Exocrine neoplasms of pancreas, Introduction: Fifth leading cause of deaths from cancer, Aggressive tumor biology, Advanced stage of disease @ diagnosis, Lack of effective systemic therapies....

1. By: Hima
EXOCRINE NEOPLASMS
OF PANCREAS

2.  Fifth leading cause of deaths from cancer
 Aggressive tumour biology
 Advanced stage of disease @ diagnosis
 Lack of effective systemic therapies
INTRODUCTION

4.  Tobacco use = N- nitroso compounds, K-ras
 Chronic pancreatitis
 Diabetes milletus
 Obesity
 Family history of pancreatitis & pancreatic cancer
 Hereditary conditions
 Mutation in trypsinogen gene – chromosome 7q
RISKS

5.  Lack of obvious signs & symptoms delays the
diagnosis
 50% - biliary obstruction - tumours in head =
jaundice
 Pain or weight loss – tumours in the body or tail
 Pain in locally advanced cancer into celiac ganglia &
mesenteric nerve plexus
CLINICAL MANIFESTATIONS

6.  Fatigue, weight loss & anorexia
 Pancreatic duct obstruction causes – malabsorption
& steatorrhea
 Diabetes milletus – altered β – cell function,
peripheral insulin resistance

7.  Treatment & prognosis depends on clinical staging
based on radiological examinations
 Potentially respectable, locally advanced
 Vascular involvement
CLINICAL STAGING AND PRE-TREATMENT
DIAGNOSTIC EVALUATION

9.  Kocher maneuver
 Tumour free plane between the neck of pancreas &
SMPV
 Inaccurate
 Can be determined only after gastric & pancreatic
resections
DIAGNOSIS

10.  Pre – operative contrast CT - Loss of fat plane
between tumour & SMV
 High resolution, contrast enhanced, helical CT
 Accurate assessment minimizes positive margin
resections
 Unresectability of tumour

13.  Periampullary carcinoma
 Localised disease to detect extra pancreatic
involvement not captured by CT
 More advanced stage diseases
 Laparotomy can be avoided
 Tumour- vessel relationships – CT = Less invasive
 MRI
LAPAROSCOPY & ANGIOGRAPHY

14.  Absence of extra – pancreatic disease
 Patent SMPV confluence
 No direct tumour extension to the celiac axis or SMA
 EUS – Guided FNA – no evidence of extra pancreatic
disease, protocol based neo-adjuvant therapy
 ERCP
 Endoscopic biliary stenting can be done
 EUS – SMA, SMV involvement
CT CRITERIA FOR RESECTABILITY
INCLUDE

16.  Open laparoscopic (biliary bypass) methods are
reserved for who survive long with minimal disease
progression
 Not for ascites, liver metastasis – median survival of
6 – 12 months
 Polyethylene stents – avoids recurrent occlusions &
cholangitis
CT – UNRESECTABLE DISEASE

17.  Exposure of the infrapancreatic SMV
 Greater omentum is removed to enter into lesser sac
 Right colon & small bowel mobilised – cattell &
brasasch method
 Middle colic vein is ligated
 SMV - exposed
PANCREATICODUODENECTOMY

18.  Kocher maneuver
 Begins @ the junction of right ureter & gonadal vein
 Gonadal vein and left renal vein are ligated
 Fatty, lymphatic, connective tissue is cleared around
right kidney &anterior to the IVC
 Gonadal vein is again ligated @ exiting into IVC

21.  Portal dissection
 Common hepatic artery proximal exposed
 Gastroduodenal artery is ligated and divided
 Common hepatic or bile duct is cut & gallbladder+ cystic
duct + CHD removed from liver bed
 Portal vein is exposed
 Bleeding due to traction may result in excessive bleeding

22.  Variations in hepatic arterial circulations complicates
portal dissection
 Hepatic artery might course beneath portal vein arise
from SMA
 Pre – operative arteriography is helpful

23.  Iatrogenic injury to the inferior PDA to be avoided
 Negative Reteroperitoneal margination hasto be
assessed carefully to prevent recurrence
 Can be achieved by full mobilisation of SMPV, &
removing soft tissue around SMA

24.  Gastric transection & stapling
 Third & fourth transverse vein – lesser curvature
 Gastorepiploic veins junction greater curvature
 Ligament of treitz dissection
 Jejunum is transected & stapled, 10 cm distal to the
ligament of treitz leaves a mobile proximal jejunum
prevents tension - reconstruction

25.  Mesentery of jejunum & duodenum is divided
 Mesenteric vessels & aorta – exposed

26.  Traction sutures - superior & inferior borders of
pancreas
 Pancreas is transection using electrocautery @ PV or
distally SMPV involvement
 The specimen is separated from the SMV by ligating &
dividing small arteries of head and uncinate process
 Complete removal of uncinate & medial retraction of
SMPV confluence facilitates SMA exposure
RETROPERITONEAL DISSECTION

27.  Segmental resection of SMPV confluence – splenic
vein intact
 Graft (IJV) is placed prior to the retroperitoneal
dissection
 IJV – Internal jugular vein
 Cross clamping of SMA to prevent small intestinal
oedema

36.  Bile duct transection margin
 Pancreatic transection margin
 Reteroperitoneal margin
 Tumor histopathologic type
 Degree of differentiation
 Tissue of origin (pancreas, bile duct etc)
 Histologic evidence of invasion – vascular. Neuro, lymphatic
 Grade of chemoradiation effect
PATHOLOGICAL EVALUATION OF
PANCREATICODUODENECTOMY SPECIMEN

37.  Pancreaticojejunostomy – pancreatic remnant is
mobilized from splenic vein & retroperitoneum +
jejunum brought retrocolic
 A two layer end to side, end to duct mucosa
pancreaticojejunostomy is performed over a silastic
stent
 The anastomosis is made with 4 0r 5 monofilament
absorbable sutures
PANCREATIC, BILIARY, GASTRO INTESTINAL
RECONSTRUCTION

38.  Hepaticojejunostomy;
 A single layer biliary anastomosis is performed – 4.0
absorbable monofilament sutures
 Reduces the tension b/w pancreas & bile duct
 Gastrojejunostomy;
 An antecolic end to end anastomosis is made by removing
staple
 Gastrostomy & feeding jejunostomy tubes are placed
using witzel technique

39.  To prevent poor gastric emptying
 Inadequate nutritional support
 Falciform ligament is placed b/w GDA & jejunum

40.  Pylorus preservation in benign disease
 Nerve of laterjet has to be saved while portal
dissection – gastroparesis

41.  EBRT + 5- FU Prolongs survival
 The preoperative benefits of adjuvant therapy
 Effective on well vascularized cells
 Retroperitoneal margin
 Peritoneal cell implantation
 Disseminated disease
 Delayed post operative recovery doesn’t affect
multimodality approach
ADJUVANT OR NEOADJUVANT TREATMENT

42.  Increased survival in ambulatory patients
 Gemcitabine appears to be evolving standard