pancreatic cancer pancreatic cancer & pancreatitis · 6 0.1.2.3.4.5.6.7.8.9 0 g 0 12 24 36 48...

1

Pancreatic Cancer &

Pancreatitis

Janak A. Parikh, MD, MSHS, FACS

Clinical Teaching Faculty

St. John Providence Hospital

January 12, 2018

Pancreatic Cancer

Goals and Objectives

• Review basics

– Epidemiology

– Diagnostic evaluation

– Staging

• Surgical Intervention

• Controversies in pancreatic cancer

Pathologic Distribution of 1423 Pancreatic Cancers

Resected by Pancreaticoduodenectomy

1175

98

90

45

117

5

4

33 3 2

2

5

Ductal adenocarcinoma (83%)

Neuroendocrine carcinoma (7%)

IPMN with invasive cancer (6%)

Adenosquamous carcinoma (1%)

Other pancreatic cancers (3%)

15

Angiosarcoma (0.1%)

Cystadenocarcinoma (0.8%)

Clear cell carcinoma (0.4%)

Anaplastic carcinoma (0.3%)

Signet ring carcinoma (0.2%)

Sarcomatoid features (0.1%)

Osteoclast-like (0.2%)

Mixed ductal/endo (0.2%)

Small cell carcinoma (0.1%)

Acinar cell carcinoma (0.5%)

Small round cell tumor (0.1%)

Giant cell carcinoma (0.1%)

Extra-GI strom. tumor (0.1%)

Pancreatoblastoma (0.1%)

Tumor (T)

TX: Primary tumor cannot be assessed

T0: No evidence of primary tumor

Tis: Carcinoma in situ

T1: Tumor limited to the pancreas, 2 cm or less in greatest dimension

T2: Tumor limited to the pancreas, >2cm but <4cm in greatest dimension

T3: Tumor limited to the pancreas but >4cm

T4: Tumor extended beyond the pancreas and into major blood vessels

Regional lymph nodes (N)

NX: regional lymph nodes cannot be assessed

N0: no regional lymph node metastasis

N1: cancer has spread to no more than 3 regional lymph nodes

N2: cancer has spread to 4 or more regional lymph nodes

Distant metastasis (M)

MX: distant metastasis cannot be assessed

M0: no distant metastasis

M1: distant metastasis

American Joint Committee on Cancer

Staging of Pancreatic Cancer American Joint Committee on Cancer

Staging of Pancreatic Cancer

Stage Grouping T N M 5-Year surv (%)

Stage IA T1 N0 M0 20–30

Stage IB T2 N0 M0 20-30

Stage IIA T3 N0 M0 10–25

Stage IIB T1,T2,T3 N1 M0 10–15

Stage III T4 Any N M0 0–5

Stage IV Any T Any N M1 —

2

Pancreatic Cancer

• Incidence 12.5:100,000

• 53,670 cases

• 43,090 deaths

– High incidence of regionally advanced and

metastatic disease @ diagnosis

• Only 10-15% pts have resectable disease @

diagnosis

Risk Factors For Pancreatic Cancer

Increased risk Possible risk Unproven risk

Demographic factors Advancing age Geography Socioeconomic Status

Male Sex Migrant status

Black Race

Host factorsHereditary nonpolyposis

colorectal cancerPeptic ulcer surgery

Familial breast Cancer

Peutz-Jeghers syndrome

Ataxia–telangectasia

Familial atypical multiple-mole melanoma

Hereditary pancreatitis

Environmental factors Tobacco Diet Alcohol

Occupation Coffee

Radiation

Pancreatic cancer – survival in

all comers

Median survival; 6 months

Conlon et al. Ann Surg 1996;223(3):273 Ann Surg 1996; 223:273-9

Median survival:

14.3 mos. vs. 4.9 months

Pancreatic Cancer Survival

Pancreatic Cancer

• High incidence of regionally advanced and metastatic disease

• Only 10-15% pts have resectable disease

Head 60% Body/Tail 40%

20% resectable <5% resectable

20% 5-yr survival <15% 5-yr survival

<3% alive at 5 years

Most patients are treated with palliative therapies

Symptoms on Presentation

• Weight loss 92

• Jaundice 82

• Pain 72

• Anorexia 64

• Dark urine 63

• Light stools 62

• Nausea 45

• Vomiting 37

• Weakness 35

• Pruritus 24

• Diarrhea 18

• Melena 12

• Constipation 11

• Fever 11

• Hematemesis 8

• Weight loss 100

• Pain 87

• Weakness 43

• Nausea 43

• Vomiting 37

• Anorexia 33

• Constipation 27

• Hematemesis 17

• Melena 17

• Jaundice 7

• Fever 7

• Diarrhea 3

Head Body and Tail

3

Pancreatic cancer – presenting symptoms

(buzz words)

• Painless jaundice

• Weight loss

• Anorexia/”food doesn’t taste right”

• Back pain

• Nausea

• Bloating

What is the differential diagnosis?

• Periampullary cancers

– Pancreatic

– Bile duct

– Ampullary

– Duodenal

• CBD stones

• Oriental cholangiohepatitis

• Choledochal cysts

• Mirizzi’s syndrome

Pancreatic Carcinoma

Diagnosis and Staging

Pancreatic Cancer

Staging

• Metastases:

– Lymph nodes

– Liver

– Peritoneum

• Vascular

encasement:

– Arterial encasement

– Venous encasement

• Lumen obstruction:

–Pancreatic duct

–Bile duct

• Contiguous organ invasion

State of the Art CT of the Pancreas

• Metastatic

– evidence of metastatic spread (typically to the liver,

peritoneum or lung)

• Locally advanced

– evidence of arterial encroachment (celiac axis or

superior mesenteric artery) or venous involvement

or occlusion (superior mesenteric / portal veins).

– 20% resectability

• Potentially resectable

– no evidence of extra-pancreatic involvement of the

tumor

– demonstration of fully patent superior mesenteric /

portal veins

– showing no evidence of encroachment

("encasement") by the tumor on the arterial celiac

axis or the superior mesenteric artery.

– 80% resectability

CT Resectability--Classification

4

Incidence Of Occult Mets And Occult Vascular

Involvement After Staging Helical CT

Institution Year NResection

Rate

Occult

Mets (%)

% Locally

advanced

Max spared

laparotomy (%)

UCLA 1998 32 75 13 13 13

Bern 1998 159 75 10 11 10

Manheim 1997 194 89 5 10 5

Duke 1997 23 78 4 4 4

MDACC 1997 118 80 15 2 15

BI 2000 68 76 4 19 4

JHH 2002 171 67 16 16 2.5

Endoscopic Ultrasound (EUS)

• Accuracy for T-stage = 78%-94%

• Accuracy for N stage = 64%-82%– Add FNA of nodes to increase sensitivity/specificity

• Better if done before endoscopic biliary stenting

• Ok for assessing PV involvement

• Not so good for SMA

• No good for mets

**think about EUS in unresectable patients potentially

eligible for trials of regional therapies

Technique Sensitivity Specificity PPV NPV Accuracy

Individual techniques

EUS 23 [12 34] 100 [96 100] 100 [96 100] 64 [51 77] 67 [54 80]

CT 67 [55 79] 97 [93 100] 95 [89 100] 77 [66 88] 83 [73 93]

MRI 57 [44 70] 90 [82 98] 81 [70 92] 73 [61 85] 75 [63 87]

A 37 [25 49] 100 [93 100] 100 [96 100] 65 [53 77] 71 [59 83]

Combination of techniques

CT+EUSa

71 [62 80] 97 [94 100] 82 [74 90] 94 [89 99] 87 [79 93]

CT+EUSb

97[94 100] 81 [73 89] 98 [95 100] 71 [62 80] 87 [79 93]

EUS+CTc

63 [54 72] 96 [92 100] 91 [85 97] 82 [74 90] 87 [79 93]

EUS and CT in determining resectability in pancreatic

adenocarcinoma

Staging Laparoscopy and Detection of Metastatic

Disease in Periampullary Carcinoma

Author Year N Mets %

Cuschieri 1978 15 5 33

Cuschieri 1988 51 42 82

Bemelman 1995 70 12 17

John 1995 40 14 35

Conolon 1996 108 39 36

Jiminez 2000 125 39 31

• Pancreatic adenocarcinoma, not ampullary,

distal bile duct, duodenal, NE, cystic

• High-quality CT to detect mets, vascular

involvement

• Larger primary tumors (Size?)

• Location in neck, body, tail

• Equivocal CT, marked weight loss, very high

CA19-9, pain

Selective Use of Laparoscopy in

Potentially Resectable Pancreatic Cancer

5

Pancreatic Cancer- surgical treatment

Pancreaticoduodenectomy

• Exploratory Laparotomy

• Kocher maneuver – from pylorus to IVC

• Open lesser sac – find inferior border of the pancreas

• Find SMV – root of transverse mesocolon

– Dissect up toward PV/splenic vein confluence

• Portal dissection

– Take duct if resectable or bypass indicated

– Dissect portal vein toward SMV

– Determine resectability

• Transect stomach (classic) or duodenum (PPPD)

• Transect jejunum distal to ligament of Treitz

• Transect pancreas

• Dissect uncinate process off SMV/SMA

• Reconstruction

Mortality %

Perioperative mortality 2

Perioperative mortality by decade:

1970s 30†

1980s 5†

1990s 2

2000s 1

† p<0.05 compared to the present decade

Pancreaticoduodenectomy for Pancreatic Cancer-

Mortality Data

1423 Whipple’s for Pancreatic Cancer- JHH 2006

Morbidity and Length of Stay %

Perioperative morbidity 38

Perioperative morbidity by decade:

1980s 30

1990s 31†

2000s 45

Reoperation rate 3

Postop LOS (days), median 9

Postop LOS (days) by decade, median

1980s 16†

1990s 11†

2000s 8

Postoperative Data

† p<0.05 compared to the present decade

Specific Complications %

Delayed gastric emptying 15

Wound infection 8

Pancreatic fistula 5

Cardiac morbidity 4

Abdominal abscess 4

Cholangitis 2

Sepsis 2

Bile leak 2

Lymph leak 1

Urinary tract infection 1

Postoperative Complications


0.1

.2.3

.4.5

.6.7

.8.9

1.0

Pro

port

ion S

urv

ivin

g

0 12 24 36 48 60 72 84 96 108 120

months

Long-term Survival of Patients Who Underwent

PD for Pancreatic Cancer, by Pathology

Ductal

adenocarcinoma,

n=1175

Neuroendocrine carcinoma,

n=98

IPMN with invasive cancer,

n=90


0.1

.2.3

.4.5

.6.7

.8.9

1.0

Pro

port

ion S

urv

ivin

g

0 12 24 36 48 60

months

0.1

.2.3

.4.5

.6.7

.8.9

1.0

Pro

port

ion S

urv

ivin

g

0 12 24 36 48 60

months

0.1

.2.3

.4.5

.6.7

.8.9

1.0

Pro

port

ion S

urv

ivin

g

0 12 24 36 48 60

months

0.1

.2.3

.4.5

.6.7

.8.9

1.0

Pro

port

ion S

urv

ivin

g

0 12 24 36 48 60

months

positive margin

negative margin

poor or

undifferentiated

well or moderate

no positive nodes

positive nodes

< 3 cm

≥ 3 cm

p<0.0001

p<0.0001

p<0.0001

p<0.0001

Long-term Survival for Ductal Adenocarcinoma of

the Pancreas

Tumor Diameter

Margin Status

Lymph Node Status

Histologic Grade

6

0.1

.2.3

.4.5

.6.7

.8.9

1.0

Pro

port

ion S

urv

ivin

g

0 12 24 36 48 60

months

Favorable Pathologic Features for Ductal Adenocarcinoma

of the Pancreas

n=56

• < 3cm

• negative lymph nodes

• negative resection margins

• well or moderately differentiated


Pancreatic Cancer

• High incidence of regionally advanced and metastatic disease

• Only 10-15% pts have resectable disease

Head 60% Body/Tail 40%

20% resectable <5% resectable

20% 5-yr survival <15% 5-yr survival

<3% alive at 5 years

Most patients are treated with palliative therapies

Palliation of Unresectable

Pancreatic Cancer

• Relief of obstructive jaundice

• Prevention of duodenal obstruction

• Control of pain

Choledochojejunostomy

+

Gastrojejunostomy

+

Chemical Splanchnicectomy

Endoscopic biliary stent

+

Duodenal Wall Stent

+

Percutaneous Celiac block

Survival in patients with clinically

resectable pancreatic cancer found to be

unresectable at surgery

Survival

Site of

MetastasesN Months Range

Liver 29 6 1-34

Peritoneal 22 7 2-36

Nodal 44 11 1-53

Vascular 53 11 3-30

Overall 148 9 1-53

Luque-de-Leon, et al (Mayo Clinic) J Gastrointest Surg 3:111-118, 1999

Local Invasion vs. Distant Metastases

Palliation of Periampullary Carcinoma

0 12 24 36 48

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0.0

Months

Local invasion (n=81)

Distant mets

(n=175)

p=0.009

Pro

po

rtio

n S

urv

ivin

g

Sohn, et al. (Johns Hopkins) J Am Coll Surg 188:658-666, 1999

8.5 months

5 months

Palliation of obstructive

jaundice for pancreatic cancer

7

Relief of

Jaundice (%)

Mortality

(%)

Morbidity

(%)

Recurrent

Jaundice (%)

Duodenal

Obst (%)

Author N Stent Surg Stent Surg Stent Surg Stent Surg Stent Surg Stent

Bornman 50 Perc 76 84 20 8* 32 28 16 38 0 14

Shepard 48 Endo 92 82 20 9* 56 30 0 30* 4 9

Anderson 50 Endo 88 96 24 20 20 36 - - 0 0

Smith 201 Endo 91 92 14 3* 29 11* 2 36* 7 17*

* p < 0.05 vs. surgical palliation

Prospective Randomized Trials of Nonoperative Palliation

of Malignant Obstructive Jaundice

Randomized Trial of Endoscopic Stenting vs.

Surgical Bypass in Malignant

Low Bile Duct Obstruction

Smith Lancet 1994;344:1655;

Stent Surgery

No. patients 100 101

Successful drainage 92% 92%

Major complications 11%* 29%

Procedure-related mortality 3%* 14%

Hospital stay 19 days 26 days

Recurrent biliary obstruction 36%* 2%

Late gastric bypass 17%* 7%

Median survival 21 weeks 26 weeks

* P <0.05 vs Surgery

Surgical Palliation of Periampullary

Carcinoma 1991-1997

N Mortality MorbidityPostop

LOS

All palliative procedures 256 3.1% 22% 10.1 days

Biliary and gastric bypass 132 3.0% 28% 11.6 days

Gastric bypass alone 48 4.2% 17% 10.4 days

Biliary bypass alone 28 0.0% 15% 9.4 days

Pancreaticoduodenectomy 512 1.9% 35%* 14.8 days


Long-Term Results

• 96% of patients undergoing choledocho- or

hepaticojejunostomy were free of recurrent

jaundice prior to death

• 98% of patients undergoing gastrojejunostomy

were free of recurrent gastric outlet

obstruction prior to death

Palliation of Periampullary Carcinoma


Prevention of Gastric Outlet Obstruction

in Unresectable Periampullary Carcinoma

Prophylactic

Gastrojejunostomy

(n=44)

No

Gastrojejunostomy

(n=43)

Mortality 0 (0%) 0 (0%)

Morbidity 14 (32%) 14 (33%)

Postop LOS (days)8.5 ± 0.05 8.0 ± 0.05

Late gastric outlet

obstruction0 (0%) 8 (19%)*

Lillemoe, et al. Ann Surg 230:322-330, 1999

Palliation of Pain with Alcohol

Splanchnicectomy

N = 20 17 19 11 0 5 19 12

9.0

8.0

7.0

6.0

5.0

4.0

3.0

2.0

1.0

0

Pai

n S

core

Alcohol *p<0.05

Saline †p<0.01

* †

PreOp 2 mos 4 mos Final

*†

*

N = 20 17 19 11 0 5 19 12

9.0

8.0

7.0

6.0

5.0

4.0

3.0

2.0

1.0

0

Pai

n S

core

Alcohol *p<0.05

Saline †p<0.01

* †

PreOp 2 mos 4 mos Final

*†

*

Lillemoe, et al. Ann Surg 217:447-457, 1993

0 3 6 9 12 15 18 21 24 26 30 33 36

100

80

60

40

20

0

Months of Survival

Alcohol (n=20)

Saline (n=14)

p=0.0001

Perc

en

t

0 3 6 9 12 15 18 21 24 26 30 33 36

100

80

60

40

20

0

Months of Survival

Alcohol (n=20)

Saline (n=14)

p=0.0001

Perc

en

t

8

Is there a role for preoperative

biliary stenting in patients with

obstructive jaundice prior to

pancreaticoduodenectomy?

Sohn et al. J Gastrointest Surg 2000;4(3):258

Preoperative biliary drainage – postoperative complications

Sohn et al. J Gastrointest Surg 2000;4(3):258

Preoperative biliary drainage – postoperative complications

Preop biliary drainage - summary

• We all agree, it increases infectious

complications

• Culture the bile – it helps

• No proof that it increases other complications

• If a stent is in place, don’t rush to the OR. Let it do what it is supposed to do (i.e 2-3

weeks).

**patients with renal insufficiency, malnutrition preop may

benefit from preop drainage

Is there a role for

adjuvant therapy ?

Adjuvant therapy in

pancreatic cancer

• GITSG – 14 institutions participated

• Randomized, controlled trial (8 yr.’74-82)

• Weekly 5-FU (500mg/M2) 40 cgy radiation

• 22 no tx. – 21 chemoradiotherapy

• Median survival: 20 mos. Vs. 11 mos.

Arch Surg 1985; 120:899-903

9

Beger et al World J Surg 2003

Pancreatic Cancer Adjuvant TherapyYeo et al,

Ann Surg, 1997; 225: 621

• 174 pts s/p curative surgery: 128 Adjuvant Tx and 52

pts did not

– MST 19.5m (CT+RT) vs 13.5m (S)

– 2y survival 39% (CT+RT) vs 30% (S)

– The advantage of Adj. Tx more significant in pts with T ≥

3cm, negative resection margins and positive LN’s

MST

(months)

Entire

series

T< 3cm

T≥ 3cm

(-) margin

(+) margin

(-) nodes

(+) nodes

Adjuvant TX 19.5* 26 / 16* 19* / 18 21 /19*

Observation 13.5* 16 / 7.5* 14* / 5 13 / 11.5*

Neoadjuvant Therapy

Agents Response Rate

FOLFIRNOX 30-40%

Gemcitabine +

Abraxane

30-40%

Pancreatic Cancer Survival

Disease Category Median Survival

(mos)

Surgically resectable 24

Locally advanced 12-18

Metastatic 6-12

BONUS:

Cystic Disease of the

Pancreas

TYPES OF CYSTIC NEOPLASMS

Benign Premalignant Malignant

Pseudocyst Main Duct IPMN

(MD-IPMN)

Main Duct IPMN

(MD-IPMN)

Serous Cystadenoma

(SCN)

Mucinous Cystic

Neoplasm (MCN)

Mucinous Cystic

Neoplasm (MCN)

Solid Pseudopapillary

Neoplasm (SPN)

Branch-Duct IPMN

(BD-IPMN)

Branch-Duct IPMN

(BD-IPMN)

Cystic Neuroendocrine

(PNET)

Cystic Pancreatic Neoplasms

10

SEROUS CYSTADENOMA


SOLID PSEUDOPAPILLARY

NEOPLASM


MUCINOUS CYSTIC

NEOPLASM


NEUROENDOCRINE TUMOR


INTRADUCTAL PAPILLARY

MUCINOUS NEOPLAMS

CT Head CT Body

Gross Pathology Microscopic Path


MAKING A

DIAGNOSIS

11

OBTAIN A THOROUGH

HISTORY• Symptoms

– Pain

– Pancreatic insufficiency

– New onset diabetes

• History of pancreatitis

• Family history of pancreatic cancer


IS THEIR PANCREATIC

DUCTAL COMMUNICATION?

• Dilated main duct or side-branch on CT/MR

• MRI/MRCP*

• EUS

– Cyst fluid aspirate for amylase

• ERCP

• Yes—DDx=Pseudocyst, IPMN

• No—DDX=SCN, MCN


DISTINGUISH BETWEEN

MUCINOUS VS. NON-MUCINOUS

• EUS-guided FNA for:

– Mucin

– CEA (>200)

• ERCP: mucin extruding from ampulla

• Yes—DDx=MCN, IPMN

• No—DDx=Pseudocyst, SCN


WHO NEEDS AN EUS?• All cysts >=1cm to look for “high-risk

stigmata” or “worrisome features”

– “High-risk stigmata”: MPD>=10mm or

enhancing solid component

– “Worrisome features”: Cyst>=3cm, MPD5-

9mm, non-enhancing solid component,

thickened or enhancing cyst wall, abrupt

change in MPD caliber with distal atrophy,

lymphadenopathy


WHO NEEDS AN EUS?

• Diagnostic uncertainty

– Cyst fluid analysis for mucin, CEA,

amylase

• Characterizing risk of malignancy

– Cyst fluid analysis for molecular markers

(investigational)


WHAT TO DO NOW?

WHEN TO OPERATE

12

0

20

40

60

80

100


SYMPTOMS & CYST PATHOLOGY

% P

ati

en

ts S

ym

pto

mati

c

*

*

*p<0.05 vs Benign

0

10

20

30

40

50

60

70

% P

ati

en

ts >

70y

rs


AGE & CYST PATHOLOGY

**p<0.02 vs Benign & Premalignant

PSEUDOCYSTS, SCN, SPN

• Pseudocysts:

– Treat if symptomatic (pain, mass effect,

infected)

– Operation: Internal drainage

• SCN:

– Treat if symptomatic (pain, mass effect) in

good risk patient

– Operation: Can enucleate if away from MPD;

otherwise resection based on location

• SPN:

– Resect


International Consensus Guidelines

• “Worrisome Features”

– MPD 5-9mm

– Cyst >3cm

– Thickened-enhanced cyst wall

– Non-enhancing mural nodule

– Abrupt change in MPD caliber w/ distal atrophy

– LAD

• “High-Risk Stigmata”

– MPD>=10mm

– Enhancing solid

component

MCN, IPMN

• 2012 Consensus guidelines

• MCN and MD-IPMN:

– Should all be formally resected in appropriate

surgical candidates

• BD-IPMN:

– Resect if “high-risk stigmata” present

– Consider resection for “worrisome” features

Cystic Pancreatic NeoplasmsINCIDENCE OF MALIGNANCY/ INVASION

BY DUCT INVOLVEMENT

19%

57%

14%

28%

0%

10%

20%

30%

40%

50%

60%

Branch Main

DUCT INVOLVEMENT

% I

nva

siv

e o

r M

alig

na

nt IP

MN

Malignant, *P<0.001

Invasive, **P=0.02

*

**

13

INCIDENCE OF MALIGNANT/ INVASIVE

BRANCH DUCT BY SIZE

17%

20% 19%17%

13% 14%

0%

10%

20%

30%

40%

50%

60%

<10mm 10mm-30mm >30mm

Size (ICG Category)

% I

nva

siv

e o

r M

alig

na

nt IP

MN

Malignant, P= NS

Invasive, P= NS

MURAL NODULE INCIDENCE :

BRANCH DUCT IPMN

7% 7%

33%

28%

0%

10%

20%

30%

40%

50%

60%

Adenoma Borderline CIS Invasive

Grade of Dysplasia

% I

ncid

en

ce

Mu

ral N

od

ule

s

* P= 0.008

**

Mural Nodule

PREDICTORS OF MALIGNANCY MULTIVARIATE ANALYSIS

MALIGNANT OR P

Main Duct IPMN 6.4 0.009

Mural nodule 4.3 <0.01

INVASIVE

Main Duct IPMN 5.4 0.02

MALIGNANT OR P

Mural nodule 6.2 0.009

Cytopathology 5.9 0.0009

INVASIVE

Mural nodule 4.3 <0.04

Male Gender 3.6 <0.002

Cytopathology 4.3 <0.04

RADIOGRAPHIC

OVERALL


IPMN SUMMARY• IPMNs occur in elderly pts, M>F

• Progression to invasive cancer 5-10 yrs

• Surgery can be performed safely

• 50-70% noninvasive, 80-100% survival

• 30-50% invasive, 40-60% survival

• 10-20% of noninvasive tumors recur

• 45-65% of invasive tumors recur


• IPMNs offer a unique opportunity to prevent or treat a less virulent form of pancreatic cancer

• Surgical resection should be recommended even in fit elderly patients

• Total pancreatectomy is not routinely recommended

• Careful follow-up is necessary after resection

IPMN CONCLUSIONS


WHEN TO OPERATE

• Older fit patients – malignancy

• Symptomatic pts – premalig or malig

• Increasing in size – premalig or malig

• Younger asymptomatic – cost effective

14


WHAT OPERATION• Benign and premalignant

Enucleation

Segmental resection

Laparoscopic resection

Splenic preservation

•Main duct IPMN and malignant

Resection - “negative” marginsPalliative bypasses

MANAGEMENT OF ACUTE PANCREATITIS

Gallstone Pancreatitis

• Acute pancreatitis – 240,000/yr

(40 cases/100,000)

• Necrotizing pancreatitis – 15-20%

(mortality: 15 – 20%)

• GSP responsible for 40-50%% of

all cases of acute pancreatitis

• Pathogenesis related to transient

obstruction of pancreatic duct

• Gallstones recovered in stool of

85% of patients with GSP vs.

10% of patients with symptomatic

cholelithiasis

Jemal, et al. CA 2007; 57: 47

Insult

Zymogen activation

Generation of inflammatory mediators

Ischemia

Inflammation

Ischemia

Necrosis

Apoptosis

Systemic inflammatory response

Multi-organ failure

Pathogenesis of Acute Pancreatitis

Day 0 - 14 = SIRS – cytokinemediated organ dysfunction

2 Phases:

Day 15 – on = resolution vs. infection

of pancreatic necrosis

Werner et al. Gut 2005; 54:426-36

Severity Scoring Systems in

Acute Pancreatitis

Acute pancreatitis

On admission or diagnosis

• Age

• White blood cell count

• Blood glucose

• LDH

• SGOT

During initial 48 h

• Hematocrit decrease

• Blood urea nitrogen increase

• Serum calcium level

• Arterial pO2

• Base deficit

• Fluid sequestration

Alcohol-induced Biliary

> 55 years

> 16000/mm3

> 200 mg/dl

> 350 U/I

> 250 U/I

> 10 %

> 5 mg/dl

> 8 mg/dl

> 60 mm Hg

> 4 mEq/I

> 6 I

> 70 years

> 18000/mm3

> 220 mg/dl

> 400 U/I

> 250 U/I

> 10 %

> 2 mg/dl

> 8 mg/dl

> 5 mEq/I

> 4 I

• 20% will have severe disease

• Clinical scoring systems to predict severity

•Ranson’s criteria

•Glasgow criteria

• APACHE-II

•Balthazar CT Grade A-E

•A: Normal

•B: Enlargement (edema)

•C: Abnl gland + peripanc inflam

•D: Fluid collection in 1 loc

•E: 2 or more fluid collections/gas

adjacent to pancreas

0

20

40

60

80

100

0 to 2 3 to 5 6 to 8 9 to 11

Score

% M

ort

alit

y

Randomized trials of early ERCP for

gallstone pancreatitis

Author Yr N ERCP Comp Mortality

Timing ERCP Control ERCP Controls

Neoptolemos1988 146 <72 hrs 24* 61 2 8

Fan1993 127 < 24 hrs 0* 12 5 9

Nowak 1995 280 < 24 hrs 17* 36 2* 13

Folsch1997 121

<72 hrs46 51 8 4

Acosta2006 61 < 48 hrs 29* 7 0 0

Oria 2007 102 <72 hrs 21 18 6 2

* Significantly different vs controls

15

Management of Gallstone

Pancreatitis

• Patients with severe gallstone

pancreatitis who fail to improve

substantially during the initial 24 hour

period should be considered for urgent

endoscopic ERCP and endoscopic

biliary sphincterotomy

• Patients with mild GSP should undergo

cholecystectomy during the initial

hospitalization

• If the gallbladder not removed risk of

recurrent pancreatitis - 90%

• 3 months recurrence - 50%

Pancreatic Pseudocyst

• A fluid collection contained within

a well-defined capsule of fibrous

or granulation tissue or a

combination of both

• Does not possess an epithelial

lining

• Persists > 4 weeks

• Etiology

• Acute Pancreatitis

• Chronic pancreatitis

• Pancreatic trauma

• Pancreatic neoplasm

Evidence Based Management of

Severe Acute Pancreatitis

• Early enteral feeding

– Reduced infectious complications

• Use of antibiotics in patients with necrosis

– Lower mortality

• Early ERCP in GS pancreatitis if CBD

stone

– Lower mortality

Natural History of Pseudocyst

• ~50% resolve spontaneously

• Size

– Nearly all <4cm resolve spontaneously

– >6cm 60-80% persist, necessitate intervention

• Cause

– Traumatic, chronic pancreatitis <10% resolve

• Duration - Less likely to resolve if persist > 6-8 weeks

Complications

• Infection

• GI obstruction

• Perforation

• Hemorrhage

• Thrombosis

• Pseudoaneurysm

Pseudoaneurysm

Recent hemorrhage

Pancreatic Pseudocyst

• Indications for drainage

• Presence of symptoms (> 6 wks)

• Enlargement of pseudocyst ( > 6 cm)

• Complications

• Suspicion of malignancy

• Intervention

• Percutaneous drainage

• Endoscopic drainage

• Surgical drainage

16

Operative Therapy

• Cystgastrostomy – for cysts adhered

to posterior wall of stomach

• Cystduodenostomy – cysts in head

and uncinate process of pancreas

• Cystjejunostomy – via Roux-en Y limb,

for cysts adhered elsewhere i.e. to

transverse mesocolon

Walled Off Pancreatic Necrosis

(WOPN)

• 15-20% of all patients with acute

pancreatitis

• Best diagnosed on contrast enhanced CT

• Two types: Infected vs Sterile

– Infected requires urgent open debridement if

patient is septic

– Sterile requires debridement ideally around 4

week mark due to ‘persistent unwellness’

Pancreatic Cancer &

Pancreatitis

Janak A. Parikh, MD, MSHS, FACS

Clinical Teaching Faculty

St. John Providence Hospital

January 12, 2018

pancreatic cancer pancreatic cancer & pancreatitis · 6 0.1.2.3.4.5.6.7.8.9 0 g 0 12 24 36 48...

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