Pancreatic Carcinoma and Gastroenteroanastomosis –Pancreatic Carcinoma and Gastroenteroanastomosis –
In July 2023, I was given a great opportunity to attend an exchange program by the International Federation of Medical Students’ Associations (IFMSA). For the first time in my life, I went to Bratislava, Slovakia. For one full month, I attended a clerkship at Kramare Hospital Bratislava, specifically in the General Surgery department. There, I was lucky to attend many different surgeries, from hernia repairment to parathyroidectomy. In the middle of all those surgeries, one caught my attention, which was a gastroenteroanastomosis on a patient with inoperable pancreatic carcinoma.
Pancreatic cancer, specifically originating from the cells lining the pancreatic ducts, is referred to as pancreatic ductal carcinoma (Puckett and Garfield, 2022). This type of cancer stands as the fourth leading cause of cancer-related fatalities in the United States. The survival prospects for patients with pancreatic cancer are notably grim, with a 5-year survival rate ranging from just 5% to 15%, and an overall survival rate of a mere 6%. Currently, surgical removal of the tumour is the sole curative option available, although the unfortunate reality is that only 20% of pancreatic cancer cases are eligible for surgical resection at the time of diagnosis. Research on pancreatic carcinoma has provided crucial insights into its risk factors, genetic mutations, and potential therapeutic approaches (Ryan DP et al., 2014). Several factors increase the risk of developing pancreatic carcinoma, including age, smoking, obesity, chronic pancreatitis, and a family history of pancreatic cancer. In recent years, advancements in molecular profiling have identified specific genetic alterations associated with this cancer, such as mutations in the KRAS, TP53, and CDKN2A genes.
The patient who experienced this condition was a 79-year-old male patient. He got hospitalised due to vomiting and pressure pains in the epigastrium and below the oblique ribs. Before this admission, he was admitted with arterial hypertension in 2021. Currently, the patient also suffers from Type 2 Diabetes Mellitus with peripheral artery disease and has been treated for it as well. On physical examination, the patient’s chest is symmetrical and has regular movement of the heart. The breathing of the patient is symmetrical, soft, and graspable. The chest is also diffusely painless on palpitation and palpation. On ultrasonography (USG) examination, there is a significant distended stomach due to gastroparesis suspension. Peristalsis is detected as weakened. There are scars after APE and CHE. The liver and spleen are non-palpable.
Surgical intervention was performed for the patient, as evidenced by both histological examination and CT imaging. This tumor was causing obstruction in the duodenum. The surgery was conducted under general anesthesia with the patient in the supine position, following appropriate preoperative preparations.
To access the abdominal cavity, a median laparotomy was performed. Upon exploration, it was observed that the stomach was not dilated, and the liver appeared normal without any notable changes. The tumor was found to have infiltrated the head of the pancreas and extended into the processus uncinatus, further infiltrating the radix of the mesentery. Although the tumor exhibited some mobility relative to its base, the extent of infiltration into the mesentery, coupled with the patient’s overall medical condition, rendered the tumor medically inoperable with curative intent.
During the surgical procedure, a notably firm lymph node was identified along the hepatoduodenal ligament. The ligamentum gastrocolicum was interrupted, and a thorough examination of the bursa omentalis was conducted, revealing no signs of carcinomatosis. Adhesions surrounding the gallbladder were released, and after cholecystoenterostomy (CHE), the hepatoduodenal ligament was revised. A dilated common bile duct (choledochus) was identified. Given the situation, a palliative approach was decided upon.
The surgical technique involved creating a segment of intestine measuring 40 cm using the Treitz ligament, followed by anastomosis to the choledochus using a lateral-lateral technique with Maxon 4-0 sutures. Further downstream, approximately 15 cm from this anastomosis site, a gastroenteroanastomosis was performed in two layers using Maxon 4-0 sutures. This anastomosis was connected to a Y-shaped intestinal loop fashioned according to the Roux-en-Y method. To facilitate bile drainage outside the gastrointestinal tract, an EEA (end-to-end anastomosis) according to Braun was added 10 cm before and after the gastroenteroanastomosis site.
To ensure the integrity and patency of the anastomoses, rigorous checks were conducted. During an attempt to biopsy the tumor through the duodenal window, significant venous bleeding occurred. The bleeding was managed locally by applying a hemostatic patch. Given the risk of severe bleeding, subsequent biopsy attempts were deferred, and instead, endoscopic biopsies were pursued. Hemostasis was carefully assessed and confirmed.
Post-surgery, a Penrose drain was placed in the vicinity of the choledochojejunostomy anastomosis and extended toward the head of the pancreas, directed to the right. After confirming all surgical materials and drapes were in order, the peritoneum and fascia were sutured using a continuous loop of PDS (polydioxanone) sutures. The wound was secured using surgical clips.
In conclusion, this experience in Bratislava allowed me to witness firsthand the complexities and challenges involved in the treatment of pancreatic carcinoma. It highlighted the critical importance of interdisciplinary collaboration, advanced surgical techniques, and the unwavering dedication of healthcare professionals in providing the best possible care for patients facing this formidable disease. My time in Bratislava has left a lasting impression on me, reinforcing my commitment to the field of medicine and the pursuit of innovative solutions to improve the lives of those affected by such challenging conditions.
Puckett Y, Garfield K. Pancreatic cancer – statpearls – NCBI bookshelf. Available at: https://www.ncbi.nlm.nih.gov/books/NBK518996/ (Accessed: 07 September 2023).
Ryan DP, Hong TS, Bardeesy N. Pancreatic adenocarcinoma. N Engl J Med.
2014;371(11):1039-1049. doi:10.1056/NEJMra1404198 (Accessed: 07 September 2023).
Scientific Article by Gifta Marshanda Qanitah H. (Student FK UNAIR – 012011133063)