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Periampullary Carcinoma
Periampullary Carcinoma
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