Pancreatic Resection

Published on 11/04/2015 by admin

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Last modified 11/04/2015

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CHAPTER 14 Pancreatic Resection

INDICATIONS FOR PANCREATIC RESECTION

Malignancies of the periampullary region are the most common indication for pancreaticoduodenectomy. These include primary pancreatic head and neck malignancies, distal common bile duct lesions, cancer of the ampulla of Vater, and periampullary duodenal cancers. Lesions localized to the body and tail of the pancreas (to the left of the mesenteric vessels) can be treated with distal pancreatectomy.

I. Pancreatic Adenocarcinoma: Surgical resection remains the only potentially curative therapy for adenocarcinoma of the pancreas. Pancreaticoduodenectomy is indicated for tumors of the pancreatic head, whereas body and tail lesions are treated with distal pancreatectomy and splenectomy. Because of the aggressive nature of most pancreatic tumors, most are diagnosed at an advanced stage and only 20% of lesions are resectable at the time of diagnosis. Locally advanced cancers are deemed unresectable if they extend beyond the pancreatic parenchyma and invade or encase adjacent vascular structures (e.g., the mesenteric vessels or portal vein). Patients with locally advanced tumors may be candidates for neoadjuvant therapy consisting of chemotherapy and radiation. Resection in this patient population is sometimes possible after treatment if tumor characteristics are favorable on repeat imaging studies. Patients with metastatic disease receive no survival benefit from pancreaticoduodenectomy, but may be offered palliative therapies. Nonsurgical palliative interventions include biliary stenting, chemotherapy, radiation, and chemical neurolysis of the celiac plexus. Surgical palliation, including Roux-en-Y hepaticojejunostomy or choledocojejunostomy to relieve biliary obstruction and gastrojejunostomy to relieve duodenal obstruction, are often performed simultaneously (i.e., double bypass) when metastatic disease is discovered at the time of surgical exploration. In patients with pancreatic cancer, the median survival time after resection with curative intent is 16 to 24 months. Patients with metastatic disease fare much worse, with a median survival of less than 6 months.

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