and therefore may not be routinely detected. Moreover, peritoneal and omental metastases are usually

only 1 to 2 mm in size and frequently can be detected only by direct visualization. With the recent

improvements in CT imaging, the rate of unsuspected positive peritoneal findings approaches 10% to

15% for all patients. The percentage however varies with tumor location. Patients presenting with

obstructive jaundice secondary to tumors in the head of the pancreas typically have only a 15% to 20%

incidence of unexpected intraperitoneal metastasis after routine staging studies. In contrast, unexpected

peritoneal metastasis is found in up to 50% of patients with cancer of the body and tail of the

pancreas.15

Selective use of staging laparoscopy should be considered for patients at high risk of occult metastatic

disease (Table 55-10). The information gained from preoperative staging provides the basis for planning

therapy for each individual patient. If the results of preoperative staging with CT/MRI and laparoscopy

show localized disease, resectability rates may approach 90% for tumors in the head of the pancreas.

Table 55-9 Preoperative Staging based on CT Findings

Algorithm 55-2. Management strategy based on CT criteria for resectability of pancreatic cancer.

RESECTION OF PANCREATIC CARCINOMA

Carcinoma of the Head, Neck, or Uncinate Process

In 1912, Kaush16 reported the first successful resection of the duodenum and a portion of the pancreas

for an ampullary cancer. In 1935, Whipple et al.17 described a technique for radical excision of a

periampullary carcinoma. The operation was originally performed in two stages. A

cholecystogastrostomy to decompress the obstructed biliary tree and a gastrojejunostomy to relieve

gastric outlet obstruction comprised the first stage. The second stage was performed several weeks later

when the jaundice had resolved and the nutritional status had improved. During the second stage, an en

bloc resection of the second portion of the duodenum and head of the pancreas was performed without

reestablishing pancreatic–enteric continuity. Although earlier contributions had been made, the report

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by Whipple et al. began the modern-day approach to the treatment of pancreatic carcinoma.

DIAGNOSIS

Table 55-10 Signs of High Risk of Occult Metastatic Disease

The operative management of pancreatic cancer consists of two phases: first, assessing tumor

resectability and then, if the tumor is resectable, completing a PD and restoring gastrointestinal

continuity. After the abdomen has been opened through an upper midline or bilateral subcostal incision,

a careful search for tumor outside the limits of a pancreaticoduodenal resection should be carried out.

The liver, omentum, and peritoneal surfaces are inspected and palpated, and suspect lesions are sampled

and specimens submitted for frozen-section analysis. Next, regional lymph nodes are evaluated for

tumor involvement. The presence of tumor in the periaortic lymph nodes of the celiac axis indicates that

the tumor is beyond the limits of normal resection. However, the presence of tumor-bearing lymph

nodes that normally would be incorporated within the resection specimen does not constitute a

contraindication to resection.

Once distant metastases have been excluded, the primary tumor is assessed in regard to resectability.

Local factors that preclude pancreaticoduodenal resection include retroperitoneal extension of the tumor

to involve the inferior vena cava or aorta or direct involvement or encasement of the superior

mesenteric artery, hepatic artery, and celiac axis. Involvement of the superior mesenteric vein (SMV),

or portal vein can be managed with venous resection and reconstruction in select cases. The technical

aspects of determining local resectability begin with a Kocher maneuver and mobilization of the

duodenum and head of the pancreas from the underlying inferior vena cava and aorta. Once the

duodenum and head of the pancreas are mobilized sufficiently, the surgeon’s hand can be placed under

the duodenum and head of the pancreas to palpate the relationship of the tumor mass to the superior

mesenteric artery. Inability of the surgeon to identify a plane of normal tissue between the mass and the

arterial pulsation indicates direct tumor involvement of the superior mesenteric artery, and the

possibility of complete tumor resection is eliminated.

The final step to determine resectability involves dissection of the superior mesenteric and portal

veins to rule out tumor invasion. Identification of the portal vein can be simplified greatly if the

common hepatic duct is divided and reflected early in the dissection. Once the hepatic duct has been

divided, the posteriorly located portal vein can be identified easily. After the anterior surface of the

portal vein is dissected posterior to the neck of the pancreas, the next step is to identify the SMV and

dissect its anterior surface. This is done most easily by extending the Kocher maneuver past the second

portion of the duodenum to include the third and fourth portions of the duodenum. During this

extensive kocherization, the first structure that one encounters anterior to the third portion of the

duodenum is the SMV. Alternatively the SMV may also be identified by tracing either the middle colic

vein or the right gastroepiploic vein back to the SMV after entering the lesser sac thru the gastrocolic

ligament. The anterior surface of the SMV then can be cleaned rapidly and dissected under direct vision

by retracting the neck of the pancreas anteriorly. The dissection is continued until it connects to the

portal vein dissection from above.

Most experienced pancreatic surgeons, at this point, proceed with a PD without obtaining a tissue

diagnosis. The clinical presentation, results of preoperative CT and cholangiography, and operative

findings of a palpable mass in the head of the pancreas surpass the ability of an intraoperative biopsy to

define the diagnosis of malignancy.

Having excluded regional and distant metastases and demonstrated no tumor involvement in major

vascular structures, the surgeon can proceed with PD with a high degree of certainty that the tumor is

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resectable. In the pylorus-preserving modification of PD, the duodenum is first mobilized and divided

approximately 2 cm distal to the pylorus. If a classic Whipple procedure is to be performed, the stomach

is divided to include approximately 40% to 50% of the stomach with the resected specimen. The

gastroduodenal artery is exposed, ligated, and divided near its origin at the common hepatic artery. It is

always important to confirm, before ligation, that the structure to be ligated is indeed the

gastroduodenal artery and not a replaced right hepatic artery. Next, the neck of the pancreas is divided,

with care taken to avoid injury to the underlying superior mesenteric and portal veins. The portal and

superior mesenteric veins are then dissected from the uncinate process and head of the pancreas. At this

point, the fourth portion of the duodenum and the proximal jejunum are mobilized, with the proximal

jejunum divided approximately 10 cm distal to the ligament of Treitz. The proximal jejunum and fourth

portion of the duodenum are passed under the superior mesenteric vessels to the right, and the uncinate

process is dissected from the superior mesenteric artery clearing all of the tissue along the right border

of the artery. The course of the superior mesenteric artery should be clearly identified to avoid injury to

this structure. At this point, the specimen consisting of the gallbladder and common bile duct; the head,

neck, and uncinate process of the pancreas; the entire duodenum; and the proximal jejunum (and the

distal stomach for a traditional Whipple procedure) is freed completely and removed from the operative

field (Fig. 55-6). Margins should be inked to facilitate pathologic analysis of the specimen.

Figure 55-6. Pancreaticoduodenectomy. A: The tissue to be resected in a standard pancreaticoduodenectomy. B: Reconstruction

after a standard pancreaticoduodenectomy. C: Reconstruction after the pylorus-sparing variation.

Table 55-11 Randomized Prospective Trials of Standard Versus Extended

Lymphadenectomy for Pancreatic Cancer

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