Pancreatic surgery

Endogenous vasoactive mediators such as bradykinin and nitric oxide may affect the severity and outcome of acute pancreatitis by altering the capillary integrity of the pancreatic microcirculation. Protease inhibitors such as gabexate have a small beneficial effect on pancreatitis-related morbidity but are not cost effective. Secondary pancreatic infection after necrotizing pancreatitis can be mitigated by selective gut decontamination but requires both oral and intravenous antibiotic administration. Combined modality treatment of pancreatic duct stones is safe and effective but may not have better or even equivalent long-term efficacy as compared with traditional surgery. Duodenum-preserving resections (Beger and Frey procedures) are especially useful in patients with chronic pancreatitis who have predominant involvement of the pancreatic head, and such procedures have fewer metabolic and nutritional consequences as compared with standard pancreatoduodenectomy. Islet autotransplantation combined with pancreatic resection for patients with small-duct disease not amenable to surgical duct decompression is safe and provides effective long-term pain relief. Cyst fluid analysis in patients with problematic pancreatic cysts may help to differentiate neoplastic cysts from pseudocysts, especially when other diagnostic studies yield inconsistent results. Mucin-hypersecreting tumors of the pancreas comprise a recently identified group of tumors with varied histopathology and malignant potential. Resection is generally recommended. Combined modality staging in patients with pancreatic cancer is strongly recommended to identify patients most likely to benefit from attempted surgical resection. Pylorus-sparing resection results in less impairment of digestive function than conventional pancreatoduodenectomy with no difference in survival. More effective adjuvant or neoadjuvant therapies are needed to extend the long-term survival benefits of surgery in patients with potentially resectable disease.