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Review
. 2012 Jun 28;18(24):3058-69.
doi: 10.3748/wjg.v18.i24.3058.

Ductal adenocarcinoma of the pancreatic head: a focus on current diagnostic and surgical concepts

Mehdi Ouaïssi  1 , Urs Giger, Guillaume Louis, Igor Sielezneff, Olivier Farges, Bernard Sastre
Affiliations
Review

Ductal adenocarcinoma of the pancreatic head: a focus on current diagnostic and surgical concepts

Mehdi Ouaïssi et al. World J Gastroenterol. .

Abstract

Complete surgical resection still remains the only possibility of curing pancreatic cancer, however, only 10% of patients undergo curative surgery. Pancreatic resection currently remains the only method of curing patients, and has a 5-year overall survival rate between 7%-34% compared to a median survival of 3-11 mo for unresected cancer. Pancreatic surgery is a technically demanding procedure requiring highly standardized surgical techniques. Nevertheless, even in experienced hands, perioperative morbidity rates (delayed gastric emptying, pancreatic fistula etc.) are as high as 50%. Different strategies to reduce postoperative morbidity, such as different techniques of gastroenteric reconstruction (pancreatico-jejunostomy vs pancreatico-gastrostomy), intraoperative placement of a pancreatic main duct stent or temporary sealing of the main pancreatic duct with fibrin glue have not led to a significant improvement in clinical outcome. The perioperative application of somatostatin or its analogues may decrease the incidence of pancreatic fistulas in cases with soft pancreatic tissue and a small main pancreatic duct (< 3 mm). The positive effects of external pancreatic main duct drainage and antecolic gastrointestinal reconstruction have been observed to decrease the rate of pancreatic fistulas and delayed gastric emptying, respectively. Currently, the concept of extended radical lymphadenectomy has been found to be associated with higher perioperative morbidity, but without any positive impact on overall survival. However, there is growing evidence that portal vein resections can be performed with acceptable low perioperative morbidity and mortality but does not achieve a cure.

Keywords: Pancreatic adenocarcinoma; Pancreatic fistula; Pancreatic surgery; Venous resection.

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Figures

Figure 1
Figure 1
Ductal dilation, computer tomography 3-phase contrast-enhanced thin-slice helical scan. A: Heterogenous tumor of the pancreatic head with consecutive extra- and intrahepatic bile duct dilatation (arrow); B: “Double duct sign” due to a tumor of the papilla of vater (arrow); C: Tumor of the pancreatic neck with an upstream dilatation of the pancreatic duct and parenchymal atrophy of the pancreatic gland. Presence of a cavernoma due to tumor thrombosis of the portal vein (arrow); D: Classic radiological presentation of a pancreatic neck tumor with a less pronounced enhancement compared to the normal pancreatic parenchyma (arrow).
Figure 2
Figure 2
Vascular tumor extension, computer tomography 3-phase contrast-enhanced thin-slice helical scan, sagittal section and 3D reconstruction. A, B: Sheathing and thrombosis of the celiac trunk (asterisk) and superior mesenteric artery (arrow) with collateral blood flow via the inferior mesenteric vessels; C: Tumor of the pancreas (arrow) in contact with the superior mesenteric artery and infiltration of the portal vein; D: Tumor sheathing or the origin of the superior mesenteric artery (arrow) with irregularities as a sign of arterial invasion.
Figure 3
Figure 3
Magnetic resonance imaging appearance. A: T1 sequence showing an adenocarcinoma of the pancreas with a hypo-intense signal (arrow), whereas normal pancreatic tissue appears hyper-intense; B: T1 sequence with fat saturation injection: after injection of gadolinium, the pancreatic adenocarcinoma is hypo-enhanced (arrow) compared to the healthy parenchyma; C: A sequence of diffusion: hyper-intensity (arrow) signal due to the hyper-cellularity of the tumor; D: Sequence 3D-magnetic resonance cholangiopancreatography: stenosis of the main pancreatic duct (arrow) with upstream dilatation due to a tumor of the pancreatic isthmus.
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