Today I have uploaded a video on one more cause for Obstructive Jaundice- Pancreatic Carcinoma. Only cancer in head of pancreas cause Obstructive Jaundice. I have talked about cancer in body and tail of pancreas as well. I have discussed the risk factors, pathology, clinical features, investigations, treatment and complications of pancreatic carcinoma. I have included a mind map and two algorithms. I hope you will enjoy this video. You can watch all my surgical teaching video casts in the following link. Surgicaleducator.blogspot.com Thank you for your support.

1. PANCREATIC CARCINOMA
Dr.B.Selvaraj MS;Mch;FICS
Professor of surgery
Melaka Manipal Medical College
Melaka 75150 Malaysia
OBSTRUCTIVE JAUNDICE

2. Pancreas- Anatomy

3. Pancreas- Blood supply

4. Classical Clinical
Vignette
• 72 yrs old man presents with jaundice for 7days
with dull abdominal discomfort for 2 months. He
gives H/O loss of appetite and loss of weight.
• His stools have become lighter in color and his
urine is much darker than before
• He has a 50+ pack-year smoking history before
quitting last year
• He was recently diagnosed with type 2 diabetes,
but has no other medical problems

5. Classical Clinical
Vignette
• O/E: he has a yellow hue to his eyes and tongue,
along with scratch marks on his skin.
• A non-tender globular mass is palpated in the
right upper quadrant (RUQ) of the abdomen
• Labs: Laboratory testing reveals total and direct
bilirubin of 18 mg/dL (normal 0.2–1.3 mg/dL) and
17.2 mg/dL (<0.3 mg/dL), respectively.
• Alkaline phosphatase (ALP) elevated at 215 μ/L
(33–131 μ/L). AST & ALT mildly elevated

6. • 3rd
most common GIT cancer.
• 4th
most common cause of cancer death
• Death to incidence ratio is one.
( lowest among all types of cancer). why???
• Male:Female ratio 2:1
• Peak age 65 to 75 yrs
• Common in black americans
Introduction

7. Risk factors
• Cigarette smoking.
• Increased age.
• Chronic pancreatitis.
• Family H/O Pancreatic Cancer in more
than 2 first degree relatives
• Increased saturated fat intake.
• Exposure to non chlorinated solvents

8. Genetic Risk factors
• Chronic familial relapsing pancreatitis.
• Familial breast cancer ( BRCA2).
• Peutz –Jeghers syndrome.
• HNPCC (Hereditary non polyposis colorectal
cancer)
• Gardener syndrome.
• Familial atypical mole and melanoma
syndrome.

9. Genetic progression

10. Pathology
• Site :55% head of pancreas;25% body
15% tail; 5% periampulary
• Macroscopic : growth is hard & infiltrating
• Histology :90% ductal adeno ca;
9% cystic neoplasms
1% endocrine neoplasms
• Spread :Lymphatics to peritoneum & regional
nodes
Blood to liver & lung
Perineural spread Back pain

11. Clinical features
• Head&Periampulary : Painless progressive
jaundice with palpable GB- “Courvoisier’s Law”;
Vomiting due to duodenal block
Tea color urine, clay color stool & pruritus
• Body : back pain,anorexia,weight loss &
steatorrhea
• Tail : often presents with metastases,malignant
ascites or unexplained anemia

12. Investigations
• Lab : Elevated total & direct bilirubin
High Alk Phosphatase& GGT
Tumor marker CA19-9 >200U/ml
• USG Abd : can detect huge tumors
can’t pickup small mass
• MDCT : Triple phase CT abdomen: with arterial &
portal venous phase is sensitive to pickup
even small hypodense lesions

13. Investigations
• ERCP & MRCP : “Dual duct sign”
Therapeutic ERCP for palliative stent in CBD
& Duodenum
• Endoscopic Ultrasound:(EUS)
Excellent for staging the tumor
EUS guided pancreatic biopsy

14. CT Abdomen

15. ERCP “Dual Duct Sign”

16. Periampulary Mass
&EUS

17. Staging
Stage1 :Tumor is limited to pancreas with no
nodes or metastases
Stage2 :Tumor extends into bile duct,
peripancreatic tissues or duodenum. No nodes or
metastases
Stage3 :as stage 2 + positive nodes or celiac or
SMA involvement

18. Staging
Stage4a : Tumor extends to stomach,colon,spleen
or major vessels with any nodal status and
no distant metastases
Stage4b : Distant metastases with any nodal
status or tumor size

19. Staging & Prognosis

20. Treatment
• Rescectable tumors
• Borderline resectability
• Unresectable tumors

21. Resectable tumors
• Normal fat planes between tumor and
SMA, SMV
• Absence of extrapancreatic disease
• Patent SMPV confluence
• No direct extension to celiac axis or SMA

22. Borderline tumors
• Short segment occlusion of SMPV
confluence with an adequate vessel for
grafting
• Short segment (< 1 cm ) abutment of the
common or proper hepatic artery or SMA on
high quality CT

23. Unresectable tumors
• Extrapancreatic disease- distant metastases
• Encasement of coelic axis or SMA
( anything more than short
abutment)

24. Treatment Algorithm

25. Whipple’s Operation

26. Complications
• Delayed gastric emptying
• Pancreatic fistula
• Intra-abdominal abscess
• Operative site hge
• GI Hemorrhage

27. Palliative Surgery
• Biliary obstruction:
 Biliary enteric bypass
 Endoscopic biliary stent
placement
 Radiographic transhepatic
stent placement

28. Palliative Surgery
• Gastric outlet obstruction:
 Gastroenteric bypass
 Endoscopically placed
duodenal stent

29. Palliative Bypass

30. Adjuvant therapy
• 85% local recurrence .→ RT
• 70% liver metastasis.→CT
• 5 FU is the only active agent.
• Gemcitabine.
• 5 FU + Gemcitabine

32. Mindmap

33. Treatment Algorithm