Periampullary

tumors
-Management
R.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
 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
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.