Edward L. Lee, M.D.

Professor & Chairman

Department of Pathology
Howard University
College of Medicine

PERIAMPULLARY TUMORS
AND THE DISSECTION OF THE
WHIPPLE RESECTION

IN
MEMORIAM
ALLEN O.
WHIPPLE,
M.D.
1881 - 1963

WHIPPLE PROCEDURE
PERFORMED FOR
Periampullary Tumors (104)

Pancreatic CA -70
Ampullary CA -20
Duodenal CA -10
Distal bile duct CA -4

Chronic pancreatitis (38)

WHIPPLE PROCEDURE
(PANCREATICODUODENECTOMY)
Specimen

Distal stomach
Duodenum
Head of pancreas
Distal bile duct
Gallbladder
Proximal jejunum

WHIPPLE PROCEDURE
Reconstruction
Pancreatico jejunostomy
Choledocho jejunostomy
Gastrojejunostomy -

WHIPPLE SPECIMEN
Frozen Section
Pancreatic resection
margin
Bile duct margins

Probe Bile Duct

Dilated
Identified by surgeons
with black suture

WHIPPLE SPECIMEN
Dissect The Unfixed
Specimen
Open the stomach along
greater curvature
Open the duodenum along the
border opposite the pancreas
- Duodenal mucosa looks
dusky because the blood
supply is ligated earlier
in the operation

WHIPPLE SPECIMEN

Dissect The Unfixed

Specimen
Open the bile duct
extending to ampulla
Identify the main
pancreatic duct

WHIPPLE SPECIMEN
PANCREATIC CA
Pathologic Features
Gross
Effacement of lobules
Invasive CA
Fibrosis

WHIPPLE SPECIMEN
Periampullary
Tumors

Pancreatic tumors
Bile duct tumors
Ampullary tumors
Duodenal tumors

WHIPPLE SPECIMEN
Record Dimensions

Stomach
Duodenum
Pancreatic head
Margins
Lymph nodes (10)

WHIPPLE SPECIMEN
PANCREATIC CA
Describe The Tumor

Size
Color
Consistency
Cysts
Relationship to anatomic
sites
Distance from margins
Obstruction of ducts

Remainder of pancreatic

parenchyma

WHIPPLE SPECIMEN
Sections (20)

Resection Margins
- Pancreatic
- Uncinate process
- Gastric
- Duodenal
- Common bile duct
Tumor
- Tumor and common bile
- Tumor and pancreatic duct
- Tumor and pancreatic parenchyma
Uninvolved pancreas
Ampulla
Lymph nodes (10)
- Common bile duct
- Pergastric
- Periduodenal
- Pancreatic

ENDOSCOPY
DUODENAL CA
Endoscopic Appearance
3 cm polypoid,
ulcerating CA

WHIPPLE SPECIMEN
DUODENAL CA

Pathologic Features
Gross
3 cm polypoid,
ulcerating CA

WHIPPLE SPECIMEN
DUODENAL CA
Pathologic Features
Micro
Ulcerating Adeno CA
Invades pancreas

Prognosis
5 year survival rate
30%

ENDOSCOPY
AMPULLARY CA - EARLY
Endoscopic Appearance
1.5 polypoid CA

WHIPPLE SPECIMEN
AMPULLARY CA - EARLY

Pathologic Features

Gross
1.5 cm mass

WHIPPLE SPECIMEN AMPULLARY

CARCINOMA - EARLY
Pathologic Features
Micro
Adeno CA
Confined to mucosa

Prognosis
5 year survival rate good

WHIPPLE SPECIMEN AMPULLARY

CARCINOMA - ADVANCED
Pathologic Features
Gross
2 cm polypoid
ulcerating CA

WHIPPLE SPECIMEN AMPULLARY

CARCINOMA - ADVANCED
Pathologic Features
Gross
Invasive adeno CA
Tumor invades pancreas

Micro
Invasive adeno CA
Tumor invades pancreas

Prognosis
5 year survival rate 34%

WHIPPLE PROCEDURE
BILE DUCT CA
Pathologic Features
Gross
Protuberant
ampulla

WHIPPLE PROCEDURE
BILE DUCT CA
Pathologic Features
Gross
Mass in distal bile
duct
3 cm papillary CA

WHIPPLE PROCEDURE BILE

DUCT CA
Pathologic Features
Gross
Invasive papillary CA

Micro
Invasive papillary CA
Metastasis to lymph
node

Prognosis
5 year survival rate
15%

ANATOMY AND FUNCTIONS OF

THE PANCREAS
Endocrine
Exocrine

PANCREAS
Anatomy
Head
Body
Tail

PANCREAS
Histology
Exocrine
Acinar cells
Ducts
Endocrine
Islet cells

Insulin
Glucagon
Somatostatin
Pancreatic
polypeptide

PANCREATIC DUCTAL ANATOMY

AND ANATOMIC RELATIONSHIP
OF THE PANCREAS

PANCREATITIS
Acute
Inflammation
Edema
Fat Necrosis
Hemorrhage

Chronic
Inflammation
Destruction of
exocrine glands
Destruction of
endocrine glands
Fibrosis

CHRONIC PANCREATITIS
Causes

Alcohol abuse
Obstruction
Cystic fibrosis
Hereditary
Tropical

CHRONIC PANCREATITIS
Pathologic Features
Gross
Fibrosis
Dilated ducts
Calcified concretions

CHRONIC PANCREATITIS
Pathologic Features
Micro
Fibrosis
Atrophy of acini
Dilated ducts with
concretions

COMPLICATIONS OF
CHRONIC PANCREATITIS

Pseudocysts
Duct obstruction
Malabsorption
Steatorrhea
Secondary diabetes
Carcinoma

NEOPLASMS OF THE PANCREAS

Cystic Neoplasms
Serous cystadenomas
Mucinous cystic
neoplasms
Intraductal papillary
mucinous neoplasms

Solid Neoplasms
Pancreatic ductal
adenocarcinoma
Endocrine tumors

PANCREATIC CARCINOMA
Clinical Features
Fourth leading cause of
cancer death in U.S.
30,000 patients diagnosed
and die from it
Genetic disease:
mutations in K-RAS, p53

5-year Survival Rate

<5%

PANCREATIC DUCTAL
ADENOCARCINOMAS
Diagnosis
ERCP (endoscopic
retrograde cholangiopancreatography)
Fine needle aspiration
biopsy
Ct scan
CA-19-9

PANCREATIC DUCTAL
CARCINOMAS
Risk Factors

Tobacco abuse
Chronic pancreatitis
Hereditary pancreatitis
Diet (high in fats and
meats)
Chemical carcinogen
exposure
Pancreatic Intraepithelial
Neoplasias (PanINs)

Pan INs 1

CA

PANCREATIC CARCINOMA
PATHOLOGY

Microscopic
Poorly formed
glands in fibrotic
stroma

METASTATIC PANCREATIC CA
TO LIVER
Hematogenous
Metastases

Portal vein
Hepatic artery

WHIPPLE PROCEDURE
Complications

Post Op Mortality Rate

- 2 - 5%
Morbidity Rate
- 20 - 50%
Leakage
- Pancreaticojejunal
anastomosis (15%)
- Choledochojejunal
anastomosis (7%)

WHIPPLE PROCEDURE
Cost
$34,000 to $92,000
High-volume centers
- Lower hospital cost
- Shorter hospital stay
- Lower morbidity

PARK