Pancreatic adenocarcinoma (core) | Risk factors: cigarette smoking, EtOH, obesity, chronic pancreatitis May present with painless jaundice, new onset diabetes, weight loss, light stools, dark urine, itching Examine abdomen, look for jaundice and scleral icterus | CBC, CMP, lipase, coagulation panel RUQ U/S in patients who present with jaundice CT pancreas protocol—look at lymph nodes, look for involvement of portal vein, SMA/SMV, common or proper hepatic artery, celiac artery CT C/A/P to rule out metastases CA 19-9—can be falsely elevated if total bilirubin >2.5 +/− EUS with FNA biopsy +/− ERCP with stent, brushings—routine pre-op biliary drainage not recommended, but should be considered in patients with significant hyperbilirubinemia | Discuss at multidisciplinary tumor board Tissue diagnosis is needed prior to starting chemo, but not required prior to surgery Criteria for Resectability: - Resectable: no arterial contact, <180° contact w/SMV/PV - Borderline: <180° contact with SMA or celiac artery, reconstructable SMV/PV involvement - Unresectable: >180° contact with celiac or SMA, unreconstructable SMV/PV involvement, M1 disease, invading other unresectable structures All patients will get systemic therapy at some point in their treatment course Preferred chemo regimen: FOLFIRINOX Head of pancreas mass → Whipple Body or tail of pancreas mass → distal pancreatectomy with splenectomy | Whipple (Pancreaticoduodenectomy) (advanced) (Figure 4.1): - Consider diagnostic laparoscopy to rule out metastatic disease, convert to open if no mets seen - Take down hepatic flexure of colon, open gastrocolic ligament, gain access into lesser sac - Kocherize the duodenum, ensure no invasion into SMA - Dissect out inferior border of pancreas and start retropancreatic tunnel between SMV and neck of pancreas - Perform cholecystectomy - Dissect out portal structures, portal lymphadenectomy - Test clamp and divide GDA - Complete retropancreatic tunnel - Divide stomach, proximal jejunum 10 cm ... |