Pancreatic Disease - a surgical dilemma - Forum

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Paranoid

Pancreatic Disease - a surgical dilemma - Ärzteforum

Post#1 »

64 yrs old female experienced dark urine and some back pain 3 weeks previously. Liver panel consistent with obstructive jaundice with a Total Birirubin of 5.0. A CAT scan and ERCP had been done previous to my seeing the patient. CAT scan - enlarged pancreas with possible mass lesion 3-4 cm head of pancreas. CBD and intrahepatic ducts dilated. GB markedly distended. ERCP - CBD and pancreatic duct dilated - no evidence of stone & probable mass in head of pancreas. Amylase was normal on two occasions. No history of alcohol or tobacco and no serious medical problems. No weight loss but poor appetite. When I saw the patient the back pain had completely subsided.

At surgery the GB was markedly distended and CBD 3-4 x's normal size. The head of the pancreas was enlarged and very firm and nodular but this same process extended thruout the entire pancreas but to a lesser degree as the tail of pancreas was approached. A site in head of pancreas was selected and open biopsy performed - path report "chronic pancreatitis." A TrueCut needle was then used and a second biopsy performed in a different location head of pancreas. Path report "Chronic pancreatitis." A Kocher maneuver was then performed and a third site in the head of the pancreas was selected and TrueCut needle biopsy performed. Path report "Chronic pancreatitis."

Now the dilemma, what would you do? Some additional information to assist - unable to find any enlarged lymph nodes. Reminder of exploration quite normal. This disease in the pancreas did involve the anterior surface of the portal vein and would have been a very difficult dissection (if you so chose) and possibly not technically feasible.


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Surgeon

Re: Pancreatic Disease - a surgical dilemma - Ärzteforum

Post#2 »

If your clinical findings were compatible with carcinoma of the head of the pancreas (and it sounds to me like they were) without obvious mets outside the pancreas, I would have proceeded to establish whether this was resectable. (Actually, last I read, it was still recommended to assess the vasculature pre-op especially to be sure the superior mesenteric artery does not have an anomalous origin but also to assess resectability.)

If, as you surmise this process was not resectable, then I would have done a cholecystectomy, palliative choledochojejunostomy and considered gastrojejunostomy. I would tell the patient and family that the biopsies were negative, but that biopsies could be negative in pancreatic cancer and back this up with print-outs from surgery texts and or Medline (because they would never believe me about this without proof).

If this was resectable, I suspect she needs Whipple plus distal pancreatectomy, but here I defer to the real experts.

Jorjo

Re: Pancreatic Disease - a surgical dilemma - Ärzteforum

Post#3 »

As Dr Kenneth Warren said once, and I think the concept continues to be valid, that patient of yours has a pancreatic cancer and must be treated as such a condition requires...A pancreaticoduodenal resection, if possible, or a double derivation to paliate the disease if not.

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الجراح

Re: Pancreatic Disease - a surgical dilemma - Ärzteforum

Post#4 »

This chronic pancreatitis-carcinoma dilemma is well known,and it is estimated that in 15% of cases of pancreatic head masses it will be impossible to distinguish between them neither pre-operatively or intra-operatively. CA19-9 tumor marker may be of help pre-operatively.

Your case is stage I (T1b,N0,M0) and have a good chance of cure,in this setting Whipple is indicated even if it turned to be chronic pancretitis. Palliative measures may rob this patients chance for cure.

canadian

Re: Pancreatic Disease - a surgical dilemma - Ärzteforum

Post#5 »

This case is almost an exact copy of a scenario that was given on the oral boards for many years. The bottom line is that you have to treat this as a pancreatic carcinoma regardless of the biopsy findings. When I took my boards the examiner was nice enough to say the second biopsy was positive; I would have done a Whipple anyway. The real question then becomes "is this resectable"? You have not described any liver, peritoneal or lymph node mets. The question becomes clearence off of the portal vein, or replacement of the portal vein if you believe in it. If it is resectable you would have to consider a total pancreatectomy because of the diffuse process in the pancreas. If the mass/tumor is not resectable you should do a biliary bypass of your choice with or without a gastro-jejunostomy depending upon your bias.

Poland

Re: Pancreatic Disease - a surgical dilemma - Ärzteforum

Post#6 »

I agree with the other respondents that this patient needs a pancreaticoduodenectomy - i would not even do intraoperative biopsy because it will not change what i do. Positive or negative i would resect if resectable. Even if it turns out to be chronic pancreatitis (which in this age group without predisposing factors is less likely) a pancreaticoduodenctomy is not inappropriate in the setting of biliary obstruction.

I do, however, get a frozen section of the pancreatic duct margin. Converting a whipple to a total pancreatectomy is a major issue for the patient in the long-term (specifically diabetes). It is not uncommon to see pancreatitis associated with a pancreatic head carcinoma.

The comment about whether you "believe in portal vein resection" is interesting. I think there is enough data now showing no difference in survival with or without portal vein resection. Therefore...since the survival is clearly better with resection than without...resect if resectable. If that means PV resection is necessary to have clear margins and the patient can tolerate the extended procedure then resect the portal vein. One other thought, sometimes "PV involvement" is really due to associated pancreatitis or inflammation from the stents and can be hard to differentiate.

Paranoid

Re: Pancreatic Disease - a surgical dilemma - Ärzteforum

Post#7 »

Thank you for the responses to the pancreatic dilemma. This patient almost certainly has CA of pancreas and should have a Pancreaticoduodenectomy if possible. After about 45 minutes of dissection I concluded this was not a resectable lesion without resection of the portal vein. This I was not prepared to do without a tissue diagnosis especially since the 5 year cure rate is usually 10 % or less and the operative mortality is about 5 %. A Roux-en-Y choleccystojejunostomy was performed. There was no evidence of impending obstruction of the duodenum and gastric bypass was not performed.

During the past 8-10 years I have dealt with this problem on several occasions and wish to share my outcomes and experience. In the past 6 mos two pancreaticoduodenectomy's have been done at the same hospital as this patient and both had CA pancreas on the final pathology report. One had metastatic lymph node involvement and one did not. Both done by surgeons other than myself.

I have been confronted with this same problem on several occasions in the past 10 years. In four cases the lesion was obviously not resectable and the patients were not alive 18 mos later. In three cases the lesion was resectable and in all three cases the diagnosis was CA pancreas on final pathology report. Two patients were deceased in less than 18 mos and one lived almost 36 mos and died of metastasis to the liver.

Three cases are very interesting:

Case # 1 a 55 year old female with a very large firm lesion at surgery and biopsy X 3 pancreatitis. Not resectable and patient and family informed that prognosis very poor and most likely malignant tumor. 5 yrs later patient was seen for abdominal pain and US of GB positive for stones and open cholecystectomy performed (mostly because of previous problem) and the pancreas was normal. She is still alive and doing well. Originally the amylase was normal.

Case # 2 was a 74 year old female with abdominal and back pain and Liver Panel consistent with obstructive jaundice. CAT scan and ERCP both highly suggestive of pancreatic tumor. Laporotomy findings a very firm mass in the head of the pancreas and biopsy X 2 negative for tumor. This lesion just did not seem malignant at the time and although the lesion was resectable I decided against same. Family and patient were told this probably malignant but without tissue diagnosis I was not prepared to do a major operation. Cholecystojejunostomy performed. Two years later I received a letter from an attorney suggesting I contact my insurance company for consideration for compensation for patient and family stress due to the fact that I said she would be "dead in less than 2 years" At that time she was apparently well and feeling "good". I have no additional follow up. No money was paid.

Case # 3 was a 60 yrs old female who was admitted to hospital for fever. Extensive investigation was done and after several consultations and multiple studies patient was found to have blood culture + for Staph Aureus on two occasions and a CAT scan which revealed a very large paraspinal abscess in the right reteroperitoneal area. I drained the abscess and the culture was Staph Aureus. ID specialist was involved and 6 weeks of IV antibiotics recommended. On the original CAT scan a mass in the body of the pancreas was described suggestive of tumor. When the 6 week ABX RX was finished a repeat CAT scan was performed and again a mass was described in body of pancreas. Liver panel was normal and tumor markers were normal. Laporotomy was performed and findings were absolutely normal. Biopsy X 2 performed in body of pancreas and both reported as "normal pancreas." Patient discharged 4 days post op.

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Billroth

Re: Pancreatic Disease - a surgical dilemma - Ärzteforum

Post#8 »

Cure is uncommon in pancreatic cancer and surgical resection,even when deemed"curative",will only result in an overall five-year survival of 10-20%,and a median survival of about 11-18 months. However,resection offers the only chance of cure in this disease,however small that may be,and prolongs the short-term survival. In non-operated patients,even with other palliative measures such as chemo-radiotherapy,two-years survival is uncommon while following surgical resection,25-40% of patients will live for two years.

It is the general consensus that mortality rates over 5% are excessive. In specialist units the mortality figures are now in the region of 2% or less and large series of patients undergoing resection without any operative deaths have been reported.

Surgical resection,although only feasible in a small proportion of patients with pancreatic cancer,provides the only chance of cure,the best palliation and maximum prolongation of life in this disease. It also allows maximum benefit from chemo-radiotherapy. Resection can now be performed safely in specialist units. Thus,every patient with pancreatic cancer,except those who are very ill or with disseminated disease at presentation,should be assessed by a specialist pancreatic surgeon. Physiological state rather than chronological age should be considered when assessing fitness for surgery. Palliative resection,although it does not prolong survival,gives good quality of life and may be considered in specialist units as an alternative to surgical bypass and endoscopic stenting in low-risk patients.

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Although isolated portal vein involvement has classically been a contraindication for resection,portal vein resection can be performed safely with a low perioperative mortality rate. Importantly,overall survival is similar between patients undergoing pancreatectomy with portal vein resection and those undergoing standard pancreatic resection. Suspected isolated portal vein involvement,therefore,frequently does not preclude operability and,by itself,should not be a contraindication for pancreatic resection.

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Your case is stage I [T1b,N0,M0] if portal vein is not involved i.e. best chance for cure,stageII [T3,NO,MO]if portal vein is involved i.e. resection will give her the best chance for palliation.

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