CASE MANAGEMENT, PRESENTATION, DISCUSSION AND SHARING OF INFORMATION ON PERIAMPULLARY CANCER

1
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

2
CASE MANAGEMENT, PRESENTATION, DISCUSSION
3

O.V., 52/M LUCENA CITY
4

• CHIEF COMPLAINT ABDOMINAL PAIN

5
HISTORY OF PRESENT ILLNESS

• 2 months PTA ? Px underwent
• cholecystectomy, IOC, and t-tube
• insertion in another institution

6
HISTORY OF PRESENT ILLNESS

• 6 weeks PTA ?the patient noted he
• had yellowish discoloration of his
• skin with associated right upper
• quadrant abdominal pain

7
HISTORY OF PRESENT ILLNESS

• 6 weeks PTA ?consultation was
• done in another institution where
• t-tube replacement was performed

8
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

9
HISTORY OF PRESENT ILLNESS

• 4 weeks PTA ? ERCP done and the
• noted perimampullary mass was
• biopsied.

10
HISTORY OF PRESENT ILLNESS

• 3 weeks PTA ? biopsy results
• revealed an adenocarcinoma

11
HISTORY OF PRESENT ILLNESS

• 3 days PTA ? abdominal CT Scan
• revealed a periampullary mass
• which was difficult to delineate
• from the pancreatic head

12
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

13

• PAST MEDICAL Hx
• ()HPN UBP 130/80 HBP 160/100 maintained on
  Metoprolol with poor compliance
• FAMILY Hx
• No heredofamilial disease noted

14

• PERSONAL/SOCIAL Hx
• - smoking history of 2.5 pack-years
• - consumed 2 bottles of beer per
• week for the past 10 years

15
PHYSICAL EXAMINATION

• G/S conscious, coherent, not in
  cardiorespiratory distress
• BP 110/70 CR80 RR 20 T370C
• SHEENT no jaundice pink palpebral
  cojunctiva,anicteric sclera, No NAD, No CLAD, No
  TPC

16
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

17
PHYSICAL EXAMINATION

• Extremities no edema, atrophy or cyanosis noted
  full and equal pulses on all extremities

18
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

19
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

20
RUQ abdominal pain and jaundice
21
S/P Cholecystectomy, IOC, placement of t-tube
RUQ abdominal pain and jaundice
22
RUQ abdominal pain and jaundice
S/P Cholecystectomy, IOC, placement of t-tube

• Inflammatory/ Metabolic
• Cirrhosis
• Hepatitis

Retained CBD Stone

• Neoplastic Disease
• Primary liver tumors
• Metastases
• Cholangiocarcinoma
• Klatskin tumors
• GB CA
• Periampullary CA

23
Clinical Diagnosis
Diagnosis Certainty Treatment
Neoplastic Disease 33 Surgical
Retained CBD Stone 33 Surgical
Metabolic/ Inflammatory 33 Surgical/ Medical
24
BASES

• 52 y/o, M
• Right upper quadrant abdominal pain
• underwent cholecystectomy, IOC, and t-tube
  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

25
Do I need a para-clinical diagnostic procedure?

• YES

26
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
27
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

28
Paraclinical Diagnostic Procedures

• Biopsy result (10/5/07)
• Adenocarcinoma

29
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

30
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

31
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

32
RUQ abdominal pain and jaundice
S/P Cholecystectomy, IOC, placement of t-tube

• Inflammatory/ Metabolic
• Cirrhosis
• Hepatitis

Retained CBD Stone

• Neoplastic Disease
• Primary liver tumors
• Metastases
• Cholangiocarcinoma
• Klatskin tumors
• GB CA
• Periampullary CA

33
RUQ abdominal pain and jaundice
S/P Cholecystectomy, IOC, placement of t-tube

• Inflammatory/ Metabolic
• Cirrhosis
• Hepatitis

Retained CBD Stone

• Neoplastic Disease
• Primary liver tumors
• Metastases
• Cholangiocarcinoma
• 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

34
RUQ abdominal pain and jaundice
S/P Cholecystectomy, IOC, placement of t-tube

• Inflammatory/ Metabolic
• Cirrhosis
• Hepatitis

Retained CBD Stone

• Neoplastic Disease
• Primary liver tumors
• Metastases
• Cholangiocarcinoma
• 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

35
Periampullary Carcinoma
Pancreas
Ampulla of Vater
CBD
Duodenum
36
Periampullary Carcinoma

• 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

Pancreas
Ampulla of Vater
CBD
Duodenum
37
Periampullary Carcinoma
Pancreas
Ampulla of Vater
CBD
Duodenum
38
Periampullary Carcinoma
Pancreas
Ampulla of Vater
CBD
Duodenum
Adenocarcinoma on biopsy
Ampullary Adenocarcinoma
39
Pretreatment Diagnosis
Diagnosis Certainty Treatment
Ampullary AdenoCA 90 Surgical
Periampullary CA (Pancreas, CBD, Duodenum) 10 Surgical
40
TREATMENT

• PRETREATMENT DIAGNOSIS
• Ampullary Adenocarcinoma

41
TREATMENT

• GOALS OF TREATMENT
• Curative extirpation of the tumor
• Relieve biliary obstruction

42
TREATMENT OPTIONS
TREATMENT BENEFIT RISK COST AVAIL
STANDARD WHIPPLE RESECTION Treatment of choice for resectable periampullary cancers. Applicable on tumors that appear to encroach on the proximal duodenum or the gastric antrum1 Pncreatic fistula 14 GE Leakage 1 Bile leakage 0 Post-op bleeding 7 Intraabdominal abscess 10 Other complications 28 Relaparotomy 19 Operative Mortality 72 Cost of OR needs and anesthetics(P5,000-P10,000) Available

43
TREATMENT OPTIONS
TREATMENT BENEFIT RISK COST AVAIL
PPPD Treatment of choice for resectable periampullary cancers. Pncreatic fistula 13 GE Leakage 0 Bile leakage 2 Post-op bleeding 7 Intraabdominal abscess 10 Other complications 22 Relaparotomy 15 Operative Mortality 32 Cost of OR needs and anesthetics(P5,000-P10,000) Available

44
TREATMENT OF CHOICE

STANDARD WHIPPLE RESECTION/ PANCREATICODUODENEC
TOMY
45
PREOPERATIVE PREPARATION

• Informed consent
• Psychosocial support
• Optimize patients health
• Screen for any condition that will interfere with
  treatment
• Prepare materials

46
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

47
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

48
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

49
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

50
OPERATIVE FINDINGS

• Intraluminal mass located in the Ampulla of Vater
  with infiltration of the mucosal layer

51
(No Transcript)
52
OPERATION DONE

• STANDARD WHIPPLE RESECTION/
• PANCREATICODUODENECTOMY

53
HISTOPATHOLOGY

• Ampullary Adenocarcinoma, well-differentiated
  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

54
POST OPERATIVE DIAGNOSIS

• Ampullary Adenocarcinoma

55
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

56
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

57
SHARING OF INFORMATION
58
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

59
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

60
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

61
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

62
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

63
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

64
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

65
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

66
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

67
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

68
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

69
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

70
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

71
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

72
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

73
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

74
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

75
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

76
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

77
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

78
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

79
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

80
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

81
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

82
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

83
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

84
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

85
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

86
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

87
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

88
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

89
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

90
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

91
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

92
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

93
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

94
MCQ

• 1. What is the most common periampullary
  carcinoma?
• a. Pancreatic Adenocarcinoma
• b. Ampullary Carcinoma
• c. Cholangiocarcinoma
• d. Duodenal Carcinoma

95
MCQ

• 1. What is the most common periampullary
  carcinoma?
• a. Pancreatic Adenocarcinoma
• b. Ampullary Carcinoma
• c. Cholangiocarcinoma
• d. Duodenal Carcinoma

96
MCQ

• 2. Which periampullary carcinoma has an 80
  resection rate?
• a. Pancreatic Adenocarcinoma
• b. Ampullary Carcinoma
• c. Cholangiocarcinoma
• d. Duodenal Carcinoma

97
MCQ

• 2. Which periampullary carcinoma has an 80
  resection rate?
• a. Pancreatic Adenocarcinoma
• b. Ampullary Carcinoma
• c. Cholangiocarcinoma
• d. Duodenal Carcinoma

98
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

99
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

100
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

101
MCR

• I. Periampullary cancers arise from
• which of the following?
• 1. Pancreas
• 2. Ampulla of Vater
• 3. Bile duct
• 4. Liver

102
MCR

• I. Periampullary cancers arise from
• which of the following?
• 1. Pancreas
• 2. Ampulla of Vater
• 3. Bile duct
• 4. Liver

103
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

104
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

105

• THANK YOU!!!

106
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

107
JOURNAL CRITICAL APPRAISAL
108
Pylorus Preserving Pancreaticoduodenectomy Versus
Standard Whipple ProcedureA Prospective,
Randomized, Multicenter Analysis of 170 Patients
With Pancreatic and Periampullary TumorsKhe 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
109
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.

110
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.

111
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.

112
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 lt
  0.23). Long-term follow-up showed no significant
  statistical differences in survival between the 2
  groups (P lt 0.90).

113
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.

114
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.

115
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.

116
Appraisal Guide THERAPY OR PREVENTION

• Are the results of the study valid?
• Primary Guides
• Was followup complete?
• YES.

117
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 patients
  demographics, intraoperative and histologic
  findings as well as post-opertative mortality,
  morbidity, and follow-up up to 115 months after
  discharge were analyzed.

118
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.

119
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.

120
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.