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INTRODUCTION

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Pancreatic cancer:

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  • In patients with localised disease the relation of the tumour to the surrounding arteries (celiac trunc, sup. mes. artery) and veins (superior mesenteric-portal vein) is crucial

  • Resection of pancreatic cancer is difficult and should preferably be done in high volume centers

  • The main intraoperative morbidity arises from vascular problems, the major postoperative morbidity is associated with pancreatic fistula

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Chronic pancreatitis:

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  • In patients with intractable pain and local complications such as bile duct or duodenal obstruction, a surgical approach is the preferred treatment

  • Duodenum preserving procedures (Berne-, Beger- or Frey procedure) are the preferred procedures if malignancy is ruled out

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1. PANCREATIC CANCER

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STATE OF THE ART

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Pancreatic cancer is the eighth most common cancer in the United States and Europe. Five-year survival rate is only around 6%, which makes it the fourth cause of cancer-related death. Over 95% of pancreatic cancers develop from the exocrine part of the pancreas, in 80% as ductal adenocarcinoma. Acinar cell carcinoma, cystadenocarcinoma, mucinous carcinoma, and endocrine tumors, which arise from hormone-producing cells, are rare entities. Harboring 75% of tumors, the pancreatic head is the predominant site.

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Pancreatic cancer is a very aggressive tumor as shown by a 1-year survival of only around 18% for all stages. The disease is often diagnosed in a locally advanced stage or with distant metastases already present. Metastases are mainly located in the liver, the peritoneum, and the lungs.1 Complete resection remains the backbone of treatment in patients with locally limited disease and offers the only chance for cure and prolonged survival. Pancreatic cancer is found in an early stage, which qualifies the patients for surgery, in as little as 10% to 15% of cases. Five-year survival rates for these patients rise to 25%. Oncological surgery with R0 resection is an important factor determining the outcome in patients with pancreatic cancer. However, more recent data based on clearly defined histopathological specimen analysis revealed many earlier studies dealing with R0 resection as possibly having been based on incorrect baseline figures.2 In addition, resections are termed R1 according to the seventh edition of the TNM classification of the Union for International Cancer Control if a tumor is located within 1 mm from the resection margin. This is particularly important in the area around the mesentericoportal vein when no invasion of the vessel wall is present. Despite the R1 status of these patients, no data support resection of the vein.

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The role of preoperative chemotherapy or radiochemotherapy is analyzed in several recent studies, especially in locally advanced tumors but not (yet) used routinely.3

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How to Operate on Pancreatic Cancer
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1. Patient selection
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The selection of patients who qualify for pancreatic surgery can be more difficult than the operation itself. Apart from the ...

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