St. Mary’s A. 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 3

Cambridge classification of image severity for chronic pancreatitis  *MPD terminates prematurely, multiple strictures, dilated >10cm, ductal filling defects (stones), “cavities”, contiguous organ involvement Cambridge ClassMain Pancreatic Duct Abnormal side branches Normal 0 EquivocalNormal<3 MildNormal>3 ModerateAbnormal>3 MarkedAbnormal*>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 5

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 7

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 Resection Subtotal 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) Relaparotomy5.6% (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.