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SSAT Patient Care Guidelines

Surgical Treatment of Pancreatic Cancer

Introduction

Pancreatic cancer is the second most common gastrointestinal malignancy, with 29,000 new cases diagnosed each year. It also has the worst prognosis, with less than 20% of patients surviving one year after diagnosis and less than 5% surviving five years. The only potentially curative treatment is operative resection. Alternative treatments are reserved for more extensive disease, but offer only temporary relief of symptoms. A pancreatic mass or suspected cancer requiring histological confirmation may benefit from surgical consultation for diagnosis. Referral to a surgeon is appropriate for resection (if feasible), biliary or gastric bypass, or assistance in planning treatment.

Symptoms And Diagnosis

More than 90% of patients with pancreatic cancer present with pain, jaundice, and/or weight loss. Acute pancreatitis or recent onset of diabetes mellitus may occasionally be the initial presentation. Vague upper abdominal symptoms may precede the onset of jaundice or overt pain by months, and illustrate the difficulty of early diagnosis in this disease. Whenever pancreatic cancer is suspected, a CT scan of the upper abdomen should be obtained. If a mass is not seen, but clinical suspicion remains high, endoscopic ultrasound or endoscopic retrograde pancreatography (ERCP) may be indicated. It should be noted that a normal endoscopic ultrasound does not rule out the presence of a tumor.. A normal pancreatic ductogram will exclude a carcinoma in the main duct, but may miss small branch duct neoplasms. Most importantly, routine ERCP for diagnostic purposes may be associated with unnecessary morbidity.

Staging

Preoperative staging in pancreatic cancer is used to determine if a patient has a resectable tumor, a localized but unresectable tumor, or metastatic disease. Contemporary staging utilizes multidetector or multislice CT scanning with intravenous contrast to determine the presence or absence of metastatic disease, vascular invasion (often precluding resection), and variations in arterial anatomy. Endoscopic ultrasonography may be helpful in assessing vascular involvement, local nodal metastasis, or extrapancreatic tumor extension, and adds the dimension of transduodenal fine-needle aspiration to confirm the diagnosis cytologically, which is important if resection is not feasible and chemotherapy or chemoradiation is planned. Laparoscopy may be useful in identifying small metastatic hepatic and/or peritoneal implants, in which case further surgery may be avoided. Surgeons with experience in pancreatic surgery should evaluate all patients with pancreatic carcinoma to ascertain their candidacy for resection unless they clearly have distant metastatic disease.

Treatment

In North America, less than one in five patients will have resectable tumors. Tumors in the head of the pancreas are treated by pancreaticoduodenectomy, with or without preservation of the pylorus. Preoperative or intraoperative histologic evidence of malignancy is not required to carry out resection in experienced hands. While a distal pancreatectomy with splenectomy is the procedure of choice for tumors of the body or tail of the pancreas, it is only possible in about 1 in 20 patients. Adjuvant therapy should be considered in all patients following surgery for pancreatic adenocarcinoma. We encourage all physicians to support available clinical trials and encourage all eligible patients to consider protocol-based therapy.

For the majority of patients with unresectable tumors, treatment is primarily one of palliation. In patients with jaundice and gastric outlet obstruction, biliary and/or gastric bypass is indicated. At the time of surgery, a celiac plexus block with 50% alcohol may prevent or relieve pain. In the presence of jaundice alone, treatment is determined by the availability of resources. An endoscopic stent is as effective as surgical bypass, with slightly less morbidity and expense. Patients with locally advanced or metastatic disease, and acceptable performance status, should be considered for protocol-based therapy. In the absence of an available clinical trial, gemcitabine (alone or in combination) is the evolving standard treatment. Patients with locally advanced disease, especially those with pain as a major symptom, may benefit from chemoradiation (capecitabine-based chemoradiation).

Risks

The mortality rate following pancreaticoduodenectomy or distal pancreatectomy is currently less than 5% (in several large series). Significant complications following pancreatic resection occur in 25-30% of patients and include pancreatic fistula, intra-abdominal abscess, or delayed gastric emptying. Intra-abdominal or gastrointestinal bleeding, once frequent, is now uncommon, and reoperation for this complication is seldom necessary. Complication and mortality rates are similar in younger patients and in patients 70 years or older.

Expected Outcomes

The average hospital stay following pancreaticoduodenectomy is less than two weeks, and for distal pancreatectomy is about one week. Recent data suggest that patients have a 5-year survival rate of 15% to 25% following resection, depending upon the histology and completeness of resection. . With current chemotherapy or chemoradiotherapy the median survival for patients with locally advanced disease is10-12 months. Patients with metastatic disease have a median survival of only 3-6 months.

Qualifications

At a minimum, surgeons who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent should perform operations for pancreatic cancer . These surgeons have successfully completed at least 5 years of surgical training after medical school graduation and are qualified to perform operations on the pancreas. Pancreatic surgery should preferably be performed by surgeons with special knowledge, training and experience in the management of pancreatic disease. The level of training in advanced laparoscopic techniques necessary to conduct minimally invasive surgery of the pancreas is important to assess. The qualifications of a surgeon performing any operative procedure should be based on training (education), experience, and outcomes.

References

Fernandez-del Castillo C, Rattner DW, Warshaw AL. Standards for pancreatic resection in the 1990s. Arch Surg 1995;130:295-300.

Lieberman MD, Kilburn H, Lindsey M, Brennan MF. Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy. Ann Surg 1995;222:638-645.

Lillemoe KD. Current management of pancreatic carcinoma. Ann Surg 1995;221:133-148.

Rivera JA, Fernandez-del Castillo C, Warshaw AL. The preoperative staging of pancreatic adenocarcinoma. In: Advances in Surgery (Cameron JL, ed). Chicago: Mosby-Year Book, Inc., 1996;30:97-122

Taoka H, Hauptmann E, Traverso LW, et al. How accurate is helical computed tomography for clinical staging of pancreatic cancer? Am J Surg 1999;177:428-432.

Yeo CJ, Abrams RA, Grochow LB, Sohn TA, Ord SE, Hruban RH, Zahurak ML, Dooley WC, Coleman J, Sauter PK, Pitt HA, Lillemoe KD, Cameron JL. Pancreaticoduodenectomy for pancreatic adenocarcinoma: postoperative adjuvant chemoradiation improves survival. A prospective, single-institution experience. Ann Surg 1997;225:621-636.

Sohn TA, Yeo CJ, Cameron JL, Koniaris L, Kaushal S, Abrams RA, Sauter PK, Coleman J, Hruban RH, Lillemoe KD. Resected adenocarcinoma of the pancreas-616 patients: results, outcomes, and prognostic indicators. J Gastrointest Surg. 2000 Nov-Dec;4(6):567-79.

Key Words - pancreatic neoplasms, patient, guideline, pancreatic adenocarcinoma, fluorouracil, radiation, pancreatic neoplasms/surgery, pancreaticoduodenectomy, postoperative complications

5-8-96
Revised 5-13-96
Board Approved October 8, 1996
Revised 9-27-96
Revised 10-10-96
Revised 2-5-97
Revised 5-8-97
Revised 5-11-97
Revised 8-22-97
Revised 9/26/99
Revised 10/25/99
Proofed 1/8/00

Revised 5/15/04

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Disclaimer
SSAT Patient Care Committee Guidelines

These patient care guidelines were written for the primary care physicians on a variety of digestive diseases to assist on when to refer the patient for surgical consultation.
Their goal is to guide PRIMARY CARE physicians to the appropriate utilization of surgical procedures on the alimentary tract or related organs and they are based on critical review of the literature and expert opinion. Both of the latter sources of information result in a consensus that is recorded in the form of these Guidelines. The consensus addressses the range of acceptable clinical practice and should not be construed as a standard of care. These Guidelines require periodic revision to ensure that clinicians utilize procedures appropriately but the reader must realize that clinical judgment may justify a course of action outside of the recommendations contained herein.

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