This document outlines a seminar plan on carcinoma of the pancreas presented by Dr. Jyotindra Singh. The seminar will cover topics such as the anatomy and surgical anatomy of the pancreas, pancreatic tumors, modes of presentation, pre-operative workup, various surgeries and surgical videos, recent updates, studies and trials, and a take home message. The seminar introduction discusses that carcinoma of the exocrine pancreas accounts for over 90% of pancreatic tumors and remains an oncologic challenge with a 5-year survival rate of 3%.
Colorectal cancer is most common GI cancer
The rectum is the most frequent site involved
Adenoma-carcinoma sequence: Arises from adenoma in stepwise progression
Gall bladder carcinoma seen in Indian popluation most common in women and presents at a very late stage .Survival is in months hence palliative treatment is being preferred .
Pancreatic cancer is sometimes called a "silent killer" because early pancreatic cancer often does not cause symptoms, and the later symptoms are usually nonspecific and varied. Therefore, pancreatic cancer is often not diagnosed until it is advanced.
Colorectal cancer is most common GI cancer
The rectum is the most frequent site involved
Adenoma-carcinoma sequence: Arises from adenoma in stepwise progression
Gall bladder carcinoma seen in Indian popluation most common in women and presents at a very late stage .Survival is in months hence palliative treatment is being preferred .
Pancreatic cancer is sometimes called a "silent killer" because early pancreatic cancer often does not cause symptoms, and the later symptoms are usually nonspecific and varied. Therefore, pancreatic cancer is often not diagnosed until it is advanced.
Today I have uploaded a video on one more cause for Obstructive Jaundice- Pancreatic Carcinoma. Only cancer in head of pancreas cause Obstructive Jaundice. I have talked about cancer in body and tail of pancreas as well. I have discussed the risk factors, pathology, clinical features, investigations, treatment and complications of pancreatic carcinoma. I have included a mind map and two algorithms. I hope you will enjoy this video. You can watch all my surgical teaching video casts in the following link.
Surgicaleducator.blogspot.com
Thank you for your support.
Common Bile Duct (CBD) is a tube that carries bile from gallbladder or liver to the small intestine. Gallstone may develop when there is too much cholesterol or bilirubin inside gallbladder secreted by the liver. CBD stones may not have any signs & symptoms for months or even years. However, if the blockage becomes severe, then some signs & symptoms may be experienced. For more information, visit at http://gisurgery.info
In this ppt I have discussed the different causes for obstructive jaundice, anatomy of biliary tract, physiology of jaundice, labs in obstructive jaundice and an algorithm to diagnose obstructive jaundice.
From famous actors like Patrick Swayze to America's first woman in space, Sally Ride, the survival rates for pancreatic cancer summarizes grim tales. To date, the overall 5-year-survival rate is 6.7%. Here, I present some of the latest information in the field.
What separates an accomplished cardiac surgeon from the reat is the right patient selection for surgery. This PPT will give insight when its best not to opearte on a mitral valve
This presentation is no way to discredit TAVI or bring the positives of SAVR. Its about trials when short term outcomes of TAVI are compared to long term benefits of surgery.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
3. SEMINAR PLAN
INTRODUCTION
ANATOMY
SURGICAL ANATOMY
PANCREATIC TUMOURS
MODE OF PRESENTATION
PRE OPERATIVE WORK UP
VARIOUS SURGERIES/ SURGICAL VIDEOS
RECENT UPDATES
VARIOUS STUDIES/TRIALS
TAKE HOME MESSAGE
4. INTRODUCTION
Carcinoma of the exocrine pancreas accounts for
over 90 % of pancreatic tumors and remains an
unreduced oncologic challenge.
By definition,periampullary cancers arise within
2 cm of the major papilla in the duodenum.
Pancreatic adenocarcinoma accounts for 80% tumours
Most common GI malignancy after Ca colon
Least 5 years survival rate of 3 %.
Incidence rate is virtually identical to the
mortality rate
5. INTRODUCTION
Pancreatic cancer is a biologically aggressive tumor
from the onset .
Clinically queisent for a long time and hence present in
advanced state.
Only 20% of pancreatic cancers are operable for cure
Only 10% - 15% of pancreatic cancers are alive 12
months after the diagnosis
Average life of metastatic pancreatic cancer is 6 months
6. ANATOMY AND RELATION OF PANCREAS
Pancreas is a long retroperitoneal organ 15 to 20 cm in
length.
Weighs about 80 gms ,lies against L1 & L2 Vertebra.
It is arbitarily divided into HEAD,NECK BODY & TAIL
Head lies within the concavity of duodenum against second
lumbar vertebra and body overlies the first lumbar vertebra
7. Cuddles L Kidney
Tickles Spleen
Cradles Aorta
Opposes IVC
Dallies with
R Renal
Pedicle
Hugs the duodenum
Wraps the SMV
Hides behind peritoneum
Durman
8. BLOOD SUPPLY
PANCREATIC BRANCHES OF SPLENIC
ARTERY
SUPERIOR PANCREATICODUODENAL
ARTERY
INFERIOR PANCREATICODUODENAL
ARTERY
VENOUS DRAINAGE IS INTO SPLENIC
VEIN ,SUPERIOR MESENTERIC & PORTAL
VEIN
14. PANCREATIC DUCT
Main duct of Pancreas ( DUCT OF WIRSUNG )-
begins in tail of pancreas and runs on the posterior surface
of the body and head of pancreas.
HERRING BONE PATTERN
DIAMETER OF PANCREATIC DUCT
TAIL - 1 to 2 mm BODY - 2 to 3 mm
HEAD - 3 to 4 mm
Upto 5-6 mm of dilatation in a 70 yr old person is considered
normal.
Joins the bile duct in the wall of second part of duodenum to
form hepatopancreatic ampulla ( of Vater )
DUCT OF SANTORINI- begins in lower part of the head and
opens in to duodenum at minor duodenal papilla ( 6-8 cm from
19. INCIDENCE
Annual incidence 10 new cases per 100000 population
Lowest incidence – India and Middle East
Incidence increases steadily with age – with 80 % over 6th
decade of life
Male: Female ratio – 2:1
Pre and post menopausal women ratio is 2: 1
20.
21. ETIOLOGY & RISK FACTORS
HEREDITY - CANCER FAMILY SYNDROMES
CIGARETTE SMOKING
DIET – high intake of animal fat or meat.
OCCUPATIONAL
EXPOSURE TO RADIATIONS
GASTRIC SURGERIES
DIABETES MELLITUS/PERNICIOUS ANAEMIA/ CHRONIC
PANCREATITIS
22. Etiology – hereditary factors
Most of the pancreatic cancers are sporadic
7.8% of pancreatic cancer patients give a positive
family history
Hereditary syndromes
HNPCC
PZ syndrome
Ataxia Telangiectasia
Hereditary Pancreatitis
Familial Atypical Mole Melanoma syndrome
FAP
23. Etiology – Diabetes – Is it a cause or effect
Several studies have shown an increased
incidence of pancreatic cancer in diabetics
Diabetes is considered as an early symptom of
pancreatic cancer rather than being a cause
The diabetes of Pancreatic cancer is due to islet
cell dysfunction (Islet Amyloid polypeptide)
and not due to the destruction of the gland
24. Etiology – Chronic
Pancreatitis- Is it premalignant
The incidence of pancreatic cancer in
various entities of chronic Pancreatitis are
as follows
Hereditary Pancreatitis 25%
Tropical Pancreatitis 10%
Alcoholic Pancreatitis 5%
27. The tumours of the pancreas can be -
A. Non-Endocrineneoplasms
B. Endocrineneoplasms
TUMOURS OF THE PANCREAS
28. ENDOCRINE NEOPLASMS:
These are less common than non-endocrine
tumours and generally benign and sometimes
multiple. They includes:
Insulinoma
Glucogonomas
Others:
- Gastrinomas
- Somatostatatinomas
- Vipomas (Vasoactive Intestinal
Polypeptide)
common
31. Carcinoma - Pancreas
A, A cross-section through the head of the pancreas and
adjacent common bile duct showing both an ill-defined
mass in the pancreatic substance (arrowheads) and the
green discoloration of the duct resulting from total
obstruction of bile flow.
B, Poorly formed glands are present in densely fibrotic
stroma within the pancreatic substance; there are some
inflammatory cells
35. CLINICAL MANIFESTATIONS
It is unfortunate that malignant pancreatic cancers are
asymptomatic until local or systemic complication develop.
1. Obstruction to bile duct – Jaundice and pruritus
2. Obstruction to duodenum /stomach- Gastric outlet obstruction
3. Ulceration- Gastro intestinal haemorrhage
4. Infiltration of peripancreatic nerve roots produce pain
The onset of symptoms are insidious and progressive
Abdominal pain is usually post prandial and in epigastrium
Pain in upper back denotes retroperitoneal extension
36. Pancreatic Tumors in the Head
Tumors in the head may compress biliary ducts or pancreatic
ducts
37. SYMPTOMS AND SIGNS
CARCINOMA HEAD OF PANCREAS
1. WEIGHT LOSS – AVERAGING ABOUT 40%
2. OBSTRUCTIVE JAUNDICE-
3. DEEP SEATED ABDOMINAL PAIN
4. NON TENDER PALPABLE GALL BLADDER
5. CHOLANGITIS OCCURS IN 10 % OF PATIENTS
39. CARCI NOMA OF BODY AND TAIL
WEIGHT LOSS
DEEP SEATED PAIN
JAUNDICE- < 10 % OF PATIENT
SUDDEN ONSET OF DIABETES MELLITUS-25% OF
PATIENT
MIGRATORY THROMBOPHLEBITIS- OCCURS IN ABOUT
10% PATIENT
40. SYMPTOMS AND SIGNS
CARCINOMA OF AMPULLA OF VATER
1. Pain occurs less frequently – usually its colicky
2. Jaundice is often intermittent
3. Chills and fever – due to associated cholangitis
41.
42. Periampullary carcinoma
Any tumor within 2
cm from the duodenal
papilla is defined as
periampullary cancer.
Ca terminal PD
Distal CBD
Ampullary tumor
Duodenal tumor
43. Periampullary carcinoma
The individual components of peri
ampullary tumors differ in their
prognosis
Duodenal carcinoma
Ampullary carcinoma
CBD growth
Pancreatic ca
45. Clinical presentation
Mid epigastric pain radiating to back
Weight loss
Fatigue
Anorexia
Symptoms are vague and hence the delayed
presentation
46. Clinical presentation
Painless progressive jaundice 50-60%
Pruritus
Staetorrhea
Malabsorption
New onset of Diabetes in older patients
47. Clinical presentation
Jaundice is a late presentation in uncinate
process growth
Severe back pain indicate irresectablity and an
omnious sign
48. Physical findings
Physical findings are rare in pancreatic cancers
and their presence usually indicate advanced
stage
Resectablity is better when patient presents
with the classical painless progressive jaundice
56. CT
“Pancreatic protocol CT” is the gold
standard of investigation to stage the
disease and assess the operability
Triple phase CT
Closer cuts
Water used as an intraluminal contrast
Helical or multislice
57. CT
Focal or diffuse mass lesion which is hypo
dense (low attenuation) and hypo vascular
(poor contrast enhancement)
Dilated MPD and CBD
63. CT
Advantages
Available easily
Surgeons are familiar with CT
Excellent in giving details of operability
Disadvantages
May miss liver mets less than 1 cm
Miss peritoneal mets
Radiation
64. MRI
Advantages
No radiation
Avoids contrast
Single investigation that gives all the
information needed
Disadvantages
Cost & availability
Surgeons are unfamiliar
65. MRI
As it stand today CT is as good as MRI
Probably in the future, MRI is likely to be used
more frequently and may replace CT
67. Role of Biopsy
Tissue diagnosis is indicated in cases which
are found inoperable by imaging
Biopsy is indicated when Neoadjuvant
chemotherapy is planned
68. Why not a biopsy
May upstage the disease
Complications of biopsy
Has a very low negative predictive value
69. What biopsy
Ideally it should be
done under EUS
guidance
Targeted
No tumor seeding
No complications
like fistula
70. ERCP
Double duct sign
Not routinely done in
pancreatic
Cancer
Preop biliary drainage
Atypical lower CBD
obstruction
71. PET
It is useful in differentiating pancreatic cancer
from chronic Pancreatitis
Extra pancreatic disease
72. EUS
Ideal method to evaluate
lower CBD obstruction
Guided FNAC
Vascular invasion
EUS+FNAC= sensitivity of
90% and specificity of 95%
76. Staging
TX primary tumor cannot be assessed
T0 no evidence of primary tumor
T1 confined to pancreas
T1a less than 2 cm
T1b more than 2 cm
T 2 tumor extend to involve the bile
duct, duodenum and peripancreatic
tissue
T3 involvement of stomach, spleen, colon,
vessels
77. Staging
NX nodes cannot
be assessed
N0 no evidence
of nodes
N1 regional
nodes present
MX cannot be
assessed
M0 no metastasis
M1 distant
metastasis
78. Stage grouping
Stage I
T1 N0 M0
T2 N0 M0
Stage II
T3 N0 M0
Stage III
Any T N1 M0
Stage IV
Any T Any N M1
99. Pancreaticoduodenectomy
Walter Kausch was the first to successfully
perform pancreaticoduodenectomy in Berlin
1912
Allen Whipple popularized the operation in US
in 1935
Now this operation is called Kausch-Whipple
procedure
100. Pancreaticoduodenectomy
This operation suffered a very bad reputation
due to the operative mortality of over 25% and
morbidity of over 50%
Some authorities have even suggested that, this
operation be abandoned
105. PANCREATICODUODENECYTOMY- PYLORUS
PRESERVATIION
Incision- transverse subcostal / midline
Exploration/mobilization- kocherization
Cholecystectomy/division of the bile duct
Exposure of superior mesenteric vein
Division of duodenum
Division of gastroduodenal artery
Division of pancreatic neck
Dissection of uncinate process
Resected specimen-gallbladder,distal bile duct,2nd 3rd &4th part
of duodenum,proximal jejunum and head ,neck & uncinate
portion of pancreas
Reconstruction
108. Duodenum- preserving resection of the head of pancreas
Incision- transverse subcostal / midline
Exploration/mobilization- kocherization
Exposure of the pancreas
Dissection of the neck of pancreas
Resection along the CBD
Pancreatic remnant
Reconstruction
Bile duct anastomosis
Stenosis of the pancreatic duct
109. TOTAL PANCREATECTOMY
This involves the en bloc resection of
The whole of pancreas
The spleen
Distal half of stomach
Duodenum
Proximal 10 cm of jejunum
Gall bladder
Cystic and common bile duct
110. TOTAL PANCREATECTOMY
Incision- Transverse muscle-cuting incision
Exploration/mobilization- kocherization
Mobilization of duodenum/head of pancreas
Exposure of body and tail of pancreas
Dissection of the vessels- hepatic artery is traced
Mobilization of spleen and pancreas
Limited gastrectomy/pylorus preserving resection
Reconstruction – choledochojejunostomy/bowel anastomosis
112. REGIONAL PANCREATECTOMY
TYPE O – TOTAL PANCREATECTOMY
TYPE I -- RESECTION OF PORTAL VEIN SEGMENT
TYPE II a – Type I plus resection of proximal SMA
TYPE II b– Type I plus resection of celiac axis/hepatic artery
TYPE II c-- Type I plus resection of celiac axis & SMA
113. PANCREATIC ENDOCRINE DISEASE
Principles- whether tumour functioning or non-functioning
tumour benign or malignant
sporadic occurrence or part of MEN-I
Operative steps
IOUS- localization of islet cell tumours
delineation of proximity of tumour to pancreatic duct
demonstration of multiple tumours as part of MEN-I
ENUCLEATION- CUSA
DISTAL PANCRETECTOMY
114. PANCREATIC CANCER- LAPROSCOPIC STAGING
7.5 Mhz linear array transducer
Port-infraumbilical and right flank
Search for serosal deposit
Lesions on liver sampled/GB visualised
Transducer placed on porta hepatis
Look for dilataion of pancreatic duct
Position of tumour relative to pancreatic duct/portal vein
Lymphnodes more than 10 mm -significant
115. PANCREATIC TRANSPLANTATION
Suitable donors between 20 and 50 yrs
Pancreatic blood flow to be maintained- warm ischemia
Gland should be perfused with a cold preservation fluid-
hypertonic citrate solution
Pancreas removed avoiding damage to the gland– injection of
collagenase enzyme into the pancreatic duct under pressure.
Pancreas transported to processing centre-within four hours-
cold ischemia
116. RECENT UPDATES/CHANGING
APPROACH
Preop biliary drainage
Preop imaging, CT vs. MR vs. EUS
Role of biopsy
Diagnostic laparoscopy
PJ vs. PG
Classical Whipple vs. PPPD
Vascular resections
Extended lymphadenectomy
Drainage
117. Controversies
Role of octreotide
Order of reconstruction
Adjuvant therapy
Palliative resections
Palliative bypass
118. Preop biliary drainage
For
Reduce the mortality and morbidity of surgery
Improves the liver function
Reduces the bleeding
Improves the nutrition
Buys time
119. Preop biliary drainage
Against
Does not reduce the mortality and morbidity
More infectious complications
It takes 6 weeks for the improvement of hepatic
microsomal functions
Makes the duct small and fibrotic – adds to
technical difficulty
120. Preop biliary drainage -
consensus
Indicated
Cholangitis
Impending renal failure
Surgery is likely to be delayed
Bilirubin of more than 20 mg%
Nutritionally very poor
Neoadjuvant chemotherapy is planned
121. Preop biliary drainage -
consensus
Routine preop biliary
drainage is not
recommended and there is
no evidence to support it
122. Diagnostic laparoscopy
30% of patients found operable by imaging are
found to have small liver mets or peritoneal
mets, on diagnostic laparoscopy
Warshaw et al
123. Diagnostic laparoscopy
With the advent of high quality
CT, Helical and Multislice,
occult peritoneal and liver
metastasis are documented in
only 10% in some series
124. PJ vs. PG
Merits of PG
Stomach is in proximity to pancreatic stump
Better vascularity
Acid in stomach inactivates enzymes
Absence of enterokinase
Even if leak occurs the enzymes are not activated
and hence fatal bleeding do not occur
125. PJ vs. PG
Two randomized controlled trials fail to
demonstrate superiority of one method over
the other
Dilated duct, texture of pancreas and surgeon’s
experience are more important than the viscera
used for drainage
126. Classical Vs PPPD
PPPD is oncologically as radical as classical
whipple except for tumors encroaching on the
D1 and pylorus
RCTs have failed to show any significant
benefit of PPPD over classical whipple
127. Vascular
involvement
Resection of SMV is
accepted provide it
enables to perform R0
resections
Involvement of SMA is
a contraindication for
resection
128. Extended
lymphadenectomy
Studies have shown
that extended
lymphadenectomies
can be done with
acceptable morbidity
Extended
lymphadenectomy do
not improve the
survival
129. Octreotide
There have been totally six RCT across the
Atlantic, three from Europe ( Buchler et al, Beger
et al , Pedrazolli et al) and three from US ( Yeo et
al, Sarr et al and Lowy et al)
The European trials favor use of octreotide and the
American trials do not favor
Recently published meta analysis of these trials
have shown a benefit f octreotide in reducing the
complications
131. Adjuvant therapy
The ESPAC trial has shown that the only
factor that positively affect the long term
survival is administration of adjuvant
chemotherapy
Ideally all patients undergoing surgery for
cancer pancreas should be given adjuvant
chemotherapy
133. Palliative resections – Is it
acceptable
Palliative resections and palliative bypass has
the same survival
Hence palliative resections are not accepted
134. Palliative resections
The series from John Hopkins has shown
survival benefits in R1 and few cases of R2
Whipple
135. Palliative resections
The consensus is that one should not willfully
perform a palliative resection, and the aim of
the surgeon should always be a R0 resection
136. Palliative bypass
Operative palliation is not the standard of care
for a patient with inoperable Ca pancreas with
obstructive jaundice
Endoscopic palliation is the treatment of
choice
137. Palliative bypass
A selected group of patients with good
performance status
Patients who are found to be inoperable on
the table
Endoscopy facilities not available or not
possible for technical reasons
138. Palliative bypass
Options of by-pass
Choledochojejunostomy ( Loop or Roux en Y)
Cholecystojejunostomy
Hepaticojejunostomy
139. Palliative bypass-prophylactic GJ
The current recommendation is to perform a
prophylactic GJ along with the biliary bypass
even if there is no gastric outlet obstruction
140. Laparoscopy in palliation
Depending on the expertise of the surgeon,
procedures can be done with laparoscopy
141. Palliation of pain
Neurolysis ( 20 ml of absolute alcohol injected
on either side of the celiac axis to destroy the
celiac ganglia)
At laparotomy
CT guided
EUS guided
Thoracoscopic splanchnectomy
143. TAKE HOME MESSAGE
Survival rate of patients after the establishment of diagnosis is
very dismal.
Surgical resection if possible ,is the only curative treatment but
it can play a role only in very small percentage of cases
Post surgery five year survival rate is least in pancreatic
malignancy.tive
Newer approaches are less radical and more effective
Concept of regional pancreatectomy has increased poet op
survival period
Survival can be further increased by- early detection
- avidance of surgery in presence of metastasis
- operative technique with avoidance of local spillage
- avoiding preoperative blood transfusion.
144. REFERENCES
BAILEY & LOVE’S- SHORT PRACTISE OF
SURGERY
SABISTON TEXTBOOK OF SURGERY
MASTERY OF SURGERY by Fischer
OXFORD TEXTBOOKOF SURGERY
MAINGOTS ABDOMINAL OPERATION
MAYO CLINIC GI SURGERY
CANCER PRINCIPLES- De Vita
SURGERY BY CORSON
RECENT ADVANCES- WOLTERS KLUWER
RECENT ADVANCES- RSG