1. Staging and Surgical Management
of Pancreatic Cancer
Justin Geoghegan
St Vincent’s University Hospital

2. Walter Kausch (1867-1928)
Allen Oldfather Whipple (1881-1963)

3. Staging of Pancreas Cancer
CT
very good at predicting resectability
moderately good at predicting unresectability
cannot distinguish between reactive and malignant
lymphadenopathy

4. Staging of Pancreas Cancer
CT

5. Staging of Pancreas Cancer
Endoscopic ultrasound
diagnosis, especially of small
lesions
tumour size
staging of lymph node
status and assessment
of vascular involvement
biopsy

6. lymph node status
? selection for neo-adjuvant
treatment

7. Staging of Pancreas Cancer
Laparoscopy and lap ultrasound
small volume peritoneal disease
metastatic liver disease
peritoneal cytology
as CT improves, the pick-up rate from laparoscopy
decreases
selective vs invariable use

8. Staging of Pancreas Cancer
Laparoscopy and lap ultrasound
“always use it”
changes management in 10-15%
?separate anaesthetic/procedure or immediately
prior to laparotomy
separate procedure needed if peritoneal cytology
is considered important

9. Laparoscopy and peritoneal cytology
Author Journal patient number effect of positive cytology
Leach Surgery 1995 80 indicates advanced disease
Merchant J Am Coll Surg 1999 228 assoc with advanced disease
predicts unresectability
Makary Arch Surg 1999 32 contraindicates resection
Nakatsuka Internat J Surg Inves 1999 50 contraindicates resection
Nakao Hepatogastroenterolgy 1999 74 no effect on survival
Yachida Br J Surg 2002 134 doesn’t predict carcinomatosis
doesn’t contraindicate resection
Meszoely Am Surg 2004 168 should not preclude resection
Ferrone J Gastrointest Surg 2006 462 same outcome as patients with
stage IV disease
Yamada Ann Surg 2007 233 no effect on survival

10. Staging of Pancreas Cancer
Laparoscopy and lap ultrasound
“selective”
larger tumours
equivocal findings on CT – ascites
weight loss
grossly elevated tumour markers
changes management in 25%

11. Staging of Pancreas Cancer
Laparoscopy and lap ultrasound
when to do it?
separate anaesthetic or immediately prior to
laparotomy for resection
decision needs to be individualised depending on
- likelihood of positive finding
- presence of jaundice
- logistical factors

12. When is biopsy required?
unresectable
imaging raises possibility of an alternative tissue type
that may be amenable to different treatment strategy
patient request
reasonable possibility of chronic pancreatitis
mimicking cancer

13. Unresectability
co-morbidity
distant metastases – liver, peritoneal
encasement of coeliac, hepatic or sup mesenteric arteries
major encasement of portal vein-superior mesenteric vein
lymph node status
surgeon-dependent

15. Pancreatic resection
balance between mortality/morbidity and benefit
mortality rate <5%
major complication rate 40%
high rate of positive margins

16. Birkmeyer,2003

17. Technical Issues
neoadjuvant treatment
extended lymphadenectomy
portal vein resection
pylorus-preserving
pancreatic reconstruction
drains
octreotide

18. Extended resections
total
pancreatectomy
extended
lympadenectomy
portal vein and
SMA resection
Fortner, Cancer 1981

21. Extended lymphadenectomy
Michalski et al Br J Surg 2007

22. Extended lymphadenectomy
Michalski et al Br J Surg 2007

23. Portal vein resection
does it affect survival?
does it affect morbidity and mortality?
does it have a role?

24. Koniaris, J Am Coll Surg 2003

25. Portal vein resection
portal vein resection does not affect survival
probably no effect on morbidity
portal vein invasion is a function of tumour location
rather than tumour biology

26. Pylorus preserving
pancreatectomy

27. Randomized trials of pylorus-
preserving vs classical Whipple

28. Pancreatic reconstruction
end-to end
pancreaticojejunostomy
end-to-side
pancreaticojejunostomy
pancreaticogastrostomy

29. Drains,Stents and Octreotide
drains – no benefit
Conlon, Ann Surg 2001
stents – no difference
Winter, J Gastrointest Surg 2006
octreotide – may be of value for high-risk
pancreatic anastomosis
Connor,Br J Surg 2005

30. Quality of life after pancreatic
resection
Schniewind et al
2006

31. Outcome of Whipple’s procedure depends on tumour type
Schmidt, C. M. et al. Arch Surg 2004;139:718-727.

33. How to improve surgery?
earlier detection
screening
better staging
high-volume centres
neoadjuvant and adjuvant treatment