Management Decisions in Operable Periampullary carcinoma

Dr H V Shivaram

Should I do staging laparoscopy & laparoscopic ultrasound ?

detects metastasis in liver & peritoneal cavity vascular & nodal involvement

useful in only 16.4% cases routine use not justified more useful in body & tail tumours

Laparoscopic Whipple’s ..?

Diagnostic lap.for periamp & pancreatic ca.J.gastrointest.surgery 2002;6:75-81

What anaesthesia ?

General anaesthesia / Thoracic epidural

Intra-operative monitoring

fluid and electrolyte balance, good epidural analgesia, temperature maintenance timing of muscle relaxants and intravenous opiods

Post-operative ICU care

“Anaesthesia for Whipple’s Procedure” IJA 2003; 47(2): 150-151)

What Incision for Whipple’s?

Bilateral sub costal

Midline vertical

Transverse

Resectable or not ? Explore, kocherise, open lesser sac, Frozen section

Unresectable: • Mets. in liver, peritoneum, omentum

• celiac axis nodes +ve (numbers 9, 16, and 14, 15)

• retroperitoneal extension

• IVC invasion

• SMA/SMV/ PV encasement

( Reexploration & resection possible in few cases )

Why Whipple’s Surgery ?

only form of treatment with chance to cure

Resectability rate: 80% ( 15% …ca.head)

5 year survival rate:

node –ve, no perineural invasion, node +ve

Riall et al : 655 pts. ( 6 to 10 yr follow up)

( 20% ca.head)

1.Results of Pancreaticoduodenectomy in Patients With Periampullary Adenocarcinoma; Annals of Surgery • Volume 248, Number 1, July 20082.Resected periamp.ca: 5 yr.survivors and their 6 to 10 yr follow up ;Riall et al ; surgery 2006;140:764-772

Is Whipple’s justified without +ve biopsy ?

Whipple’s should not be denied….

Tissue diagnosis is a must for palliative Rx

( high volume centers, mortality < 5% )

Guidelines for the management of patients with pancreatic cancer, Pancreatic Section of the British Society of Gastroenterology,periampullary and ampullary carcinomas; Gut 2005;54:1-16

Which type of Surgery ?

Classical Whipple’s ?

Pylorus Preserving Whipple’s ?

Extended/ Radical Whipple’s ?

Local excision/ Ampullectomy ?

Classical Whipple’s Pylorus Preserving PD

Pylorus preserving PD :

Will it affect oncological radicality ?

Advantages : less blood loss, less time consuming Wt. gain & nutritional status

Disadvantages :

? delayed gastric emptying

no difference in morbidity, mortality & survival

Randomised prospective trial of PPPD Vs. classic PDJ.gastroint.surgery 2004;443-452Cochrane database 2008

Ampullectomy ?

matter of debate

2 criteria to be met : nodes -ve, free margin

Indications : Tis, T1

more expertise required

morbidity & mortality is not less than Whipple’s

Extended/Radical lymphadenectomy ?

1.standard 2.extended 3. extended radical

No long-term survival benefit

Longer operative time, hospital stay

Higher complication rates

Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinomad—part 3: Update on 5-year survival Journal J.GI Surg.vol.9.no.9;Dec.2005

Vascular resections ?

Venous - Yes (adherence/invasion)

Arterial – No

Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer. Br J Surg. 2006 Jun;93(6):662-73

“By the time of tumour involvement of the portal vein cure is unlikely, even with radical resection”

Reconstruction: mobilisation splenic vein transection Lt.renal vein

Pre-op.CBD stenting – will it affect decision making ?

1.Effect of pre-op biliary stenting on immediate outcome after PD; Br.J.Surg 2005;92;356-361 2.The effect of preoperative biliary stenting on postoperative complications after pancreaticoduodenectomy . American Journal of Surgery , Volume 186 , Issue 5 , Pages 420 - 425

operative time, blood loss infective complications -higher bile cultures are +ve till 6 wks

Pancreato-gastrostomy or pancreato-jejunostomy ?

both are appropriate

no superiority over the other

1.Meta-analysis of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy: Brit.J.Surg 2006;vol.93;929 - 936 2.Pancreaticojejunostomy versus pancreaticogastrostomy: systematic review and meta-analysisAmerican Journal of Surgery - Volume 193, Issue 2 (February 2007.

Pancreato-jejunostomy – which is better ?

Duct to mucosa technique

Dunking PJ

Binding PJ

Mesh reinforced PJ

1.Comparison of Wirsung-jejunal duct-to-mucosa and dunking technique for pancreatojejunostomy after pancreatoduodenectomy Hepatobiliary Pancreat Dis Int. 2005 Aug;4(3):450-52. Binding Pancreatojejunostomy ;ANZ journal of surgery; vol 78;issue S1, A68 - A803. Polypropylene mesh-reinforced pancreaticojejunostomy for periampullar neoplasm :World J Gastroenterol 2007 December 7; 13(45): 6072-6075

stitches are applied to a fairly thick pancreatic parenchyma and seromuscle layers of the jejunal wall of the posterior part of the anastomosis

Stents or no stents ?

Small duct , soft pancreas

Internal stent

An Antecolic Roux-En-Y type reconstruction decreased Delayed Gastric Emptying after Pylorus-Preserving Pancreatoduodenectomy J Gastrointest Surg (2008) 12:1812

Antecolic or retrocolic Roux en Y G J ?

antecolic

decreases DGE

Feeding Jejunostomy ?

1.Feeding jejunostomy: is there enough evidence to justify its routine use? Dig Surg. 2004;21(2):142-5. 2.T-tube jejunostomy feeding after pancreatic surgery: a safe adjunct; Asian J Surg. 2004 Apr;27(2):80-4

Disadvantages :

Tube related: blockage, dislodgement, pericatheter leakage and peritonitis

Feeds related : transient diarrhoea, abdominal distension, nausea or vomiting and pain

Advantages : cost effevtive enteral nutrition superior

Drains ?

How many ?

Type ?

when to remove ?

Is intraabdominal drainage necessary after pancreaticoduodenectomy? J.gastroint.surg . vol 2; no.4 August 1998

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Should I use octreotide ?

routine use is controversial

use: soft pancreas, small duct

start intra-op or pre-op.

dose,duration