c l i n i c a l f o l i o s : d i s c u s s i o n



Whipple Procedure

 

 

Etiology

 

• Mucinous neoplasm - diagnosis (adenoma vs. carcinoma) made at surgery

 

 

• Adenoma

 

 

• Carcinoma

 

• Serous cystadenoma

 

 

• Indolent local growth can cause compressive symptoms

 

 

 

• Biliary or duodenal obstruction

 

 

 

• Invasion of local structures with fistula formation

 

 

 

 

Differential Diagnosis

 

• Intraductal papillary mucinous tumors

 

 

• Often confused with mucinous cystic lesions

 

 

• Neoplastic epithelium produces mucin which dilates pancreatic duct

 

 

 

• May result in obstructive jaundice (14-50% of cases)

 

 

 

Mucinous cystic lesions do not communicate with duct

 

 

• Good prognosis when tumor limited to epithelium, poor with invasive disease

 

 

• Most common in elderly men 60 - 80 years old

 

 

• Acute pancreatitis most common presentation with relapsing episodes

 

 

• ERCP gold standard for diagnosis (91% sensitivity/specificity)

 

 

 

• Diagnosostic tests otherwise same as cystic lesions (see below)

 

 

• Surgical resection mainstay of treatment (see below)

 

• Simple cysts

 

 

• Epithelial wall lining

 

 

• Extremely rare (12 cases in literature)

 

• Inflammatory pseudocyst

 

 

• Result from recurrent pancreatitis

 

 

• No epithelial lining

 

 

• No malignant potential

 

 

• No loculations on CT scan

 

 

• Wall biopsy at drainage may miss mucinous lesions

 

 

• Treated with observation, external or internal drainage

 

 

 

 

Diagnosis

 

• No history of pancreatitis

 

• ERCP

 

• CT scan

 

 

• Mucinous – small number of large cysts (> 2cm)

 

 

• Serous – many small cysts

 

• Cyst fluid aspiration (endoscopic or CT guided FNA)

 

 

Indicated to rule out cystic neoplasm in suspected inflammatory pseudocyst or to diagnosis serous cystadenoma in patient who may not tolerate resection well

 

 

• Cytology

 

 

 

• Mucinous – positive for mucin, malignant cells if carcinoma

 

 

 

• Serous – positive for glycogen

 

 

• CEA level

 

 

 

• Mucinous – > 500 (varies)

 

 

 

• Serous – < 5

 

 

• Cyst fluid amylase

 

 

 

• Mucinous – > 2000 (varies)

 

 

 

• Serous – < 5000

 

 

 

 

Operative Approach

Resection of all cystic neoplasms of the pancreas except in those patients felt not to be a candidate for resection and when a serous cystadenoma can be diagnosed. Mucinous carcinomas of the pancreas are treated the same as pancreatic adenocarcinoma with respect to adjuvant treatment.
 

 

• Pancreatic head lesions

 

 

• Whipple procedure (pancreaticoduodenectomy)

 

 

• Pylorus preserving pancreaticoduodenectomy

 

 

 

• Thought to increase postoperative weight gain and nutrition

 

 

 

• Recent study indicates increase in gastric emptying with pylorus preserving procedure and no significant difference in operative mortality or morbitity

 

• Pancreatic tail lesions – distal pancreatectomy

 

 

 

 

Complications

 

• Pancreaticoduodenectomy with 1-5% perioperative mortality

 

• Pancreaticoduodenectomy with 46% incidence significant complications

 

• Pancreatic fistula

 

 

 

• Treatment with ligation and drainage of pancreatic stump, pancreaticojejunostomy, pancreaticogastrostomy

 

 

 

• Somatostatin may reduce incidence of fistula formation

 

• Gastrointestinal bleeding

 

• Delayed gastric emptying

 

• Postgastrectomy syndrome

 

• Wound infection

 

 

 

 

References

Textbook of surgery: the biological basis of modern surgical practice.-15th ed. / [edited by] David C. Sabiston, Jr.; editor for basic surgical science, H. Kim Lyerly.

Surgical attending rounds/ [edited by] K. Francis Lee, Cornelius M. Dyke - 2nd ed.

P.W. Lin and Y.J. Lim. Prospective randomized comparison between pylorus-preserving and standard pancreaticoduodenectomy. Brit Jour Surg. 86: 603-607. (1999).

Current Surgical Therapy.-6th ed. / [edited by] John C. Cameron. 1998.

Azar, C., Van de Stadt, J., et al. Intraductal papillary mucinous tumours of the pancreas. Clinical and therapeutic issues in 32 patients. Gut. 39(3): 457-464. (1996).


This page was last modified on 10-Aug-2000.