Preoperative staging and evaluation of resectability in pancreatic ductal adenocarcinoma

BackgroundCancer of the pancreas is a common disease, but the large majority of patients have tumours that are irresectable at the time of diagnosis. Moreover, patients whose tumours are clearly beyond surgical cure are best treated non‐operatively, if possible, by relief of biliary obstruction and percutaneous biopsy to confirm the diagnosis and then consideration of oncological treatment, notably chemotherapy. These facts underline the importance of a standard protocol for the preoperative determination of operability (is it worth operating?) and resectability (is there a chance that the tumour can be removed?). Recent years have seen the advent of many new techniques, both radiological and endoscopic, for the diagnosis and staging of pancreatic cancer. It would be impracticable in time and cost to submit every patient to every test. This review will evaluate the available techniques and offer a possible algorithm for use in routine clinical practice.DiscussionIn deciding whether to operate with a view to resecting a pancreatic cancer, the surgeon must take into account factors related to the patient, the tumour and the institution and team entrusted with the patient's care. Patient‐related factors include age, general health, pain and the presence or absence of malnutrition and an acute phase inflammatory response. Tumour‐related factors include tumour size and evidence of spread, whether to adjacent organs (notably major blood vessels) or further afield. Hospital‐related factors chiefly concern the volume of pancreatic cancer treated and thus the experience of the whole team. Determination of resectability is heavily dependent upon detailed imaging. Nowadays conventional ultrasonography can be supplemented by endoscopic, laparoscopic and intra‐operative techniques. Computed tomography (CT) remains the single most useful staging modality, but MRI continues to improve. PET scanning may demonstrate unsuspected metastases and likewise laparoscopy. Diagnostic cholangiography can be performed more easily by MR techniques than by endoscopy, but ERCP is still valuable for preoperative biliary decompression in appropriate patients. The role of angiography has declined. Percutaneous biopsy and peritoneal cytology are not usually required in patients with an apparently resectable tumour. The prognostic value of tumour marker levels and bone marrow biopsy is yet to be established. Preoperative chemotherapy or chemoradiation may have a role in down‐staging an irresectable tumour sufficiently to render it resectable. Selective use of diagnostic laparoscopy staging is potentially helpful in determination of resectability. Laparotomy remains the definitive method for determining the resectability of pancreatic cancer, with or without portal vein resection, and should be undertaken in suitable patients without clear‐cut evidence of irresectability

Bacterial translocation, endotoxaemia and apoptosis following Pringle manoeuvre in rats

Background: Intraoperative occlusion of the hepatoduodenal ligament (Pringle manoeuvre (Pm)) is often employed for the reduction of blood loss during liver surgery. No data exist to date on the effects of Pm on mucosal barrier dysfunction, systemic bacterial translocation (BT), endotoxaemia and apoptosis. Materials and methods: Sixty-five mate Wistar rats in three groups: I (n = 25) controls, II (n = 20) sham operation, III (n = 20) occlusion of the hepatoduodenal ligament (Pm). Tissue samples from mesenteric lymph nodes (MLNs), liver, lungs and spleen were analysed after 30 min and at 24 h. Endotoxin was measured in portal and aortic blood and routine haematological. and biochemical parameters were measured before and after Pm. Results: No differences were found in the blood parameters before and after Pm, but a significant increase in contaminated MLNs and liver was noted. ALL cultured bacteria were enteric in origin. Portal and aortic endotoxin were significantly increased. Overall the ileal architecture remained intact in all specimens studied and no significant pathology was observed. The ABC increased after Pm significantly (P < 0.01). Conclusion: Normothermic Pm of 30 min duration results in immediate and delayed gut barrier failure by significantly increasing BT and endotoxaemia which might be attributed to portal stasis leading to intestinal congestion as well as temporary Liver ischaemia. Apoptosis increased significantly 30 min after performing the Pm. (C) 2003 Elsevier Ltd. All rights reserved