The Pancreas Revisited Editor AVRAM M. COOPERMAN SURGICAL CLINICS OF NORTH AMERICA www.surgical.theclinics.com Consulting Editor RONALD F. MARTIN February 2018 • Volume 98 • Number 1 ELSEVIER 1600JohnF.KennedyBoulevard(cid:1)Suite1800(cid:1)Philadelphia,Pennsylvania,19103-2899 http://www.surgical.theclinics.com SURGICALCLINICSOFNORTHAMERICAVolume98,Number1 February2018ISSN0039–6109,ISBN-13:978-0-323-57002-2 Editor:JohnVassallo,[email protected] DevelopmentalEditor:MeredithMadeira ª2018ElsevierInc.Allrightsreserved. ThisperiodicalandtheindividualcontributionscontainedinitareprotectedundercopyrightbyElsevier,andthe followingtermsandconditionsapplytotheiruse: Photocopying Singlephotocopiesofsinglearticlesmaybemadeforpersonaluseasallowedbynationalcopyrightlaws. 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ThePancreasRevisited Contributors CONSULTING EDITOR RONALDF.MARTIN,MD,FACS Colonel(ret.),UnitedStatesArmyReserve,DepartmentofSurgery,YorkHospital,York, Maine,USA EDITOR AVRAMM.COOPERMAN,MD,FACS ThePancreas,BiliaryandAdvancedLaparoscopyCenterofNewYork,NewYork, NewYork,USA AUTHORS MAHMOUDAHMAD,MD,MBA GeneralSurgeryResident,DepartmentofGeneralSurgery,AventuraHospitalandMedical Center,Aventura,Florida,USA HORACIOJ.ASBUN,MD,FACS DepartmentofSurgery,MayoClinic,Jacksonville,Florida,USA MURRAYF.BRENNAN,MD InternationalCenter,MemorialSloanKetteringCancerCenter,NewYork,NewYork,USA HOWARDBRUCKNER,MD TheCenterforPancreatic,BiliaryandAdvancedMinimallyInvasiveSurgeryofNewYork, NewYork,NewYork,USA CARLOCATALANO,MD ProfessorofRadiology,DepartmentofRadiologicalSciences,SapienzaUniversityof Rome,Rome,Italy SETHCOHEN,MD Attending,DivisionofDigestiveDiseases,TheCenterforPancreatic,BiliaryandAdvanced MinimallyInvasiveSurgeryofNewYork,MountSinaiBethIsrael,NewYork,NewYork, USA AVRAMM.COOPERMAN,MD,FACS ThePancreas,BiliaryandAdvancedLaparoscopyCenterofNewYork,NewYork, NewYork,USA SUSANDABABOU,MD DepartmentofRadiologicalSciences,SapienzaUniversityofRome,Rome,Italy iv Contributors ALEXANDERT.ELGAMMAL,MD DepartmentsofGeneral,VisceralandThoracicSurgeryandExperimentalOncology, UniversityMedicalCenterHamburg-Eppendorf,Hamburg,Germany ANDREWFADER,MD TheCenterforPancreatic,BiliaryandAdvancedMinimallyInvasiveSurgeryofNewYork, NewYork,NewYork,USA MICHAELFELD,MD TheCenterforPancreatic,BiliaryandAdvancedMinimallyInvasiveSurgeryofNewYork, NewYork,NewYork,USA SEPIDEHGHOLAMI,MD UCDavisComprehensiveCancerCenter,DepartmentofSurgery,Sacramento, California,USA FRANKGOLIER,MD TheCenterforPancreatic,BiliaryandAdvancedMinimallyInvasiveSurgeryofNewYork, NewYork,NewYork,USA MARINAGORELIK,DO GeneralSurgeryResident,DepartmentofGeneralSurgery,AventuraHospital andMedicalCenter,Aventura,Florida,USA DAVIDGROSSMAN,MD AssociateProgramDirectorofSurgicalResidencyProgram,DepartmentofGeneral Surgery,AventuraHospitalandMedicalCenter,Aventura,Florida,USA MARTINGROSSMAN,MD GeneralSurgeon,DepartmentofGeneralSurgery,AventuraHospitalandMedicalCenter, Aventura,Florida,USA HILLELHAMMERMAN,MD TheCenterforPancreatic,BiliaryandAdvancedMinimallyInvasiveSurgeryofNewYork, NewYork,NewYork,USA MAZENE.ISKANDAR,MD AssistantProfessor,DepartmentofSurgery,DivisionofSurgicalOncology,MountSinai BethIsrael,IcahnSchoolofMedicineatMountSinai,MountSinaiStLuke’sandMount SinaiWest,NewYork,NewYork,USA JAKOBR.IZBICKI,FACS,FRCSed.Hon,MD DepartmentofGeneral,VisceralandThoracicSurgery,CenterforOperativeMedicine, ClinicandPolyclinicforGeneral,VisceralandThoracicSurgery,Hamburg,Germany ALEXANDERC.KAGEN,MD AssociateProfessor,SiteChair,DepartmentofRadiology,MountSinaiStLuke’s andMountSinaiWest,IcahnSchoolofMedicineatMountSinai,NewYork,NewYork, USA SHALOMKALNICKI,MD,FACRO RadiationOncology,MontefioreMedicalPark,Bronx,NewYork,USA FRANKLINKASMIN,MD TheCenterforPancreatic,BiliaryandAdvancedMinimallyInvasiveSurgeryofNewYork, NewYork,NewYork,USA Contributors v TOMOAKIKATO,MD,MBA DepartmentofSurgery,ColumbiaUniversityMedicalCenter,NewYork,NewYork,USA MATHEWH.G.KATZ,MD,FACS Chief,PancreaticSurgeryService,AssociateProfessorofSurgicalOncology, TheUniversityofTexasMDAndersonCancerCenter,Houston,Texas,USA EVANLANDAU,MD 21stCenturyOncology,Ft.Lauderdale,Florida,USA NATASHALEIGH,MD DepartmentofSurgery,MountSinaiStLuke’sandMountSinaiWest,NewYork, NewYork,USA PETERLIOU,MD DepartmentofSurgery,ColumbiaUniversityMedicalCenter,NewYork,NewYork,USA THINZARM.LWIN,MS,MD DepartmentofSurgery,UCSanDiego,SanDiego,California,USA;Departmentof Surgery,MountSinaiBethIsrael,NewYork,NewYork,USA CRISTINAMARROCCHIO,MD DepartmentofRadiologicalSciences,SapienzaUniversityofRome,Rome,Italy ALESSANDRONAPOLI,MD,PhD AggregateProfessorofRadiology,DepartmentofRadiologicalSciences,Sapienza UniversityofRome,Rome,Italy TOMRUSH,MD TheCenterforPancreatic,BiliaryandAdvancedMinimallyInvasiveSurgeryofNewYork, NewYork,NewYork,USA RICHARDD.SCHULICK,MD,MBA,FACS TheArago´n/Gonzalez-Gı´ust´ıChair,DepartmentofSurgery,UniversityofColorado, Aurora,Colorado,USA JEROMESIEGAL,MD TheCenterforPancreatic,BiliaryandAdvancedMinimallyInvasiveSurgeryofNewYork, NewYork,NewYork,USA HARRYSNADY,MD TheCenterforPancreatic,BiliaryandAdvancedMinimallyInvasiveSurgeryofNewYork, NewYork,NewYork,USA JOHNA.STAUFFER,MD,FACS DepartmentofSurgery,MayoClinic,Jacksonville,Florida,USA JUSTING.STEELE,MD ThePancreas,BiliaryandAdvancedLaparoscopyCenterofNewYork,NewYork, NewYork,USA ROBERTJ.TORPHY,MD GeneralSurgeryResident,DepartmentofSurgery,UniversityofColorado,Aurora, Colorado,USA vi Contributors TIMOTHYJ.VREELAND,MD Fellow,ComplexGeneralSurgicalOncology,TheUniversityofTexasMDAnderson CancerCenter,Houston,Texas,USA MICHAELG.WAYNE,DO ThePancreas,BiliaryandAdvancedLaparoscopyCenterofNewYork,NewYork, NewYork,USA ROBERTA.WOLFF,MD ProfessorofMedicine,DepartmentofGastrointestinalMedicalOncology,TheUniversity ofTexasMDAndersonCancerCenter,Houston,Texas,USA ThePancreasRevisited Contents Foreword xiii RonaldF.Martin Preface:ASymposiumonPancreaticCancer:TimeforaParadigmShift. AnOverviewandPersonalReflections xvii AvramM.Cooperman PreventionandEarlyDetectionofPancreaticCancer 1 AvramM.Cooperman,MazenE.Iskandar,MichaelG.Wayne,and JustinG.Steele Preventingcancerhasmuchtooffer.Asidefromplummetinghealthcare costs,wemightenjoyahealthierlifefreeofcancerandchronicdisease. Prevention requires the adoption of healthier choices and a moderate amount of exercise. The supporting evidence is observational, clinical, and partly common sense. Further investigations reveal several sub- stances in a whole-food plant-based diet that have protective effects and an inhibitory effect on tumor development. For pancreatic cancer, thebasisofcureremainsacentury-oldoperationthatrarelycures.With littletolose,preventiondeservescenterstageandadditionalstudies. PreoperativeEvaluationofaPancreasMass:DiagnosticOptions 13 SethCohenandAlexanderC.Kagen As modern abdominal imaging equipment advances, pancreatic lesion detection improves. Most of these lesions are incidental and present a conundrumtotheclinicianandcreategreatanxietytothepatientuntila finaldiagnosisismade.Forthepracticingphysician,theplethoraofdiag- nosticoptionsisoverwhelming.Therelevantquestionis,whatisthemost efficient algorithm to follow and to arrive at a timely and accurate diag- nosis. This article presents a logical approach to the initial evaluation of a pancreatic lesion to get the most information possible with the least amountoftestingandtoavoidduplicativemeasures. ScreeningofPatientsatRiskforFamilialPancreaticCancer:WhatIsBeneficial? 25 RobertJ.TorphyandRichardD.Schulick Familyhistoryisasignificantriskfactorfordevelopingpancreaticcancer, andthishereditaryriskcanbesecondarytofamilialcancerpredisposition syndromes,hereditarypancreatitis,orfamilialpancreaticcancer.Certain high-riskindividualsarerecommendedtoundergoscreeningforpancre- atic cancer with endoscopic ultrasound imaging or MRI/magnetic reso- nance retrograde cholangiopancreatography because of the potential to identifyandcurativelyresectprecursorlesions.Themanagementofsus- picious lesions identified on screening high-risk individuals is also discussed. viii Contents PreoperativeStentingforBenignandMalignantPeriampullaryDiseases: UnnecessaryifNotHarmful 37 SepidehGholamiandMurrayF.Brennan Preoperative biliary drainage (PBD) is often performed in patients with jaundicewiththepresumptionthatitwilldecreasetheriskofpostoperative complications. PBD carries its own risk of complications and, therefore, has been controversial. Multiple randomized controlled trials and meta- analyseshaveshownthatPBDhassignificantlyincreasedoverallcompli- cationscomparedwithsurgeryalone.Assuch,theroutineapplicationof PBDshouldbeavoidedexceptinasubsetofclinicalsituations.Thisisdis- cussedindetailinthisarticle. ATaleof2Techniques:PreoperativeBiliaryDrainageandRoutineSurgical DrainagewithPancreaticoduodenectomy 49 MazenE.Iskandar,MichaelG.Wayne,JustinG.Steele,and AvramM.Cooperman Preoperativedrainageofanobstructedbiliarytreebeforepancreaticoduo- denal resection (PDR) and placement of intraabdominal drains following pancreatic resection have been suggested to be both unnecessary and associatedwithahighercomplicationrate.Theevidenceforandagainst thatpracticeispresentedandanalyzedtohighlightitsrisksandbenefits. Aselectiveapproachonanindividualbasisforpreoperativebiliarydecom- pressionisadvocated,basedonmultiplefactors.Inaddition,theevidence forroutine useofsurgical drains afterPDRiscritically reviewedand the rationaleforroutinedrainageismade. TimingofPancreaticResectionandPatientOutcomes:IsThereaDifference? 57 TimothyJ.VreelandandMathewH.G.Katz Rates of long-term survival after treatment of pancreatic cancer remain low,inpartbecausemostpatientsarestilltreatedwithprimaryresection. Thisapproachisofteninadequatebecauseofearlylocalcontrolfailures, early manifestation of metastatic disease because of the unrecognized and untreated systemic componentof this disease, and because half of patients never receive multimodal therapy. Preoperative therapy can be usedtoimprovelocalcontrolandtreatthesystemicnatureofpancreatic cancerwhilealsoselectingforpatientswhobenefitfromamorbidopera- tion.Preoperativetherapymakessenseformostpatientswiththisaggres- siveanddeadlydisease. CancerofthePancreas—Actual5,10,and20DYearSurvival:TheLucky andFortunateFew 73 AvramM.Cooperman,HowardBruckner,HarrySnady,HillelHammerman, AndrewFader,MichaelFeld,FrankGolier,TomRush,JeromeSiegal, FranklinKasmin,SethCohen,MichaelG.Wayne,MazenE.Iskandar, andJustinG.Steele Cancer of the pancreas (CaP) is a dismal, uncommon, systemic malig- nancy.Thisarticleupdatesanearlierexperienceofactuallong-termsur- vivalofCaPinpatientstreatedbetween1991and2000andreviewsthe literature.Survivalisexpressedasactual,notprojected,survival. Contents ix Rare,Uncommon,andUnusualComplicationsAfterPancreaticoduodenal Resection 87 ThinzarM.Lwin,NatashaLeigh,MazenE.Iskandar,JustinG.Steele, MichaelG.Wayne,andAvramM.Cooperman Complicationsafterpancreaticoduodenalresection(PDR)occurinatleast 30%ofpatients.Mostareadirectresultofanintraoperativeevent,dissec- tion, or anastomoses, which account for the most serious morbidities, sepsis, pseudoaneurysms, and hemorrhage. Rarely, complications are duetothesystemicimpactoftheprocedureeveniftheprocedureitself was unremarkable. Rare systemic complications after PDR (transfusion- transmitted babesiosis, pituitary apoplexy, and TRALI) and a number of uncommonandunusualothercomplicationsarediscussed.Pancreatico- duodenalresectionisasignificantoperationwithseriousconsequences. Decisions on selection of candidates and safe operations should be thoughtfulandalwaysinsurgeons’minds. AdjuvantorNeoadjuvantTherapyintheTreatmentinPancreaticMalignancies: WhereAreWe? 95 RobertA.Wolff Since the advent of modern surgery for pancreatic cancer, clinicians have recognized this cancer’s propensity to recur locally, metastasize, and cause death. Despite significant efforts to improve patient out- comes with better adjuvant therapy, only modest gains in survival havebeenobserved.Analternativestrategyofneoadjuvanttherapyfol- lowed by surgery has the potential to improve patient selection and survival and expand the pool of patients eligible for curative surgery. Thisarticlesummarizeslarge,randomizedtrialsofadjuvanttherapy,ex- plainsthelimitationsimposedbyup-frontsurgery,andsuggestsneoad- juvant therapy as a rational alternative to initial surgery and adjuvant therapy. TheEvolvingRoleofRadiationinPancreaticCancer 113 EvanLandauandShalomKalnicki Pancreaticcancerisanaggressivemalignancywithapoorlong-termsur- vivalandonlymildimprovementinoutcomesoverthepast30years.Local failureremainsaproblem,andradiationcanhelpimprovecontrol.Therole ofradiationtherapyhasbeencontroversialandisstillevolving.Thisarticle reviewsthetrialsofpancreaticcancerandradiationinadjuvant,neoadju- vant,andunresectablelesions.Italsoreviewstheimpactandoutcomesof evolvingradiationtechnology. NonoperativeAblationofPancreaticNeoplasms 127 CristinaMarrocchio,SusanDababou,CarloCatalano,andAlessandroNapoli Pancreaticcancerisapoorprognostictumorandabout20%ofpatients areeligibleforsurgicalresectionatthetimeofdiagnosis.Recently,mini- mallyinvasiveprocedureshaveprovidedpromisingresultsasatherapeutic optionforlocallyadvancedunresectablepancreaticcancer.Inparticular, high-intensity focused ultrasound is an emerging noninvasive thermally ablativeprocedurethatmayhaveadominantroleinthefuture.Although