PERIAMPULLARY TUMORS -

MANAGEMENTR.Srivathsan

ENDOSCOPIC VIEW

PATHOLOGY Adenocarcinoma accounts for 95% Arises from 4 different tissues of origin• Head of pancreas (40-60%)• Ampulla of Vater (10-20%) • Distal Bile duct (10%)• Periampullary duodenum (5-10%)• Could be that pancreatic causes account

for abt 90% cases.

PATHOLOGY 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.

PATHOLOGY 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).

SPREAD Locoregional spread results from

lymphatic invasion and direct tumor spread to adjacent soft tissue.

Ampullary lesions spread to LN 33%, typically to a single LN in the posterior pancreatcoduodenal group.

Duodenal has intermediate spread. Pancreas metastasizes 88% to multiple

sites.

TREATMENT 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 pathology.

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 cancers. Standard pancreaticoduodenectomy Pylorus preserving

pancreaticoduodenectomy Total pancreatectomy Regional pancreatectomy Extended resection (MD Anderson)

WHIPPLE PROCEDURE Thorough abdominal exploration by

laparoscopy should proceed resection. There is no role for resection in presence

of metastatic disease. Exploration includes inspection of liver,

peritoneal surfaces, paraaortic LN, root of mesentery.

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

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 origin.

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 divided.

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 margin.

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).

INTRAOPERATIVE 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 Intraoperative transduodenal biopsy

may show inflammation ,but does not rule out malignancy.

Occasionally you suspect malignancy 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 rates.

Morbidity rates were 50% in 60s, not less than 25%.

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%

COMPLICATIONS

PROGNOSIS Little change 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 (Germany)

18 0 24

Cameron (Johns Hopkins)

36 2 19

Grace (UCLA)

26 2 13

Geer (MSKCC)

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.