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Decisions Periamp

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  • 1. Management Decisions in Operable Periampullary carcinoma Dr H V Shivaram
  • 2.
    • 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
  • 3.
    • 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)
  • 4. What Incision for Whipple’s? Bilateral sub costal Midline vertical Transverse
  • 5.
    • 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 )
  • 6.
    • 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
  • 7.
    • 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
  • 8.
    • Which type of Surgery ?
          • Classical Whipple’s ?
          • Pylorus Preserving Whipple’s ?
          • Extended/ Radical Whipple’s ?
          • Local excision/ Ampullectomy ?
  • 9. Classical Whipple’s Pylorus Preserving PD
  • 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.
    • 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
  • 12.
    • 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
  • 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. 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
  • 15.
    • 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 .
  • 16.
    • 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
  • 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
  • 19. Stents or no stents ? Small duct , soft pancreas Internal stent
  • 20. 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
  • 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
  • 22. Drains ? How many ? Type ? when to remove ? Is intraabdominal drainage necessary after pancreaticoduodenectomy? J.gastroint.surg . vol 2; no.4 August 1998
  • 23. 1 2 3 4 5
  • 24.
    • Should I use octreotide ?
          • routine use is controversial
          • use: soft pancreas, small duct
          • start intra-op or pre-op .
          • dose,duration

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