Management of carcinoma pancreas

1. Dr.Chaitanya Chittimuri
DEPARTMENT OF GENERAL SURGERY
ANDHRA MEDICAL COLLEGE
UNDER GUIDANCE OF
Prof Dr.C.JayaRaj M.S,M.Ch
Prof Dr.V.Raj Kamal M.S,D.N.B
Dr.S.B.Ratna Kishore M.S
Dr.K.Suresh Babu M.S

2. ROLE OF FNAC
PRE OP BILIARY DE-COMPRESSION
STAGING LAPAROSCOPY
CLINICOPATHOLOGICAL STAGING
CURATIVE SURGERIES
OPERATIVE PALLIATION
COMPLICATIONS OF SURGERIES
NON OPERATIVE PALLIATION
ADJUVANT THERAPY
NOVEL AGENTS

3. ROLE OF FNAC
key determination in the workup of a periampullary cancer is that of resectability
No Tissue Dx needed in
• patients with a resectable lesion
• Pt with good GC
• absence of distant spread
Treatment should not be delayed by attempts to obtain histologic confirmation of
malignancy.
→ PROCEED TO CURATIVE RESECTION

4. ROLE OF FNAC
Tissue Dx needed
• for palliative therapy
 -ve biopsy in suspected Ca Pancreas
 low operative risk
 resectable tumor
• FNAC report- Benign Villous Adenoma +/- Dysplasia ,Cannot rule out Maliganancy
• Pre Op Histological Dx of Distal CBD Ca ≈ 50% false negatives
→ DONOT ALTER THE DECISION TO EXPLORE
EXCEPTIONS
 Neo Adjuvant T/t
 Uncertain Pancreatic Mass
• Neuro endocrine tumors EUS FNA
• lymphomas
• cystic lesions
• non neoplastic conditions

5. PRE OP BILIARY DECOMPRESSION
Pre Op Jaundice - No increased risk of morbidity for Resection of Periampullary Ca
Decompression - NOT absolute requirement prior to resection
Decompression needed in
• Neo adjuvant therapy
• Referral to specialist
• limited operating room availability
Stented vs Unstented group
• mortality same
• wound infectio greater in Decompressed group

6. STAGING LAPAROSCOPY
 varies widely among institutions
 related to the confidence with which the preoperative diagnosis of carcinomatosis or
small hepatic metastases can be made
 Proponents
• save from the morbidity and mortality of exploratory laparotomy -unresectable disease.
• if a patient cannot be resected for potential cure, they are best palliated by
nonoperative means.

7.  Against routine laparoscopy
• current cross-sectional imaging studies are sensitive enough to identify patients
who have abdominal metastases
• added expense of laparoscopy.
• 20% of the unresectable patients will go on to develop gastric outlet obstruction
requiring surgical intervention
• Additionally,operative chemical splanchnicectomy
• Most high-volume hepatobiliary and pancreatic surgeons will selectively use
staging laparoscopy.
• The likelihood of finding disease that is unresectable is highest in those with
pancreas cancers involving the body or tail or uncinate process.
• The likelihood of finding disease that is unresectable is lower for duodenal,
ampullary, and distal common bile duct cancer compared to pancreas cancer

8. Recent consensus for laparoscopy
• high risk for occult disease
• large tumors (>3 cm)
• significantly elevated CA 19-9 level (>100 U/mL)
• uncertain findings on CT, or body or tail tumors

9. STAGING

10. tumors are classified into
1. Resectable - proceed with operative resection.
2. Borderline Resectable - Historically, locally advanced, unresectable
(T4) disease,require arterial resection and
complex procedures
3. Unresectable

11.  Resectable tumors
• localized to the pancreas
• no evidence of SMV or portal vein involvement (i.e., no abutment, distortion, thrombus, or encasement)
• preserved fat plane surrounding the SMA and celiac artery branches, including the hepatic artery
 Borderline resectable
• severe unilateral or bilateral SMV-portal impingement
• less than 180-degree tumor abutment on the SMA
• abutment or encasement of hepatic artery, if reconstructible
• SMV occlusion, if of a short segment and reconstructible.
 Unresectable tumors
• exhibit metastasis (including lymph node metastasis outside the field of resection)
• ascites
• vascular involvement beyond what has been detailed above

12. CURATIVE SURGERIES
1. PANCREATICO DUODENECTOMY
2. DISTAL PANCREATECTOMY AND EN BLOC SPLENECTOMY
3. TOTAL PANCREATECTOMY

13. CURATIVE SURGERY
HISTORY
first successful resection of a periampullary tumor was performed by
Halsted in 1898
Codivilla - first en bloc resection of the head of the pancreas and
duodenum for periampullary carcinoma, but this patient did not survive
first successful two-stage pancreaticoduodenectomy was performed in
Germany by Kausch in 1909.
Whipple and colleagues reported three successful, two-stage, en bloc
resections of the head of the pancreas and the duodenum in 1935.
first one-stage pancreaticoduodenectomy, reported in the United States by
Trimble in 1941

14. PANCREATICO DUODENECTOMY

26. DISTAL PANCREATECTOMY
1. STAGING LAPARAOSCOPY
2. INCISION-MIDLINE OR B/L SUBCOSTAL
3. LESSER SAC ENTERED REMOVING GASTROCOLIC LIG. FROM
TRANSVERSE COLON AND WHITE LINE OF TOLDT IS DIVIDED
4. OMENTUM ANTERIOR TO HILUM,SHORT GASTRIC VESSELS
DIVIDED
5. STOMACH MOBILISED AND RETRACTED SUPERIORLY
6. PERITONEUM DIVIDED ALONG INF.EDGE OF PANCREAS
7. SPLENIC ARTERY TEST CLAMPED,LIGATED AND CUT
8. IF TUMOR AT S,PV CONFLUENCE,SPLENIC VEIN IS DIVIDED.
9. TRANSECTION OF PANCREAS
10. IF PV,SMV INVOLVED, EN BLOC REMOVAL WITH PV
RECONSTRUCTION

30. OPERATIVE PALLIATION
 Without widespread metastasis
 relative long life expectency
 weighing mortality and morbidity with palliation acheivable
 FOR JAUNDICE
 MC-HepaticoJejunostomy
i. Roux limb
ii. Loop of jejunum with Braun JejunoJejunal anastomosis
 CholecystoJejunostomy-No longer performed

31. FOR DUODENAL OBSTRUCTION
 Operative stenting
 Endoscopic stenting
 Prophylactic Gastrojejunostomy
FOR PAIN
Chemical sphanchnectomy
20ml Ethanol or Saline
Either side of Aorta at Celiac Plexus

32. NON OPERATIVE PALLIATION
 FOR OBSTRUCTIVE JAUNDICE
• Endoscopic drainage
i. plastic stent
ii. SEMS
• Percutaneous Stent
 FOR DUODENAL OBSTRUCTION
expandible metallic bowel stents
 FOR PAIN
• Opioids
• NSAIDS
• US/CT Guided Celiac plexus block
• External beam radiotheraphy

33. ADJUVANT THERAPY
Modest benefit over surgery alone
No one regimen better than other
Only Chemo - ineffective
Chemo radiation
20Gy , 10 daily fractions for 2 wks
IV 5FU on days 1-3 and 15-17

34. NOVEL AGENTS
Angiogenesis Inhibitors
K-ras Inhibitors
Immunotherapy

35. T H A N K Y O U