Whereas distal pancreatectomy is performed for tumors in the distal half of the pancreas, subtotal pancreatectomy involves resection of the pancreas from the mesenteric vessels distally, leaving the head and uncinate process intact. In about 95% of patients with pancreatic cancer, the cancer is ductal adenocarcinoma, and most of these tumors occur in the head of the pancreas. Insulinoma is the most commonly occurring endocrine tumor of the pancreas.
Pancreatic cancer may appear as a localized mass or as a diffuse enlargement of the gland on computed tomography of the abdomen. Biopsy of the lesion is necessary to confirm the diagnosis. Complete surgical resection is the only effective treatment of ductal pancreatic cancer.
2. Preoperative assessment
Patients requiring pancreatic surgery can be divided into four groups: (1) those with acute pancreatitis in whom medical treatment has failed in the past, (2) patients with adenocarcinoma of the pancreas, (3) patients with neuroendocrine-active or -inactive islet cell tumors, and (4) patients with the sequelae of chronic pancreatitis (abscess or pseudocyst).
a) History and physical examination
(1) Cardiovascular: Patients with acute pancreatitis may be hypotensive and may require aggressive volume resuscitation with crystalloid and even blood before surgery. Severe electrolyte disturbances may be associated with acute pancreatitis and some hormone-secreting tumors of the pancreas. Hypocalcemia is often present and can cause dysrhythmias and hypotension.
(2) Respiratory: Respiratory compromise such as pleural effusions, atelectasis, and adult respiratory distress syndrome progressing to respiratory failure may occur in up to 50% of patients with acute pancreatitis.
(3) Gastrointestinal: Jaundice and abdominal pain are common symptoms in this group of patients. The presence of ileus or intestinal obstruction should mandate full-stomach precautions and rapid-sequence induction. Electrolyte disturbances are common in acute pancreatitis and may include hypochloremic metabolic alkalosis, decreased calcium and magnesium, and increased glucose. These abnormalities should be corrected preoperatively.
(4) Endocrine: Many patients with acute pancreatitis may have diabetes secondary to loss of pancreatic tissue. Hormone-secreting tumors of the pancreas are occasionally associated with multiple endocrine neoplasia syndromes. Insulinoma is the most common hormone-secreting tumor of the pancreas and can result in hypoglycemia.
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