Tài liệu The Pancreas: An Integrated Textbook of Basic Science, Medicine, and Surgery_1 pdf

Raymond Aerts MDDepartment of Abdominal Surgery, University Clinics, Gasthuisberg, Catholic University, Leuven, Belgium Assistant Professor of Surgery, University of Cincinnati, OH, USA

The Pancreas:

An Integrated Textbook of Basic Science, Medicine, and Surgery

The Pancreas: An Integrated Textbook of Basic Science, Medicine, and Surgery, Second Edition

Edited by H G Beger, A L Warshaw, M W Büchler, R A Kozarek, M M Lerch, J P Neoptolemos,

The Pancreas:

An Integrated Textbook

of Basic Science, Medicine, and Surgery

Founding Editor Emeritus Professor of Surgery c/o Universitätsklinikum Ulm University of Ulm

Germany

Andrew L Warshaw MD

Surgeon-in-Chief and Chairman Department of Surgery, Massachusetts General Hospital

W Gerald Austen Professor of Surgery Harvard Medical School

Boston, MA, USA

Markus W Büchler MD

Chairman and Head, Department of General and Visceral Surgery Professor of Surgery

University of Heidelberg Germany

Director, Digestive Disease Institute Virginia Mason Medical Center Seattle, WA, USA

Markus M Lerch MD FRCP

Professor and Chair, Department of Gastroenterology, Endocrinology and Nutrition, Ernst-Moritz-Arndt University, Greifswald

Chair and Professor, Department of Gastroenterology, Tokyo Women’s Medical University School of Medicine Tokyo, Japan

Professor of Medicine and Chief Division of Gastroenterology, Hepatology, and Nutrition University of Pittsburgh

PA, USA

Bettina M Rau MD

Coordinating Editor Associate Professor of Surgery Department of General, Thoracic, Vascular and Transplantation Surgery University of Rostock

Germany

S E C O N D E D I T I O N

© 1998, 2008

Blackwell Publishing Limited

Blackwell Publishing, Inc.,

350 Main Street, Malden,

Massachusetts 02148-5020, USA

Blackwell Publishing Ltd,

9600 Garsington Road,

Oxford OX4 2DQ, UK

Blackwell Publishing Asia Pty Ltd,

550 Swanston Street, Carlton,

Victoria 3053, Australia

The right of the Author to be identified as the Author of this Work

has been asserted in accordance with the Copyright, Designs and

Patents Act 1988

All rights reserved No part of this publication may be reproduced,

stored in a retrieval system, or transmitted, in any form or by any

means, electronic, mechanical, photocopying, recording or otherwise,

except as permitted by the UK Copyright, Designs and Patents Act

1988, without the prior permission of the publisher

First published 1998

Second edition 2008

1 2008

Library of Congress Cataloging-in-Publication Data

The pancreas: an integrated textbook of basic science, medicine and

surgery/Hans Beger [et al.] — 2nd ed

p ; cm

Includes bibliographical references and index

ISBN-13: 978-1-4051-4664-7 (alk paper)

1 Pancreas—Diseases 2 Pancreas 3 Pancreatectomy

I Beger, H G (Hans G.)

[DNLM: 1 Pancreatic Diseases—physiopathology 2 Pancreatic

Diseases—therapy 3 Pancreas—physiology 4 Pancreatectomy—

Editorial Assistant: Jennifer SewardDevelopment Editor: Rob BlundellProduction Controller: Debbie WyerFor further information on Blackwell Publishing, visit our website:http://www.blackwellpublishing.com

The publisher’s policy is to use permanent paper from mills that operate a sustainable forestry policy, and which has beenmanufactured from pulp processed using acid-free and elementarychlorine-free practices Furthermore, the publisher ensures that thetext paper and cover board used have met acceptable environmentalaccreditation standards

Blackwell Publishing makes no representation, express or implied,that the drug dosages in this book are correct Readers musttherefore always check that any product mentioned in thispublication is used in accordance with the prescribing informationprepared by the manufacturers The author and the publishers do notaccept responsibility or legal liability for any errors in the text or forthe misuse or misapplication of material in this book

David C Whitcomb and Hans G Beger

Section One Anatomy of the pancreas

2 The history of the pancreas, 9

Irvin M Modlin, Manish C Champaneria, Anthony K.C Chan, Mark Kidd, and Geeta N Eick

3 Development of the pancreas and related structures, 42

Brian Lewis

4 Anatomy and fine structure, 50

Dale E Bockman

5 Congenital and inherited anomalies, 58

Martin Zenker and Markus M Lerch

Section Two Physiology of pancreatic functions

6 Physiology of acinar cell secretion, 71

Ole H Petersen

7 Physiology of duct cell secretion, 78

Min Goo Lee and Shmuel Muallem

8 Physiology of experimental pancreatitis, 91

Ashok K Saluja, Vijay P Singh, and Phoebe Phillips

9 Physiology of sphincter of Oddi function, 107

Keiko Shiratori and Kyoko Shimizu

Section Three Acute pancreatitis

13 Etiopathogenesis and epidemiology of alcohol-induced

acute pancreatitis, 145

Minoti V Apte, Ron C Pirola, and Jeremy S Wilson

14 Etiology and epidemiology of biliary acute

pancreatitis, 154

Michael G.T Raraty and John P Neoptolemos

15 Acute pancreatitis associated with congenital anomalies, 163

Tracy C Grikscheit and Andrew L Warshaw

16 Acute pancreatitis associated with metabolic, infectious, and drug-related diseases, 172

Stefan Turi, Matthias Kraft, and Markus M Lerch

17 Acute pancreatitis in children, 184

Mark E Lowe and Véronique D Morinville

18 Understanding of acute pancreatitis from animal experiments, 193

Thomas Foitzik

19 Genetic factors in acute pancreatitis, 200

David C Whitcomb and Georgios I Papachristou

20 Histopathology of acute pancreatitis, 209

22 Clinical course of alcoholic acute pancreatitis, 226

Roland H Pfützer and Manfred V Singer

23 Clinical course and treatment principles of biliary acute pancreatitis, 231

Julia Mayerle, Ashok K Saluja, and Markus M Lerch

24 Clinical assessment and biochemical markers to objectify severity and prognosis, 242

Paul Georg Lankisch

ICU treatment of severe acute pancreatitis

Mark Topazian and Henry J Schiller

27 Bacterial and fungal infections in necrotizing pancreatitis: pathogenesis, prevention, and treatment, 288

Bettina M Rau and Hans G Beger

28 Indications for interventional and surgical treatment

of acute pancreatitis, 298

Thomas E Clancy and Stanley W Ashley

29 Surgical management of necrotizing pancreatitis, 308Débridement and continuous closed lavage

Bettina M Rau and Hans G Beger

Débridement and open packing/staged laparotomy

Raymond Aerts and Freddy M Penninckx

Débridement and closed packing

J Rubén Rodríguez, Carlos Fernández-del Castillo, and Andrew L.Warshaw

30 Strategies for surgical treatment of pseudocysts after

acute pancreatitis, 321

Antonio Ramos-De la Medina, Kaye M Reid-Lombardo, and Michael G Sarr

31 Endoscopic treatment of necrotizing pancreatitis, 331

Stefan Seewald, Salem Omar, and Nib Soehendra

32 Minimal-access surgical treatment of necrotizing

pancreatitis and pancreatic abscess, 336

Saxon Connor, Michael G.T Raraty, Jonathon Evans, and John P Neoptolemos

33 Management of fluid collections in acute

pancreatitis, 344

Gregory Stringfellow, Eric Vansonnenberg, Giovanna Casola, Gerhard R Wittich, Sridhar Shankar, and Ray Shamos

34 Management of pancreatic fistula in acute

pancreatitis, 356

Jens Werner and Markus W Büchler

35 Enteral nutrition and parenteral nutrition, 362

Keiko Shiratori

36 Long-term outcome after acute pancreatitis, 368

Werner Hartwig, Jens Werner, and Markus W Büchler

Section Four Chronic pancreatitis

37 Chronic pancreatitis: consequences of recurrent acute

44 Chronic pancreatitis: a risk factor for cancer? 437

Albert B Lowenfels and Patrick Maisonneuve

45 Molecular understanding of chronic pancreatitis, 444

David C Whitcomb

46 Pain mechanisms in chronic pancreatitis, 454

Fabio F di Mola and Pierluigi di Sebastiano

47 Clinical and laboratory diagnosis of chronic pancreatitis, 458

Julia Mayerle, Peter Simon, and Markus M Lerch

48 Contrast-enhanced computed tomography and magneticresonance imaging, 469

Hans-Jürgen Brambs

49 Endoscopic retrograde cholangiopancreatography, magnetic resonance cholangiopancreatography, and endoscopic ultrasound in chronic pancreatitis, 477

Andrew S Ross and Irving Waxman

50 Natural course of chronic pancreatitis, 484

Paul Georg Lankisch

51 Treatment of pseudocysts in chronic pancreatitis, 495

Syed A Ahmad and Jeffrey B Matthews

52 Medical treatment of chronic pancreatitis, 504Pain management

Indications for and goals of surgical treatment

Hans G Beger, Frank Gaunsauge, Michael Schwarz, and Bertram Poch

Pancreatic duct drainage procedures

Oscar J Hines and Howard A Reber

Duodenum-preserving pancreatic head resection

in inflammatory and cystic neoplastic lesions ofthe pancreas

Hans G Beger, Bettina M Rau, and Bertram Poch

Major pancreatic resections

Kaye M Reid-Lombardo, Michael B Farnell, and Michael G Sarr

Nerve ablation techniques in chronic pancreatitis

Colin J McKay and Peter Wysocki

55 Chronic pancreatitis: late outcome after medical andsurgical treatment, 561

Hans G Beger and Bertram Poch

56 Management of pancreatic diabetes secondary tochronic pancreatitis, 565

Keiko Shiratori

Section Five Neoplastic lesions of exocrine tissue: pancreatic cancer

57 Epidemiology of pancreatic cancer, 573

Nicholas Alexakis, Paula Ghaneh, and John P Neoptolemos

59 Familial pancreatic cancer, 591

William Greenhalf, Louis J Vitone, and John P Neoptolemos

60 Pathology of exocrine pancreatic tumors, 601

Günter Klöppel, Bence Sipos, and David S Klimstra

61 Precancerous lesions, 614

Roland M Schmid

62 Role of endoscopic ultrasound for diagnosis and

differential diagnosis of neoplastic lesions, 621

Drew Schembre

63 Radiologic diagnosis of pancreatic cancer: computed

tomography and magnetic resonance imaging, 629

Enrique Lopez Hänninen and Roland Felix

64 Screening of hereditary pancreatic cancer families, 636

Christopher Carlson, William Greenhalf, and Teresa A Brentnall

65 Clinical assessment and staging of pancreatic cancer, 643

J Ruben Rodriguez, Andrew L Warshaw, and Carlos Fernández-del Castillo

66 Role of positron emission tomography in diagnosis of

pancreatic cancer and cancer recurrence, 648

Helmut Friess, Mert Erkan, Jörg Kleeff, Uwe Haberkorn, and Markus W Büchler

67 Tumor markers in pancreatic malignancies, 658

Fuyuhiko Motoi, Shin-ichi Egawa, and Seiki Matsuno

68 The role of laparoscopy and peritoneal cytology in the

management of pancreatic cancer, 668

Kevin Conlon and Paul Balfe

69 Pancreatic cancer staging systems and their clinical

impact, 678

Hans G Beger and Dieter Birk

70 Endoscopic and interventional palliation of pancreatic

cancer, 682

Todd H Baron

71 Pancreatic cancer: indications for resection, 689

Akimasa Nakao

72 Pancreaticoduodenectomy for pancreatic cancer:

results after Kausch–Whipple and pylorus-preservingresection, 696

Ramon E Jimenez and Andrew L Warshaw

73 Extended radical surgery for pancreatic cancer, 707

Jens Werner and Markus W Büchler

74 Palliative pancreaticoduodenectomy: benefits and

limitations, 714

Helmut Friess, Jörg Kleeff, Mert Erkan, and Markus W Büchler

75 Bypass surgery for advanced pancreatic cancer, 719

Jürgen Weitz, Peter Kienle, and Markus W Büchler

76 Neoadjuvant treatment of pancreatic cancer:

borderline-resectable disease, 727

Gauri Varadhachary, Christopher H Crane, Eric P Tamm, Huamin Wang, Robert A Wolff, and Douglas B Evans

77 Adjuvant chemotherapy in pancreatic cancer, 741

Paula Ghaneh and John P Neoptolemos

78 Palliative chemotherapy for advanced pancreatic cancer, 749

Yu Jo Chua and David Cunningham

79 Management of cancer pain, 757

Sergio Pedrazzoli, Claudio Pasquali, Cosimo Sperti, and Francesca Avogaro

80 Role of radiotherapy in the treatment of pancreatic cancer, 765

Shilpen Patel, Michael C Garofalo, and William F Regine

81 Management of cancer recurrence, 772

Helmut Friess, Jörg Kleeff, and Markus W Büchler

82 Survival and late morbidity after resection of pancreatic cancer, 776

Osamu Ishikawa, Hiroaki Ohigashi, Hidetoshi Eguchi,

Yo Sasaki, Terumasa Yamada, and Shingi Imaoka

Section Six Endocrine tumors of the pancreas

83 Diagnosis of endocrine tumors of the pancreas, 787

Masayuki Imamura

84 Islet cell tumors, 794

Peter E Goretzki and Hans-Dietrich Röher

85 Pancreatic endocrine tumors in multiple endocrine neoplasia syndrome, 802

Elisabeth Spilcke-Liss, Peter Simon, Markus M Lerch, and Henri Wallaschofski

86 Nonfunctioning endocrine tumors, 813

Hodaka Amano, Tadahiro Takada, Fumihiko Miura, Takehide Asano, Masahiro Yoshida, Naoyuki Toyota, Keita Wada, Takahiro Isaka, Naoyuki Tamura, and Kenichiro Kato

87 Surgical treatment of endocrine tumors, 818

Masayuki Imamura

88 Treatment of carcinoids of the pancreas and biliarytract, 823

Andrea Frilling and Vito Cicinnati

89 Nonsurgical management of endocrine tumors, 832

Rudolf Arnold and Anja Rinke

90 Liver transplantation in advanced disease of endocrine tumors, 839

Christoph E Broelsch and Andrea Frilling

91 Long-term outcome after treatment of endocrinetumors, 845

Henning Dralle, Andreas Machens, Michael Brauckhoff, and Oliver Gimm

Section Seven Periampullary tumors

92 Periampullary tumors: clinical presentation and diagnostic strategy, 855

Amanda B Cooper and Keith D Lillemoe

93 Histology of cancer of the papilla, distal common bileduct, and duodenum, 863

Hans-Peter Fischer

94 Adenoma and adenocarcinoma of the ampulla of

Vater: diagnosis and management, 870

William R Brugge and Andrew L Warshaw

95 Endoscopic treatment of adenomas of the ampulla of

Vater: benefits and limits, 880

Richard A Kozarek and L William Traverso

96 Surgical treatment of periampullary cancer: early and

late results after resection, 885

Hans G Beger, Bertram Poch, and Bettina M Rau

Section Eight Other tumors of the pancreas

97 Histology of cystic tumors of the pancreas, 893

Wataru Kimura

98 Diagnostic imaging of cystic tumors, 912

Masao Tanaka, Kiichiro Kobayashi, Reiko Tanabe, and Koji Yamaguchi

99 Diagnosis and natural history of intraductal papillary

mucinous neoplasms, 918

L William Traverso and Richard A Kozarek

100 Mucinous cystic neoplasm, 924

Suresh T Chari and Thomas C Smyrk

101 Surgical treatment and long-term outcome of cysticneoplasms of the pancreas, 932

Carlos Fernández-del Castillo and Andrew L Warshaw

102 Minimally invasive and local ablation techniques ofserous and mucinous cystic lesions, 940

Laureano Fernández-Cruz

Section Nine Transplantation of the pancreas

103 Transplantation of pancreatic islets, 949

Reinhard G Bretzel and Mathias D Brendel

104 Transplantation of the pancreas, 960

Markus K Müller and Hans W Sollinger

Index, 971

Color plate sections follow pp 16 and 560

Raymond Aerts MD

Department of Abdominal Surgery, University Clinics, Gasthuisberg,

Catholic University, Leuven, Belgium

Assistant Professor of Surgery, University of Cincinnati, OH, USA

Associate Professor, Pancreatic Research Group; Faculty of

Medicine Director, South Western Sydney Clinical School,

University of New South Wales, Sydney, Australia

Professor Emeritus, Department of Internal Medicine,

Division of Gastroenterology and Endocrinology,

Philipps University, Marburg, Germany

Vice Chairman of Surgery, Brigham and Women’s Hospital;

Frank Sawyer Professor of Surgery, Harvard Medical School,

Boston, MA, USA

Anesthesiology and Intensive Care Unit – Pain Therapy,

University Hospital of Padua, Italy

Director, Department of Clinical Chemistry,

University Hospital Ulm, Germany

Paul Balfe MB FRCSI

Consultant Surgeon, St Luke’s Hospital, Kilkenny, Ireland

Professor of Medicine, Mayo Clinic College of Medicine,

Rochester, MN, USA

Founding Editor; Emeritus Professor of Surgery,

c/o Universitätsklinikum Ulm, University of Ulm, Germany

Dieter Birk MD

Surgeon in Chief, Department of Surgery,

Evang Krankenhaus Zweibrücken, Germany

Professor and Chairman Emeritus, Department of Cellular

Biology and Anatomy, Medical College of Georgia, Augusta,

Professor and Chairman, Department of General, Visceral and Transplantation Surgery, University Hospital Essen,

Kevin C.P Conlon MCh MBA FRCSI FACS

Professor of Surgery, The University of Dublin, Trinity College,

Ireland

HPB Surgeon, Department of Surgery, Christchurch Hospital,

New Zealand

Department of Surgery, Indiana University School of Medicine,

Indiana, IN, USA

Eithne Costello PhD

Lecturer in Molecular Biology, Division of Surgery and Oncology,

Royal Liverpool University Hospital, UK

Department of Molecular & Integrative Physiology,

University of Michigan, Ann Arbor, MI, USA

Department of Medicine, Royal Marsden Hospital, Sutton, UK

Professor of Surgery and Chairman, Department of General,

Visceral and Vascular Surgery, University of Halle, Germany

Professor of Surgery, Department of Surgical Oncology and the

Pancreatic Cancer Study Group, The University of Texas

M.D Anderson Cancer Center, Houston, TX, USA

Director, Clinic of Radiology, Charite Campus Virchow,

University Medical Center Berlin, Germany

Head of General and Gastrointestinal Surgery,

Hospital Clinic I Provincial de Barcelona, Spain

Associate Professor of Surgery, Harvard Medical School; Associate

Visiting Surgeon, Massachusetts General Hospital, Boston, MA, USA

Professor of Pathology, University of Bonn, Germany

Associate Professor of Surgery, Department of General, Thoracic,

Vascular and Transplantation Surgery, University of Rostock,

Germany

Emeritus Professor of Radiology; Director, Department of Radiology, University of Washington School of Medicine, Seattle,

WA, USA

Chairman and Head, Department of Surgery;

Professor of Surgery, University Hospital of Surgery, Technical University Munich, Germany

Professor of Surgery and Vice Chairman, Department of Surgery and Transplantation, University Hospital Essen, Germany

Pancreatic Research Group, University of California at Los Angeles and

VA Greater Los Angeles Health Care System, CA, USA

Professor Emeritus, Kyoto University; Director, Osaka Saiseikai Noe

Hospital, Osaka, Japan

Osaka Medical Center for Cancer and Cardiovascular Diseases,

Japan

Deputy President, Department of Surgery, Osaka Medical Center for

Cancer and Cardiovascular Diseases, Japan

Assistant Professor of Surgery, University of Connecticut Medical

School, Hartford, CT, USA

Department of Surgery, Yale University School of Medicine,

New Haven, CT, USA

Professor and Chairman, Department of Surgery, Yamagata

University School of Medicine, Japan

Jörg Kleeff MD

Associate Professor, Department of Surgery, University Hospital

Rechts der Isar, Technical University Munich, Germany

Department of Pathology, Memorial Sloan-Kettering Cancer Center,

New York, NY, USA

Professor of Pathology and Director, Department of Pathology,

University of Kiel, Germany

Director, Digestive Disease Institute, Virginia Mason Medical Center,

Seattle, WA, USA

Head of the Medical Center, Clinic for General Internal Medicine,

Municipal Clinic of Lüneburg, Germany

Peter Layer MD PhD

Professor of Medicine, University of Hamburg; Medical Director and

Director of Department of Internal Medicine, Israelitic Hospital,

Hamburg, Germany

Associate Professor, Department of Pharmacology,

Yonsei University College of Medicine, Seoul, Korea

Professor and Chair, Department of Gastroenterology,

Endocrinology and Nutrition, Ernst-Moritz-Arndt University,

Clinic of Radiology, Charite Campus Virchow, University Medical Center Berlin, Germany

Professor of Pediatrics and Chief, Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Pittsburgh at University of Pittsburgh Medical Center, PA, USA

Vice Chairman, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA

Daniel K Mullady MD

Division of Gastroenterology, University of Pittsburgh Medical

School, PA, USA

Division of Visceral and Transplant Surgery, University Hospital,

Zurich, Switzerland

Professor and Chairman, Gastroenterological Surgery (Department of

Surgery II), Nagoya University Graduate School of Medicine, Japan

The Owen and Ellen Evans Chair of Cancer Studies; Head, Division

of Surgery and Oncology; Head, School of Cancer Studies; Professor

of Surgery, University of Liverpool, UK

Chairman and Professor, The Third Department of Internal

Medicine, Division of Gastroenterology and Hepatology,

Kansai Medical University, Osaka, Japan

Division of Gastroenterology, Hepatology and Nutrition,

University of Pittsburgh, PA, USA

Professor of Surgery, A Alfred Taubman Health Care Center,

Ann Arbor, MI, USA

Professor of Medicine and Director of Pancreatic Research Group,

University of California at Los Angeles; Staff Physician, VA Greater

Los Angeles Health Care System, CA, USA

Department of Medicine, University of Pittsburgh, PA, USA

Shilpen Patel MD

Assistant Professor, Department of Radiation Oncology, University

of Washington Medical Center, Seattle, WA, USA

Sergio Pedrazzoli MD FACS

Professor and Chairman, Departments of Medical and Surgical

Sciences, IV Surgical Clinic, University of Padua, Italy

Professor and Chairman, Department of Abdominal Surgery,

University Clinics Gasthuisberg, Catholic University, Leuven,

Belgium

Ole H Petersen FRS FMedSci

Vice President of The Royal Society; MRC Research Professor and

George Holt Professor of Physiology, University of Liverpool, UK

Department of Surgery, University of Minnesota; Department of

Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA

Department of Visceral Surgery, Donauklinik, Neu-Ulm, Germany

Advanced GI Surgical Fellow, Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA

Emeritus Professor, Department of Surgery, University of Düsseldorf, Germany

Professor and Vice Chair, Department of Surgery, University of Minnesota, Minneapolis, MN, USA

Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, USA

C O N T R I B U T O R S

xiii

Henry J Schiller MD

Division of Gastroenterology and Hepatology, Mayo Clinic College

of Medicine, Rochester, MN, USA

Professor of Internal Medicine, II Medizinische Klinik und

Poliklinik, Technical University Munich, Germany

Pierluigi di Sebastiano MD

Associate Professor of Surgery, Department of General Surgery,

IRCCS Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Italy

Department for Interdisciplinary Endoscopy, University Medical

Center Hamburg-Eppendorf, Hamburg, Germany

Departments of Radiology and Surgery, St Joseph’s Hospital and

Medical Center, Phoenix, AZ, USA

Assistant Professor, Department of Gastroenterology and

Departments of Internal Medicine and Gastroenterology, Tokyo

Women’s Medical University School of Medicine, Japan

Chair and Professor, Department of Gastroenterology,

Tokyo Women’s Medical University School of Medicine, Japan

Department of Surgery, Community Hospital Aelen, Ulm, Germany

Manfred V Singer MD Hon Doc Mult

Professor of Medicine and Chairman, Department of Medicine II

(Gastroenterology, Hepatology and Infectious Diseases), University

Hospital of Mannheim, Germany

Vijay P Singh MD

Department of Gastroenterology and Hepatology, Mayo Clinic

College of Medicine, Rochester, MN, USA

Department of Pathology, Mayo Clinic College of Medicine,

Rochester, MN, USA

Professor of Surgery, Department for Interdisciplinary Endoscopy,

University Medical Center Hamburg-Eppendorf, Hamburg,

Germany

Professor of Surgery, University of Wisconsin Hospitals and Clinics,

Madison, WI, USA

Elisabeth Spilcke-Liss MD

Department of Gastroenterology, Endocrinology and Nutrition,

Ernst-Moritz-Arndt University, Greifswald, Germany

Departments of Radiology and Surgery, St Joseph’s Hospital and Medical Center, Phoenix, AZ, USA

Professor of Surgery, Teikyo University School of Medicine, Tokyo, Japan

Professor of Surgery and Chairman, Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan

Professor and Head, Department of Gastroenterology, Pushpawati Singhania Research Institute for Liver, Renal and Digestive Diseases, New Delhi, India

Professor of Surgery, Department of General and Digestive Surgery, Flinders University, Adelaide, Australia

Division of Gastroenterology and Hepatology, Mayo Clinic College

of Medicine, Rochester, MN, USA

Professor of Medicine and the Cancer Research Center, Director of Endoscopy, University of Chicago, IL, USA

Jürgen Weitz MD

Associate Professor of Surgery, Department of General and Visceral

Surgery, University of Heidelberg, Germany

Professor of Surgery, Department of General and Visceral Surgery,

University of Heidelberg, Germany

Professor of Medicine and Chief, Division of Gastroenterology,

Hepatology and Nutrition, University of Pittsburgh, PA, USA

Professor and Chair, Department of Molecular and Integrative

Physiology, University of Michigan Medical School, Ann Arbor,

MI, USA

Professor of Medicine, Clinical Associate Dean, South Western Sydney Clinical School, University of New South Wales, Sydney, Australia

At the beginning of the 21st century, medicine is increasingly

based on understanding the functions of genes and the

molec-ular mechanisms of diseases In pancreatology, the

under-standing of functions and dysfunctions of the exocrine and

endocrine pancreas is derived from molecular biological data

on the actions of compounds in subcellular compartments and

intracellular transcription pathways In clinical medicine new

and improved technical devices enable the gastroenterologist

and the gastrointestinal surgeon to identify lesions by

high-resolution imaging techniques, imaging of metabolic processes,

and intrapancreatic ductal investigations Decision making is

increasingly based on the evidence of data from clinical trials

on treatment modalities of pancreatic lesions

Well into the 20th century the pancreas was considered ahidden organ Now, at the beginning of the 21st century, only

ductal pancreatic cancer remains largely an uncontrollable

mystery disease Today, understanding the pancreas, its normal

and abnormal functions, and its morphological pathology has

become an international focus of established scientists Medical

sciences are not uniform around the world However, the

impact of information technology, international data exchange,

and global communications networks have resulted in a broadly

increased level in the understanding and practice of

pancre-atology The synergistic interaction of basic scientists,

gastro-enterologists, and gastrointestinal-tract surgeons in the field of

investigative and clinical pancreatology has led to better

understanding of pancreatic diseases through combining the

knowledge of each to achieve the best evidence-based

manage-ment Although care of patients cannot be made a global affair,

this book brings the most recent knowledge on the pancreasfrom international experts to readers everywhere

The goal of this second edition of The Pancreas – An

Integrated Textbook of Basic Science, Medicine, and Surgery

is to provide the clinician with the most current data-basedsynthesis of understanding of pancreatic diseases, functionalassessments, diagnostic and technical devices, and treatmentoptions A major part of this edition has been contributed byleading international basic scientists, who provide an under-standing of the molecular basis of pancreatic functions anddiseases

The editors acknowledge and are deeply indebted to allauthors and co-authors who have contributed to this edition.Their diligent efforts have provided state-of-the-art knowledge,particularly in regard to clinical decision making Our profoundgratitude goes also to all who were involved in the develop-ment and production of the book We greatly appreciate theirsupport

Hans G Beger, UlmAndrew L Warshaw, BostonMarkus W Büchler, HeidelbergRichard A Kozarek, SeattleMarkus M Lerch, GreifswaldJohn P Neoptolemos, Liverpool

Keiko Shiratori, TokyoDavid C Whitcomb, PittsburghBettina M Rau, Rostock

xv

Preface

Plate 2.1 Timeline of notable advances in elucidation of the anatomy, physiology, pathology, and therapy of the pancreas The horizontal and

vertical axes indicate general advances in medical science that contributed to progress in the management of pancreatic disease R de Graaf(bottom left) defined early pancreatic secretory physiology, O Minkowski (top left) identified the relationship between the pancreas and diabetes,

J Purkinje (top right) demonstrated its role in fat digestion, and W Kuhne (bottom right) identified the proteolytic powers of trypsin

Plate 2.2 A Vesalius (1514–1564) (top left)

of Padua and B Eustachio (1520–1574) of

Rome (bottom right) were among the first to

define the anatomy of the pancreas However,

it was Vesalius who provided the first definitive

anatomic depiction of the human pancreas

(center) in his De Humani Corporis Fabrica

(frontispiece at background left) of 1543 but

erroneously considered its function to be a

cushion to the stomach and valve to close

the pylorus

The Pancreas: An Integrated Textbook of Basic Science, Medicine, and Surgery, Second Edition

Edited by H G Beger, A L Warshaw, M W Büchler, R A Kozarek, M M Lerch, J P Neoptolemos,

Plate 2.3 A copper engraved plate (center)

made by J Wirsung (1589–1643) depictinghis initial identification of the humanpancreas in 1642 in the dissecting room ofPadua (bottom left) Sadly his blazon (topright) remains the only extant image ofWirsung who was tragically murdered by astudent The small oblong folio drawing ofthe pancreas clearly distinguishes 21branches of the pancreatic duct as well asthe bile and pancreatic ducts, the duodenum,and spleen The medical cognoscenti of thetime were unable to explain the function ofthe duct

Plate 2.4 R Oddi (1866–1913) (top right), while a medical student

at the University of Perugia, published in 1887 his observations of

the structure and function of the choledochal sphincter in Archives

Italiennes de Biologie (background) His further investigations into

bile duct structure and the function of the sphincter (left) defined its

physiologic properties and laid the basis for understanding its role in

pancreatic and biliary disease

Plate 2.5 R de Graaf (1641–1673) (center) devised novel surgical

techniques to create pancreatic fistulas (bottom) and at the age of 23

years published his text De Succo Pancreatico in 1664 (background).

A goose quill inserted into the ductal orifice enabled the direct collection

of pancreatic juice (succus pancreaticus) and his investigations achievedmuch acclaim, as did his work on ovarian function (Graafian follicle)

Plate 2.6 C Bernard (1813–1878) (top left) placed the physiology of

the pancreas into a modern context of physiologic and clinical relevance

with the 1856 publication of Mémoir sur le Pancreas (top right) His

accurate depictions of the organ (left and right) and his studies of its

metabolic function defined its pivotal role in protein and fat digestion

In 1889, the artist L’Hermitte memorialized his laboratory group and

his experimental skills (bottom right)

Plate 2.7 I Pavlov (1849–1938) (left)

propounded the theory of neural regulation

of pancreatic secretion in 1897 using vagally

denervated fistula models W Bayliss

(1860–1924) (bottom center) and E Starling

(1866–1927) (top right) developed the

alternative concept of a chemical messenger

system, discovered secretin, named it a

hormone, and established endocrinology in

the Croonian Lectures of 1905 (right) Their

classic text The Principles of General

Physiology (center) of 1914 defined their

contributions

Plate 2.8 Chronology of observations (beginning 1685, top left,

clockwise) that identified the enzymatic role of the pancreas indigestion and mechanisms of regulation of pancreatic function

Plate 2.9 J Berzelius (1779–1848) (bottom left) denied the concept

of a vital force and proposed chemical catalysis as the mechanism

W Kuhne (1837–1900) (center) and R Heidenhain (1834–1897)

(bottom right) introduced the terms “enzyme” and “zymogens” to

identify the active and inactive forms of such chemical compounds

in pancreatic juice This work was based on the observations of

T Schwann (1810–1882) (top right) who in 1836 had reported the

first digestive zymogen (pepsinogen) in the laboratory of T Muller

(1801–1858) (top left)

Plate 2.10 P Langerhans (1847–1888) (bottom right), scion of a

distinguished medical family (top left), described structures called

Zellhäufchen (little heaps of cells) (left) in his medical student thesis of

1869, Contributions to the microscopic anatomy of the pancreas

(background) Langerhans noted their unusual structure: “this cell is asmall irregularly polygonal structure with brilliant cytoplasm… Thecells lie together in considerable numbers diffusely scattered in theparenchyma of the gland.” In 1893, G.-E Laguesse (1861–1927)hypothesized their role in internal secretion and named them “d’îots deLangerhans” (islets of Langerhans) to commemorate the early tragictuberculous death of Langerhans on the island of Madeira

Plate 2.11 In 1921, F Banting (1891–1941) (background), an

orthopedic surgeon, and his student collaborator C Best (1899–1978)(left) demonstrated that pancreatectomy rendered dogs diabetic butreversal occurred when islet extracts were injected With the aid of

J Collip (1882–1965), they purified an islet extract, insulin (top left)

A year later, Banting was awarded the Nobel Prize in Medicine, ascientific travesty since both Best and Collip were ignored

Plate 2.12 The relationship between

observations in anatomy (top) and physiology

(bottom) and exocrine (left) and endocrine

(right) pathology, integrated with the resultant

evolution of pancreatic therapy (center)

Seminal contributions to pancreatic progress

were made by J Meckel (top left, embryology),

C Best (top right, discovery of insulin),

F Trendelenburg (bottom right, first resection

of a pancreatic neoplasm), and R Fitz

(bottom left, classification of pancreatitis)

Plate 2.13 Evolution of diagnostic modalities

for pancreatic disease The outer ring defines

the broad context of medical advance, each

radius delineating the year of individual

discoveries Initiation of the scientific era of

diagnosis may be regarded as the histologic

examination of tissue by R Virchow in

1854, with subsequent clockwise progression

Plate 2.14 R Fitz (1843–1913) (bottom left), a pathologic anatomist,

studied in Germany before returning to Harvard Medical School (top

right) where he published his contributions to pancreatitis Fitz

described three forms of acute pancreatitis and suggested that fat

necrosis was a sequela of severe pancreatitis

Plate 2.15 E Opie (1873–1971) (bottom) of Johns Hopkins Hospital

concluded that gallstones (center), duct obstruction, and pancreatitis

were causally linked This led to his proposal of the “common channel”

hypothesis and the theory that bile reflux into the pancreatic duct

would result in enzyme activation and culminate in acute pancreatitis

Plate 2.16 In 1909, R Coffey (1869–1933) (right) reported experimental

techniques utilizing pancreaticoenterostomy and established the possibility

of pancreatectomy and pancreatic anastomosis (top) Although heconsidered the possibility of a retrograde pancreaticojejunostomy, hebelieved it would fail due to obstruction Fifty years later C Puestow(bottom left) successfully introduced lateral pancreaticojejunostomy(background) for “dilated duct chronic pancreatitis.”

Plate 2.17 In 1973, K Kawai (top left) and M Claasen (bottom right)

independently developed endoscopic papillotomy in Osaka and Munich,respectively Their contributions initiated access to the biliary and pancreaticductular system The subsequent diagnostic and therapeutic advances,including papillotomy, balloons, baskets, and stents, introduced the era ofminimal access surgery of pancreatic and biliary disease

Plate 2.18 In 1883, C Gussenbauer (1842–1903) (top left) detailed

his successful surgical technique (background) for the marsupialization

(right) of a pancreatic cyst His report initiated the concept that the

pancreas might successfully be surgically addressed

Plate 2.19 Zollinger–Ellison syndrome was described in 1955 by

R Zollinger (1903–1992) (top right) and E Ellison (1919–1970)(bottom left) They noted the relationship between non-
cellpancreatic tumors and ulcers in the duodenum (bottom) and smallbowel The causal agent, gastrin, was subsequently identified as thetumor secretagogue in 1959 by R Gregory of Liverpool

Plate 2.20 A timeline of the introduction of pancreatic surgical procedures The horizontal and vertical axes define the medical and scientific advances

that facilitated evolution of the various surgical techniques Resection of pancreatic tumors was introduced by A Codivilla (bottom left) in 1898 inImola, Italy, W Halsted (top right) in 1898 in Baltimore, W Kausch (top left) in 1909 in Berlin, and A Whipple (bottom right) in 1935 in New York

Plate 2.21 A Codivilla (1861–1912)

(bottom left) of Imola, Italy (background),first performed an en bloc resection of thehead of the pancreas and duodenum in

1898 (center) Reanastomosis was undertakenusing a cholecystojejunostomy and aRoux-en-Y gastroenterostomy Codivillanever published his procedure andachieved prominence as an orthopedicsurgeon describing transcalcaneal bonetraction (top left, bottom right)

Plate 2.22 In 1912, W Kausch (1867–1928) (left) of the Auguste

Victoria Hospital, Berlin (center), published a review of the world

literature on ampullary cancer (top) and described the first successful

two-stage partial pancreaticoduodenectomy (bottom) The success

of Kausch owed much to his surgical mentor (and father-in-law)

J von Mikulicz (1850–1905) (right)

Plate 2.23 In 1934, A Whipple (1881–1963) (bottom right)

performed procedures that culminated in the publication of hiseponymous procedure In 1935, the technique (background) and theresults of the first three cases were reported to the American SurgicalAssociation (top) The potential disadvantages of this en blocresection, including modest outcome and potentially seriousdisturbances in digestion, were noted

Plate 5.1 Ectopic pancreas 4 cm distant from the duodenal papilla under endoscopic vision and during endocopic snare dissection

(top images) and histologically (bottom panels, at bottom right cytokeratin staining) Note the complete absence of endocrine cells on histologywhich corresponds to a type II ectopic pancreas according to Heinrich (1909), i.e composed of only exocrine cells Histology courtesy of

M Androshchuk and G Lorenz, Greifswald

Acinar lumen

Global (4–7)

50 sec

100 nM

ACh

[C 2
]i

Apical

Basal 1µM

Cl channel

Ca2
pump

LumenExocytosisGranules

MitochondriaLumenallyconnected ER

Base

SERCASOC

m

Rhod-2

IP3RRyR

SOC channels

ADP-ribosylcyclase Ca2
Ca2
Ca2

Matrix

IP 3 R

RyR

cADPRNAADP

IP 3 R

IP 3

NAADP cADPR

PLC

PM

α γβPMCA

N ERER

ⴙ

ZGsSP:

ACh

NSP

of the Na
/Ca2
exchanger is highlighted Ca2
extrusion by the plasma membrane Ca2
-activated ATPase is shown Ca2
entry occurs throughstore-operated Ca2
channels (SOC) (b) Schematic illustration of Ca2
release from the ER through the IP3R elicited by IP3and through the RyR

by NAADP or cADPR Positive and negative Ca2
interactions between the two Ca2
release channels are also shown (c) Confocal fluorescentimages illustrating changes in organellar [Ca2
] following ACh stimulation The left image shows the high resting [Ca2
] in the ER (mostly in thebasal (left) part of the cell After maximal ACh stimulation, [Ca2
] in the ER has been reduced markedly (shift from warm (red) to cold (green)colour) and the perigranular mitochondrial belt is now clearly seen (yellow) This indicates that Ca2
lost from the ER has been taken up in part

by the mitochondria The third image shows the almost complete loss of Ca2
from the ER and the still elevated [Ca2
] in the perigranularmitochondria (d) Confocal image showing the distribution of fluorescent thapsigargin (white), a very specific marker for the ER Ca2
pump Theoptical slice goes through two cells (but only through one nucleus – N) It is seen that by far the highest ER Ca2
pump density is in the

basolateral parts of the cell, but it is important to note that there are some light elements in the darker granular (secretory pole – SP) areassignifying ER elements with Ca2
pumps also in this part of the cell (e) Schematic drawing of Ca2
, H
and K
transports across the ZGmembrane Adapted from Petersen and Sutton, 2006 [21]

10 s

Between spikes Apical Ca 2ⴙ spike

ICl, Ca2

IP3 inPipette

IP 3 in pipette

CellCl

Ca2

Ca2

activated

Clconductance

3 nS

800 fF

500 ms

Secretion(exocytosis)

Apical Ca 2ⴙ exit Basal Ca 2ⴙ entry

(f)(e)

(d)

(i)(h)

1

B

Plate 6.5 Overall Ca2
homeostasis: Ca2
entry and exit The left part illustrates an experiment in which [Ca2
] is measured outside an isolatedacinar cell by using a Ca2
-sensitive fluorescent indicator linked to high molecular weight dextran, thereby limiting the indicator mobility Themorphology of the cell, with clear identification of the granular apical (Ap) pole is shown in (a) (b) – (i) are fluorescent images (taken at 3-s intervals) showing the distribution of the extracellular [Ca2
] rise immediately following stimulation with ACh (10µM) It is clear that the

Ca2
extrusion from the cell occurs predominantly across the apical membrane The right part of the figure illustrates the rise in [Ca2
] ofmitochondria close to the basal plasma membrane during store-operated Ca2
entry Mitochondrial [Ca2
] ([Ca2
]m) was measured with afluorescent probe and traces from three regions of interest (red, black, and green) are shown The cell was initially poisoned with thapsigargin inthe absence of external Ca2
to deplete the ER of Ca2
During the time period indicated by the bar labelled 10 mM Ca2
, Ca2
was readmitted

to the external solution and it is seen that there was a marked rise in [Ca2
]mparticularly in the red region of interest, very close to the basalplasma membrane The image marked with a red arrow shows the distribution of the elevated [Ca2
] at the time indicated by a similar red arrowabove the fluorescence traces Clearly the elevation of [Ca2
]mhas essentially occurred in a region very close to the plasma membrane The EMpicture shows a mitochondrion (Mit) situated very close to the plasma membrane (PM) Adapted from Belan et al., 1996 [39] and Park et al.,

2001 [40]

Plate 10.1 c-Fos immunofluorescence in vagal nodose ganglia neurons in response to an intra-arterial injection of secretin A: administration of

saline did not stimulate c-Fos expression in nodose ganglia neurons B: administration of secretin significantly increases c-Fos expression innodose ganglia C: vagotomy abolished secretin-stimulated c-Fos expression in nodose neurson Reprinted with permission from Li et al [77]

(a)

100µm

Plate 14.1 Postmortem finding of a stone in the main bile duct of a

patient with jaundice, necrotizing pancreatitis, and multiorgan failure

Plate 14.2 Bile pigmentation among necrotic pancreatic tissue in a

patient who underwent necrosectomy following a severe attack of

gallstone acute pancreatitis

Plate 14.3 A gallbladder specimen demonstrating cholesterolosis; the

diagnosis was missed by bile microscopy, ultrasound, and endoscopic

retrograde cholangiopancreatography but suspected following an

abnormal radionuclide biliary scan

Plate 14.4 (a) Cholesterol crystals seen under ultraviolet light

following duodenal bile collection and incubation at 37°C (b)Calcium bilirubinate granules seen among biliary “sludge.”

Plate 14.5 A gallbladder specimen containing microlithiasis that had

been missed by all investigations, including bile crystal analysis andendoscopic retrograde cholangiopancreatography

Plate 15.1 Annular process.

Plate 15.2 Operative photograph of a pancreatic duplication cyst

bulging into the duodenal lumen, as shown in Figure 15.4 The

catheter has been introduced through the ampulla into the pancreatic

duct Excision of the cyst with suture ligation of its narrow neck was

curative of her recurrent pancreatitis

Plate 19.1 Stereotactic figure of cationic trysinogen (PRSS1) The two

globular domains of PRSS1 are shown in yellow and blue The SPINK1

molecule blocking the active catalytic site of PRSS1 is shown in red

Plate 20.2 Severe form of acute pancreatitis with type 1 necrosis

pattern Confluent peripancreatic fat necrosis (top) and a focus ofintrapancreatic fat necrosis (center) involving neighboring acinarcells H&E,  40

Plate 20.1 Mild form of acute pancreatitis type 1 necrosis pattern.

Spotty necrosis of peripancreatic fatty tissue (top) H&E,  40

Plate 20.3 Severe form of acute pancreatitis with fat necrosis

involving vessels and leading to venous thrombosis (T), hemorrhage(H) and partial necrosis of an arterial wall (A) H&E,  120

Plate 20.4 Acute pancreatitis with type 2 necrosis pattern Ductal

necrosis with protein precipitate (P), rupture of duct wall (arrows)

and leukocytes infiltrating the interstitial space H&E,  120

Plate 20.5 Acute pancreatitis with type 3 necrosis pattern.

Centrolobular acinar cell necrosis (arrows) with inflammatory

infiltrate H&E,  250

Plate 29.1 Intraoperative situs after lesser sac access and incision of

a large cavity containing well demarcated subtotal infected necrosis

which could be easily removed with instruments

Plate 29.2 Situs after completion of necrosectomy and intraoperative

lavage with no relevant residual necrosis left

Plate 31.1 Balloon dilation of the cystogastrostomy stoma under

direct endoscopic view

Plate 31.2 Transgastric stent placement into the cavity Purulent

material is pouring out of the abscess cavity

Plate 31.3 Endoscopic necrosectomy (a) The cavity lumen is filled

with large pieces of necrotic material (b) After complete removal of

all necrotic material

(a)

(b)

Plate 37.1 Alcoholic chronic pancreatitis: Whipple resection

specimen showing parenchymal scarring, stenosis of the bile duct

and multiple intraductal calculi

Plate 37.2 Alcoholic chronic pancreatitis, early stage: pancreatic

tissue showing an area of autodigestive fatty tissue necrosis (left side)and cell-rich perilobular fibrosis

Plate 37.3 Alcoholic chronic pancreatitis, advanced stage: extensive

peri- and intralobular fibrosis replacing most of the acinar tissue

Plate 37.4 Hereditary chronic pancreatitis: ductal and periductal

inflammation

Plate 38.1 Histology of a pancreas adenocarcinoma (a) Pronounced fibrosis in pancreas carcinoma Imunofluorescence stainings of

α-smooth-muscle actin (b), desmin (c), collagen type I (d), collagen type III (e), and fibronectin (f) Intense immunostaining to αSMA is associated with

stainings for collagens and fibronectin High numbers of αSMA positive cells and desmin positive cells are present in fibrotic areas.

Plate 42.1 Immunohistochemistry of the pancreas in

autoimmune pancreatitis Immunohistochemistry showed

T-cells mainly infiltrated around the pancreatic duct

( 250) (a) pan T cells (pancreatic duct); (b) pan B cell

(pancreatic duct); (c) pan T cell (intrapancreatic bile duct);

(d) pan B cell (intrapancreatic bile duct)

Plate 41.1 Histopathologic slides showing intraductal protein plug (a) and periductal fibrosis with very little inflammatory infiltration (b)

(Taken from ref 1 with permission from S Karger AG, Basel)

Plate 42.2 Histophathologic findings of the liver and

minor salivary gland in autoimmune pancreatitis

Infiltration of lymphocytes and plasma cells with fibrotic

changes (a,c) and IgG4-positive plasmacyte cells (b,d)

(b)

Plate 53.1 Following ESWL multiple stone fragments are extracted

(a,b) followed (c) by dual stent placement

Plate 54.1 Operative specimen of a multicystic IPMN of the

pancreatic head

Plate 54.2 Greater splanchnic nerve running across vertebral bodies.

(c)

Plate 60.1 Gross specimen of ductal adenocarcinoma in the head of

the pancreas showing stenosis of the common bile duct and the

pancreatic duct

Plate 60.2 Ductal adenocarcinoma with well-formed tubular and

glandular structures embedded in desmoplastic stroma

Plate 60.3 Pancreatic intraepithelial neoplasia, grade 1 (a) and

grade 3 (b)

Plate 60.4 Undifferentiated carcinoma composed of large

pleomorphic cells

Plate 60.5 Gross specimen of intraductal papillary mucinous

neoplasm, intestinal type showing a markedly dilated ampulla of

Vater, main pancreatic duct and a secondary duct The remaining

pancreatic tissue is severely fibrotic

Plate 60.6 Intraductal papillary mucinous neoplasm, intestinal type,

with intraductal papillary proliferation of well-differentiated

columnar epithelium

Plate 60.7 Acinar cell carcinoma showing acinar and trabecular

growth pattern

Plate 64.1 PanIN II, or low-grade dysplasia, is indicated by red

arrowheads Note the abnormal, palisading nuclei Adjacent to thesmall ducts with PanIN II are pancreatic ducts that are normal inappearance This pathology highlights the widespread, but focalnature of the dysplastic ducts Such changes would be subject tosampling error by needle aspirate

Plate 65.1 (a) EUS examination demonstrating a pancreatic head mass with portal vein invasion (b) Resulting FNA demonstrating

well-differentiated adenocarcinoma

Plate 65.2 (a) Unsuspected liver (solid arrow) and (b) peritoneal implants (dashed arrow) discovered during staging laparoscopy in a patient with

pancreatic cancer believed to be resectable preoperatively

Plate 65.3 Peritoneal wash with positive results for malignancy

showing a cluster of adenocarcinoma cells with nuclear overlapping

and cytomorphologic features of malignancy, including an increased

nuclear to cytoplasmic ratio and nuclear membrane irregularities

Plate 65.4 Coronal reconstruction of a combination PET/CT

demonstrating a large tumor in the head of the pancreas (solidarrows)

Plate 73.1 Extended lymph node dissection for pancreatic cancer.

Aorta, CT – celiac trunk, SMA – superior mesenteric artery, RRA – right renal artery, IVC – inferior vena cava, PV – portal vein,LRV – left renal vein

Plate 73.2 Pancreatic head with portal vein resection Reconstruction

of the portal vein with a goretex-graft PV – portal vein, SMV –superior mesenteric vein, IVC – inferior vena cava, CT – celiac trunk,CHA – common hepatic artery, SA – splenic artery, SMA – superiormesenteric artery, Pancreas – pancreatic remnant after extendedresection to achieve negative margins on frozen section

Plate 73.3 Extended lymph node dissection for M1 disease: resection

of interaortocaval lymph nodes

Plate 70.2 Illustration of EUS-guided celiac plexus neurolysis.

Plate 70.1 Illustration of ERCP placement of plastic biliary stent

across a malignant stricture for relief of malignant biliary obstruction

Plate 74.1 Example of a palliative (R1) pancreatic resection

Intra-operative situs depicting the celiac trunk with microscopically

positive margin at the common hepatic artery (arrowheads) A:

aorta; CHA: common hepatic artery; SA: splenic artery; LGA: left

gastric artery; PV: portal vein; SV: splenic vein

(a)

Plate 75.1 (a) Creation of a side-to-side gastrojejunostomy: a window is created in an avascular region of the left transverse mesocolon The

most dependent portion of the stomach is pulled through this opening The first jejunal loop is used to create an isoperistaltic gastrojejunostomy.(b) Creation of a side-to-side gastrojejunostomy: The posterior side of the gastrojejunostomy is completed (c) Creation of a side-to-sidegastrojejunostomy: The gastrojejunostomy is completed; the stomach is tagged to the mesocolon in order to prevent hernia formation