MBBS UM (malaya) EXTENDERS

Let's talk about Pancreatic tumour. There are many types of pancreatic tumour. Although ductal carcinoma of the pancreas is one of the most lethal of all gastrointestinal tumours, 10–15% of tumours of the pancreas (including those of the periampullary region) are not of the same histological type as ductal carcinoma and have a much better prognosis. This group of tumours includes ampullary carcinoma, islet cell tumours of the pancreas and cystic tumours of the pancreas. A tumour of the pancreas should, therefore, not be assumed to carry a poor prognosis. Ok?

Ductal adenocarcinoma of the pancreas is highly malignant and has usually metastasised by the time of diagnosis. Smoking is the only recognised aetiological factor and the disease is uncommon under the age of 40. The disease occurs in the head of the pancreas in 80% of cases. It presents with obstructive jaundice in 70% of cases but may also present with severe upper abdominal pain (which may radiate into the back), weight loss, anorexia, malaise, or rarely, thrombophlebitis migrans.

On examination, there may be cervical lymphadenopathy, an abdominal mass, hepatomegaly or ascites. The gallbladder may be palpable. Courvoisier’s law states that if, in the presence of jaundice, the gallbladder is palpable, then the cause is unlikely to be gallstones. Investigations include basic blood tests and specific diagnosis by ultrasound, CT or MRI. The ERCP may be helpful too, and may also allow therapeutic manoeuvres such as stent insertion (see section on obstructive jaundice).

Most tumours are treated palliatively by insertion of a biliary stent or bypass surgery. Resectional surgery is suitable for 15–20% of patients with a ductal carcinoma but 50–75% of patients with ampullary carcinoma, islet cell tumours or cystic tumours of the pancreas. Five-year survival following curative resection in ductal carcinoma is 10–15% although resection is also associated with good relief of symptoms. For those with ampullary tumours, islet cell tumours or cystic tumours, 5 year survival of 40% can be anticipated.

For tumours of the head of the pancreas or peri-ampullary region, pancreatico-duodenectomy (Whipple’s operation) is the operation of choice. The pylorus-preserving operation is the operation of choice. The mortality rate of pancreatico-duodenectomy is less than 5%.