Periampullary Carcinoma by liuqingzhan

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									Periampullary Carcinoma and
       The Whipple
      Vic Vernenkar, D.O.
      St. Barnabas Hospital
           Bronx, NY
Endoscopic View
 Adenocarcinoma    accounts for 95%
 Arises from 4 different tissues of origin
 Head of pancreas
 Distal Bile duct
 Ampulla of Vater
 Periampullary duodenum
 Prognosis  for each of these are different.
 Five year survival for pancreas: 18%
 Five year for ampulla: 36%
 Five year for distal bile duct: 34%
 Five year for duodenum: 33%
 Determination of tissue origin is important for
  prognosis, extent of resection.
 Determination  of tissue origin from FNA,
  endoscopic biopsy.
 Also from thin section CT scan, ERCP
 Determination of k-Ras also helps (95% of
  pancreatic cancer).
 Locoregional  spread results from lymphatic
  invasion and direct tumor spread to adjacent soft
 Ampullary lesions spread to LN 33%, typically to
  a single LN in the posterior pancreatcoduodenal
 Duodenal has intermediate spread.
 Pancreas metastasizes 88% to multiple sites.
 Standard Whipple pancreaticoduodenectomy
  thought to provide adequate tumor clearance in the
  case of non-pancreatic ampullary tumor, because
  tumor spread is localized.
 Biopsy proven paraduodenal LN is thought by
  most to preclude curative resection
       Surgery and Chemotherapy
 Retrospective  review of 41 patients identified low
  risk and high risk patients determined by
 Low risk: limited to ampulla or duodenum, well
  differentiated, negative margins and LN.
 High risk: tumor invasion of pancreas, poorly
  differentiated, positive margin, positive LN.
        Surgery and Chemotherapy
 Low   risk patients had 5 year local control and
  survival of 100% and 80% respectively.
 High risk patients had 5 year local control and
  survival of 50% and 38%, respectively.
 Based on these findings, some have proposed a
  course of preoperative chemoradiation to improve
  local disease control in these high risk patients.
             Whipple Procedure
 Five basic techniques are used to resect pancreatic
 Standard pancreaticoduodenectomy
 Pylorus preserving pancreaticoduodenectomy
 Total pancreatectomy
 Regional pancreatectomy
 Extended resection (MD Anderson)
             Whipple Procedure
 Thorough   abdominal exploration should proceed
 There is no role for resection in presence of
  metastatic disease.
 Exploration includes inspection,palpation of liver,
  peritoneal surfaces, paraaortic LN, root of
             Whipple Procedure
 Mobilize  right colon and terminal ileum
 Open Lesser sac, which exposes anterior surface of
  pancreas, SMV at inferior border.
 Duodenum is mobilized (Kocher) until IVC and
  renal veins are visualized.
 Assess relationship of tumor to SMA by palpation.
 Cholecystectomy done to facilitate dissection of
  structures in gastroduodenal ligament.
Kocherizing the Duodenum
Vessel Involvement
SMA Involved?
             Whipple Procedure
 Dilated CBD is divided proximal to cystic duct,
  which allow identification of portal vein and its
  relationship to pancreas.
 Periportal LN are biopsied and frozen sectioned.
 Hepatic artery is followed proximally to
  gastroduodenal artery which is divided at its
             Whipple Procedure
 Stomach   is divided, or first portion of duodenum if
  pylorus preserving.
 Although CBD and proximal GI tract has been
  divided, you can still abort and bypass.
 Proximal jejunum dissected from its mesentery and
 Pancreas divided overlying SMV, venous branches
  ligated to head and uncinate process.
SMV Identification
Dividing the Neck
             Whipple Procedure
 Specimen   is now only attached to retroperitoneum
  and SMA.
 SMA skeletonized to its origin, the tissue dissected
  from the SMA represents the retroperitoneal
 Ligate inferior pancreaticoduodenal artery,
  preserve possible aberrant right hepatic if seen.
The End Result
               Pylorus Preserving
 Introduced  in 1978 in an attempt to eliminate
  postgastrectomy syndromes.
 It does not adversely affect local control or
  survival. Blood loss and operative time less.
 Only differs in that blood supply to proximal
  duodenum is preserved (preserve right
  gastroepiploic arcade after ligation of
  gastroepiploic artery and vein at its origin).
 Morbidity  and mortality for pancreatic resections
  are greater than those seen after other operations.
 Patients and families must be informed of potential
  complications, especially when there is no
  preoperative confirmation of diagnosis.
 Neoplasms of the head can cause pancreatitis
  making definitive diagnosis difficult.
 Intraoperative transduodenal biopsy may show
  inflammation ,but does not rule out malignancy.
 Occasionally you suspect malignance but cannot
  confirm radiologically or histologically.
 Potential morbidity of resecting benign disease is
  preferred over leaving a curative lesion in situ.
 Inform patients that resection may be required
  without confirmation of malignancy.
               Surgical Results
 Many   physicians have adopted a nonoperative or
  palliative approach to pancreatic cancer due to
  previously high operative morbidity and mortality
 Morbidity rates were 50% in 60s, not less than
 Mortality rates low as 3% in most recent reviews.
     Complications Postoperatively
 Sepsis 13%
 Fistula 10%
 Biliary fistula 5%
 Renal failure 13%
 Hemorrhage 10%
 Pancreatitis 2%
 Cardiac 5%
 Littlechange in survival.
 Remains less than 25% over 5 years
 Median survival in 20 months
 Body and tail have worse prognosis because
  detected late, advanced disease.
 MD Anderson does more than 50 Whipple
  procedures over a three year period.
Mortality and Volume of Surgery
 5 year survival, morbidity, mortality
Author      Morbidity(%) Mortality(%) Survival (%)
Trede       18           0            24
Cameron     36           2            19
Grace       26           2            13
Geer        27           3            24
              Adjuvant Therapy
 Autopsy   series show that 85% of patients will
  experience recurrence in operative field.
 70% have metastases to liver.
 So need to address local control (radiation) and
  distant disease (chemotherapy).
 Most commonly used is 5 FU and this only has a
  15-28% response on its own, but it’s a
  radiosensitizer, so it improves response to chemo.

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