MANAGEMENT

Jennifer BorjaRaiza Bondoc

SURGICAL RESECTION

• Only potentially curative treatment for patients with pancreatic cancer

• The resectability of malignant pancreatic tumors needs to be established

• Pancreatic masses are characterized– resectable, unresectable, or borderline

resectable.

SURGICAL RESECTION

• Pancreaticoduodenectomy (whipple procedure)

• Distal pancreatectomy• Total pancreatectomy

PANCREATICODUODENECTOMY (WHIPPLE PROCEDURE)

• Removal of the head and uncinate process of the pancreas, duodenum, proximal 6 in (15 cm) of jejunum, gallbladder, common bile duct, and distal stomach

• With anastomosis of the common hepatic duct and the remaining pancreas and stomach to the jejunum

• All share a common blood supply

PANCREATICODUODENECTOMY (WHIPPLE PROCEDURE)

The Whipple procedure. Before the procedure(A). After the procedure; note the anastomosis of the hepatic duct and the remaining pancreas and stomach to the jejunum(B).

PANCREATICODUODENECTOMY (WHIPPLE PROCEDURE)

• Patients who will most likely benefit from this procedure have a tumor located in the head of the pancreas or the periampullary region

DISTAL PANCREATECTOMY

• May be an effective procedure for tumors located in the body and tail of the pancreas

• Isolation of the distal portion of the pancreas containing the tumor

• Resection of that segment• Oversewing of the distal pancreatic duct

TOTAL PANCREATECTOMY

• Tumor involves the neck of the pancreas.– Either the tumor originates from the neck or is

growing into the neck

Metastatic Lesions

• Single- and multiple-agent chemotherapeutic regimens

• gemcitabine vs. fluorouracil– first-line therapy – 12-month survival advantage– improves or stabilizes pain, performance status,

and weight

• Clinical trial (gene therapy)

Locally Advanced Lesions

• External beam and intraoperative radiation therapy – ↓ local progression – neither affects survival or metastasis

• Radiation therapy alone – not effective• Combined radiation therapy and

fluorouracil-based chemotherapy vs. radiation therapy alone – 40 vs. 10% survival after 1 year, NNT = 3

Palliative Care

3 clinical problems in advanced pancreatic CA:1. Pain2. Jaundice3. Duodenal obstruction

** cachexia, malabsorption

Palliative Care: PAIN

• Oral narcotics – mainstay– SR preparations of morphine sulfate

• Celiac plexus neurolysis – i.e. chemical splanchnicectomy of the celiac

plexus with alcohol. – injecting 50% alcohol directly into the tissues

along the sides of the aorta just cephalad and posterior to the origin of the celiac trunk.

– intraoperatively, percutaneously, or endoscopic ultrasonography.• effective • minimal risk of the potentially serious complications

Palliative Care: JAUNDICE

• Choledochojejunostomy – surgical formation of a communication between the

common bile duct and the jejunum

• Cholecystojejunostomy– surgical formation of a communication between the

gallbladder and the jejunum.

** can be performed with gastrojejunostomy

Palliative Care: JAUNDICE

• Expandable wire stents: endoscopically– Lower risk vs. surgery– not as durable as a surgical bypass– Complications: bleeding, infection, and

pancreatitis; recurrent obstruction & cholangitis– effectively manage duodenal obstruction in 81%

of patients– Metal stents cost less and require a shorter

hospital stay than surgical treatment

Palliative Care: DUODENAL OBSTRUCTION

• Gastrojejunostomy– GI surgery procedure in which the duodenum is

excised or bypassed and the stomach is end-to-end anastomosed to the jejunum

– relieves gastric outlet or duodenal obstruction– sometimes associated with delayed gastric

emptying

Gastrojejunostomy

Palliative Care: CACHEXIA, MALABSORPTION

• Pancreatic enzyme replacement– Exocrine pancreatic insufficiency and subsequent

malabsorption– 30,000 IU of pancrelipase – before, during, and after a meal, with ↑ titration

as needed

• Appetite stimulants, high-calorie diet or nutritional supplements