Transcript Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy

CASE MANAGEMENT,
PRESENTATION, DISCUSSION AND
SHARING OF INFORMATION ON
PERIAMPULLARY CANCER
by
Michael Angelo L. Suñaz, M.D.
Department of Surgery
Ospital ng Maynila Medical Center
CASE MANAGEMENT,
PRESENTATION, DISCUSSION
O.V., 52/M
LUCENA CITY

CHIEF COMPLAINT: ABDOMINAL PAIN
HISTORY OF PRESENT ILLNESS:

2 months PTA  Px underwent
cholecystectomy, IOC, and t-tube
insertion in another institution
HISTORY OF PRESENT ILLNESS:

6 weeks PTA the patient noted he
had yellowish discoloration of his
skin with associated right upper
quadrant abdominal pain
HISTORY OF PRESENT ILLNESS:

6 weeks PTA consultation was
done in another institution where
t-tube replacement was performed
HISTORY OF PRESENT ILLNESS:

6 weeks PTA there was noted
increase in the intensity of the
abdominal pain and passage of
black, tarry stool after t-tube
replacement
HISTORY OF PRESENT ILLNESS:

4 weeks PTA  ERCP done and the
noted perimampullary mass was
biopsied.
HISTORY OF PRESENT ILLNESS:

3 weeks PTA  biopsy results
revealed an adenocarcinoma
HISTORY OF PRESENT ILLNESS:

3 days PTA  abdominal CT Scan
revealed a periampullary mass
which was difficult to delineate
from the pancreatic head
HISTORY OF PRESENT ILLNESS:

Persistence of his condition as well
the results of the abovementioned
diagnostics prompted consultation
and subsequent admission.

Pertinent (+): approximately 10%
weight loss in the past 2 months
 PAST
MEDICAL Hx:
(+)HPN – UBP 130/80 HBP 160/100;
maintained on Metoprolol with poor
compliance
 FAMILY
Hx:
No heredofamilial disease noted

PERSONAL/SOCIAL Hx:
- smoking history of 2.5 pack-years
- consumed 2 bottles of beer per
week for the past 10 years
PHYSICAL EXAMINATION:
G/S: conscious, coherent, not in
cardiorespiratory distress
BP= 110/70 CR=80 RR= 20 T=370C
SHEENT: no jaundice; pink palpebral
cojunctiva,anicteric sclera, No NAD,
No CLAD, No TPC
PHYSICAL EXAMINATION:
C/L: SCE, no retractions, clear BS
CVS: adynamic precordium, NRRR, no
murmur
Abdomen: flabby; (+) right subcostal
surgical scar with t-tube in place; soft;
no palpable masses
PHYSICAL EXAMINATION:
Extremities: no edema, atrophy or
cyanosis noted; full and equal pulses
on all extremities
SALIENT FEATURES:
 52 y/o, M

Right upper quadrant abdominal pain

approximately 10% weight loss in the
past 2 months

underwent cholecystectomy, IOC,
and t-tube insertion in another
institution 2 months PTA
SALIENT FEATURES:
 yellowish discoloration of the skin
associated with right upper quadrant
abdominal pain 6 weeks PTA

t-tube replacement 6 weeks PTA

increase in the intensity of the
abdominal pain and passage of
black, tarry stool after t-tube
replacement
RUQ abdominal pain and jaundice
RUQ abdominal pain and jaundice
S/P
Cholecystectomy,
IOC, placement of
t-tube
RUQ abdominal pain and jaundice
Inflammatory/
Metabolic
•Cirrhosis
•Hepatitis
Retained CBD
Stone
S/P Cholecystectomy,
IOC, placement of t-tube
Neoplastic
Disease
•Primary liver
tumors
•Metastases
•Cholangiocarci
noma
•Klatskin
tumors
•GB CA
•Periampullary
CA
Clinical Diagnosis:
Diagnosis
Certainty
Treatment
Neoplastic
Disease
33%
Surgical
Retained CBD
Stone
33%
Surgical
Metabolic/
Inflammatory
33%
Surgical/
Medical
BASES:





52 y/o, M
Right upper quadrant abdominal pain
underwent cholecystectomy, IOC, and ttube insertion 2 months PTA
yellowish discoloration of the skin
associated with right upper quadrant
abdominal pain 6 weeks PTA
increase in the intensity of the abdominal
pain and passage of black, tarry stool after
t-tube replacement
Do I need a para-clinical diagnostic
procedure?
YES
Paraclinical Diagnostic Procedures
Benefit
Risk
Cost
Availability
HELICAL
CT SCAN
Single most valuable study
for staging 1
Can provide 3D
reconstruction of vascular
structures surrounding the
lesion1
Radiation
Exposure
+++
not readily
available
MRI
Can provide 3D
reconstruction of vascular
structures surrounding the
lesion1
Can be reconstructed to give
the image of the pancreatic
and bile ducts1
NONE
++++
not readily
available
ENDOSCOPIC
UTZ with
BIOPSY or FNA
Can be used to establish a
tissue diagnosis1
BLEEDING
++
not readily
available
Paraclinical Diagnostic Procedures

ERCP with biopsy (9/29/07)
– Normal esophagus and gastric
mucosa
– Fungating mass at the
periampullary area. Pus noted
extruding from the papilla.
– Moderately dilated CBD, CHD, and
right and left hepatic ducts
– 0.5 filling defect at the distal CBD
Paraclinical Diagnostic Procedures

Biopsy result (10/5/07)
– Adenocarcinoma
Paraclinical Diagnostic Procedures

Abdominal CT Scan (10/24/07)
– Nodular soft tissue density in the
periampullary region (66.1 x 49.5 x
40.6mm)
– Hyperdense tubular structure,
most likely a tube noted within the
mass
Paraclinical Diagnostic Procedures

Abdominal CT Scan (10/24/07)
– Head of the pancreas difficult to
delineate from the mass
– Body and tail of the pancreas are
unremarkable
– Liver and spleen normal in size
and homogeneity
Paraclinical Diagnostic Procedures

Abdominal CT Scan (10/24/07)
– GB not visualized
– Biliary tree unremarkable
– Kidneys normal in size, position,
and configuration with good
excretory function
– Rest of the soft tissue, vascular,
and osseous structures intact
RUQ abdominal pain and jaundice
Inflammatory/
Metabolic
•Cirrhosis
•Hepatitis
Retained CBD
Stone
S/P Cholecystectomy,
IOC, placement of t-tube
Neoplastic
Disease
•Primary liver
tumors
•Metastases
•Cholangiocarci
noma
•Klatskin
tumors
•GB CA
•Periampullary
CA
RUQ abdominal pain and jaundice
Inflammatory/
Metabolic
•Cirrhosis
•Hepatitis
Retained CBD
Stone
S/P Cholecystectomy,
IOC, placement of t-tube
Neoplastic
Disease
•Primary liver
tumors
•Metastases
•Cholangiocarci
noma
•Klatskin
tumors
•GB CA
•Periampullary
CA
•Fungating mass at the
periampullary region
on ERCP
• Nodular soft tissue
density in the
periampullary region
on abdominal CT Scan
RUQ abdominal pain and jaundice
Inflammatory/
Metabolic
•Cirrhosis
•Hepatitis
Retained CBD
Stone
S/P Cholecystectomy,
IOC, placement of t-tube
Neoplastic
Disease
•Primary liver
tumors
•Metastases
•Cholangiocarci
noma
•Klatskin
tumors
•GB CA
•Periampullary
CA
•Fungating mass at the
periampullary region
on ERCP
• Nodular soft tissue
density in the
periampullary region
on abdominal CT Scan
Periampullary Carcinoma
Pancreas
Ampulla of Vater
CBD
Duodenum
Periampullary Carcinoma
Pancreas
Ampulla of Vater
CBD
Duodenum
Abdominal CT
Scan
–Head of the
pancreas difficult
to delineate from
the mass
–Body and tail of
the pancreas are
unremarkable
ERCP with
biopsy
•Fungating mass
at the
periampullary
region
•Pus noted
extruding from
the papilla
Periampullary Carcinoma
Pancreas
Ampulla of Vater
CBD
Duodenum
Periampullary Carcinoma
Pancreas
Ampulla of Vater
CBD
Duodenum
Adenocarcinoma on biopsy
Ampullary
Adenocarcinoma
Pretreatment Diagnosis:
Diagnosis
Certainty
Treatment
Ampullary
AdenoCA
90%
Surgical
Periampullary
CA (Pancreas,
CBD,
Duodenum)
10%
Surgical
TREATMENT

PRETREATMENT DIAGNOSIS:
Ampullary Adenocarcinoma
TREATMENT

GOALS OF TREATMENT:
– Curative extirpation of the tumor
– Relieve biliary obstruction
TREATMENT OPTIONS
TREATMENT
STANDARD
WHIPPLE
RESECTION
BENEFIT
Treatment of
choice for
resectable
periampullary
cancers.
Applicable on
tumors that
appear to
encroach on the
proximal
duodenum or the
gastric antrum1
RISK
COST
Pncreatic fistula
14%
GE Leakage 1%
Bile leakage 0%
Post-op bleeding
7%
Intraabdominal
abscess 10%
Other
complications 28%
Relaparotomy
19%
Operative
Mortality 7%2
Cost of OR
needs and
anesthetics(P
5,000P10,000)
AVAIL
Available
TREATMENT OPTIONS
TREATMENT
PPPD
BENEFIT
Treatment of
choice for
resectable
periampullary
cancers.
RISK
COST
Pncreatic fistula
13%
GE Leakage 0%
Bile leakage 2%
Post-op bleeding
7%
Intraabdominal
abscess 10%
Other
complications 22%
Relaparotomy
15%
Operative
Mortality 3%2
Cost of OR
needs and
anesthetics(P
5,000P10,000)
AVAIL
Available
TREATMENT OF CHOICE
STANDARD WHIPPLE RESECTION/
PANCREATICODUODENECTOMY
PREOPERATIVE PREPARATION
Informed consent
 Psychosocial support
 Optimize patient’s health
 Screen for any condition that will
interfere with treatment
 Prepare materials

OPERATIVE TECHNIQUE






Patient supine under GETA
Asepsis/Antisepsis
Sterile drapes placed
Bilateral subcostal incision
Assessment of the abdomen for
metastatic disease
Mobilization of the duodenum and the
head of the pancreas with identification of
the superior mesenteric vein
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
OPERATIVE TECHNIQUE
Mobilization of the stomach and
proximal duodenum with transection
of the proximal duodenum (or
stomach) as soon as the decision of
resection has been made
 Skeletonization of the structures of
the porta

•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
OPERATIVE TECHNIQUE

Cholecystectomy and division of the
common bile duct
 Mobilization and division of the proximal
duodenum
 Transection of the neck of the pancreas
and division of the remaining attachments
of the specimen to the superior
mesenteric and portal veins and the
superior mesenteric artery
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
OPERATIVE TECHNIQUE
Reconstruction of gastrointestinal
continuity
 Correct sponge and instrument
count
 Layer by layer closure
 DSD

•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
OPERATIVE FINDINGS

Intraluminal mass located in the
Ampulla of Vater with infiltration of
the mucosal layer
OPERATION DONE:
STANDARD WHIPPLE RESECTION/
PANCREATICODUODENECTOMY
HISTOPATHOLOGY

Ampullary Adenocarcinoma, welldifferentiated arising from a villous adenoma
 Acute Pancreatitis
 Negative for tumor:
– All surgical margins labelled (superior, inferior,
anterior, posterior, and pancreatic surgical
margins), proximal ad distal surgical margins
– Pancreatic dict and CBD
– All 8 lymph nodes labelled “inferior, superio,
posterior pancreatic nodes and periduodenal
lymph nodes”
POST OPERATIVE DIAGNOSIS
Ampullary Adenocarcinoma
POST-OP CARE
Sufficient analgesia
 NPO
 IV hydration and medication
 Daily wound care
 Monitoring of complications and treat
as indicated
 Clear liquid diet started on the 5th POD
then progression to a regular diet in the
next 24-48 hours

•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
POST-OP CARE
 Biliary
drain removed the day after
oral intake is started if there is no
evidence of biliary leak
 Pancreatic drain removed on the
day of discharge as long as there
is no pancreatic leak
• Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed):
Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
SHARING OF INFORMATION
PERIAMPULLARY CARCINOMA

Refer to cancers that arise from:
– Pancreas (pancreatic adenocarcinoma
is the most common periampullary
CA)
– Ampulla of Vater
– Bile duct
– Duodenum
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA


similar in terms of clinical presentation,
symptoms, and treatment
precise tumor type is often unknown
preoperatively; periampullary mass that
appears to be malignant should be
resected when feasible
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

PANCREATIC ADENOCARCINOMA
–
–
–
4th leading cause of cancer death
6% of cancer deaths in the US
Most common form of pancreatic cancer
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

PANCREATIC ADENOCARCINOMA
–
–
–
23% 1-year survival rate after diagnosis
4% 5-year survival rate
20% 5-year survival rate for those
diagnosed with local disease and
underwent resection
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

PANCREATIC ADENOCARCINOMA
–
Symptoms:
 Weight loss
 Jaundice
 Abdominal or back pain
 Malabsorption (rarely)
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

PANCREATIC ADENOCARCINOMA
–
20% of patients will have had a new
diagnosis of diabetes in the prvious 1-2
years
 Patients in their 50s with a new
diagnosis of diabetes and no risk
factors should be screened
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

PANCREATIC ADENOCARCINOMA
–
Evaluation:
 Family Hx: 10% of pancreatic cancers
have a genetic basis
 P.E.: focus on evidence of matastasis
(supraclavicular nodes, assessment of
the liver)
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

PANCREATIC ADENOCARCINOMA
– Evaluation:
 Diagnostics:
– CBC
– LFT
– Serum albumin
– Tumor markers (carbohydrate antigen
19-9, carcinogenic embryonic antigen)
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

PANCREATIC ADENOCARCINOMA
– Evaluation:
 Helical CT Scan
– Performed as a pancreatic protocol
scan
– Most valuable study to stage patients
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

PANCREATIC ADENOCARCINOMA
– Evaluation:
 MRI
– With newer software and protocols for
imaging, may produce images as
informative as those from a CT Scan
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

PANCREATIC ADENOCARCINOMA
– Evaluation:
 CT Scan and MRI
– Can provide 3D reconstruction of
vascular structures surrounding the
pancreatic lesion – replacing
preoperative angiography
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

PANCREATIC ADENOCARCINOMA
– Evaluation:
 Endoscopic ultrasound (EUS)
– Can provide information about
resectability
– Needs CT Scan to corroborate the
findings
– Reliable in tissue diagnosis
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

PANCREATIC ADENOCARCINOMA
– Evaluation:
 Patients with metastatic disease
are not operative candidates
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

PANCREATIC ADENOCARCINOMA
– Evaluation:
 The mass is considered unresectable if
it involves:
– Hepatic, celiac or superior mesenteric
arteries
– Celiac or periaortic nodes
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA
The American Joint Committee on Cancer
6thEdition Staging System – Pancreatic Cancer

Primary Tumor (T)
– T1 - Tumor limited to the pancreas, 2 cm or
smaller in greatest dimension
– T2 - Tumor limited to the pancreas, larger than 2
cm
– T3 - Tumor extension beyond the pancreas (eg,
duodenum, bile duct, portal or superior
mesenteric vein) but not involving the celiac axis
or superior mesenteric artery
– T4 - Tumor involves the celiac axis or superior
mesenteric arteries (unresectable primary tumor)
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA
The American Joint Committee on Cancer
6thEdition Staging System – Pancreatic Cancer
 Regional lymph nodes (N)
–
–
–
NX - Regional lymph nodes cannot be assessed
N0 - No regional lymph node metastasis
N1 - Regional lymph node metastasis
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA
The American Joint Committee on Cancer
6thEdition Staging System – Pancreatic Cancer
 Distant metastasis (M)
–
–
–
MX - Distant metastasis cannot be assessed
M0 - No distant metastasis
M1 - Distant metastasis
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA
The American Joint Committee on Cancer
6thEdition Staging System – Pancreatic Cancer

Stage grouping for pancreatic cancer is as follows:
–
–
–
–
–
–
–
Stage 0 - Tis, N0, M0
Stage IA - T1, N0, M0
Stage IB - T2, N0, M0
Stage IIA - T3, N0, M0
Stage IIB - T1-3, N1, M0
Stage III - T4, Any N, M0
Stage IV - Any T, Any N, M1
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

PANCREATIC ADENOCARCINOMA
– Staging and resectability
 Stage 0, I, II – generally considered
resectable
 Patients with tumors confined to the
pancreas and lymph nodes included in
the resection and who have no vascular
invasion are candidates for resection
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

PANCREATIC ADENOCARCINOMA
– Chemoradiation

Neoadjuvant therapy
– is not routinely performed
– used when the tumor appears locally
invasive
– Downstaging in about 10% of cases
which allows for resection
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

PANCREATIC ADENOCARCINOMA
– Chemoradiation
 Adjuvant therapy
– Standard of care
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

AMPULLARY CARCINOMA
– Carcinoma of the Ampulla of Vater
– Rare tumor
– More likely to be resectable than other
periampullary malignancies – jaundice
presents earlier
– Less aggressive than pancreatic or bile
duct cancers
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

AMPULLARY CARCINOMA
– Patients present with abdominal pain,
jaundice and weight loss
– Resection rate 80%
– 30-70% 5-year survival rate
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

AMPULLARY CARCINOMA
– Evaluation
 CT Scan
 EUS with biopsy or fine needle
aspiration
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

AMPULLARY CARCINOMA
– Evaluation
 EUS with biopsy or fine needle
aspiration
– Determine the true nature of the
neoplasm and the depth of
involvement into the duodenal wall
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

AMPULLARY CARCINOMA
– Evaluation
 EUS with biopsy or fine needle
aspiration
– Pancreaticoduodenectomy –for
patients with biopsy-proved cancers
penetrating the muscularis of the
duodenum
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

AMPULLARY CARCINOMA
– Evaluation
 EUS with biopsy or fine needle
aspiration
– Local excision of the Ampulla of Vater
– for benign lesions; a frozen section of the specimen is
performed and a diagnosis of cancer requires conversion
to pancreaticoduodenectomy
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA
The American Joint Committee on Cancer
6thEdition Staging System – Ampulla of Vater
Carcinoma

Primary Tumor (T)
– T1 - Tumor limited to the Ampulla of Vater or
Sphincter of Oddi
– T2 - Tumor invades the duodenal wall
– T3 - Tumor invades the pancreas
– T4 - Tumor invades peripancreatic soft tissues or
other adjacent organs or structures
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA
The American Joint Committee on Cancer
6thEdition Staging System – Ampulla of Vater
Carcinoma
 Regional lymph nodes (N)
–
–
N0 - No regional lymph node metastasis
N1 - Regional lymph node metastasis
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA
The American Joint Committee on Cancer
6thEdition Staging System – Pancreatic Cancer
 Distant metastasis (M)
–
–
M0 - No distant metastasis
M1 - Distant metastasis
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA
The American Joint Committee on Cancer
6thEdition Staging System – Pancreatic Cancer

Stage grouping for pancreatic cancer is as follows:
–
–
–
–
–
–
–
Stage 0 - Tis, N0, M0
Stage IA - T1, N0, M0
Stage IB - T2, N0, M0
Stage IIA - T3, N0, M0
Stage IIB - T1-3, N1, M0
Stage III - T4, Any N, M0
Stage IV - Any T, Any N, M1
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

AMPULLARY CARCINOMA
– Chemoradiation

No trials indicate that chemotherapy or
radiation improves survival but
resection clearly does
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current
Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

CHOLANGIOCARCINOMA
–
–
–
–
Involve the bile ducts
More common in Asian countries
Associated with chronic bile duct
inflammation
25% in the distal duct
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

CHOLANGIOCARCINOMA
–
–
–
Symptoms indistinguishable from
pancreatic cancer
Diagnosis suspected – isolated bile duct
stricture with a normal pancreatic duct
Poor prognosis – 15% 5-year survival rate
after resection
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

DUODENAL CARCINOMA
–
–
–
–
Adenocarcinoma of the duodenum
Presumed to originate from duodenal
polyps
0.5% of all GI tract malignant neoplasms
45% of small bowel cancers
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
PERIAMPULLARY CARCINOMA

DUODENAL CARCINOMA
–
–
–
–
Can occur along the entire length of the
duodenum
Usually diagnosed at an advanced stage
Resection is the only potetially curative
treatment
Up to 50% 5-year survival rate
•
Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical
Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513
MCQ
1. What is the most common
periampullary carcinoma?
a. Pancreatic Adenocarcinoma
b. Ampullary Carcinoma
c. Cholangiocarcinoma
d. Duodenal Carcinoma
MCQ
1. What is the most common
periampullary carcinoma?
a. Pancreatic Adenocarcinoma
b. Ampullary Carcinoma
c. Cholangiocarcinoma
d. Duodenal Carcinoma
MCQ
2. Which periampullary carcinoma has
an 80% resection rate?
a. Pancreatic Adenocarcinoma
b. Ampullary Carcinoma
c. Cholangiocarcinoma
d. Duodenal Carcinoma
MCQ
2. Which periampullary carcinoma has
an 80% resection rate?
a. Pancreatic Adenocarcinoma
b. Ampullary Carcinoma
c. Cholangiocarcinoma
d. Duodenal Carcinoma
MCQ
3. Which periampullary carcinoma has
a 15% 5-year survival rate after
resection?
a. Pancreatic Adenocarcinoma
b. Ampullary Carcinoma
c. Cholangiocarcinoma
d. Duodenal Carcinoma
MCQ
3. Which periampullary carcinoma has
a 15% 5-year survival rate after
resection?
a. Pancreatic Adenocarcinoma
b. Ampullary Carcinoma
c. Cholangiocarcinoma
d. Duodenal Carcinoma
MCR
A – 1, 2, and 3 are correct
B – 1 and 3 are correct
C – 2 and 4 are correct
D – only 4 is correct
E – none are correct
MCR
I. Periampullary cancers arise from
which of the following?
1. Pancreas
2. Ampulla of Vater
3. Bile duct
4. Liver
MCR
I. Periampullary cancers arise from
which of the following?
1. Pancreas
2. Ampulla of Vater
3. Bile duct
4. Liver
MCR
II. Which is true about duodenal carcinomas
1. It is the 2nd most common
periampullary carcinoma
2. It accounts for up to 45% of small
bowel cancers
3. It has a 5-year survival rate of 15%
4. It represents less than 0.5% of all GI
tract malignant neoplasms
MCR
II. Which is true about duodenal carcinomas
1. It is the 2nd most common
periampullary carcinoma
2. It accounts for up to 45% of small
bowel cancers
3. It has a 5-year survival rate of 15%
4. It represents less than 0.5% of all GI
tract malignant neoplasms
THANK YOU!!!
REFERENCES


Hines OJ, Reber HA: Periampullary cancer, in
Cameron JL (ed): Current Surgical Therapy 9th
Ed. Philadelphia, Mosby, 2008, pp 506-513
Khe TC, et al: Pylorus preserving
pancreaticoduodenectomy versus standard
Whipple procedure: a prospective, randomized
multicenter analysis of 170 patients with
pancreatic and perampullary tumors, Ann Surg
240(5):738-745, 2004
JOURNAL CRITICAL APPRAISAL
Pylorus Preserving
Pancreaticoduodenectomy Versus
Standard Whipple Procedure
A Prospective, Randomized, Multicenter Analysis of
170 Patients With Pancreatic and Periampullary
Tumors
Khe T. C. Tran, MD,* Hans G. Smeenk, MD,* Casper H. J. van Eijck,
MD, PhD,* Geert Kazemier, MD,* Wim C. Hop, MSc, PhD,* Jan Willem
G. Greve, MD, PhD,† Onno T. Terpstra, MD, PhD,‡ Jan A. Zijlstra, MD,§
Piet Klinkert, MD,§ and Hans Jeekel, MD, PhD*
ABSTRACT

Objective:
– A prospective randomized multicenter
study was performed to assess whether
the results of pylorus-preserving
pancreaticoduodenectomy (PPPD)
equal those of the standard Whipple
(SW) operation, especially with respect
to duration of surgery, blood loss,
hospital stay, delayed gastric emptying
(DGE), and survival.
ABSTRACT

Summary Background Data:
– PPPD has been associated with a higher
incidence of delayed gastric emptying,
resulting in a prolonged period of
postoperative nasogastric suctioning. Another
criticism of the pylorus-preserving
pancreaticoduodenectomy for patients with a
malignancy is the radicalness of the resection.
On the other hand, PPPD might be associated
with a shorter operation time and less blood
loss.
ABSTRACT

Methods:
– A prospective randomized multicenter study
was performed in a nonselected series of 170
consecutive patients. All patients with
suspicion of pancreatic or periampullary tumor
were included and randomized for a SW or a
PPPD resection. Data concerning patients’
demographics, intraoperative and histologic
findings, as well as postoperative mortality,
morbidity, and follow-up up to 115 months after
discharge, were analyzed.
ABSTRACT

Results:
– There were no significant differences noted in
age, sex distribution, tumor localization, and
staging. There were no differences in median
blood loss and duration of operation between
the 2 techniques. DGE was observed equally in
the 2 groups. There was only a marginal
difference in postoperative weight loss in favor
of the standard Whipple procedure. Overall
operative mortality was 5.3%. Tumor positive
resection margins were found for 12 patients
of the SW group and 19 patients of the PPPD
group (P < 0.23). Long-term follow-up showed
no significant statistical differences in survival
between the 2 groups (P < 0.90).
ABSTRACT

Conclusions:
– The SW and PPPD operations were associated
with comparable operation time, blood loss,
hospital stay, mortality, morbidity, and
incidence of DGE. The overall long-term and
disease-free survival was comparable in both
groups. Both surgical procedures are equally
effective for the treatment of pancreatic and
periampullary carcinoma.
Appraisal Guide:
THERAPY OR PREVENTION
Are the results of the study valid?
Primary Guides:
Was the assignment of patients to treatments randomized?
– YES. The design of the study was a
prospective multicenter trial which consisted
of a pretreatment evaluation and a rendomized
treatment with either SW or PPPD.
Appraisal Guide:
THERAPY OR PREVENTION
Are the results of the study valid?
Primary Guides:
Were all patients who entered the trial properly accounted
for and attributed at its conclusion?
YES. Based on the final histologic diagnosis, 29 patients
with benign lesions and 7 with endocrine tumors were
excluded from the survival analysis. For long-term
follow-up, a total of 134 patients with histologic and
proven pancreatic periampullary adenocarcinoma were
included and analyzed.
Appraisal Guide:
THERAPY OR PREVENTION
Are the results of the study valid?
Primary Guides:
Was followup complete?
YES.
Appraisal Guide:
THERAPY OR PREVENTION
Are the results of the study valid?
Primary Guides:
Were patients analyzed in the groups to which they were
randomized?
YES. All patients with suspicion of pancreatic or
periampullary tumor were included and randomized for
a SW or a PPPD. Data concerning patient’s
demographics, intraoperative and histologic findings as
well as post-opertative mortality, morbidity, and followup up to 115 months after discharge were analyzed.
Appraisal Guide:
THERAPY OR PREVENTION
Are the results of the study valid?
Secondary Guides:
Were patients, health workers, and study personnel
"blind" to treatment?
YES. An equal number of blind envelopes with protcols
were prepared and used sequentially as patients were
wnrolled in the study.
Appraisal Guide:
THERAPY OR PREVENTION
Are the results of the study valid?
Secondary Guides:
Were the groups similar at the start of the trial?
YES. Included were 170 patients with suspected pancreatic
or periampullary cancer that were aswsumed resectable
base on CT and or MRI. Patients with previous gastric
resection were excluded.
Appraisal Guide:
THERAPY OR PREVENTION
Are the results of the study valid?
Secondary Guides:
Aside from the experimental intervention, were the groups
treated equally?
YES. They were subjected to the same
preoperative evaluation, exclusion criteria and
post operative management.