Mass in the head of the pancreas: a practical approach

Periampullary tumors, especially carcinoma of the ampulla of Vater and, to a lesser degree, carcinoma of the distal common bile duct and duodenum, are potentially and theoretically curable, even in the presence of regional lymph node metastases. Adenocarcinoma of the anatomic head of the pancreas or of the uncinate process, regardless of the status of the local lymph nodes, may be an incurable tumor because of its late clinical presentation. The treatment of choice for selected, curable carcinomas of the periampullary region is radical pancreatoduodenectomy. Carcinoma of the head of the pancreas should be resected when careful dissection does not reveal regional or distant lymph node involvement. Other presumed curable malignancies presenting as a mass in the pancreatic head, such as cystadenocarcinoma, islet cell carcinoma, and rare connective tissue sarcomas, also should be treated by the Whipple operation. If the remaining, distal pancreatic duct is unsuitable for anastomosis, total pancreatectomy should be completed. The so-called "regional pancreatectomy," as well as resection of portal and superior mesenteric veins, can be performed, but the value of these procedures has not been proved. Palliative bypass procedures should be performed for all malignant masses in the head of the pancreas if distant spread of disease is evident. The only exception is an islet cell carcinoma; this tumor can be resected with satisfactory palliation of symptoms of hypoglycemia despite the presence of advanced disease. Biliary enteric bypass also should be employed when diseased regional lymph nodes are associated with carcinoma of the head of the pancreas or large carcinomas of the periampullary duodenum. A side-to-side choledochojejunostomy is the preferred method of decompression. Gastrojejunostomy is a frequent companion procedure.