Pancreaticojejunostomy: A Case Study

Treatment Currently the only curative therapy for PDAC is complete surgical resection. Unfortunately due to the aggressive nature of this disease, only 15- 20% of diagnosed patients undergo surgical resection (Al-Hawary et al., 2013a; Castellanos & Merchant, 2013). Of those who do undergo resection, the average survival time for the patient is only 12-20 months (Brouda, 2010). Once a patient has been deemed with a resectable tumor, the type of surgery they will undergo will depend on the location of the tumor (Gall, Tsakok, Wasan & Jiao, 2015). A tumor located in the uncinated process or right of the SMV in the pancreatic head, which is about 60% of the tumors, are potentially suitable for a Whipple procedure, otherwise known as a pancreaticoduodenectomy
procedure, or a pylorus-preserving pancreaticoduodenctomy. A tumor located left of the SMV in the pancreatic body or tail potentially suitable for a distal pancreatectomy (Al-Hawary et al., 2014b).
A Whipple surgery involves the removal of the distal stomach and pylorus, the duodenum, portions of the bile duct, gallbladder, and head of the pancreas (Gall et al., 2015).
After the removal of these structures three anastomoses are required to be made. In order to reconnect the remaining pancreas and main pancreatic duct, a pancreaticogastrostomy or pancreaticojejunostomy will be performed; a gastrojejunostomy will be placed to reconnect the post pylorus duodenum to the jejunum or a duodenojejunostomy to reconnect post pylorus to jejunum in a PPPD procedure; and a hepaticojejunostomy to reconnect the common hepatic duct of the GI tract (Gall et Al., 2015; Shroff et al., 2011). Most common problems following surgery include delayed gastric emptying, postoperative pancreatic fistulas and wound infections (Gall et al.,
2015).
Distal pancreatectomy (DP) is performed when the lesion is located in the pancreatic body or tail. The surgery removes the tail and body of the pancreas as well as the spleen. This operation is performed as both an open and laparoscopic procedure (Gall et al., 2015). Caution is typically advised when resection of a tail lesion is considered because of the increased risk of seeding (Shroff et al., 2011).The greatest complication associated with DP is postoperative pancreatic fistula and sepsis (Gall et al., 2015). Whether the patient had a DP or Whipple procedure, adjuvant therapy may be prescribed in hopes to reduce the risk of relapse (Shroff et al., 2011). The optimal adjuvant chemotherapy is usually initiated within 4-6 weeks following surgery and sustained for a total of six months (Gall et al., 2015).
If a patient is not a candidate for surgery, palliative chemotherapy is the core treatment. Typically gemcitabine has been the chemotherapy of choice (Al-Hawary et al., 2013a). The National Comprehensive Cancer Network recommends use of chemoradiation followed by systemic chemotherapy for those with locally advanced disease (Vincent et al., 2011). If a patient has poor performance status then chemotherapy may not be deemed beneficial. Even if deemed useful, the use of chemotherapy is controversial because some patients actually become worse with such treatments (Brouda, 2010).
Follow-Imaging
Primary purpose of surveillance after surgical resection is for the timely detection of recurrence in hopes to offer further treatment options or at least an improved survival. Surveillance also allows a patient to receive reassurance on their health progression (Castellanos & Merchant, 2013). Current guidelines by the NCCN recommend a history and physical exam every 3-6 months for 2 years (Castellanos & Merchant, 2013). A CT scan of the abdomen and pelvis is also recommended every 3-6 months for 2 years, and then annually. Chest x-rays may be ordered to check for any possible metastases in the lungs (Castellanos & Merchant, 2013). PET or PET/CT, with fluorine 18-fluorodeoxyglucose as the radiotracer, can be used for treatment monitoring following chemoradiotherapy and depicting tumor recurrence. PET relies on functional activity that allows for differentiation between metabolically active lesions, such as PDAC, from non-malignant masses which is a reason it is a useful modality for follow up imaging (E. Lee & J. Lee, 2014).
Conclusion
Overall pancreatic adenocarcinoma is a highly aggressive disease with majority of the patients presenting advanced, non-resectable disease.
Unfortunately, even those with a resectable tumor have a poor survival rate and a high recurrence rate. The use of a combination of the different imaging modalities is important in order to diagnose and stage PDAC, as well as provide the basis if the tumor is resectable or not. Each modality has something to offer but overall CT remains the most commonly used modality for diagnosing and staging. CT allows for quick scans and provides radiologists with cross-sectional images that are key to determining the resectability of the tumor. CT is also the primary modality used for follow-up imaging after a patient has undergone a
resection.