Preoperative evaluation and preparation in pancreatic carcinoma

The preoperative evaluation in patients with pancreatic carcinoma includes ultrasonography or CT to diagnose and localize the tumour, to rule out metastases and to guide biopsy for cytological and/or histological verification. In patients with jaundice direct cholangiography, either transhepatic (PTC) or endoscopic (ERC), is necessary to give exact anatomical delineation of the tumour. Further, these procedures may be used to establish preoperative biliary drainage or to insert an endoprosthesis for permanent biliary drainage in inoperable cases. In patients without jaundice endoscopic pancreaticography (ERP) may delineate the pathology. Selective arteriography, both of the coeliac and superior mesenteric artery, visualize possible variations in arterial anatomy and tumour invasion. Stricture of one of the main arteries is usually a sign of inoperability. As venous phase portography only in some cases gives precise visualization of both the splenic, superior mesenteric and portal vein, transhepatic portography with selective catheterization of the splenic and superior mesenteric vein should be performed to diagnose strictures or invasion of the portal venous system. Only a few cases with invasion of these veins will be operable. The preoperative preparation in patients with pancreatic carcinoma includes correction of electrolytes, hypoalbuminemia, anemia, and, in patients with jaundice, treatment of K-vitamin deficiency. All patients should have prophylactic anti-thromboembolic treatment. Whether preoperative biliary drainage in jaundiced patients is of any benefit is still controversial, but may be indicated in patients with heavy jaundice and/or septic cholangitis.