A 70-year-old man presented to the Jefferson Pancreas, Biliary, and Related Cancer Center for an opinion regarding surgical intervention for a pancreatic mass discovered 1 year earlier, during workup for epigastric pain, thought to be heartburn. He had no history of pancreatitis or obstructive jaundice. He also had no weight loss or steatorrhea. The patient did, however, develop new onset diabetes one year ago.
Routine hematology and metabolic studies were normal. The tumor marker CA19-9 was slightly elevated at 41 U/mL (<35 U/mL) and the CEA was normal at 2.1 ng/mL (<4.7 ng/mL). An abdominal MRI with and without contrast revealed pancreas divisum with a dominant 2.4 cm multicystic uncinate process lesion communicating with the main pancreatic duct (duct of Wirsung) with an associated uncinate duct dilation to between 4 and 5 mm (Fig. 1). Imaging also showed simple hepatic cysts and minimal steatosis, but no evidence of metastasis. The lesion was believed to be an IPMN, based on this study and previous CT scans.
The patient underwent an open cholecystectomy and PPPD without complication. There was no evidence of malignant ascites, carcinomatosis, omental implants, or metastatic disease. Pathological study of the surgical specimen revealed the lesion to be an IPMN with intermediate-grade dysplasia without any invasive component. All surgical resection margins and 15 specimen lymph nodes were negative for malignancy.
The patient was placed on our institution's Whipple Accelerated Recovery Pathway (WARP) with the goal to discharge on postoperative day 5. However, he did develop a slight ileus, which prolonged his stay by 1 day. He was subsequently discharged on postoperative day 6. The patient and his family were appropriately educated on the postoperative recovery expectations, exercise recommendations, diet, and medications. He has fully recovered from his pancreatic resection and is scheduled to have annual surveillance of his pancreatic remnant through MRI/MRCP.