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Decisions Periamp
 

Decisions Periamp

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    Decisions Periamp Decisions Periamp Presentation Transcript

    • Management Decisions in Operable Periampullary carcinoma Dr H V Shivaram
      • Should I do staging laparoscopy & laparoscopic ultrasound ?
          • detects metastasis in liver & peritoneal cavity
          • vascular & nodal involvement
          • useful in only 16.4% cases
          • routine use not justified
          • more useful in body & tail tumours
          • Laparoscopic Whipple’s ..?
      Diagnostic lap.for periamp & pancreatic ca.J.gastrointest.surgery 2002;6:75-81
      • What anaesthesia ?
          • General anaesthesia / Thoracic epidural
          • Intra-operative monitoring
      • fluid and electrolyte balance,
      • good epidural analgesia,
      • temperature maintenance
      • timing of muscle relaxants and intravenous opiods
          • Post-operative ICU care
      “ Anaesthesia for Whipple’s Procedure” IJA 2003; 47(2): 150-151)
    • What Incision for Whipple’s? Bilateral sub costal Midline vertical Transverse
      • Resectable or not ?
      • Explore, kocherise, open lesser sac,
      • Frozen section
      • Unresectable:
            • Mets. in liver, peritoneum, omentum
            • celiac axis nodes +ve (numbers 9, 16, and 14, 15)
            • retroperitoneal extension
            • IVC invasion
            • SMA/SMV/ PV encasement
            • ( Reexploration & resection possible in few cases )
      • Why Whipple’s Surgery ?
          • only form of treatment with chance to cure
          • Resectability rate: 80% ( 15% …ca.head)
          • 5 year survival rate:
          • node –ve, no perineural invasion,
          • node +ve
      • Riall et al : 655 pts. ( 6 to 10 yr follow up)
      • ( 20% ca.head)
      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
      • Is Whipple’s justified without +ve biopsy ?
          • Whipple’s should not be denied….
          • Tissue diagnosis is a must for palliative Rx
          • ( high volume centers, mortality < 5% )
      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
      • Which type of Surgery ?
            • Classical Whipple’s ?
            • Pylorus Preserving Whipple’s ?
            • Extended/ Radical Whipple’s ?
            • Local excision/ Ampullectomy ?
    • Classical Whipple’s Pylorus Preserving PD
    • 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
      • Ampullectomy ?
          • matter of debate
          • 2 criteria to be met : nodes -ve, free margin
          • Indications : Tis, T1
          • more expertise required
          • morbidity & mortality is not less than Whipple’s
      • Extended/Radical lymphadenectomy ?
      • 1.standard 2.extended 3. extended radical
            • No long-term survival benefit
            • Longer operative time, hospital stay
            • Higher complication rates
      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
    • 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
    • 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
      • operative time, blood loss
      • infective complications -higher
      • bile cultures are +ve till 6 wks
      • Pancreato-gastrostomy or pancreato-jejunostomy ?
          • both are appropriate
          • no superiority over the other
      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 .
      • Pancreato-jejunostomy – which is better ?
          • Duct to mucosa technique
          • Dunking PJ
          • Binding PJ
          • Mesh reinforced PJ
      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
    •  
    • stitches are applied to a fairly thick pancreatic parenchyma and seromuscle layers of the jejunal wall of the posterior part of the anastomosis
    • Stents or no stents ? Small duct , soft pancreas Internal stent
    • An Antecolic Roux-En-Y type reconstruction decreased Delayed Gastric Emptying after Pylorus-Preserving Pancreatoduodenectomy J Gastrointest Surg (2008) 12:1812
      • Antecolic or retrocolic Roux en Y G J ?
            • antecolic
            • decreases DGE
    • 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
    • Drains ? How many ? Type ? when to remove ? Is intraabdominal drainage necessary after pancreaticoduodenectomy? J.gastroint.surg . vol 2; no.4 August 1998
    • 1 2 3 4 5
      • Should I use octreotide ?
            • routine use is controversial
            • use: soft pancreas, small duct
            • start intra-op or pre-op .
            • dose,duration