19) Cysts & Neoplasms of Pancreas
Cyst of the Pancreas –
2 groups – A) Pseudocyst – common & 80 %
B)True cyst – constitutes only 20 %
Pseudocyst of Pancreas (Pseudo-pancreatic cyst)
-Caused by encapsulation of fluid or blood in the lesser sac of peritoneum or in peripancreatic cellular tissue.
i)Pseudocyst may devlop from trauma – a severe blow to the epigastrium may cause laceration of the pancreas. Pancreatic secretion & blood escape into the lesser sac and the foramen of winslow is sealed by inflammatory exudates.This causes encapsulation of the effusion.
ii)It may follows an attack or repeated attacks of Acute pancreatitis.
iii)Following a few operations such pseudocyst may devlop i.e.
Pancreatolithotomy, caudal pancreatotomy, Partial gastrectomy.
Clinical features –
-Epigastric swelling –upper abd. pain –Kehr’s sign (indicating irritation of diaphragm)
-Dyspepsia, nausea & vomiting are commonly noted.
-Sometimes the mass consist of the odematous pancreas and peripancreatic swelling of the omental & retroperitoneal tissues and this is called, ‘Pseudo Pseudocyst’.
i)Sr. Amylase – it is of little value to diagnose the Pseudocyst.
ii)Straight X-ray show calcification of wall.
iii)Ba-meal X-ray show widened C- shaped duodenal loop, a filling defect distortion & indentation of the stomach.
v)CT Scan- are popular as they are non invasive, reliable & safe.
i)Infection leading to abscess formation.
ii)Rupture into the peritoneal cavity, pleural cvity.
iv)Obstruction of the G.I tract.
i)Internal drainage –cysto-jejunostomy, cystogastrostomy, cysto-duodenostomy (depends on the location of the pseudocyst)
ii)Excision of Pseudocyst-
iii)External drainage –associated with gross infection.
True cysts of the Pancreas
1)Single or multiple cysts .
2)Polycystic disease of pancreas.
3)Fibrocystic disease (mucoviscidosis)
1)Retention cyst (due to ductol obstruction )
2)Parastic cyst (Hydatid cyst )
3)Neoplastic cyst –cystadenoma cystadenocarcinoma,cystie teratoma.
Neoplasms of the Pancreas-
A)Carcinoma of the pancreas .
B)Neoplasm of the islet cells.
Pathogensis—i)Cigarette smoking ii)Consumption of coffee iii)Diet rich in fat iv)Chemical agents –naphthylamine & Benzidine v)Diabetes .
vi)Carcinogens in duodenal contents vii)Alcohol ingestion.
a)CA of the head proper-
-Adenocarcinoma is the predominant lesion .
-tumours may be mucinous or nonmucin secreting.
-the lesion is in irregular nodularity.
B)CA of the body & tail –
-tumours are usually large hard & irregular masses
Spread – i)Local spread
iii)Vascular spread –is extremely uncommon.
iv)Pritoneal implantation –rejulting in ascites.
Clinical features -2 types of presentations
A)Painless progressive obstructive jaundice
B)Intractable pain without jaundice-
Investigations –1)Blood exam-L F T
-Sr.bilirubin almost never rises above 30 to 35 mg/100ml in pancreatic cancer.
-Serological markersfor pancreatic carcinoma
-Carcinoembryonic antgen (CEA)
-Alpha – fetoprotein (AFP)
-Pancreatic oncofetal antigen (POA)
-Carbohydrate antigen 19-9 (CA 19 -9 ) & DU PAN -2
-MRI-particularly in this disease-appears no advantage over CT.
4)ERCP –it can be biopsied .while dudenoscopy
-Billary endoprosthesis- to palliate billary obstruction & to allow for reduction in th degree of jaundice.
5)Percutaneous Cholangiography –(PTC)-to know the causes of obstruction .
6)FNAB-Safe and accurate in about 70%of cases.
7)Selective celiac & mestenteric angiography-
8)Laparoscopy- advocated for improving staging & to detect unsuspected liver metastasis & peritoneal implants.
Treatment of CA of the head of pancreas-
Rx is early operation, once diagnosed.
less than 3 cm in diameter is resectable (frequently situated at ampulla) &
more than 5cm in diameter are not resectable (situated at body & tail)
Pancreatic duodenectomy (Whipple’s Operation)-
Operation –(Whipple’s Operation)
-The duodenumwith the head of the pancreas is mobilized medially by diving the peritoneum on the lateral side of the duodenum. (Kocher’s manoeuvre)
-Clear that sup. mesenteric vessels & the portal vein are not involved in CA.
1)Gastrectomy with Pylorectomy- Gastro-jejunostomy (Billroth-II)
2)Pancreatico- jejunostomy (duct of wirsung)
(Modification of standard whipple operation –pylorus preserving pancreatico duodenctomy)
-overall 5 –year survival rate for all patients with resected periampullary CA.
CA of the body & tail of the pancreas
-Adenocarcinoma represents about 30%
-Peculiarity of this region’s CA is that it grows silently.
Rx- Resectabiity rate of CA is even less than 6 %
–Subtotal distal pancreatectomy –keeping only a portion of pancreas right to the bile duct along with duodenum is the of choice.