NMS. Casos Clínicos

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Chapter 7 ♦ Pancreatic and Hepatic Disorders

Other determinations of unresectability include tumor involvement of the inferior vena cava, aorta, and superior mesenteric artery. If these findings indicate no metastasis and no local invasion, pancreaticoduodenectomy may proceed. Q: What are the basic steps in pancreaticoduodenectomy? A: After evaluation for metastasis and resectability, the head of the pancreas is mobilized from the retroperitoneum and superior mesenteric vein and portal vein. The CBD and the first portion of the duodenum are transected in order to preserve the pylorus if possible. The pancreatic neck is transected, followed by detachment of the head and uncinate process from the posterior structures. The jejunum at the ligament of Treitz is transected, the spec- imen removed, and the GI tract reconstructed (Fig. 7-19). Tumor resection is successful. The pathology returns with complete removal of the primary adenocarcinoma of the pancreas with negative margins and no local or metastatic disease. The patient asks about his prognosis. Q: How would you respond? A: The overall cure rate at 5 years is very low , in the range of 5%–10%. However, in some studies, the reported 5-year survival rate for resected pancreatic adenocarcinomas in the head of the pancreas has been as high as 35%–48% in patients with negative nodes. Several factors favor long-term survival, such as tumor diameter less than 3 cm, nega- tive nodal status, diploid tumor deoxyribonucleic acid (DNA) content, tumor S-phase fraction less than 19%, negative resection margins, and the use of postoperative adjuvant chemotherapy and radiotherapy. Q: How would your response change if you had performed a palliative biliary and gastric bypass after finding unresectable pancreatic adenocarcinoma with local spread? A: Surgical palliation with biliary and gastric bypass may prevent gastric outlet or duodenal obstruction and bile duct obstruction. Abdominal and back pain can be decreased by celiac axis injection with alcohol to ablate the nerves. The mean survival in patients undergoing surgical palliation is less than 8 months. Surgical palliation can often be avoided with biliary and duodenal stents (Fig. 7-20) . Q: What is the next step? A: If intrahepatic biliary obstruction but no extrahepatic biliary obstruction is present, this may represent a cholangiocarcinoma or Klatskin tumor. Klatskin tumors are tumors of the biliary tree at the bifurcation of the hepatic ducts. Because they are not always seen as a mass on CT, the next best step is either ERCP or percutaneous transhepatic cholangiog- SAMPLE Case 7.12 Painless Jaundice due to Obstruction at the Common Bile Duct Bifurcation You are asked to evaluate a 60-year-old with painless jaundice. An abdominal ultra- sound shows dilated intrahepatic ducts but no dilation of the CBD.