignancy, then resection is recommended. In the absence of worrisome features, no fur-ther initial work-up is recommended, but surveillance is still required.The interval between surveillance imaging is based on the size of the cyst with a lengthening of the interval once sta-bility is established. Patients with noninvasive MCNs require no surveillance after resection, but patients with IPMNs need surveillance after resection. In the absence of |
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