Decisions Periamp

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Decisions Periamp

  1. 1. Management Decisions in Operable Periampullary carcinoma Dr H V Shivaram
  2. 2. <ul><li>Should I do staging laparoscopy & laparoscopic ultrasound ? </li></ul><ul><ul><ul><li>detects metastasis in liver & peritoneal cavity </li></ul></ul></ul><ul><ul><ul><li>vascular & nodal involvement </li></ul></ul></ul><ul><ul><ul><li>useful in only 16.4% cases </li></ul></ul></ul><ul><ul><ul><li>routine use not justified </li></ul></ul></ul><ul><ul><ul><li>more useful in body & tail tumours </li></ul></ul></ul><ul><ul><ul><li>Laparoscopic Whipple’s ..? </li></ul></ul></ul>Diagnostic lap.for periamp & pancreatic ca.J.gastrointest.surgery 2002;6:75-81
  3. 3. <ul><li>What anaesthesia ? </li></ul><ul><ul><ul><li>General anaesthesia / Thoracic epidural </li></ul></ul></ul><ul><ul><ul><li>Intra-operative monitoring </li></ul></ul></ul><ul><li>fluid and electrolyte balance, </li></ul><ul><li>good epidural analgesia, </li></ul><ul><li>temperature maintenance </li></ul><ul><li>timing of muscle relaxants and intravenous opiods </li></ul><ul><ul><ul><li>Post-operative ICU care </li></ul></ul></ul>“ Anaesthesia for Whipple’s Procedure” IJA 2003; 47(2): 150-151)
  4. 4. What Incision for Whipple’s? Bilateral sub costal Midline vertical Transverse
  5. 5. <ul><li>Resectable or not ? </li></ul><ul><li>Explore, kocherise, open lesser sac, </li></ul><ul><li>Frozen section </li></ul><ul><li>Unresectable: </li></ul><ul><ul><ul><ul><li>Mets. in liver, peritoneum, omentum </li></ul></ul></ul></ul><ul><ul><ul><ul><li>celiac axis nodes +ve (numbers 9, 16, and 14, 15) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>retroperitoneal extension </li></ul></ul></ul></ul><ul><ul><ul><ul><li>IVC invasion </li></ul></ul></ul></ul><ul><ul><ul><ul><li>SMA/SMV/ PV encasement </li></ul></ul></ul></ul><ul><ul><ul><ul><li>( Reexploration & resection possible in few cases ) </li></ul></ul></ul></ul>
  6. 6. <ul><li>Why Whipple’s Surgery ? </li></ul><ul><ul><ul><li>only form of treatment with chance to cure </li></ul></ul></ul><ul><ul><ul><li>Resectability rate: 80% ( 15% …ca.head) </li></ul></ul></ul><ul><ul><ul><li>5 year survival rate: </li></ul></ul></ul><ul><ul><ul><li>node –ve, no perineural invasion, </li></ul></ul></ul><ul><ul><ul><li>node +ve </li></ul></ul></ul><ul><li>Riall et al : 655 pts. ( 6 to 10 yr follow up) </li></ul><ul><li>( 20% ca.head) </li></ul>1.Results of Pancreaticoduodenectomy in Patients With Periampullary Adenocarcinoma; Annals of Surgery • Volume 248, Number 1, July 2008 2.Resected periamp.ca: 5 yr.survivors and their 6 to 10 yr follow up ;Riall et al ; surgery 2006;140:764-772
  7. 7. <ul><li>Is Whipple’s justified without +ve biopsy ? </li></ul><ul><ul><ul><li>Whipple’s should not be denied…. </li></ul></ul></ul><ul><ul><ul><li>Tissue diagnosis is a must for palliative Rx </li></ul></ul></ul><ul><ul><ul><li>( high volume centers, mortality < 5% ) </li></ul></ul></ul>Guidelines for the management of patients with pancreatic cancer, Pancreatic Section of the British Society of Gastroenterology, periampullary and ampullary carcinomas; Gut 2005;54:1-16
  8. 8. <ul><li>Which type of Surgery ? </li></ul><ul><ul><ul><ul><li>Classical Whipple’s ? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pylorus Preserving Whipple’s ? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Extended/ Radical Whipple’s ? </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Local excision/ Ampullectomy ? </li></ul></ul></ul></ul>
  9. 9. Classical Whipple’s Pylorus Preserving PD
  10. 10. Pylorus preserving PD : Will it affect oncological radicality ? Advantages : less blood loss, less time consuming Wt. gain & nutritional status Disadvantages : ? delayed gastric emptying no difference in morbidity, mortality & survival Randomised prospective trial of PPPD Vs. classic PDJ.gastroint.surgery 2004;443-452 Cochrane database 2008
  11. 11. <ul><li>Ampullectomy ? </li></ul><ul><ul><ul><li>matter of debate </li></ul></ul></ul><ul><ul><ul><li>2 criteria to be met : nodes -ve, free margin </li></ul></ul></ul><ul><ul><ul><li>Indications : Tis, T1 </li></ul></ul></ul><ul><ul><ul><li>more expertise required </li></ul></ul></ul><ul><ul><ul><li>morbidity & mortality is not less than Whipple’s </li></ul></ul></ul>
  12. 12. <ul><li>Extended/Radical lymphadenectomy ? </li></ul><ul><li>1.standard 2.extended 3. extended radical </li></ul><ul><ul><ul><ul><li>No long-term survival benefit </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Longer operative time, hospital stay </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Higher complication rates </li></ul></ul></ul></ul>Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinomad—part 3: Update on 5-year survival Journal J.GI Surg.vol.9.no.9;Dec.2005
  13. 13. Vascular resections ? Venous - Yes (adherence/invasion) Arterial – No Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer . Br J Surg. 2006 Jun;93(6):662-73 “ By the time of tumour involvement of the portal vein cure is unlikely, even with radical resection” Reconstruction: mobilisation splenic vein transection Lt.renal vein
  14. 14. Pre-op.CBD stenting – will it affect decision making ? 1.Effect of pre-op biliary stenting on immediate outcome after PD; Br.J.Surg 2005;92;356-361 2.The effect of preoperative biliary stenting on postoperative complications after pancreaticoduodenectomy . American Journal of Surgery , Volume 186 , Issue 5 , Pages 420 - 425 <ul><li>operative time, blood loss </li></ul><ul><li>infective complications -higher </li></ul><ul><li>bile cultures are +ve till 6 wks </li></ul>
  15. 15. <ul><li>Pancreato-gastrostomy or pancreato-jejunostomy ? </li></ul><ul><ul><ul><li>both are appropriate </li></ul></ul></ul><ul><ul><ul><li>no superiority over the other </li></ul></ul></ul>1.Meta-analysis of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy: Brit.J.Surg 2006;vol.93;929 - 936 2.Pancreaticojejunostomy versus pancreaticogastrostomy: systematic review and meta-analysis American Journal of Surgery - Volume 193, Issue 2 (February 2007 .
  16. 16. <ul><li>Pancreato-jejunostomy – which is better ? </li></ul><ul><ul><ul><li>Duct to mucosa technique </li></ul></ul></ul><ul><ul><ul><li>Dunking PJ </li></ul></ul></ul><ul><ul><ul><li>Binding PJ </li></ul></ul></ul><ul><ul><ul><li>Mesh reinforced PJ </li></ul></ul></ul>1.Comparison of Wirsung-jejunal duct-to-mucosa and dunking technique for pancreatojejunostomy after pancreatoduodenectomy Hepatobiliary Pancreat Dis Int. 2005 Aug;4(3):450-5 2. Binding Pancreatojejunostomy ;ANZ journal of surgery; vol 78;issue S1 ,  A68 - A80 3. Polypropylene mesh-reinforced pancreaticojejunostomy for periampullar neoplasm : World J Gastroenterol  2007 December 7; 13(45): 6072-6075
  17. 18. stitches are applied to a fairly thick pancreatic parenchyma and seromuscle layers of the jejunal wall of the posterior part of the anastomosis
  18. 19. Stents or no stents ? Small duct , soft pancreas Internal stent
  19. 20. An Antecolic Roux-En-Y type reconstruction decreased Delayed Gastric Emptying after Pylorus-Preserving Pancreatoduodenectomy J Gastrointest Surg (2008) 12:1812 <ul><li>Antecolic or retrocolic Roux en Y G J ? </li></ul><ul><ul><ul><ul><li>antecolic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>decreases DGE </li></ul></ul></ul></ul>
  20. 21. Feeding Jejunostomy ? 1.Feeding jejunostomy: is there enough evidence to justify its routine use? Dig Surg. 2004;21(2):142-5. 2.T-tube jejunostomy feeding after pancreatic surgery: a safe adjunct ; Asian J Surg. 2004 Apr;27(2):80-4 Disadvantages : Tube related : blockage, dislodgement, pericatheter leakage and peritonitis Feeds related : transient diarrhoea, abdominal distension, nausea or vomiting and pain Advantages : cost effevtive enteral nutrition superior
  21. 22. Drains ? How many ? Type ? when to remove ? Is intraabdominal drainage necessary after pancreaticoduodenectomy? J.gastroint.surg . vol 2; no.4 August 1998
  22. 23. 1 2 3 4 5
  23. 24. <ul><li>Should I use octreotide ? </li></ul><ul><ul><ul><ul><li>routine use is controversial </li></ul></ul></ul></ul><ul><ul><ul><ul><li>use: soft pancreas, small duct </li></ul></ul></ul></ul><ul><ul><ul><ul><li>start intra-op or pre-op . </li></ul></ul></ul></ul><ul><ul><ul><ul><li>dose,duration </li></ul></ul></ul></ul>

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