Copyright ©2012 Baishideng Publishing Group Co.
World J Gastroenterol. Jun 28, 2012; 18(24): 3058-3069
Published online Jun 28, 2012. doi: 10.3748/wjg.v18.i24.3058
Table 1 Summary of preoperative evaluation of pancreatic adenocarcinoma
Painless jaundice in an appropriately aged patient is highly suspicious for pancreatic cancer
Contrast-enhanced computer tomography is the diagnostic standard
High overall diagnostic sensitivity and specificity
Highly accurate in determining local respectability
Less adequate in identifying small hepatic metastases, extent of local lymphadenopathy and peritoneal tumor deposits
Magnetic resonance imaging gives additional information on small isodense or atypical pancreatic lesions
More accurate than contrast-enhanced computer tomography in detecting smaller hepatic metastases
Enhanced ultrasonography/fine-needle biopsy are reserved for the work-up of small lesions (< 2 cm), or in cases where a fine-needle biopsy is required before palliative or neoadjuvant therapy is initiated
Table 2 Indications for preoperative biliary drainage
Total bilirubin > 250 mmol/L
Acute cholangitis
Severe malnutrition and delayed surgery scheduled (relative indication)
Patients who require neo-adjuvant chemotherapy
Perioperative antibiotic treatment with penicillin in cases with evident infection of the biliary tree and in all patients undergoing biliary drainage
Table 3 Prevention of pancreatic fistula
There is currently no favored pancreatico-digestive anastomotic technique with regard to decreased pancreatic fistula rates
The routine use of octreotide can only be recommended in the case of:
Friable pancreatic tissue
Small diameter of the main pancreatic duct (< 3 mm)
Trans-anastomotic, percutaneously placed drainage of the main pancreatic duct decreases the risk of pancreatic fistula formation
Table 4 Improvement of radicality of resection
ResectionExclusion of resection
Standard lymph node clearance for PPPD/CKW include the regional peripancreatic lymph nodes, hepato-duodenal ligament, common hepatic artery, portal vein, cranial portion of the superior mesenteric vein, right border along the mesenteric superior artery and celiac trunkExtended lymphadenectomy can not be recommended
Vascular resection of the portal vein or superior mesenteric vein is feasible and safe and should not be an exclusion criterion in curative surgeryThrombosis of the mesenteric-portal vein or tumoral infiltration > 180° of these vascular structures are contraindications in attempting curative resection