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Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
Decisions Periamp
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Decisions Periamp

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  1. Management Decisions in Operable Periampullary carcinoma Dr H V Shivaram
  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. <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. What Incision for Whipple’s? Bilateral sub costal Midline vertical Transverse
  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. <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. <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. <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. 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. <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. <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. 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 <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. <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. <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
  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 <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>
  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. <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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