B55. Symptomatology and surgical management of pancreatic tumors.

Page created on October 4, 2021. Last updated on October 19, 2021 at 21:14

Introduction

For introduction, etiology, and pathology, see the corresponding pathology 2 topic. For palliative surgery, see topic B47.

Clinical features

Pancreatic cancer generally causes symptoms late, which contributes to the poor prognosis. Tumours in the pancreatic head cause symptoms earlier than tumours in the body or tail.

When symptoms do occur, jaundice, weight loss, anorexia, abdominal pain, vomiting, and constitutional symptoms may occur. Delayed gastric emptying occurs in up to 60% of people with pancreatic cancer and may contribute to the symptoms of anorexia and vomiting. Obstruction of the biliary tract is what leads to jaundice.

Courvoisier sign may be present. It refers to an enlarged, nontender gallbladder with painless jaundice. This contrasts with cholelithiasis, in which the gallbladder is tender.

Trousseau syndrome may also be present. It refers to a migratory, superficial thrombophlebitis.

Diagnosis and evaluation

Abdominal ultrasound is often the first investigation used in patients presenting with jaundice or epigastric pain. US is highly sensitive for pancreatic masses.

Contrast CT or MRI shows the mass and whether it’s resectable or not. It will also show any distant metastases.

The tumour marker CA 19-9 may be elevated; if it is, it may be used for follow-up. Liver enzymes may be elevated if cholestasis has occurred.

The diagnosis requires histological confirmation, which is acquired by biopsy in most cases. However, if the suspicion is high and the mass appears to be resectable, the patient may skip biopsy and proceeds directly to surgery, where the diagnosis is made by intraoperative frozen sections.

Treatment

Even with curative treatment, the survival rate of pancreatic cancer is poor. The 5-year survival after radical surgery + adjuvant oncological therapy is only 15 – 40%. The median survival is only 18 months.

There are two options for surgical treatment of pancreatic head tumours, conventional pancreaticoduodenctomy (Whipple procedure), and pylorus-preserving pancreaticoduodenectomy. See also topic B35. Both should be combined with regional lymphadenectomy.

For resectable tumours in the body or tail of the pancreas, an extended distal pancreatectomy is performed, usually with splenectomy.

Adjuvant chemotherapy is frequently used, usually with gemcitabine or 5-FU, combined with erlotinib.

Prognosis

About 85% of cases are irresectable due to being metastatic or locally advanced.


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B54. Surgery for chronic pancreatitis.

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B56. Morbid obesity, and bariatric surgery

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Surgery – Traumatology

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