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Surgery of the pancreas including transplantation

Prof Dr Dr Ernst Hanisch Director Department of Surgery Asklepios Hospital Langen Affiliated Teaching Hospital University of Frankfurt/Main

Mangement of major abdominal trauma

Beckingham, I J et al. BMJ 2001;322:783-785

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Pancreatic leak cause by a gunshot wound. The bullet is also visible

Beckingham, I J et al. BMJ 2001;322:783-785

Copyright ©2001 BMJ Publishing Group Ltd.

ERCP pancreatic duct with obstruction in the pancreatic neck showing injury

Beckingham, I J et al. BMJ 2001;322:783-785

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Pancreatic trauma Complications
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Intra-abdominal abscess Wound infection Pancreatic fistual Pseudocyst Pancreatic abscess or ascites Acute or chronic pancreatitis

Aetiology of chronic pancreatitis
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Alcohol (80-90%) Nutritional (tropical Africa and Asia) Pancreatic duct obstruction Cystic fibrosis Hereditary Idiopathic

Chronic pancreatitis – natural course

Heavily drinking for over 10 years before symptoms develop Pancreatic calcification occurs about 8-10 years after the first clinical presentation Life expectancy is typically shortened by 10-20 years

Chronic pancreatitis Symptoms

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Severe dull epigastric pain radiating to the back Nausea, Vomiting Severe weight loss when steatorrhoea is present Overt diabetes mellitus

Patient using hot water bottle to relieve back pain due to chronic pancreatitis

Bornman, P C et al. BMJ 2001;322:660-663

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Chronic pancreatitis Diagnosis

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Early diagnosis is often made by exclusion based on typical symptoms and a history of alcohol misuse Computed tomography Plain abdominal radiographs Endoscopic retrograde cholangiopancreaticography

ERCP showing dilated common bile duct and main pancreatic ducts in patient with advanced chronic pancreatitis

Bornman, P C et al. BMJ 2001;322:660-663

Copyright ©2001 BMJ Publishing Group Ltd.

Plain abdominal radiograph showing multiple calcified stones within the pancreatic duct

Bornman, P C et al. BMJ 2001;322:660-663

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Computed tomogram showing dilated pancreatic duct with multiple calcified stones

Bornman, P C et al. BMJ 2001;322:660-663

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Chronic pancreatitsTreatment

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Pain control (slow release opioid patches) Abstinence from alcohol Pancreatic enzyme supplements Endoscopic procedures to remove duct stones (extracorporal lithotripsy, stenting) Surgery (Beger‘s procedure)

Duodenal preserving resection of the pancreatic head

Bornman, P C et al. BMJ 2001;322:660-663

Copyright ©2001 BMJ Publishing Group Ltd.

Chronic pancreatitis Complications
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Pseudocysts Biliary stricture Gastroduodenal obstruction Splenic vein thrombosis (Splenomegaly, gastric varices) Gastrointestinal bleeding

Large pseudocyst in patient with chronic pancreatitis. The cyst wall is thin walled and bulging into the stomach and is ideal for endoscopic drainage

Bornman, P C et al. BMJ 2001;322:660-663

Copyright ©2001 BMJ Publishing Group Ltd.

Endoscopic drainage of pseudocyst: sphincterotome is cutting a hole between stomach and pseudocyst wall

Bornman, P C et al. BMJ 2001;322:660-663

Copyright ©2001 BMJ Publishing Group Ltd.

Fig 3 Laparoscopic drainage of a pancreatic pseudocyst. The stomach is insufflated via the nasogastric tube to provide a "working chamber." Intragastric instruments are used to drain the pseudocyst into the stomach lumen

Corvera, C. U et al. BMJ 1997;315:586-589

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Pancreatic tumours – Types

Benign exocrine – serous cyst adenoma, mucinous cyst adenoma Malignant exocrine – ductal adenocarcinoma, mucinous cyst adenocarcinoma Endocrine – Gastrinoma, Insulinoma, other

Factors predicting poor prognosis
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Back pain Rapid weight loss Poor performance status (Karnofsky scoring index) Ascites and liver metastasis High C reactive protein and low albumin concentrations

Rarer presentations of pancreatic carcinoma

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Recurrent or atypical venous thrombosis (thrombophlebitis migrans) Acute pancreatitis Late onset diabetes mellitus Upper gastrointestinal bleeding

Epidemiology of pancreatic cancer

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Incidence: 10 in 100 000 population Median age at diagnosis: 69 years Male to female ratio: 1.2-1.5 to 1 Overall one year survival: 12 % Overall five year survival: 0.4-4 %

Pancreatic cancer – Stage at presentation
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Stage I: 20 % Stage II: 40 % Stage III-IV: 40 %

Pancreatic cancer diagnosis

Serological markers such as CA 19-9 may be used in patients who have symptoms ERCP – cytology, biopsy specimen, insertion of stents Computed tomography or endoscopic ultrasound guided fine needle aspiration EUS is the most sensitive technique for detection of cancer

Treatment of pancreatic ductal carcinoma Resectable

Low risk patient – Pancreatoduodenectomy (Whipple) High risk patient – Endoscopic stent

Tumours suitable for resection
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<4 cm in diameter Confinded to pancreas No local invasion or metastasis

Treatment of pancreatic ductal carcinoma – advanced
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Endoscopic stent Palliative care

Metal wall stent in common bile duct of patient with pancreatic carcinoma

Bornman, P C et al. BMJ 2001;322:721-723

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Pancreatic cancer – summary points

Presentation usually with painless insidious jaundice Median survival from diagnosis is less than six months Less than 15% of all pancreatic tumours are resectable 5-year survival after resection is 10-15%

Patient with jaundice, bruising, and weight loss due to pancreatic carcinoma

Bornman, P C et al. BMJ 2001;322:721-723

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Cystic tumour in head of pancreas with calcified rim

Bornman, P C et al. BMJ 2001;322:721-723

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Necrolytic erythema migrans is pathognomic in patients with glucagonoma

Bornman, P C et al. BMJ 2001;322:721-723

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Pancreatic transplantation - Indications

Diabetic renal failure Simultaneous pancreas and kidney transplantation Prerenal failure, unstable diabetic control, severe neuropathy – Pancreas transplant alone Extensive abdominal tumour – Multivisceral (pancreas, liver, small bowel)

Simultaneous transplantation of pancreas and kidney with bladder drainage

Prasad, K R et al. BMJ 2001;322:845-847

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Pancreatic transplantation

First year mortality 3-10% (overwhelming sepsis) Transplant survival is 86% for the kidney and 70% for the pancreas