الفهرس 
AnatomyOnly 14 pages are availabe for public view
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Abstract
The pancreas is perhaps the most unforgiving organ in the human body, leading most surgeons to avoid even palpating it unless necessary. Situated deep in the center of the abdomen, the pancreas is surrounded by numerous important structures and major blood vessels. Therefore seemingly minor trauma to the pancreas can result in the release of pancreatic enzymes and cause life-threatening pancreatitis. Surgeons that choose to undertake surgery on the pancreas require a thorough knowledge of its anatomy.
Pancreatic carcinoma is one of the most aggressive human malignancies. It is the tenth most common malignancy and the fourth largest killer in adult. It has an overall cumulative 5 years survival rate below1%.
Approximately 90% of pancreatic exocrine tumors arise from pancreatic ductules and 80% of these tumors are adenocarcinoma, 60-70% arises in the head and the rest of the tumors located in the body, tail or diffusely throughout the gland.
The cause of pancreatic carcinoma remains unclear; there are many risk factors for developing pancreatic carcinoma as: tobacco smoking, high fatty meals, alcohol consumption, diabetes mellitus, pernicious anemia, chronic pancreatitis, cholelithiasis, gastric surgery, radiation and genetic factors. Pancreatic carcinoma is uncommon before the age of 45 years old; more than 80% of Patients are aged 60-80 years.
Unfortunately, only 15-20% of patients diagnosed with pancreatic adenocarcinoma are candidates for resection, and even after complete (R0) resection the 5-year survival is only 15-20%.
This poor prognosis, attributable to delayed presentation, tumor biology, complexity of surgical intervention, and paucity of multimodality therapy, has engrained a pessimistic mindset in many clinicians, leading to an underutilization of surgery despite recent evidence challenging these long established beliefs.
Due to its poor prognosis there is a high unmet medical need to improve the treatment of pancreatic cancer and to extend patients’ lives. Unfortunately, the majority of patients are deemed unresectable at the time of diagnosis and may die within one year, long term survivors are an exception, due to distant metastasis or a locally extensive disease.
The presenting symptoms of pancreatic cancer can include pain, unexplained weight loss, nausea, vomiting, steatorrhea, dyspepsia, depression and jaundice. There are no well known warning signs of pancreatic cancer. However, new onset diabetes in an old patient has been associated with pancreatic cancer.
The main reason for the poor outlook for patients with pancreatic cancer is that very few of these cancers are found early, since the clinical features of pancreatic cancer initially are non-specific and vague, this contributes to delay in diagnosis of usually about 8 weeks, moreover the pancreas is located deep inside the body thus early stage tumors cannot be seen or felt by health care providers during routine physical exams. That’s why diagnosis is more dependent on imaging studies and other methods of investigations.
Imaging Studies:
1. Transabdominal Ultrasound US (TUS).
2. Computed tomography scanning.
3. Spiral CT.
4. Endoscopic ultrasonography (EUS).
5. Magnetic resonance imaging.
6. Endoscopic retrograde cholangiopancreatography.
7. Positron emission tomography scanning (PET).
FDG-PET/CT may represent a useful add-on diagnostic tool in the evaluation of patients with suspected pancreatic cancer, especially when CT and biopsy results are inconclusive.
8. Percutaneous Biopsy.
9. Staging laparoscopy:
Patients who are suitable for resection, five-year survival rates of 25% are possible, which underlines that surgery offers the only chance of cure and long-term survival.
The operative management of pancreatic carcinoma involving head, neck and uncinate process consists of 2 phases, first assessing the tumor resectability and then if the tumor is resectable the Standard resections can be done which include pancreatico-duodenectomy with distal stomach resection or recently accepted as the preferable procedure preservation of the pylorus for tumors in the head of the pancreas, distal pancreatectomy for tumors of the body and tail as well as total pancreatectomy for more extended tumors or intraductal papillary mucinous neoplasias (IPMN) if necessary.
Adjuvant chemoradiotherapy like: 5-florouracil and gemcitabine improve the results of surgery, Surgical palliation of unresectable pancreatic tumors can improve the quality of life of these patients.
Surveillance and screening of high risk groups by effective and cost-effective methods will improve the detection of precancerous lesions thus improving the prognosis, However Prognosis of pancreatic cancer is generally bad even with resected cancer.
Total pancreatectomy has been used to treat both benign and malignant disease of the pancreas, but its use has been limited by concerns about management of the apancreatic state with its attendant total endocrine and exocrine insufficiency.Total pancreatectomy remains a viable option in the treatment of intractable pain associated with chronic pancreatitis, multicentric or extensive neuroendocrine tumors, patients with familial pancreatic cancer with premalignant lesions, and in patients with intraductal papillary mucinous neoplasia with diffuse ductal involvement or invasive disease, Also it helps to avoid complications of other procedures like pancreatic fistula and recurrences. Improvements in postoperative management include auto-islet cell transplantation, advances in insulin formulations, and the use of glucagon rescue therapy which allow much tighter control of blood glucose than previously possible. This markedly lessens the risk of life-threatening hypoglycemia and decreases the risk of long-term complications, resulting in improved quality of life for these patients.