Pancreatic Cancer Medical Slides

Present the three anastomoses and their complication rates: (1) Pancreaticojejunostomy (or pancreaticogastrostomy) — highest-risk anastomosis, pancreatic fistula rate 10-25%. Fistula risk stratification by Fistula Risk Score (soft gland texture, small duct diameter, non-pancreatic pathology, high intraoperative blood loss). (2) Hepaticojejunostomy — bile leak rate 2-5%. (3) Gastrojejunostomy (or duodenojejunostomy in pylorus-preserving variant) — delayed gastric emptying in 20-40% (most common complication, usually self-resolving). Emphasize the volume-outcome relationship: high-volume centers (>20 Whipples/year) have mortality <3% vs 12-16% at low-volume centers. This is the strongest surgical volume-outcome relationship and supports centralization.

Present the evolving evidence: PREOPANC-1 (2020): neoadjuvant gemcitabine-based chemoradiation vs upfront surgery for borderline/resectable — improved R0 resection rate (71% vs 40%), improved DFS, and trend toward OS benefit. PREOPANC-2 (2023): neoadjuvant FOLFIRINOX vs gemcitabine-based chemoradiation — FOLFIRINOX showed improved median OS (21.9 vs 21.3 months, not significant) but higher R0 rates. Alliance A021501: neoadjuvant mFOLFIRINOX (without radiation) for borderline resectable — median OS 29.8 months, supporting chemotherapy-alone neoadjuvant approach. Teaching message: neoadjuvant therapy is increasingly standard for borderline resectable disease, with FOLFIRINOX-based regimens preferred when tolerated (patient fitness is key — ECOG 0-1 required).

Present the 2016 ISGPF updated classification: Biochemical leak (formerly Grade A) — elevated drain amylase >3× serum on POD 3 or beyond, no clinical impact, no management change. Grade B — requires change in management (drain maintenance >3 weeks, percutaneous drainage, antibiotics, nutritional support, somatostatin analogs). Grade C — requires reoperation, organ failure, or death. Prevention strategies: octreotide/pasireotide (TOPS trial showed pasireotide reduces clinically significant fistula from 21% to 8% in high-risk patients), external stenting, sealants (evidence limited). Management: maintain drains, NPO/TPN, octreotide, percutaneous drainage of collections, interventional radiology for hemorrhage (sentinel bleed from GDA/SMA pseudoaneurysm is life-threatening — maintain a high index of suspicion).