Surgery - Pancreatic Cancer

Surgery - Pancreatic Cancer 

Introduction 
cancer originating in the pancreatic endocrine or exocrine organs.

Etiology 
Cause unknown. Hereditary syndromes include BRCA-2 mutation, Familial Atypical Multiple Mole Melanoma (CDKN2A), Peutz-Jeghers (STK11/LKB1), Hereditary Pancreatitis (PRSS1), MEN, HNPCC, FAP, Gardner, and von Hippel-Lindau syndromes. Five to ten percent of cases have a familial component. Pancreatic intraductal neoplasia, pancreatic mucinous neoplasm, and mucinous cystic neoplasm are examples of precursor lesions.

Epidemiology 
Incidence is rising (8–12/100,000), making cancer the eighth leading cause of death globally. Males twice as many, peak age 60–80 years.

History 
The earliest signs of pancreatic cancer are typically fairly non-specific, making a clinical diagnosis challenging. These consist of nausea, weight loss, anorexia, and malaise. Later, stomach ache and jaundice.

Examination 
indications of weight loss, discomfort, or mass in the stomach.
Gallbladder palpation and jaundice (Courvoisier's law).
Patients who have had metastatic spread may get hepatomegaly.
An accompanying superficial thrombophlebitis is Trousseau's sign.

Pathogenesis 
Five to ten percent occur in the tail, fifteen to twenty percent occur in the body, and seventy-five percent occur in the pancreatic head or neck (where it may manifest as a periampullary tumor). Spread only affects the liver locally. Eighty percent of cancers are adenocarcinomas; mucinous and adenosquamous cystadenocarcinomas are among the other forms. Gastrinomas, glucagonomas, and insulinomas are examples of endocrine tumors.

Investigations

Blood: Elevated levels of the tumor markers CEA and CA19-9 (formerly more specific, although neither is diagnostic) are possible. If causing "bilirubin, "ALP, "clotting may be abnormal if causing obstructive jaundice.
Imaging: CT, MRI, PET, laparoscopy, ultrasound, endoscopic ultrasonography, FNA, and other imaging methods are helpful in staging the illness. Bile cytology/biopsy stenting may be permitted by ERCP.
Other: arranging for an intraoperative ultrasound or laparoscopy.

Management 

Medical: Palliative care is provided to the majority of patients whose illness prevents them from receiving curative resection. Chemotherapy such as gemcitabine, cisplatin, or erlotinib, an antagonist of the epidermal growth factor receptor, may be used for this. Utilizing celiac plexus block, radiation therapy, or pharmacological analgesia to relieve pain. Endoscopic stent implantation or surgical choledochojejunostomy for obstructive jaundice. either a gastrojejunostomy or endoscopic stenting for duodenal blockage.
Surgery: Merely 20% of patients meet the criteria; tumors located on the body and tail are frequently incurable at the time of diagnosis.
Pancreaticoduodenectomy (surgery involving the whipple; see page 184): for head tumors that do not have metastases or vascular involvement. involves resectioning the distal antrum, the distal common bile duct, the pancreatic head, and the first through third segments of the duodenum all at once. With a gastrojejunostomy, the GI tract is rebuilt. A section of the small intestine is anastomosed with the common bile duct and residual pancreas.
Pylorus-preserving duodenectomy of the pancreas: Preserving the pylorus permits the stomach to empty more naturally.

Complications 
Pain, obstructive jaundice, pruritus, cholangitis, diabetes, splenic vein thrombosis, and malignant ascites are among the conditions that are incurable.
Following surgery, there were pancreatic fistulas, anastomotic leaks, hemorrhage, collections, and brittle diabetes.


Prognosis 
At five years, less than 5% of patients remain alive. After the first diagnosis, the median survival for all patients is 4-6 months. Patients who are able to have a curative resection with success have a 5-year survival rate of 15-20% with a median survival of 12-19 months.Individuals with endocrine and periampullary tumors are more likely to survive.