TOPICS IN PANCREATIC SURGERY
| ACUTE PANCREATITIS —Howard A. Reber, MD, Professor of Surgery, Director of Pancreatic Cancer Program,
David Geffen School of Medicine at the University of California, Los Angeles
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| Disease severity: edematous pancreatitis—mild form of disease; occurs in 90% of patients; necrotizing
pancreatitis—more serious; occurs in 10% of patients; more likely to require surgery; mortality rate 15% to 25%;
mortality rate higher when infection supervenes; significant complication rate
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| Necrotizing pancreatitis: mortality usually results from systemic effects of cytokine release; cytokines affect pancreas,
lungs, microcirculation, and liver; liver responds by releasing more cytokines, which travel directly to lungs
and cardiac circulation
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| Contrast-enhanced computed tomography (CT): best diagnostic tool; speaker does not scan all patients with
acute pancreatitis; speaker scans patients who have bad prognostic signs, have hemodynamic instability and large
fluid requirements, are not improving after 2 or 3 days of conservative treatment, or exhibit abnormal disease
course; goals—reveal fluid collections, which correlate to prognosis; show presence of extrapancreatic extension
of inflammatory processes; show evidence of pancreatic necrosis; rationale—normal pancreas enhanced when
perfused with intravenous contrast; necrotic tissue not enhanced because not being perfused with blood; however,
does not indicate whether tissue infected; implications of scan results—even if clinical evaluation does not suggest
infection, speaker requests percutaneous fine-needle aspiration (FNA) of necrotic tissue or adjacent fluid if significant
necrosis present; Gram stain or culture that shows organisms proves infection; generally, presence of infection
indication for surgery; gas bubbles on CT indicate infection (aspiration not required)
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| Percutaneous drainage: not recommended by speaker for patients with infected necrosis; necrotic material thick
and particulate, so insertion of large-bore tubes not practical; in speaker’s experience, drainage tubes have not improved
infection, and operation required; pancreatic abscess—patients with infected pancreatic necrosis often said
to have pancreatic abscess; however, true abscess has little or no necrosis and mostly liquid pus without much particulate
material; percutaneous drainage often satisfactory
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| Sterile necrosis: pancreatic necrosis without infection; surgery now believed unnecessary, although issue controversial;
possible indications for surgery—patient deteriorates despite management with medical therapies in intensive
care setting; patient remains stable but does not improve; rationale for surgery—infection may be present but
not proven; even in absence of infection, removal of necrotic debris may remove source of cytokines and, therefore,
source of problem
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| Gallstone pancreatitis: laparoscopic cholecystectomy indicated for patients with mild disease; delay cholecystectomy
in patients with severe disease; allow patients to get over episode of severe acute pancreatitis, discharge from
hospital, then bring patient back after clinically severe attack when, generally, CT shows considerable improvement;
endoscopic sphincterotomy allows gallstone to pass through bile duct and not precipitate another episode of
pancreatitis while patient waiting for cholecystectomy
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| Surgery for infected necrotizing pancreatitis: debride and drain widely; do not remove living pancreatic tissue;
inform patient and family that 10% to 15% of patients require >1 operation; mortality rate 15% to 20%; after
drainage and removal of solid material, speaker inserts large Axiom drains and maintains patients on continuous-irrigation
regimen until exit fluid cleared significantly and clinical course improved
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| Summary: use CT and FNA to confirm severe acute pancreatitis, with possible complication of infection; if infection
present, debride and drain during operation; consider nutritional support in all patients, but feeding jejunostomy
rarely necessary; follow disease course with CT; sterile necrosis generally treated with medical therapies, and
reasonable to follow patients with weekly CT to monitor for infection
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| OPERATIVE MANAGEMENT OF CHRONIC PANCREATITIS —Dr. Reber
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| Pain: most common reason patients referred to surgeon or gastroenterologist; most common symptom; characteristics
vary, eg, can be mild, intermittent, severe, constant
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| Decision to operate: alcoholic patients need to stop consuming alcohol (some patients experience significant pain
relief with cessation); determine whether description of pain manifestation of drug-seeking behavior; operation
should be performed before patient becomes addicted to pain-relieving narcotics; operation indicated if pain interferes
with quality of life, eg, ability to attend school, maintain employment; type of operation affects decision to
operate
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| Choice of operation: choice between drainage or resection operation depends on whether pancreatic duct dilated;
preoperative evaluation—CT indicated for all patients; some patients require magnetic resonance cholangiopancreatography
(MRCP); very few patients require endoscopic retrograde cholangiopancreatography (ERCP);
normal duct diameter—≤5 mm in head; ≤4 mm in body; ≤3 mm in tail
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 | Dilated duct (≥7 mm in body): data suggest pancreaticojejunostomy achieves reasonable success
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| Nondilated duct: requires resection of pancreas; option 1—resect head of gland with standard Whipple or, more
commonly, pylorus-preserving Whipple procedure; option 2—distal pancreatectomy
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| Pancreaticojejunostomy (Puestow procedure): advantages—very safe (operative mortality <1%); short- and
long-term morbidity very low (morbidity that does occur related to underlying disease); no risk for diabetes because
no pancreas removed; 85% to 90% of patients experience prompt pain relief; reasonable operation for alcoholic
patient who has not stopped drinking or patient addicted to narcotics; disadvantages—less likely to provide
permanent pain relief than some other procedures; in some series, ≤50% of patients have recurrent pain at 5 yr; recurrent
pain may indicate pseudocyst or other complication, but usually represents progression of disease
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| Pancreatic resection: removal of head of gland seems to work; often, head represents most diseased area of pancreas;
distal pancreatectomy—reasonable option if head and body not particularly diseased but much disease
present in distal portion; total pancreatectomy—almost never performed for diffuse disease because morbidity and
mortality unacceptably high, and can usually solve problem with Whipple procedure; advantages—operative mortality
higher than Puestow procedure but still low; acceptable short-term morbidity, but clearly higher than Puestow
procedure; prompt pain relief similar to Puestow procedure; pain relief more likely to be permanent;
disadvantages—greater risk for diabetes due to removal of parenchyma that may have functional significance
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| New surgical approaches: trend toward more conservative approach combining advantages of resection (ie, permanence
of pain relief) with those of drainage (ie, lower morbidity and reduced risk for diabetes); new operations
do not remove as much tissue as conventional Whipple procedure, therefore avoiding diabetes, and some
maintain gastrointestinal (GI) continuity
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| Beger’s operation: duodenal-preserving resection with pancreaticojejunostomy (developed by Hans Beger); transect
neck of pancreas as in Whipple procedure, but instead of removing all of head, shell out pancreas and maintain
rim of pancreatic tissue on inner portion of C-loop of duodenum; maintain capsule behind head of pancreas
and bring up Roux-Y limb of jejunum and anastomose to cut edge of pancreas and area exposed by removing
portion of head; technically challenging procedure; data suggest pain relief similar to Whipple procedure; not associated
with diabetes; not widely performed in United States
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| Frey’s operation: pancreaticojejunostomy with coring of head of pancreas (developed by Charles Frey); in patient
with dilated duct and large swollen head of pancreas, ducts lie deep posteriorly; therefore, unrooting duct as in
Puestow procedure probably does not achieve adequate drainage; in Frey’s operation, large amount of pancreatic
tissue removed (coring procedure); neck of pancreas not transected (critical difference between procedures);
technically easier to perform; bring up Roux-Y limb of jejunum and anastomose to cavity created by removal of
tissue; early results suggest pain relief equivalent to other operations and may last longer
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| CURRENT TRENDS IN MANAGEMENT OF CYSTIC AND PAPILLARY NEOPLASMS OF THE
PANCREAS —Mark Sesto, MD, Chair, Department of General and Vascular Surgery, Cleveland Clinic Florida,
Weston
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| Cystic pancreatic neoplasms: not as common as ductal adenocarcinomas; incidence 0.7%; tend to increase in
size over 18 mo; more likely to be malignant in elderly patients
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| Microcystic cystadenomas: also known as glycogen-rich or serous cystadenomas; large multilocular masses;
small cystic cavities filled with clear serous fluid; cut surface very spongy; occasionally, can be macrocystic or
unilocular; usually solitary, but can be multicentered; microscopic appearance—composed of small cysts lined by
flat or cuboidal cells; contain abundant glycogen; papillae absent or inconspicuous; trabeculae between loculus
may show calcifications (occasionally appears as starburst radiating pattern on CT); cystic fluid has low carcinoembryonic
antigen (CEA) or carbohydrate antigen 19-9 (CA 19-9) and very little mucin; prominent vascularization,
which may be visible with arteriography or contrast CT; presentation—patients usually elderly; no sex
predilection; usually discovered incidentally or present as large painful abdominal mass; often located in head of
pancreas; can cause GI or biliary obstruction; cured by excision
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| Cystadenocarcinomas (serous or microcystic): rare; similar microscopically to cystadenomas; can define malignancy
by metastases, nuclear atypia, perineural invasion, vascular invasion, or DNA pattern; after resection, 5-yr
survival 35% to 40%
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| Mucinous cystic neoplasms (MCNs): patients younger and predominantly female; large multilocular (rarely
unilocular) cysts, lined with tall columnar, mucin-producing cells; often form papilla; more commonly found in
body and tail of pancreas; can have calcifications in cyst wall; microscopic appearance—stroma very cellular (often
looks like ovarian stroma); presentation—similar to microcystic adenomas; fluid aspiration—useful for differential
diagnosis; evidenced by tall columnar cells that have exfoliated into cyst cavity and mucin; higher levels of
CEA or CA 19-9; malignancy—tumors often malignant in older patients or patients presenting with symptoms or
large nodules/cysts; after resection of adenoma or minimally invasive cancer, 5-yr survival 100%; after resection of
invasive cancer, 5-yr survival 37%; malignancy defined by invasion of wall by neoplastic glands or frank anaplasia;
speaker recommends excision of all tumors; diagnosis—speaker uses endoscopic ultrasonography (EUS) for
diagnosis and to guide treatment; cyst walls usually irregular
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| Intraductal papillary mucinous neoplasms (IPMNs): World Health Organization definition (1996)—
intraductal mucinous-producing neoplasms that have tall columnar, mucin-containing epithelium with or without
papillary projections; extensively involve main pancreatic ducts or major side branches; lack ovarian stroma;
progression—premalignant lesions; similar progression to adenoma-carcinoma sequence of colorectal cancer or
pancreatic ductal adenocarcinomas, ie, adenoma, to borderline lesion with dysplasia, to frank carcinoma in situ, to
invasive cancer; differentiation—MCNs have ovarian stroma and do not involve main pancreatic duct; invasive
and noninvasive IPMNs can recur after partial pancreatectomy (noninvasive MCNs never recur after resection);
survival—5-yr survival 77%; recurrences attributed to synchronous IPMN missed during resection or metachronous
lesion resolved from widespread neoplastic field defect in pancreatic duct epithelium; after resection of invasive
IPMN, 5-yr survival 43% (better than survival for resected invasive pancreatic duct cancers [15%-25%]);
treatment—after resection of invasive IPMN, any recurrent disease usually at distant sites (not pancreatic remnant),
so removing entire pancreas unlikely to improve survival; in patients with noninvasive IPMN, physiologic
consequences of total pancreatectomy may outweigh risk for recurrence in pancreatic remnant; most recommend
complete resection with microscopic negative margins and close surveillance with CT, MRCP, or EUS with or
without FNA biopsy
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| Treatment: choice of resection operation depends on ability of surgeon and capabilities of institution; adjunctive
chemoradiation does not improve recurrence rate or survival; long-term surveillance indicated
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Educational Objectives
| The goal of this program is to educate the listener on issues in pancreatic surgery. After hearing and assimilating this
program, the clinician will be better able to:
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| 1. Evaluate patients with acute pancreatitis.
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| 2. Treat patients with acute necrotizing pancreatitis.
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| 3. Describe the roles of pancreaticojejunostomy and pancreatic resection in the treatment of chronic pancreatitis.
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| 4. Discuss new surgical approaches to chronic pancreatitis.
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| 5. Review current trends in management of cystic and papillary neoplasms of the pancreas.
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Suggested Reading
Abe H et al: Mixed serous cystadenoma with mucinous cystadenoma of the pancreas. Pancreas 31:98, 2005;
Andersen DK, Topazian MD: Pancreatic head excavation: a variation on the theme of duodenum-preserving
pancreatic head resection. Arch Surg 139:375, 2004; Cheung MT et al: Percutaneous drainage and necrosectomy
in the management of pancreatic necrosis. ANZ J Surg 75:204, 2005; Choi MG et al: High incidence of extrapancreatic
neoplasms in patients with intraductal papillary mucinous neoplasms. Arch Surg 141:51, 2006; Connor S et
al: Surgery in the treatment of acute pancreatitis--minimal access pancreatic necrosectomy. Scand J Surg 94:135,
2005; Heinrich S et al: Evidence-Based Treatment of Acute Pancreatitis: A Look at Established Paradigms. Ann
Surg 243:154, 2006; Kim SG et al: Comparison of epigenetic and genetic alterations in mucinous cystic neoplasm
and serous microcystic adenoma of pancreas. Mod Pathol 16:1086, 2003; Kloppel G: Acute pancreatitis. Semin Diagn
Pathol 21:221, 2004; Lempinen M et al: Clinical value of severity markers in acute pancreatitis. Scand J Surg
94:118, 2005; Leppaniemi A, Kemppainen E: Recent advances in the surgical management of necrotizing pancreatitis.
Curr Opin Crit Care 11:349, 2005; Madura JA et al: Mucin secreting cystic lesions of the pancreas:
treatment by enucleation. Am Surg 70:106, 2004; Malangoni MA, Martin AS: Outcome of severe acute pancreatitis.
Am J Surg 189:273, 2005; Nathens AB et al: Management of the critically ill patient with severe acute pancreatitis.
Crit Care Med 32:2524, 2004; O'Neil SJ, Aranha GV: Lateral pancreaticojejunostomy for chronic
pancreatitis. World J Surg 27:1196, 2003; Pitchumoni CS et al: Factors influencing mortality in acute pancreatitis:
can we alter them? J Clin Gastroenterol 39:798, 2005; Rollins MD, Meyers RL: Frey procedure for surgical management
of chronic pancreatitis in children. J Pediatr Surg 39:817, 2004; Sandrasegaran K et al: Surgery for
chronic pancreatitis: cross-sectional imaging of postoperative anatomy and complications. AJR Am J Roentgenol
184:1118, 2005; Strate T et al: Long-term follow-up of a randomized trial comparing the beger and frey procedures
for patients suffering from chronic pancreatitis. Ann Surg 241:591, 2005; Tanaka M et al: International consensus
guidelines for management of intraductal papillary mucinous neoplasms and mucinous cystic neoplasms of
the pancreas. Pancreatology 6:17, 2005; Werner J et al: Surgery in the treatment of acute pancreatitis--open pancreatic
necrosectomy. Scand J Surg 94:130, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the speakers reported no conflict.
Dr. Reber was recorded March 18, 2005, in San Francisco at the University of California, San Francisco, School of
Medicine’s Postgraduate Course in General Surgery. Dr. Sesto was recorded February 21, 2005, in Coral Gables,
Florida at the Cleveland Clinic Florida’s 4th Annual Surgery of the Foregut Symposium. The Audio-Digest Foundation
thanks the speakers and the sponsors for their cooperation in the production of this program.
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