This document provides information on pancreatic carcinoma, including: - The anatomy and blood supply of the pancreas. - Risk factors, signs and symptoms, investigation, classification, and staging of pancreatic cancer. - Surgical treatments including pancreaticoduodenectomy, distal pancreatectomy, and palliative procedures. - Adjuvant therapies and palliation of advanced or unresectable pancreatic cancer.

1. Pancreatic Carcinoma
By- Piyush Giri
Intern

2. Anatomy
• Pancreas is derived from Greek
‘pan’ meaning all and ‘kreas’
flesh.
• 12-15–cm long J-shaped soft,
lobulated, retroperitoneal organ.
It lies transversely, although a bit
obliquely, on the posterior
abdominal wall behind the
stomach, across the lumbar (L1-
2) spine divided into Head, Neck
and Tail.
• Weighs approximately 80 grams,
Head occupies 30% by weigh
and body and tail together
constitutes 70%

3. Head of Pancreas
• The head of the pancreas lies
in the duodenal C loop in
front of the inferior vena
cava (IVC) and the left renal
vein.
• The uncinate process is an
extension of the lower
(inferior) half of the head
toward the left; it is of
varying size and is wedged
between the superior
mesenteric vessels (vein on
right, and artery on left) in
front and the aorta behind it.

4. • The lower (terminal) part
of the CBD runs behind (or
sometimes through) the
upper half of the head of
pancreas before it joins the
main pancreatic duct
(MPD) to form a common
channel (ampulla of vater).

5. Body and tail
• The body and tail of the
pancreas run obliquely
upward to the left in front of
the aorta and left kidney. The
pancreatic neck is the
arbitrary junction between
the head and body of the
pancreas. Portal vein lies
behind the neck of the
pancreas. The narrow tip of
the tail of the pancreas
reaches the splenic hilum in
the splenorenal (lienorenal)
ligament.

6. Ducts of Pancreas
1. Duct of Wirsung
begins in the tail of pancreas
and runs on posterior surface
of body and head and
receives tributaries at right
angle along its length, joins
bile duct in wall of
duodenum to form hepato
pancreatic ampulla ( ampulla
of vater) opening on major
duodenal papilla.
2. Accessory pancreatic duct
which begins at lower part of
head and opens into minor
duodenal papilla.

7. Histology
• Composed of exocrine acinar tissue and cluster of
endocrine cells known as islets of Langerhans.

8. Blood supply
1. Pancreatic branches of splenic
artery branch of Celiac artery
2. Superior pancreaticoduodenal
artery branch of
Gastroduodenal artery
3. Inferior pancreaticoduodenal
artery branch of Superior
Mesenteric artery
• Capillaries draining the islet
cells drain into portal vein
forming pancreatic portal
system.

9. Nerve supply
• Parasympathetic supply is from Vagus nerve
• Sympathetic innervation is from splanchnic
nerves.

10. Physiology of Pancreas
• Can be divided into Endocrinal and Exocrinal
functions.
• Exocrinal function includes; Pancreatic digestive
enzymes being released in response to secretin and
Cholecystokinin secreted from duodenal mucosa.
• Pancreatic juice constitutes:
• 98% water and 2% solid
• Solid contents includes:
• Organic (0.8%) and Inorganic (1.2%)
• Pancreatic juice helps in digestion of
proteins, carbohydrate and fats.

11. Contents of Pancreatic juice
Organic Components (0.8%)
Pancreatic enzymes:
1 Pancreatic amylase
2 Pancreatic lipase and colipase
3 Phospholipases
4 Trypsinogen
5 Chymotrypsinogen
6 Procarboxypeptidases
7 Proelastase
8 Procollagenase and nuclease
• Inorganic components (1.2%)
Cations
Sodium
Potassium
Calcium
Magnesium
Zinc
Anions
bicarbonate
Chloride
Sulphate

12. Endocrinal function
• Endocrinal part of pancreas formed by Islets of
Langerhans secretes Insulin ( B cells), Glucagon ( A
cells), Somatostatin ( D cells) and Pancreatic
polypeptide ( F cells)
• Endocrinal part helps in
-Carbohydrate metabolism
-Lipid metabolism
-Protein metabolism
-Ion transport: specially increasing potassium transport
into the cell
-Growth and development.

13. Pancreatic Carcinoma

14. Introduction
• Epidemiology
• Pancreatic cancer is sixth leading cause of
cancer deaths in the UK and fourth highest
cause of death in USA
• Incidence is 10 cases per 100000 population
per year
• Incidence has declined slightly over last 25
years.
• World wide it constitutes 2-3% of all cancers

15. Classification
• A. Exocrine tumours.
• B. Endocrine tumours.
• C. Lymphomas.

16. Exocrine Tumours
• Benign :
1. Benign cystadenoma (rare)
• Malignant
1. Adenocarcinoma
2. Squamous cell carcinoma
3. Combination of adenocarcinoma and squamous
cell carcinoma
4. Cystadenoma: occurs commonly in body and
tail of the pancreas and attains a large size.

17. Endocrine Tumours
• 1. Insulinoma (B cells)
• 2. Gastrinoma ( G cells)
• 3. Glucagonoma ( A cells)
• 4. Vipoma – Pancreatic cholera ( Verner-
Morrison syndrome)
• 5. Somatostatinoma (D cells)

18. Risk Factors
Demographic factors
1. Age (peak incidence 65-75 years)
2. Male gender
3. Black ethnicity
Environment/Life style
1. Cigarette smoking

19. Risk factors
Genetic factors and medical conditions
1. Family history: Two first degree relatives with
pancreas cancer relative increases 18 to 57 fold
and Germline BRCA2 mutation (rare).
2. Hereditary pancreatitis (50 to 70 fold increased
risk).
3. Chronic pancreatitis ( 5 to 15 fold increased risk)
4. Hereditary non polyposis colorectal cancer.
5. Ataxia telangiectasia.
6. Peutz-jeghers syndrome.

20. continued.
7. Familial breast - ovarian cancer syndrome.
8. Familial atypical multiple mole melanoma.
9. Familial adenomatous polyposis – risk of
ampullary/ duodenal carcinoma.
10. Diabetes Mellitus.

21. Clinical features
• History:
• Age: peak in 65 – 75 years
• Sex: Mostly male
• Ethnicity: more commonly in Black community
• Carcinoma of the head of the pancreas:
• Most common presenting symptom being Jaundice : Very common,
is painless, progressively deepening, can be on and off
(intermittent) and associated with nausea and epigastric discomfort
and majority of cases it precedes pain
• Pain in abdomen can be first symptom, though it is usually a
painless condition and present at advanced stage.
• Occasionally symptoms are similar to those of acute pancreatitis

22. Presentation of Ca. of head of
Pancreas Contd.
• Bowel habit: Diarrhoea; foul smelling, pale
stool which is quite common and steatorrhoea
• Anorexia and loss of weight are very common
• Other non-specific symptom can be: vague
discomfort
• Upper abdominal symptoms in recently
diagnosed diabetic especially in one above 50
years with no family history or obesity should
raise suspicion

23. • Carcinoma of body and tail
• Pain in epigastric region is
the cardinal symptom,
radiating through the back
aggravating on lying down
and decreasing when
sitting up so that the
patient spends the night
sitting up with arms folded
across the chest.
• Thrombophelbitis migrans;
Trousseau’s sign.

24. • On Examination:
• Jaundice
• Left supraclavicular palpable
lymph node
• Scratch marks
• Weight loss
• Palpable liver
• Palpable spleen (rare)
• Palpable Gallbladder
(Courvoisier's law)
• Tumour is seldom palpable
• Ascites may be present only
in late cases.

25. Investigation
1. Complete blood count: Raised
bilirubin; raised direct bilirubin, Serum
albumin decreased, PT prolonged and
serum alkaline phosphatase is
increased
2. Ultrasound: if bile duct is dilated in
jaundiced patient; tumour in head of
pancreas can be suspected.
3. Contrast-enhanced CT scan: preferred
test
• Tumour resectable?
• Hepatic or peritoneal or lymphatic
metastasis?
• Encasement of Superior
mesenteric, hepatic or coeliac artery?
• Local spread?

26. 4. MRI and MRI angiography: information
comparable to CT scan
5. ERCP: if diagnostic doubt (small tumours
not detected on CT) and biliary stent
can also be done to relieve
jaundice, obtain brush cytology and
biopsy to confirm diagnosis.
6. EUS: useful if CT fails to demonstrate
tumour
• Tissue diagnosis
• Vascular invasion?
• Distinguishing cystic tumours from
pseudocysts
• Transduodenal or transgastic FNA or
Trucut biopsy to be done, it avoids
spillage of tumour cells into the
peritoneal cavity

27. 7. Diagnostic laparoscopy
• Identify small peritoneal and
liver metastases.
• Can also be combined with
laparoscopic ultrasonography
8. Tumour marker CA 19-9
• Not highly specific or
sensitive, useful to identify
recurrence.
9. Barium meal: Reverse 3 sign
in periampullary carcinoma
10. Urine for bile salts ( Hay’s
test), bile pigments
(Fouchet’s test)

28. Treatment
• Needs to be multimodal: Primary
care, radiology, gastroenterology, surgery, &
oncology
• Surgery is the only cure
Cure only in those with complete resections
• Only 10-15% are operable
• 40-50% are locally advanced
• 40-50% have distant spread to liver or lungs

29. Treatment
• Surgical management
• Palliation

30. Surgical management
• Pylorus preserving pancreatoduodenectomy
• Whipple’s procedure
• Distal pancreatectomy
• Total pancreatectomy

31. Pylorus preserving
pancreatoduodenectomy
• Standard for tumour of
pancreatic head
• It involves removal of
duodenum, pancreatic
head, distal part of bile duct
and local lymphandectomy
• It preserves antrum and
pylorus
• Yields more physiological
outcome with no difference
in survival or recurrence rate

32. Pancreatoduodenectomy
• Indication
• in conditions where entire duodenum has to
be removed eg. FAP
• In cases tumour is encroaching first part of
duodenum or distal stomach
• PPPD does not achieve clear resection margin

33. Procedure of
Pancreatoduodenectomy
• Three phages
1. Exploration and assesment
2. Resection
3. Reconstruction
Procedure:
• Cholecystectomy done
• Bile duct and hepatic artery exposed
with removal of local lymphatic tissue
• Division of gastroduodenal artery and
portal vein is visualized
• Distal part of gastric antrum
, duodenum and right colon is
mobilized
• Superior mesenteric vein is exposed
• Dissection into the plane between vein
and the pancreatic substance
• Fourth part is dissected and freed
from ligamentum treitz
• Decide to continue to resection?

34. Procedure contd.
• If yes
• Jejunum is divided 20-30 cm
downstream from duodenal
jejunal flexure and mesentery of
proximal jejunum detached.
• First part of duodenum is divided
• Uncinate process is separated
from superior mesenteric artery
and vein, working upwards to
upper bile duct which is divided
and release of specimen achieved
• Retro peritoneal lymph node
within the operative field is
removed

35. Procedure contd.
• Reconstruction
• Pancreatic stump, divided
bile duct, duodenal stump
and stomach are
anastomosed on to jejunum
in that order
• Pancreas can also be
anastomosed to posterior
wall of stomach
• Or can separate Roux loop of
jejunum created and
anastomsed to that.

36. Distal Pancreatectomy
• In tumours affecting body
and tail
• Distal pancreatectomy with
splenectomy is standard
• In benign condition though
spleen may be preserved
• Antibiotic prophylaxis and
immunization prior to
splenectomy against
pneumococci, meningococci
and Haemophilus influenza
required.

37. Total Pancreatectomy
• In multifocal tumour (eg.
Multifocal tumour,)
• If body and tail of pancreas is
too inflamed or too friable to
achieve safe anastomosis.
• If tumour is adherent to
portal or superior mesenteric
vein, short segment can be
removed with
reconstruction.

38. Complication
• Bleeding
• Gastroparesis
• Pancreatic duct leak
• Bile duct leak
• Diabetes
• Malabsorption
• Infection
• Octreotide may be administered in perioperative
period to reduce likelihood of leak.

39. TNM staging
• Tis : In situ carcinoma and
Pancreatic Intraepithelial
Neoplasm (PaIN)
• T1 : Growth limited to pancreas
T1a <2 cm, T1b > 2 cm
• T2 Extension occurs to
duodenum, bile duct,
peripancreatic tissue
• T3 Extension to stomach, spleen,
colon and large vessels
• N0 No lymph node
• N1 +ve lymph node
• M0 - No metastases
• M1 - +ve metastases

40. Adjuvant therapy
• In a large multicentre
European study, adjuvant
radiotherapy or
chemoradiotherapy showed
no advantages
• Chemotherapy with 5-
fluorouracil provided overall
benefit
• Combination of gemcitabine
and 5 Flurouracil in
combination are under trial
• Patient with adenocarcinoma
are offered adjuvant
chemotherapy

41. Palliation
• In unresectable tumours
• Locally advanced
• Locally advanced disease in patients with
vascular involvement of less than 50% of
portal vein
• Invasion or encasement of SMA (or hepatic
artery)

42. Palliation of pancreatic
cancer
• Relieve jaundice and treat
biliary sepsis
1. Surgical biliary bypass
2. Stent placed at ERCP or
percutaneous
transhepatic
cholangiography
• Improving gastric
emptying
1. Surgical
gastroenterostomy
2. Duodenal stent

43. Palliation cont.
• Pain relief
1. Stepwise escalation of analgesia
2. Coeliac plexus block
3. Transthoracic splanchicectomy
• Symptoms relief and quality of life
1. Feeding jejunostomy
2. Enzyme replacement
3. Treatment of diabetes
4. Encourage normal activity

44. Feeding jejunostomy
• Indications
• Inability to use the mouth, stomach, or
esophagus for feeding due to dysfunction
• Loss of brain function secondary to head trauma
or cerebrovascular accident.
• Two types:
1. Witzel jejunostomy: site of placing is 30cm from
duodenojejunostomy
2. Needle jejunostomy: using catheter of small size

45. Procedure for Feeding jejunostomy
(Witzel)
• The patient is placed supine on the operating
room table
• Midline incision is made
• Dissection is done through the subcutaneous
tissues using cautery
• The midline between the layers of the rectus
muscle is identified, anterior fascia is incised, the
preperitoneal fat is identified and grasped
• The peritoneum is identified and incised using
thus allowing entry into the abdomen

46. Procedure contd.
• Cautery is used to open the
peritoneal cavity cephalad (toward
the head) and caudally (toward the
feet).An abdominal wall retractor is
placed if needed to increase
exposure.
• The small bowel is traced
proximally (toward the head) until
the ligament of Treitz marking the
juncture between the duodenum
and the jejunum is located.
• Approximately 30 cm is measured
from the ligament of Treitz for
optimal placement of the
enterostomy
• The loop of small bowel where the
entry is to be grasped

47. Procedure contd.
• incision on its antimesenteric
border through the longitudinal
muscle layer for about 8 cm
• At the distal end, a hole through
into the lumen
• Insert a feeding catheter or a long
Ryle's tube, through this hole for
about 10 cm
• Close the gut around it with
continuous catgut, as doing the
Lembert suture of a bowel closure
• Make a second incision in his
abdominal wall above where this
loop of jejunum will comfortably
lie. Draw the end of the tube back
through his abdominal wall

48. Procedure contd.
• Draw jejunum and the interior of
his abdominal wall together with a
purse string suture
• Close his abdomen and anchor the
tube to abdominal wall with stitch,
or with tape
• Advantages of Feeding
jejunostomy:
1. Comfortable
2. Can be kept for long time
3. Easier to do

49. Reference
• Bailey and love’s Short Practice of Surgery 25th
edition
• SRB’s manual of surgery 3rd edition
• A manual of Clinical Surgery, S.Das 8th edition.

50. Thank you
Have a nice day