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GS52 General Surgery and Thoracic Surgery Pancreas Toronto Notes 2019
Total Pancreatectomy and Islet Autotransplantation: A Decade Nationwide Analysis
World J Transplant 2016 Mar 24; 6(1): 233–238 Aim: To investigate outcomes and predictors
of in-hospital morbidity and mortality after total pancreatectomy (TP) and islet autotransplantation. Results: We evaluated a total of 923 patients
who underwent IAT after pancreatectomy during 2002-2012. The most common indication of surgery was chronic pancreatitis (86%) followed by acute pancreatitis (12%). Overall mortality and morbidity of patients were 0% and 57.8 %, respectively. Post-surgical hypoinsulinemia was reported in 42.3% of patients, indicating that 57.7% of patients were insulin independent during hospitalization. Predictors of in-hospital morbidity were obesity, fluid and electrolyte disorders, alcohol abuse, and weight loss.
Conclusion: Total pancreatectomy + islet autotransplantation is a safe procedure with no mortality, acceptable morbidity, and achieved high rate of early insulin independence. Obesity is the most significant predictor of in-hospital morbidity.
Trousseau’s Sign
Spontaneous peripheral venous thrombosis, often associated with pancreatic and other cancers
Vague abdominal pain with weight loss ± jaundice in a patient over 50 yr is pancreatic cancer until proven otherwise
Courvoisier’s Sign
Palpable, nontender distended gallbladder due to CBD obstruction. Present in 33% of patients with pancreatic carcinoma. The distended gallbladder could not be due to acute cholecystitis or stone disease because the gallbladder would actually be scarred and smaller, not larger
• surgicaloptions
■ drainage procedures: only effective if ductal system is dilated
• Puestowprocedure(lateralpancreaticojejunostomy):improvespainin80%ofpatients ■ pancreatectomy: best option in absence of dilated duct
• proximaldisease:Whippleprocedure(pancreaticoduodenectomy)–painreliefin80% • distaldisease:distalpancreatectomy±Roux-en-Ypancreaticojejunostomy
• totalpancreatectomy:refractorydisease
• isletcellsautotransplantationcanbeusedtocontrolinsulin-relatedmorbidity
■ denervation of celiac ganglion and splanchnic nerves
WALLED-OFF PANCREATIC FLUID COLLECTIONS (PSEUDOCYST)
• localizedfluidcollectionsrichinpancreaticenzymes,withanon-epithelializedwallconsistingof fibrous and granulation tissue
• complicationofchronicand/oracutepancreatitis
• upto40%resolvespontaneously
• cyst wall must be mature prior to drainage (4-6 wk)
• pseudoaneurysm an absolute contraindication to endoscopic drainage, must embolize first
Treatment
• ifasymptomatic:expectantmanagement
• ifsymptomatic:choiceofdrainageproceduredependsonlocationoffluidcollection
■ endoscopic drainage: transmural vs. transpapillary
■ surgical drainage: cystogastrostomy vs. cystoduodenostomy vs. cystojejunostomy ■ percutaneous catheter drainage
■ resection
■ consider biopsy of cyst wall to rule out cystadenocarcinoma
Pancreatic Cancer
Epidemiology
• fourthmostcommoncauseofcancer-relatedmortalityinbothmenandwomeninCanada • M:F=1.3:1,averageage:50-70yr
Risk Factors
• increasedage
• smoking:2-5xincreasedrisk,mostclearlyestablishedriskfactor • highfat/lowfibrediets
• heavyalcoholuse
• obesity
• DM,chronicpancreatitis
• partialgastrectomy
• cholecystectomy
• chemicals: betanaphthylamine, benzidine
• Africandescent
Clinical Features
• headofthepancreas(70%)
■ weight loss, obstructive jaundice, steatorrhea, and vague constant mid-epigastric pain (often worse
at night, may radiate to back)
■ painless jaundice, pruritis, dark urine, pale stools, and Courvoisier’s sign
• bodyortailofpancreas(30%)
■ tends to present later and usually inoperable (80% are unresectable at diagnosis) ■ weight loss, vague mid-epigastric pain
■ <10%jaundiced
■ sudden onset DM
Investigations
• serumchemistryisnon-specific,canhaveelevatedALPandhighbilirubin • CA19-9(mostusefulserummarkerofpancreaticcancer)
• U/S,CT(alsoevaluatesmetastasisandresectability)±ERCP,MRI,EUS
Pathology
• ductaladenocarcinoma:mostcommontype(75-80%);exocrinepancreas
• intraductalpapillarymucinousneoplasm(IPMN)
• other:pancreaticneuroendocrinetumours(non-functional,insulinoma,gastrinoma,VIPoma,
glucagonoma, somatostatinoma), mucinous cystic neoplasm (MCN), acinar cell carcinoma • seeSurgicalEndocrinology,GS60forfunctionalpancreaticneuroendocrinetumours
Treatment
• resectable(10-20%ofpancreaticcancer)
■ no involvement of liver, peritoneum, or vasculature (hepatic artery, SMA, SMV, portal vein, IVC,
aorta), no distant metastasis
■ Whipple procedure (pancreaticoduodenectomy) for cure <5% mortality