Surgical Management of Pancreatic Cancer

							            Surgical Management of
               Pancreatic Cancer


                  Mark S. Talamonti, MD
              Chairman, Department of Surgery
            NorthShore University HealthSystem
           Northwestern University Medical School




Anatomic Site at Presentation

                                              Head

                       61%                    Body

                                              Tail
                                  13%         Head-Body

                                              Body-Tail
                                  5%
                        15%                   Diffuse

                                           302 PATIENTS
   Cubillo, JSO, ‘78




                                                          1
Common Clinical Manifestations of
      Pancreatic Cancer
    • Abdominal pain or abdominal pain
      radiating to back
    • Weight loss, anorexia
    • Diarrhea, nausea/vomiting
    • Jaundice
    • New onset diabetes
    • Depression




     Staging Pancreatic Cancer
   Optimize treatment for subgroups of patients

     •   localized and resectable

     •   localized but unresectable

     •   distant metastases

   Avoid redundant or unnecessary procedures

   Prevent excessive testing and expenditures




                                                  2
Clinical/Radiographic Staging
Stage   Clinical/Radiographic Criteria
 I      Resectable (T1-2, selected T3, Nx, M0)
              No encasement of celiac axis or SMA
              Patent SMPV confluence
              No extrapancreatic disease
 II     Locally advanced (T3, Nx-1, M0)
              Arterial encasement (celiac axis or
              SMA) or venous occlusion (SMV or
              portal vein)
              No extrapancreatic disease
 III    Metastatic (T1-3, Nx-1, M1)
              Metastatic to liver, lung, peritoneum




                                                      3
4
5
                                              Needle
                           TUMOR




                        Triphasic Spiral CT            + Mets &/or
                                                       Locally advanced

                        Periampulllary Mass
                                                 Endobiliary stent
                                                 +/- celiac plexus block
                              ERCP
                              EUS



Malignancy suspected,                         Malignancy Confirmed
   Not confirmed



Explore for resection                          Neoadjuvant Trials




                                                                           6
PANCREATIC CARCINOMA
Surgical Advances and Current Controversies

          The Whipple Procedure




 “ I believe that the attempt to do a
   radical operation had disseminated
   the tumor and resulted in a shorter
   and more uncomfortable course
   than the patient would have had if
   he had been treated by a bypass
   operation.”
                          Crile, 1970




                                              7
                           Long-term Survival
                     After Pancreaticoduodenectomy
Author                  Patients         Median Survival        Estimated 5-yr survival
                                               (mo)                   (%)
Cameron, 1991                  81              12.7                       21

Trede, 1990                    133             NA                         24

Whittington, 1991              72              16                         NA

Geer, 1993                     146             18                         24

Willett, 1993                  72              NA                         13

Yeo, 1995                      201             15.5                       21

Nitecki, 1995                  174             17.5                       6.8

Staley, 1996                   39              19                         19

GITSG, 1987                    22              11                         15

EORTC, 1999                    54              12.6                       10




                            Pancreaticoduodenectomy mortality
                                                       (1994-
                              based on hospital volume (1994-1999)
                                         No. Operations
               18
                    < 1/yr.     1-2/yr    3-5/yr      6-16/yr      >16
               16
               14
 % mortality




               12
               10
               8
               6
               4
               2
               0
                    1,563       2,757      1,885      2,166       2,159
                                         No. Patients
                                                        Birkmeyer, NEJM 2002;346:1128




                                                                                          8
9
Controversies regarding pancreaticoduodenectomy

   • Classic vs. Pylorus-preserving
     pancreaticoduodenectomy

   • Extent of lymph node dissection

   • Role of portal vein-SMV resection and
     reconstruction




                                                  10
     Standard Whipple




Pyloric-preserving Whipple




                             11
            Type of resection
• Two small randomized trials* have compared
  classic Whipple resection to pylorus-
  preserving pancreaticoduodenectomy
• No major differences were observed
• Oncologic equivalence, short-term and long-
  term functional advantages equivocal

              *Lin et al Br J Surg 86:603-7, 1999
               Seiler et al J Gastrointest Surg 4:443-52, 2000




                   lymph                       distant
tumor                                          organs
                   nodes




                                                                 12
           Regional Lymphadenectomy
Standard Lymph Node Stations
 Anterior pancreaticoduodenal

 Posterior pancreaticoduodenal

     SMV & R-lateral SMA

      Porta-hepatis nodes

 Common hepatic artery nodes




           Regional Lymphadenectomy
 Extended Lymph Node Stations

Hepatic artery up to and including
             celiac axis

 SMA between origin and jejunal
           branches

        Aorto-caval nodes




                                      13
                      CHD

 CBD
                         Celiac Axis
                             &
                          Branches
Hepatic
artery


   APD
    &
   PPD
                                 Aorto-Caval
   SMV                                &
    &                            Distal SMA
  R-SMA




          Vascular Resection




                                               14
          Venous resection
                                        Median
                                        Survival
With SMV resection                      22 mos.
(n=31)
Without SMV resection                    20 mos.
(n=44)

 Leach SD et al British Journal of Surgery. 85(5):611-7, 1998




                                                                15
   Complications and Consequences

     • Short-term complications after surgery
        – Pulmonary
           • Pneumonia
           • Pulmonary Embolism


        – Hemorrhage
           • Gastrointestinal
           • Intra-abdominal




   Complications and Consequences
• Short-term complications after surgery
  – Infections
     • Wound infections
     • Intra-abdominal abscess and pancreatic anastomotic leaks
       (pancreatic fistula)


  – Delayed gastric emptying and malnutrition




                                                                  16
Complications and Consequences
 • Long-term consequences of surgery
   – Gastric problems
      • Reflux, ulcers, dumping syndrome, early satiety
   – Pancreas problems
      • Diabetes or glucose intolerance
      • Pancreatic enzyme insufficiency
   – Nutrition and weight loss
      • Dietary modifications
      • Nutritional supplements




                                                          17