THE PANCREAS
| PANCREATIC PSEUDOCYSTS —Alice C. Wei, MD, Assistant Professor of Surgery, University Health Network, University
of Toronto Faculty of Medicine
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| Case of Mr B: man, 64 yr of age, heavy drinker; presented to emergency department with left flank pain of 3 wk duration
and elevated serum amylase; first computed tomography (CT) image showed acute fluid collection; treated with observation
and pain control; follow-up at 8 wk showed flank pain persisting; repeat imaging showed some resolution and
pseudocyst in lesser sac; what to do with pseudocyst?
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| Pancreatic pseudocyst: cystic cavity bound by wall of granulation tissue; no true epithelium; can be called pseudocyst
only if occurs >4 wk after episode of inciting pancreatitis; nomenclature confusing with many terms used (eg, infected
abscesses), making treatment plan difficult; in 1993, Atlanta classification provided nomenclature
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| Acute fluid collections: occur early in pancreatitis; present at <4 wk after inciting pancreatitis; characterized by absence
of wall of inflammatory tissue; confusion arises with acute pseudocyst and chronic pseudocyst; nothing to do with
age of pseudocyst but type of inciting pancreatitis; acute pseudocysts result of acute pancreatitis or trauma (chronic
pseudocysts result from chronic pancreatitis); pancreatic abscess is collection of peripancreatic pus not associated with
(pancreatic) necrosis
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| Epidemiology of pseudocysts: complication of pancreatitis; associated more with alcoholic pancreatitis than biliary
pancreatitis (occasionally with trauma)
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| Incidence of pseudocysts: related to tracking; finding more due to cross-sectional imaging; 50% seen after acute pancreatitis;
studies suggest 8% to 87% disappear; incidence depends on severity of antecedent pancreatitis
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| Signs and symptoms: many present asymptomatically; if symptoms present, usually pain, nausea, vomiting, early satiety,
and weight loss; abdominal tenderness; up to 50% of patients have palpable mass on examination; some have fever,
jaundice, and occasionally ascites
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| Investigation: take good history and determine whether antecedent pancreatitis present; on physical examination, look
for evidence of chronic physical disease or alcohol use; serum amylase occasionally moderately elevated (neither specific
nor sensitive); mainstay is imaging (CT, magnetic resonance imaging [MRI], endoscopic ultrasonography [US], and endoscopic
retrograde cholangiopancreatography [ERCP])
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| Complications: occasionally life-threatening; hemorrhage into pseudocyst; very rarely, free hemorrhage; secondary infection;
gastrointestinal (GI) obstruction; left-sided portal hypertension; splenic artery or splenic vein thrombosis; very occasionally
rupture to cause pancreatic ascites or fistula
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| Treatment options: 1) observation, 2) percutaneous drainage, 3) endoscopic drainage, and 4) surgical drainage; observation
good for asymptomatic pseudocysts, especially small asymptomatic pseudocysts; 10-cm cyst considered “larger”;
15% to 30% of patients eventually come to surgery, primarily for pain; small risk for cystic neoplasm, so reach diagnosis
comfortably and obtain good history
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| Percutaneous drainage: initially met with much enthusiasm, but most studies focus on technical success rather than
short- or long-term success; high recurrence rate; high complication rate (64%); has role in patient with infected
pseudocyst and patient with high operative risk; not good choice for definitive treatment of pseudocyst
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| Endoscopic drainage: efficacy reported as 80% to 90%, but this refers only to technical side and initial success; slightly
higher long-term success rate of 75%; recurrence rate 15% to 25%; transpapillary or ERCP pancreatic stent useful for patient
with documented duct disruption; complications and stent blockage possible; requires interested and experienced endoscopist
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| Surgical drainage: gold standard; success rate 88% to 92%; low morbidity; surgical approach guided by location of cyst;
good approximation between cyst wall and back wall of stomach; sometimes need to bring loop of jejunostomy out and use
Roux-en-Y approach; allows for concomitant cholecystectomy
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| Study: national inpatient sample (20% of American population) of 27,000 patients admitted with pseudocysts between 1997
and 2001; ≈50% treated (50% drainage; 50% surgery); surgery found superior, with lower morbidity and mortality (2.8% in
surgical patients vs almost 6% in those treated percutaneously)
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| Approach for peripancreatic fluid: determine early or late; <4 wk considered “acute fluid collection”; if asymptomatic,
observe; presence of symptoms indication for percutaneous drain; for diagnosed pseudocysts with no symptoms, observe;
liberal approach watches pseudocysts up to 10 cm; observe for regression with CT; if no regression, consider
surgery; obtain good history; do not delay acting on large tumor; if symptoms present, move directly to surgery due to recurrence
and complication rate; if patient not surgical candidate, try percutaneous or endoscopic drainage; realize significant
proportion will fail and require surgery, but goal to stabilize until ready for surgery
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| PALLIATION FOR UNRESECTABLE PANCREATIC TUMORS —Richard Bold, MD, Associate Professor, Division of
Surgical Oncology, University of California, Davis, School of Medicine
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| Palliation: involves prevention and reduction of symptoms; pancreatic cancer symptoms include biliary obstruction and
duodenal obstruction when tumor in head of gland; pain another symptom and significant disease component
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| Presentation: 3 aspects of palliation depend on how patient presents; whether metastatic disease present and whether unresectable
at laparoscopy or unresectable at laparotomy
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| Metastatic disease: mean survival <6 mo; palliation should have minimal side effects and complications so as not to detract
from patient’s remaining days
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| Biliary obstruction: endoscopic metal stenting has patency time (6 to 9 mo) usually longer than patient’s remaining
life; low complication rate (now preferred technique for patient who presents with metastatic disease); if patient presents
first with jaundice, metal stent first step (provides good palliation during remaining life)
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| Duodenal obstruction: patients usually have shorter remaining life (3 mo); tumor of such size recognized as premorbid
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| Endoscopic stenting: moved from experimental to “option”; alternative to gastrojejunostomy, which can involve up to
2-wk hospitalization and complication rate of 20%; patients have short survival anyway
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| Alcohol celiac plexus block: highly effective supplement to oral narcotics; improves quality of life; improves mood,
and potentially, survival due to increased quality of life; important to realize good palliation can prolong survival
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| Laparoscopy (staging): when metastatic disease with biliary or duodenal obstruction found, options include endoscopic
palliation, laparoscopic palliation, or conversion of laparoscopy to open laparotomy; laparoscopic palliation easy
via cholecystojejunostomy, but not durable palliation; choledochojejunostomy better palliation but technically not viable,
despite reports; speaker prefers to observe and rely on postoperative endoscopic biliary stenting to palliate biliary obstruction;
duodenal obstruction rare
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| Laparotomy: when tumor unresectable, plan on postoperative endoscopic stent for biliary obstruction; perform immediate
biliary decompressive operation (choledochojejunostomy) or close and ask endoscopist to do stent later; must contact endoscopist
right away (speaker’s study found that within 2 mo, complications seen in 20% of waiting patients)
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| Cholecystojejunostomy vs choledochojejunostomy: latter better than former because recurrent biliary problems
likely related to tumor growth into biliary tree; Surveillance Epidemiology and End Results Trial (SEER) data (1919 patients)
showed mean survival of 4 mo with cholecystojejunostomy, but almost 2 mo longer with choledochojejunostomy;
palliative, not therapeutic; also allows cytotoxic therapy
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| Duodenal obstruction: can wait and see because most patients do not develop; manage with stent or operate later
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| Prophylactic gastrojejunostomy: if nothing done, patients still have significant morbidity from laparotomy; in Johns
Hopkins study, survival no different in patients who did not get prophylactic surgery; 20% developed duodenal obstruction,
not immediately but ≈5 mo after staging (keep in mind mean survival only 6 mo)
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| Summary: consider celiac plexus block in all patients; if unresectable disease discovered on laparoscopy, stop and palliate
endoscopically later; if discovered on laparotomy, do choledochojejunostomy; consider gastrojejunostomy in selected
patients with large locally advanced tumors and no evidence of metastatic disease
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| ENDOCRINE TUMORS OF THE PANCREAS— Russell G. Postier, MD, Professor and Chair, Department of Surgery,
University of Oklahoma College of Medicine, Oklahoma City
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| Tumors: now described as endocrine (rather than neuroendocrine) tumors of pancreas; in 1960s, 2 theories of tumor origins,
1) neural crest theory that all cells had amine precursor uptake and decarboxylation capacity, and 2) tumors from
central acinar cells or ductal cells; now appears clear tumors originate in ductal and acinar cells; tumors clinically rare (5-
10 cases per million per year)
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| Multiple endocrine neoplasia (MEN) syndrome: MEN-1 includes parathyroid hyperplasia, pituitary tumors, as
well as endocrine tumors of pancreas; many of these nonfunctional tumors, meaning they stain for some pancreatic hormones
but functional only if associated with clinical syndrome
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| Malignancy potential: extremely variable; insulinomas rarely malignant (≈10%), whereas glucagonomas and somatostatinomas
almost always malignant; nonfunctional tumors somewhere in between; difficult to explain to patients, especially
given variable behavior of nonfunctional tumors (most common)
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| Presentation: variable; if tumor secretes significant hormone, then classified by dominant hormone; many secrete >1
hormone; many have no endocrine symptoms (nonfunctional)
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| Location: variable; 2 to 3 can occur outside pancreas with no pancreatic involvement; insulinomas and glucagonomas arise
in pancreas; gastrinomas arise in gastrinoma triangle, sometimes in duodenum; somatostatinomas in pancreas or proximal
small bowel; vasoactive intestinal peptide tumors (VIPomas) not only in pancreas but also in thorax, without pancreatic involvement
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| Diagnosis: based on hormone-related symptoms or result of biliary or pancreatic duct obstruction or as incidental CT
finding; speaker also notes seeing increasing number of tumors on CT brought in by asymptomatic patients; in general,
endoscopic US most sensitive, but many tumors large and seen on CT; endoscopic US not always available
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| Treatment: insulinomas usually benign and solitary; adequately treated with simple enucleation; small number of multiple
growths best treated with partial pancreatectomy; no specific location in pancreas; occasionally need to do Whipple resection;
in few cases of malignant tumors, curative resection indicated; but most cases of patients with endocrine tumors benefit
from surgical debulking which specialists perform frequently; results in significant symptom-free survival but not curative
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| Zollinger-Ellison (ZE) syndrome: patients presenting earlier; starting to reconsider role of surgery; exception MEN-1
because tumors usually multiple; perform Whipple resection for tumor in head of pancreas, then use standard procedure that
takes pylorus
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| Medical therapy: nothing effective available; for insulinomas, diazoxide (Hyperstat IV, Proglycem), octreotide (Sandostatin),
and streptozocin (Zanosar); for ZE syndrome, proton pump inhibitors; for VIPomas, long-term octreotide
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| Prognosis: overall malignancy rates >60% with exception of insulinomas (mostly benign); resection with debulking provides
best chance of survival; 5-yr survival commonly seen, even with metastatic disease; treat gastric acid secretion in ZE syndrome
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| SURGERY IN ACUTE PANCREATITIS —Dr. Postier
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| Epidemiology: likelihood of developing pancreatitis depends on social customs (regional ethanol consumption and gallstone
prevalence) of group; in Britain, high incidence of acute pancreatitis and condition well studied
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| Pathophysiology: gallstone pancreatitis occurs due to passage of stone; edema of distal pancreatic duct coupled with
high-fat meal causes hypersecretion (results in pancreatitis)
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| Assess severity: important to predict likelihood of complication; number of ways to do so; Ranson’s criteria; need 5 criteria
on admission and 6 in first 48 hr; also can predict mortality using Ranson’s (2 criteria, mortality very low; 7 criteria,
death)
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| Disease characteristics: differ in men and women; in women, predominantly result of gallstones; in men, result of alcohol
consumption; described in unborn fetus; seen commonly in elderly; idiopathic pancreatitis seen with some frequency
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| Complications: shock and respiratory failure (most common cause of death in first 10 days); abscess; necrosis;
pseudocyst
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| Treatment: aggressive surgical therapy early in patient with severe fulminant pancreatitis; speaker advocates therapeutic
peritoneal lavage (developed in mid 1960s by Australian nephrologist who observed improvement of acute pancreatitis in
patients on therapy for renal failure); Ranson’s nonrandomized study showed early deaths reduced in lavage group; no
difference in overall survival rate, but subset of patients lavaged for >5 days showed survival benefit
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| Mortality: infected peripancreatic necrosis most common cause; usually presents in 1 to 3 wk after onset, with same
symptoms of severe pancreatitis; if in doubt, proceed to surgery; no role for percutaneous pigtail catheter drainage
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| Surgery: often >1 surgery required; bilateral subcostal incision makes later surgeries easier; peripancreatic fat usually
present; aggressively resect; key for surgeon to resect enough to prevent (recurrent) sepsis but not cause fatal hemorrhage
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| Nutritional support: important; metabolic response often comparable to that of burn patient; enteral; jejunostomy during
initial resection; give many calories enterally; supplement parenterally
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| Surgery summary: appropriate surgical aggression; try to débride phlegmon; consider fungal infection
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| Sterile pancreatic necrosis: problematic; utilizes resources; patient may be in hospital bed unable to eat; question of surgical
débridement; speaker puts patients on total parenteral nutrition (TPN) and sends home
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| Pseudocyst: avoid surgery unless lesion symptomatic, regardless of size; avoid drainage because of likely infection
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| Conclusion: acute pancreatitis surgical disease where complications targeted for treatment; prolonged convalescence; resource
consumption high; radiologist not always surgeon’s “friend”
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Educational Objectives
| The goal of this program is to educate the listener about pancreatic pseudocysts, palliation in unresectable tumors, endocrine
tumors of the pancreas, and surgical therapy in acute pancreatitis. After hearing and assimilating this program, the clinician
will be better able to:
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 | 1. Discuss the management of pancreatic pseudocysts.
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| 2. Discuss palliation in unresectable pancreatic cancer.
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| 3. List types of endocrine tumors affecting the pancreas and their location.
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| 4. Discuss treatment options for acute pancreatitis.
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| 5. Describe the characteristics of sterile pancreatic necrosis.
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Discussed on This Program
Diazoxide [Hyperstat IV, Proglycem]
Octreotide acetate [Sandostatin]
Streptozocin [Zanosar]
Suggested Reading
Andersson B et al: Treatment and outcome in pancreatic pseudocysts. Scand J Gastroenterol 41:751, 2006; Andtbacka
RH et al: Surgical and endoscopic palliation for pancreatic cancer. Minerva Chir 59:123, 2004; Croce E et
al: Laparoscopic surgery of pancreatic cancer: state of the art. Hepatogastroenterology 52:1889, 2005; Dugernier T
et al: Current surgical management of acute pancreatitis. Acta Chir Belg 106:165, 2006; Goh BP et al: Non-neoplastic
cystic and cystic-like lesions of the pancreas: may mimic pancreatic cystic neoplasms. ANZ J Surg 76:325, 2006;
Haan JM et al: Laparoscopic debridement of recurrent pancreatic abscesses in the hostile abdomen. Am Surg 72:511,
2006; Isaji S et al: JPN Guidelines for the management of acute pancreatitis: surgical management. J Hepatobiliary
Pancreat Surg13:48, 2006; Kahaleh M et al: Endoscopic ultrasound drainage of pancreatic pseudocyst: a prospective
comparison with conventional endoscopic drainage. Endoscopy 38:355, 2006; Kuhlmann KF et al: Surgical palliation
in pancreatic cancer. Minerva Chir 59:137, 2004; Maetani I et al: Comparison of duodenal stent placement with
surgical gastrojejunostomy for palliation in patients with duodenal obstructions caused by pancreaticobiliary malignancies.
Endoscopy 36:73, 2004; Mann O et al: Surgery for advanced and metastatic pancreatic cancer—current state and perspectives.
Anticancer Res 26:681, 2006; Moyshenyat I et al: Antibiotic prophylaxis of pancreatic infection in patients
with necrotizing pancreatitis: rationale, evidence, and recommendations. Curr Gastroenterol Rep 8:121, 2006;
Nealon WH: Non-operative management of pancreatic pseudocysts: there is still a role. Ann Surg 244:162, 2006;
Pitchumoni CS et al: Factors influencing mortality in acute pancreatitis: can we alter them?.. J Clin Gastroenterol
39:798, 2005; Rau B et al: Surgical treatment of necrotizing pancreatitis by necrosectomy and closed lavage: changing
patient characteristics and outcome in a 19-year, single-center series. Surgery 138:28, 2005; Thomson BN et al: Palliation
of pancreatic neoplasms. Minerva Chir 59:113, 2004
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 faculty
reported nothing to disclose.
Dr. Wei spoke at the Update in General Surgery 2006, held April 20-22, 2006, in Toronto. Drs. Bold and Postier
spoke at the General Surgery Meeting 2005, held September 16-17, 2005, in Napa, CA. The Audio-Digest Foundation
thanks the speakers and the sponsors for their cooperation in the production of this program.
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