St. Mary’sA. Tubbs

3.3cm cystic mass head of pancreas on CT

Chronic epigastric abdominal pain worsening over past year

CT abd/pelv 3mos ago consistent with acute interstitial pancreatitis

Drinks several beers daily and smokes Past medical history: Asthma, sciatica,

gastritis Meds: Flexeril, Combivent, Robaxin,

Nexium Past surgical history: Tubal ligation CA19-9: 8 (0-35), Alb 2.9

2

Imaging

CT Sept 2011 and Feb

2012 3.1x2 3.3x2.3 Nonspecific lesion in

the inferior aspect of the junction of the pancreatic head and uncinate process

Acute interstitial pancreatitis

MRI Sept 2011 and Feb

2012 Cystic and solid

component Septations No pancreatic ductal

dilatation or continuity with the ductal system

Enlargement

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Cambridge classification of image severity for chronic pancreatitis

*MPD terminates prematurely, multiple strictures, dilated >10cm, ductal filling defects (stones), “cavities”, contiguous organ involvement

Cambridge Class Main Pancreatic Duct

Abnormal side branches

Normal Normal 0

Equivocal Normal <3

Mild Normal >3

Moderate Abnormal >3

Marked Abnormal* >3

Pancreaticoduodenectomy No occult metastasis Cholecystectomy Kocher maneuver Not attached to the SMV Common bile duct transection GDA isolated, clamped and divided Limited distal gastrectomy due to extensive

fibrotic adhesions End-to-end pancreaticojejunostomy End-to-side hepaticojejunostomy Gastrojejunostomy

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Pathology Marked acute and chronic pancreatitis with

fibrosis and acinar atrophy Pancreatic ductal dilatation with abundant

acellular material No malignancy, 12 benign nodes

Chronic pancreatitis

Endotherapy Resection

Failure of endotherapy Recalcitrant stone disease with MPD stricture MPD stricture with no stones, stent dependent

Meet criteria for severe chronic abdominal pain centered at head of pancreas

PPPD Frey and Berger procedures

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Pancreatic Cystic Lesions

Inflammatory pseudocysts Mucinous cysts

Intraductal Papillary Mucinous Neoplasms (IPMNs) Mucinous Cystadenomas (MCAs) Nondysplastic Mucinous Cysts (NDMCs)

Serous cysts Serous cystadenomas (SCAs) Serous cystadenocarcinomas

Other cysts Malignancies uncharacteristically demonstrating

cystic morphology Neoplasms

Premalignant versus malignant

Pancreatic Cystic Lesions

Pancreatic cystic lesions are being found commonly due to widespread use of CT & US for all abdominal conditions

Rarely is it possible to make a specific diagnosis based on imaging alone Clinical presentation important

Age & gender (e.g., young woman: SPEN or mucinous cystic; older man: Serous)

Location of lesion (e.g., head/neck for serous & side branch IPMT; body/tail for mucinous cystic neoplasm)

Calcification within lesion (e.g., peripheral in mucinous, central in serous cystadenoma)

Mural nodularity (enhancement = neoplastic) Duct communication (favors IPMT; use multiplanar reformations to follow

long axis of pancreatic duct) Endoscopic US is complementary study, giving high resolution images of

cyst and opportunity to sample contents of cyst Unless patient has clear history of pancreatitis, all cystic masses should be

considered potential neoplasms Although small lesions in elderly or ill patients may require no additional

evaluation or treatment

Pancreatic pseudocyst

Most common etiology for a symptomatic cystic mass

Has definable wall which may calcify (but lacks epithelial lining)

+/- Septum; no mural nodules

FNA: high amylase

Mucinous Cystic Pancreatic Tumor (cystadenoma) Most common cystic

neoplasm Malignant potential,

resection Usually in middle-

aged women, in body-tail segment

Thick wall, may have peripheral calcification, no communication with duct system

FNA: Mucin-rich, CEA >200

IPMNs

Intraductal mucin-producing cystic neoplasms of the pancreas with clear malignant potential

Main duct type: Marked distention of pancreatic duct

Side branch type: Causes "cystic" dilation of side branches, usually in head-uncinate

May simulate serous microcystic adenoma

Serous Cystadenoma

Innumerable "microcysts" in spherical pancreatic mass

Innumerable thin septa, may coalesce and calcify in center of mass

Starburst/stellate or honeycomb/cluster of grapes

Thin wall, benign FNA: clear, serous low in

CEA and mucin, atypia This form is difficult to

distinguish from mucinous cystic neoplasm

Cystadenocarcinoma

Solid Psuedopapillary Neoplasm Usually mostly solid

with necrotic, hemorrhagic foci

Cystic appearance reflects necrotic degeneration

Usually in young women

Metastatic potential, resection

Pancreatic Ductal Carcinoma Rarely cystic, but

hypovascular or necrotic tumor may simulate cystic mass

Axial CECT shows a remarkable cystic or necrotic pancreatic ductal carcinoma (white arrow), that encases the celiac axis (white curved).

Epithelial (true) Cyst

Congenital, epithelial-lined, benign

Occurs in children & adults

No mural nodularity

Partial, Subtotal, and Total Duodenum-preserving Resection of the Pancreatic Head in Chronic Pancreatitis and Neoplastic Cystic Lesions

Alcohol is most frequently the cause of chronic pancreatitis Most have a severe abdominal pain

syndrome No preventive therapy for chronic

pancreatitis Avoidance of alcohol consumption Analgesic treatment Supplementation with exogenous enzyme

substitutes Treatment of diabetes mellitus. Medically intractable pain and the

development of severe local complications are reasons to change from medical management to surgical treatment

Indications for ResectionSubtotal duodenum preserving pancreatic head

resection

Chronic pancreatitis complicated by Inflammatory mass in the pancreatic head

Stenosis of CBD Multiple stenoses and dilatations of Pancreatic Main Duct Severe narrowing of peripapillary duodenum, causing

gastric outlet syndrome Compression/stenosis of PV/SMV Pancreas divisum, causing CP or recurrent acute

pancreatitis Intraductal, papillary mucinous tumor in pancreatic head Mucinous cystic tumor in pancreatic head Large (>2 cm) endocrine neoplasia in pancreatic head

Subtotal pancreatic head resection After subtotal resection, a

shell-like remnant of the pancreatic head along the duodenal wall is maintained.

The blood supply to the duodenum is maintained by the dorsal pancreaticoduodenal arcades and the supraduodenal and mesoduodenal vessels.

Subtotal, Duodenum-preserving Pancreatic Head Resection in Chronic Pancreatitis: Early Postoperative Results

From Beger HG, Schlosser W, Friess HM, et al. Duodenum-preserving head resection in chronic pancreatitis changes the natural course of the disease. A single-center 26-year experience. Ann Surg 1999; 230:512, with permission.

Postoperative hospital stay

14.5 d mean (7–87)

Relaparotomy

5.6% (28 of 504 patients)

Hospital deaths

0.8% (4 of 504 patients)

Subtotal pancreatic head resection In patients with alcoholic-related chronic

pancreatitis who have developed an inflammatory mass in the pancreatic head, a subtotal duodenum-preserving pancreatic head resection results in a change of the natural course of the disease with regard to pain status, frequency of acute episodes of chronic pancreatitis, need for further hospital admissions, late mortality rate, and quality of life.

Results in a delay or even a break in the progressive loss of pancreatic exocrine and endocrine function

Subtotal pancreatic head resection Benefits in cystic neoplastic lesions restricted to the head

are the preservation of the stomach, duodenum, intestine, and biliary main duct as well as maintenance of the exocrine and endocrine functions

Duodenum and spleen conservation is even recommended in patients suffering from IPMN that is localized in the pancreatic head and body and is treated with total pancreatectomy

To avoid the risks of ischemic lesions of periampullary duodenum, total resection of the pancreatic head and a segmental resection of the duodenum, including the papilla, has been introduced in clinical practice

An oncologic pancreatic head resection (e.g., a Whipple-type resection) has to be performed in patients suffering from a cystic neoplastic lesion and an invasive cancer.