Several biopsies of a 2x2 cm solid lesion in the head of pancreas showed no neoplastic cells

Pancreas 3
1- Several biopsies of a 2x2 cm solid lesion in the head of pancreas showed no neoplastic cells. The CT showed no metastasis or invasion of the vessels/adjacent organs. What is the next step in management?

This process in the head of pancreas remains a tumor and we still have to perform a pancreaticodudenectomy. This is a carcinoma until proven otherwise. Failure to prove the malignancy histologically doesn’t change our strategy. The presence of a painless jaundice increases the probability of malignancy but its absence can’t exclude malignancy.

2- You refer a patient with a painless jaundice and a tumor of the head of pancreas for ERCP and stent placement. Is there any evidence that biliary decompression prior to surgery has any benefit? Plastic vs. metallic stent?
No. However many surgeons advocate to do it prior to surgery in case of cholangitis. BUT the duration of obstructive jaundice is a risk factor for postoperative pancreatic fistula. So if the decision was to send the patient for neoadjuvant chemoradiotherapy prior to surgery we have to do it.

You have decided to place a stent in the CBD: Plastic or metallic stent?
If our plan is to perform a resection we prefer to place a plastic stent. It is temporary and well be removed with the specimen during surgery. It’s also cheaper. Moreover the technique of placement is easier than in the metallic one. However, plastic stents have a higher tendency for obstruction and displacement and thus are not suitable for palliative purposes when the tumor has metastases or it is locally advanced and unresectable.

3- Postoperatively your patient develops a well drained pancreatic fistula. Do you give somatostatin to facilitate the closure of the fistula?
There is no evidence that somatotatin increases the rate of pancreatic fistula closure. However many surgeons do this. The main stem of the therapy is drainage, drainage and drainage.

4- What is the most important independent risk factor for the development of pancreatic fistula after whipple procedure?
The presence of a SOFT pancreatic tissue. However this is often not the case in tumors of the head of pancreas due to accompanying inflammation and fibrosis of the remaining pancreas tissue.

5- Are there major benefits of performing a pylorus preserving pancreaticodudenectomy over classic whipple procedure?
Both have the same major morbidity and mortality. However, we have more cases of postoperative delayed gastric emptying after PPPD. PPPD is the most commonly performed form of pancreaticodudenectomy in the western countries.