Surgery of the pancreas

EMBRYOLOGY OF PANCREAS

EMBRYOGENESIS:

Pancreas is formed by fusion of dorsal and ventral segments (7th week)

Origin: endodermal hepatic and ventral mesenteric bud (4th week)

Ductal system: duct of dorsal pancreas – SANTORINI

duct of ventral pancreas – WIRSUNG

Anomalies: agenesis, ectopia, annular pancreas, pancreas divisum

Agenesis: rare, and being associated with multiple anomalies

Ectopic pancreas: 5% of autopsies

Site: stomach, duodenum, small intestine

Symptoms: peptic ulcer (gastrin release), pyloric obstruction (inflammation), haemorrhage

Treatment: local excision

Annular pancreas: Origin: fixation of free end of ventral pancreas --encirclement of duodenum – obstruction

Symptoms: colicky abdominal pain, duodenal ulcer, vomit

Treatment: bypass procedure: gastroenterostomy

Pancreas divisum: Failure of fusion of ductal system

Symptoms: epigastric pain, recurrent pancreatitis

Treatment: pancreatic head resection, sphincteroplasty of minor papilla

ANATOMY

Retroperitoneal organ, 15-20 cm length, 80-90 G weight.

Four parts of pancreas:

head (uncinate process), neck, body, tail

Blood supply:

Pancreato-duodenal arteries, Splenic artery

Mesenteric superior -, Splenic vein, Portal vein

Lymphatic drainage is diffuse, complex (celiac and mesenteric nodes)

PHYSIOLOGY

Pancreas consist of exocrine and endocrine functions.

Endocrine functions: islets of Langerhans (1-2 M): insulin , glucagon, somatostatine

Exocrine functions: acinar cells: enzymes for digestion: amylase, lipase, trypsin etc.

Pancreatic juice: 1-2 l/day, Ph 7.6-8.3, clear, contains water, electrolytes and protein

Laboratory examinations: amylase, lipase, stool elastase, blood glucose, hormones determinations; stimulate pancreatic secretion (effect of secretin, cholelcystokinin)

DIAGNOSTIC EXAMINATIONS

Abdominal X-ray (calcifications, „sentinel loop”)

Sonography, endosonography

CT, MRI, MRCP

Endoscopic retrograde cholangio-pancreatography (ERCP)

Angiography (selective)

PTC, PTD

ACUTE PANCTREATITIS

Definition: Acute pancreatitis is a clinical syndrome of

epigastric pain, associated with fever, tachycardia,

ileus, haemorrhage and shock.

Pancreatitis is a nonbacterial inflammation on the

pancreas.

Base of pathologic manifestations: obstruction and/or

stimulated secretion results in extravasations of

activated pancreatic enzymes and in production of

vasoactive polypeptides. The presence of these

agents accounts for local and systemic

manifestations of the disease.

Pathology of acute pancreatitis

Marseille definition 1984:

mild form: interstitial oedema, focal necrosis

severe form: extensive necrosis, haemorrhage,

suppuration

Atlanta definition 1992:

1. mild and severe acute pancreatitis

2. sterile and infected necrotizing pancreatitis

3. post acute pseudocyst

4. pancreatic abscess

ETIOLOGIES OF ACUTE PANCREATITIS

1. Biliary tract disease (gallstone, common-channel)

2. Alcohol ingestion (1.-2.: cc. 90%)

3. Hyperlipidemy

4. Trauma (external, operative, ERCP, EST)

5. Hypocalcemy

6. Vascular (hypotension, embolism, vasculitis)

7. Pancreatic duct obstruction (tumour, pancreas divisum)

8. Drugs

9. Viral infection

CLINICAL PRESENTATION AND

DIAGNOSIS

No characteristic clinical picture, the symptoms depend on the

severity of the attack.

Symptoms: midepigastric pain, back pain, vomiting,

tachycardia, dyspnoe, fever, jaundice, hypotension, shock

Physical examination: abdominal distension, epigastric

tenderness, discoloration in the flank (Gray-Turner’s sign)

or around the umbilicus (Cullen’s sign)

The base of DIAGNOSIS: anamnesis, clinical presentation,

laboratory determinations, radiographic findings

DIAGNOSIS OF ACUTE PANCREATITIS

Laboratory test:

• Serum, urine amylase

• Serum lipase

• Serum elastase

• WBS

• Serum Ca

• Blood gases

• C-reactive protein (CRP)

• Procalcitonin (PCT)

• Il-6

Radiographic procedures:

• Plain chest X-ray

• Plain abdominal X-ray („sentinel loop”)

• ultrasonography

• Fine needle aspiration (FNA)

• CT

• MRI

• ERCP

DISORDERS ASSOCIATED WITH

HYPERAMYLASAEMIA

Intra-abdominal:

• Biliary tract disease

• Perforated peptic ulcer

• Intestinal obstruction

• Peritonitis

• Acute appendicitis

• Mesenteric infarction

• Ruptured aortic aneurysm

Extra-abdominal:

• Salivary gland disorders

• Renal failure

• Cerebral trauma

• Severe burns

• Myocardial infarction

• Drugs

PROGNOSIS

Nearly 90% of the patients with mild, self-limited illness,

mortality rate is 0-3%. 10 to 15% of the patients develop a

severe from with complications, mortality rate is 35-40%.

Prediction of severity:

• Ranson’s score

• APACHE II score

Ranson's prognostic signs help predict the

prognosis of acute pancreatitis.

Five of Ranson's signs can be documented at admission:

• Age > 55 yr

• Plasma glucose > 200 mg/% (> 11.1 mmol/L)

• Serum LDH > 350 IU/L

• Serum GOT > 250 UL

• WBC count > 16,000/μL

The rest of Ranson's signs are determined within 48 h of admission:

• Hcrt decrease > 10%

• BUN increase > 5 mg/% (> 1.78 mmol/L)

• Serum Ca < 8 mg/% (< 2 mmol/L)

• PaO2 < 60 mm Hg (< 7.98 kPa)

• Base deficit > 4 mEq/L (> 4 mmol/L)

• Estimated fluid sequestration > 6 L

Mortality increases with the number of positive signs: if < 3 signs are positive, the mortality rate is < 5%; if ≥ 3 are positive, mortality is 15 to 20%.

COMPLICATIONS OF ACUTE

PANCREATITIS

Systemic (early)

• Shock

• ARDS

• Renal insufficiency

• Gastrointestinal bleeding

• DIC

• Multiple organ failure (MOF)

Localised (late)

• Infected pancreatic necrosis (IPN)

• Abscesses

• Pseudocyst

• Disruption of pancreatic duct (pancreatic ascites)

• Disruption of arterial pseudoanaurism

TREATMENT

Acute pancreatitis is not a surgical disease, therefore the

immediate treatment is nonoperative (!)

if gallstone are present: ERCP, EST, stone extraction is

indicated, in afraid state laparoscopic cholecystectomy must

be performed.

BASIC THERAPY

1. Relief of pain: iv. procaine, epidural anaesthesia

2. Supportive care: (deficits of circulating blood volume, „internal burn”)

• general fluid resuscitation: plasma, electrolyte solution, dextran

• cardio-respiratory support

• administration of calcium

• nutritional support: TPN, jejunal feeding

• fasting, nasogastric suction, antacid, proton pump antagonist

3. Inhibition of excess cytokine production (pentoxifylline)

4. Antibiotics: prophylaxis in severe form (imipenem)

5. Indication of surgery: uncertainty of clinical diagnosis;progressive clinical status despite adequate therapy

COMPLICATIONS OF NECROTIZING

PANCREATITIS

1. Infected pancreatic necrosis: a serious and life threatening

complication following secondary infection of necrotic

pancreatic, peripancreatic and retroparitoneal tissue.

Source of infection: large bowel, infected bile

Bacteria: enteric bacteria, Candida

Diagnosis: clinical and laboratory manifestation of sepsis,

palpable abdominal mass, sonography (?) CT scan, PCT,

FNA, bacteriological examinations

Treatment: Surgery: débridement, necrosectomy, widespread

continuous washing drainage

supportive therapy

adequate antibiotic

“THERE IS NO GOOD

MEDICINE

AGAINST BAD SURGERY “

J. Goris

COMPLICATIONS OF ACUTE

PANCREATITIS

Systemic (early)

• Shock

• ARDS

• Renal insufficiency

• Gastrointestinal bleeding

• DIC

• Multiple organ failure (MOF)

Localised (late)

• Infected pancreatic necrosis (IPN)

• Abscesses

• Pseudocyst

• Disruption of pancreatic duct (pancreatic ascites)

• Disruption of arterial pseudoanaurism

2. Abscess: localized infection of necrotic pancreas or

retroperitoneal area; or infected pseudocyst

Diagnosis: septic condition, palpable mass

sonography, CT scan

Treatment: adequate drainage (internal, external)

antibiotics

3. Pancreatic ascites: disruption of pancreatic duct or

perforation of pseudocyst

Diagnosis: laboratory examination: high amylase level in the

ascites fluid, increased protein content

ERCP

Treatment: internal drainage (Wirsungo-jejunostomy)

pancreatic resection

4. Rupture of arterial pseudoaneurism: a serious complication

following pancreatic pseudocyst formation

Localization: gastroduodenal, pancreaticoduodenal or splenic

arteries

Symptoms: anaemia, shock, severe pain, haemosaccus

Diagnosis: sonography (Doppler), CT scan, angiography

Treatment: angiographic occlusion, in afroid state internal

drainage or resection

5. Pseudocyst: encapsulated collection of necrotic tissue, old

blood, and secretion from the pancreas (no true capsule!)

Diagnosis: clinical findings, sonography, CT scan

Complications: (depending on the size and location) jaundice,

gastrodoudenal obstruction, rupture, infection,

haemorrhage

Treatment: internal drainage (open abdomen, or laparoscopic

surgery, endoscopic stent implantation)

resection operations

percutaneous aspiration and drainage (?)

CHRONIC PANCREATITIS

Definition: a progressive, obstructive process, with cellular

infiltration, fibrosis, necrosis and calcification with loss of

functioning exocrine and endocrine tissue

Etiology: alcoholism (70%!)

gallstones

hyperlipidemy

idiopathic

Types: 1. obstructive

2. calcificated

3. fibrosis

4. mixed

Clinical findings: chronic abdominal pain, weight loss, steatorrhea (exocrine insufficiency), diabetes mellitus (endocrine insufficiency), duodenal obstruction, jaundice

Diagnosis: evocative testing (ATT, Lund’s test, stool elastase)

glucose tolerance test

sonography, CT scan

ERCP, MRCP

Treatment: avoidance and treatment of etiologic factors (especially alcohol), stent implantation (?)

Surgery: drainage operation: sphincteroplasty, Wirsungo-jejeunostomy, Wirsungo-gastrostomy

resection operation: PPPD, DPPHR, DOPPHR, distal resection, subtotal pancreatectomy (?) and implantation of pancreatic islets

Postoperative supportive therapy: diet, pancreatin, no alkohol (!)

Epidemiology

● Incidence rate: 12-15/100.000/year

● Incidence has tripled in the past 80 years

● Fourth leading cause of cancer death

● Accounts for 6% cancer death

● Increase with age

● Male>female, black>white

Precursors of ductal adenocarcinoma

PanIN: pancreatic intraepithelial neoplasia

• PanIN 1A - flat hyperplasia

• PanIN 1B - ductal papillary hyperplasia

• PanIN 2 - ductal papillary hyperplasia with

atypia

• PanIN 3 - severe dysplasia or in situ carcinoma

IPMT: intraductal papillary mucinous

tumorsBiankin AV et al: Pathology 5: 14-24, 2003

Pancreatic cancer – risk factors

Epidemiologic Associations:

● Diabetes mellitus: 1,5x, 9-year

● Chronic pancreatitis: 15x, 20-year

● Cystic fibrosis

● Hereditary pancreatitis: 50x

● Peutz-Jeghers sy.: 100x

● Familial Atypical Mole-Malignant Melanoma: 15x

● Hereditary breast and ovarian cancer sy.

● HNPCC

● Familial clusters: variable risk

Pathology

94% - adenocarcinoma

95% - ductal cell (ERCP!)

70% - pancreatic head (icterus)

20% - pancreatic body

10% - pancreatic tail

5% - acinar cell

5% - islet cell carcinoma

1% - others (cystadenocc., sarcoma, carcinoid,

lymphoma etc.)

Symptoms

● Non specific, insidious (lack of appetite, weakness)

● In advanced stage (90% inoperable)

● Abdominal pain

● Belt-like

● Eating, supine position worsens

● Jaundice, pruritus, Courvoisier sign

● Weight loss

● Migratory thrombophlebitis

● Nausea, vomiting, early satiety

● Diarrhoea, anorexia, splenomegaly

● IGT, diabetes mellitus

Diagnosis – imaging procedures

1. Detection

2. Staging

3. Confirmation

Non-invasive:

● US

● CT, (MDCT)

● MRI, MRCP

Invasive:

● ERCP, IUS

● EUS

● Laparoscopy

Abdominal CT

„gold standard” in detection and

staging

Contrast-enhanced, helical CT

MDCT 3D reconstruction

ERCP: diagnosis + palliation

● 95 % ductal origin

● Indication:

● obstr. icterus

● neg. CT

● diff. dg. (CP – PC)

● Diagnosis

● brush cytology

● biopsy

● Endotherapy

● plastic stent

● self expandable wallstent

TREATMENT OF CANCER OF

THE PANCREAS

• Explorative laparotomy (laparoscopy!)

• Duodeno-pancreatectomia (Whipple) +

lymph node dissection

• Pylorus preserving pancreatic head resection

+ lymph node dissection

• Distal pancreatic resection + splenectomy

• Total pancreatectomy (?)

• Palliation: choledocho-duodenostomy, -

jejunostomy; GEA

Prognosis

● 5-year survival: 3-5%. Silent killer.

● complete surgical resection – possible in only

15-25% of patients – offers the only potential

for cure

● The prognosis depends on the early diagnosis!

● After curative resection - 5-year survival:

pancreatic head: 10-20%. cc <2 cm: 20%, cc

>2cm: 10%; ampulla Vateri: 40-45%

● Not suitable for surgery – survival: 4-6 months

Pancreatic cancer

Can an earlier diagnosis be made?

Back pain + weight loss → gastroenterologist

Newly diagnosed diabetes (old, non obese) →

abdominal US/CT

Jaundice in pts. over 40 → biliary obstruction

Acute pancreatitis with unknown etiology →

CT/MRCP or ERCP