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Pancreatic cancer: approach to diagnosis, selection for surgery and choice of operation.

The physician must suspect pancreatic cancer in patients older than age 40 years who present with minimal vague symptoms. The presence of common disorders such as gallstones, hiatal hernia and diverticulosis coli, does not exclude pancreatic cancer. Ultrasonography, computed tomography, ERCP and cytology are the essential diagnostic tools. Angiography delineates anatomic variations of the foregut vasculature and detects nonresectability of some tumors. Percutaneous fine needle aspiration of pancreatic masses for cytologic examination is recommended for lesions of the body and tail. Percutaneous transhepatic biliary drainage is advised preoperatively in patients whose serum bilirubin exceeds 20 mg/dl. Total pancreatoduodenectomy is recommended for all resectable pancreatic cancers. Surgical palliative procedures include biliary bypass, duodenal bypass and celiac plexus nerve block. Currently, only 30% of all pancreatic cancers seen are resectable and they are confined to the head of the pancreas. About 10% of all pancreatic cancers are potentially curable at the time of presentation. The operative mortality should be under 10%.