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Staging and Surgical Management of Pancreatiic Cancer
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Staging and Surgical Management of Pancreatiic Cancer






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Staging and Surgical Management of Pancreatiic Cancer Presentation Transcript

  • 1. Staging and Surgical Management of Pancreatic Cancer Justin Geoghegan St Vincent’s University Hospital
  • 2. Walter Kausch (1867-1928) Allen Oldfather Whipple (1881-1963)
  • 3. Staging of Pancreas Cancer CT very good at predicting resectability moderately good at predicting unresectability cannot distinguish between reactive and malignant lymphadenopathy
  • 4. Staging of Pancreas Cancer CT
  • 5. Staging of Pancreas Cancer Endoscopic ultrasound diagnosis, especially of small lesions tumour size staging of lymph node status and assessment of vascular involvement biopsy
  • 6. lymph node status ? selection for neo-adjuvant treatment
  • 7. Staging of Pancreas Cancer Laparoscopy and lap ultrasound small volume peritoneal disease metastatic liver disease peritoneal cytology as CT improves, the pick-up rate from laparoscopy decreases selective vs invariable use
  • 8. Staging of Pancreas Cancer Laparoscopy and lap ultrasound “always use it” changes management in 10-15% ?separate anaesthetic/procedure or immediately prior to laparotomy separate procedure needed if peritoneal cytology is considered important
  • 9. Laparoscopy and peritoneal cytology Author Journal patient number effect of positive cytology Leach Surgery 1995 80 indicates advanced disease Merchant J Am Coll Surg 1999 228 assoc with advanced disease predicts unresectability Makary Arch Surg 1999 32 contraindicates resection Nakatsuka Internat J Surg Inves 1999 50 contraindicates resection Nakao Hepatogastroenterolgy 1999 74 no effect on survival Yachida Br J Surg 2002 134 doesn’t predict carcinomatosis doesn’t contraindicate resection Meszoely Am Surg 2004 168 should not preclude resection Ferrone J Gastrointest Surg 2006 462 same outcome as patients with stage IV disease Yamada Ann Surg 2007 233 no effect on survival
  • 10. Staging of Pancreas Cancer Laparoscopy and lap ultrasound “selective” larger tumours equivocal findings on CT – ascites weight loss grossly elevated tumour markers changes management in 25%
  • 11. Staging of Pancreas Cancer Laparoscopy and lap ultrasound when to do it? separate anaesthetic or immediately prior to laparotomy for resection decision needs to be individualised depending on - likelihood of positive finding - presence of jaundice - logistical factors
  • 12. When is biopsy required? unresectable imaging raises possibility of an alternative tissue type that may be amenable to different treatment strategy patient request reasonable possibility of chronic pancreatitis mimicking cancer
  • 13. Unresectability co-morbidity distant metastases – liver, peritoneal encasement of coeliac, hepatic or sup mesenteric arteries major encasement of portal vein-superior mesenteric vein lymph node status surgeon-dependent
  • 14. Pancreatic resection balance between mortality/morbidity and benefit mortality rate <5% major complication rate 40% high rate of positive margins
  • 15. Birkmeyer,2003
  • 16. Technical Issues neoadjuvant treatment extended lymphadenectomy portal vein resection pylorus-preserving pancreatic reconstruction drains octreotide
  • 17. Extended resections total pancreatectomy extended lympadenectomy portal vein and SMA resection Fortner, Cancer 1981
  • 18. Extended lymphadenectomy Michalski et al Br J Surg 2007
  • 19. Extended lymphadenectomy Michalski et al Br J Surg 2007
  • 20. Portal vein resection does it affect survival? does it affect morbidity and mortality? does it have a role?
  • 21. Koniaris, J Am Coll Surg 2003
  • 22. Portal vein resection portal vein resection does not affect survival probably no effect on morbidity portal vein invasion is a function of tumour location rather than tumour biology
  • 23. Pylorus preserving pancreatectomy
  • 24. Randomized trials of pylorus- preserving vs classical Whipple
  • 25. Pancreatic reconstruction end-to end pancreaticojejunostomy end-to-side pancreaticojejunostomy pancreaticogastrostomy
  • 26. Drains,Stents and Octreotide drains – no benefit Conlon, Ann Surg 2001 stents – no difference Winter, J Gastrointest Surg 2006 octreotide – may be of value for high-risk pancreatic anastomosis Connor,Br J Surg 2005
  • 27. Quality of life after pancreatic resection Schniewind et al 2006
  • 28. Outcome of Whipple’s procedure depends on tumour type Schmidt, C. M. et al. Arch Surg 2004;139:718-727.
  • 29. How to improve surgery? earlier detection screening better staging high-volume centres neoadjuvant and adjuvant treatment