Unresectability of Carcinoma of Pancreas

Criteria of Unresectability:
1. If there are distant metastases - liver or pelvis, area of ligament of Treitz.
2. Regional metastases - celiac axis lymph nodes and nodes posterior to CBD
3. Local invasion - invasion of either the SMV and/or PV. Ability to separate the anterior
portion of these vessels from the posterior neck of the pancreas is a key phase of the
procedure.

Specific Intra-Operative Steps to Determine Resectability

1. Kocher maneuver - retropancreatic space is evaluated, separating the pancreas
anteriorly and vena cava/aorta posteriorly. Check junction of the uncinate process with
the SMA. Extension beyond the pancreas to involve the retropancreatic space and SMA
makes the tumor unresectable.
2. Mobilize distal stomach and pylorus - identify structures in the hepatogastric and
hepatoduodenal ligaments: check the hepatic artery, CBD, nodes and PV.
3. Exploration of base of the transverse mesocolon and the anterior surface of pancreas:
- Puckering at root of mesentery indicates invasion.
- Inspect SMA, SMV, middle colic and inferior pancreaticoduodenal vessels.
- Open lesser sac and inspect the anterior surface of the pancreas.
- Follow middle colic vessels to SMV and insert index finger from below to elevate the
neck of the pancreas.
- Insert index finger from above - ensure the space between the neck of the pancreas and
anterior surface of the portal and SMV is not invaded.
Steps in Resection:
1. Transect common hepatic duct, retract distal biliary system and clear the porta hepatis
nodes down to celiac axis.
2. Transection of the stomach at junction of the body and antrum, add truncal vagotomy
3. Transect neck of the pancreas just to the left of the PV. VanHeerden, Common
Problems in Cancer Surgery, pp 131-138. Cameron's Current Surgical Therapy, pp
334-337

Characteristics of Amylase
Amylase is an enzyme responsible for the digestion of starch. The molecule is
approximately 55,000 daltons and is secreted by the salivary glands (S-type amylase) and
by the pancreas (P-type amylase). Dietary carbohydrates consist predominately of starch,
sucrose and lactose. Digestion begins in the mouth and 30-40% is converted to maltose,
isomaltose and dextrins before S-amylase is inactivated by gastric juice.
Pancreatic amylase completes the hydrolysis of the remaining starch in the jejunum.
Elevated amylase levels are common with pancreatitis. Values above 100 Iu/dl are
characteristic of biliary pancreatitis, lower values are typical for acute alcoholic
pancreatitis. The amylase level does not correlate with the severity of the pancreatitis.
Normal serum amylase levels may be reported in patients with pancreatitis if:
1. The amylase is rapidly cleared by the kidneys,
2. The pancreatic parenchyma is destroyed as in chronic pancreatitis or
3. Hyperlipidemia interferes with the amylase determination, serum amylase levels are
usually false in this setting! Elevated amylase may also be encountered with perforated
duodenum ulcer, gangrenous cholecystitis and small bowel obstruction or infarction.
Schwartz, 6th Ed., pg 1409. O'Leary, Physiologic Basis of Surgery, p. 365

Secretion of Bicarbonate by Pancreatic Duct Cells

The exocrine pancreas is responsible for secreting pancreatic juice, which is a
combination of water and electrolytes along with pancreatic enzymes. This process is
largely controlled by neurohumoral mechanism. The final secretory product is a clear
isotonic solution with pH of 8. Basal secretory rate is approximately 15ml/hr. Maximal
rates approach 300ml/hr. The alkalinity of pancreatic juice is controlled by the
concentration of HCO3, which increases as the rate of secretion increases in response to
secretagogues. The alkaline secretions will neutralize the acidic gastric juices and provide
a pH environment optimal for the pancreatic enzymes. Pancreatic enzyme secretion is
mainly controlled by CCK, an endogenous hormone, which is released in response to fat
or protein entering the duodenum. Bicarbonate secretion from pancreatic duct cells is
stimulated by secretin released from the mucosal S-cells in the crypts of Lieberkuhn in
the proximal small bowel. Bile and gastric/duodenal acid provide the stimulus for
secretin release. O'Leary: The Physiologic Basis of Surgery, First Edition, pp 267-269.

Decreased Chloride Levels in Increased Pancreatic Exocrine Secretion

The principal cations of this juice are sodium and potassium, which are always present in
concentrations similar to those found in plasma (the sum of the two is approximately 165
mmol/L).
The concentration of the principal anions - bicarbonate and chloride vary. When the
stimulus to secrete is minimal the chloride concentration is high (e.g. 110 mmol/L), and
that of bicarbonate low - 50 mmol/L. When the secretory stimulus is maximal, the
bicarbonate concentration rises to approximately 140 mmol/L, and the chloride
concentration falls to 20 mmol/L. The variable relationship of the two anions is a result of
the passive exchange of intraductal bicarbonate for interstitial chloride. This exchange
occurs as the juice flows through the larger pancreatic ducts on its way to the duodenum.
At slower rates, there is more opportunity for exchange to take place and more for the
bicarbonate to be lost. The alkaline pancreatic juice helps to neutralize gastric acid in the
duodenum, thus providing the optimum pH for the activity of pancreatic digestive
enzymes. Schwartz, Principles of General Surgery, 6th Ed, p 1404

Treatment of Pseudocyst Post Acute Pancreatitis

Approximately 40% of acute pseudocysts will disappear spontaneously in 4-6 weeks as
the pancreatitis resolves. Treatment is needed if the cyst doesn't resolve, enlarges in size,
if symptoms develop (nausea, vomiting, jaundice, weight loss), or a complication occurs
(hemorrhage, rupture, or infection). All cysts operated on must be biopsied to rule out a
neoplasm, such as a cystadenocarcinoma. There are three types of operative treatments
for pancreatic pseudocysts: resection, internal drainage, and external drainage. An
elective procedure on a pseudocyst should be delayed for 4-6 weeks for cysts arising
during acute pancreatitis. This provides time to determine if the pseudocyst will regress
in size or disappear and, if persistent, allow the wall to become firm enough to hold
sutures. Resection, the preferred treatment, is usually only performed for those cysts
arising in the tail of the gland. External drainage is performed in acute cases, i.e. when
the acute cyst has ruptured, causing peritonitis or in the face of gross clinical infection.
Risk of recurrence or persistent fistula formation with external drainage is 20%.
Internal drainage is the most frequently used technique. Cystojejunostomy can be
performed for cysts arising in any location. Cystogastrostomy should be used if the
pseudocyst is located in the lesser omental sac posterior to the stomach.
Cystoduodenostomy is chosen whenever the pseudocyst abuts the wall of the duodenum.
Schwartz, Principles of Surgery, 6th ed, 1994, pp 1417-19. Cameron, Current Surgical
Therapy, 5th ed, 1995

Rx of Pancreatic Fistula
Conservative management of pancreato-cutaneous fistulas consist of replacing electrolyte
and fluid output, maintenance of nutritional status with TPN, and local skin care. These
measures alone result in closure of 80% of fistulas after an average of 3-4 weeks. Agents
such as atropine, acetazolamide, epinephrine, glucagon, terbutaline and somatostatin have
been tried with limited success to hasten closure.
Fistula closure is unlikely if any of the following occur: the presence of a proximal
pancreatic duct stricture, the presence of bile or enteric contents, the presence of infection
or foreign body, or the presence of a high output fistula (greater than 200 cc of fluid/day)
for more than 4-6 weeks.
Evaluation of the pancreatic duct with ERCP is necessary to rule out proximal stricture
prior to surgical treatment. If the above conditions are present and conservative
management fails, operative closure of the pancreatic duct fistula is necessary. Fistulas
originating in the tail of the pancreas without obstruction of the proximal pancreatic duct
are treated by distal pancreatectomy. Distal fistulas with proximal obstruction can be
treated with distal pancreatectomy with a pancreaticojejunostomy. Fistulas of the head,
neck or body are best treated by Roux-en-Y pancreaticojejunostomy to the fistula tract.
Internal pancreatic fistulas are manifest as pancreatic pseudocysts. Often occurring after
heavy alcohol intake, pancreatic pseudocysts should be followed for about 6 weeks
before surgery to allow resolution and maturation. Internal drainage using either the
stomach or small bowel (Roux-en-Y cystogastrostomy, -duodenostomy or -jejunostomy)
is considered the optimal surgical treatment. Schwartz, Principles of Surgery, Sixth
Edition, p. 1388. Sabiston, Textbook of Surgery, Sixteenth Edition, pp 1074-1075

Characteristics of Pancreas Divisum

The pancreas appears at about the 5th or 6th week of gestation, and is composed of a
ventral and dorsal anlage. Both possess ducts, the ventral duct is related to the common
bile duct and the dorsal duct empties more proximally into the duodenum. Both ducts
(when present) empty into the second part of the duodenum. At about 7 weeks the
anlages fuse secondary to asymmetric gut rotation. The ventral anlage forms the uncinate
process and a portion of the head. The dorsal component forms the body, tail, and the
remainder of the head. Fusion of dorsal and ventral ductal elements produces the major
duct of Wirsung. Patency of the dorsal duct beyond the site of fusion forms the accessory
duct of Santorini, this occurs in about 70% of individuals. In the other 30%, the proximal
aspect of the dorsal duct (Santorini) regresses after anastomosis with the ventral duct (of
Wirsung). In 4-10% of individuals there is failure of fusion of the dorsal and ventral
ducts; this is termed pancreas divisum. Drainage of the dorsal and ventral aspects of the
pancreas remain separate and the majority of pancreatic exocrine secretion exits via the
accessory duct. In this case the "main" pancreatic duct empties through the minor papilla.
Only pancreatic drainage from the uncinate process drains through the ampulla of Vater.
It is felt by many authors that pancreatitis can result from relative outflow obstruction as
the minor papilla is not able to adequately accommodate such a large volume. Schwartz,
6th Ed, pp 1402, 1408. Simmons & Steed, pp 257-59. O'Leary, pp 63-65