peri ampullary ca

1. Pancreatic Cancer

2. Why Pancreas is a nemesis
Anatomical relations
Potent enzymes
Difficult to anastamose
Access

3. Incidence

4. Incidence
• Male : Female is 1.5:1
• Disease of old age. 80% of pancreatic
cancer occurs beyond the age of 60 years
• American Blacks-highest incidence (11-13
per 1,00,000)

5. Incidence
• In 2005, the American Cancer society
estimates that there will be approximately
32,180 new cases of pancreatic cancer in
the US, with 31,800 deaths
• Fourth most common cause of cancer
deaths
American cancer society. Cancer facts and figures
2005, Atlanta, GA

6. Ca Pancreas- The grim
situation
• Only 20% of pancreatic cancers are operable
for cure
• Only 10% - 15% of pancreatic cancers are alive
12 months after the diagnosis
• 5 year survival is less than 5%
• Average life of metastatic pancreatic cancer is 6
months

7. Etiology
• Cigarette smoking
• Diet – high fat and low fiber
• Diabetes
• Occupational
– benzidine
– naphthalimine
– Ethylene Dichloride
• Coffee – not proved

8. Etiology – Hereditary factors
Hereditary syndromes
– HNPCC
– PZ syndrome
– Ataxia Telangiectasia
– Hereditary Pancreatitis
– Familial Atypical Mole Melanoma syndrome
– FAP

9. Is Chronic Pancreatitis premalignant
• The incidence of pancreatic cancer in
various entities of chronic Pancreatitis are
as follows
– Hereditary Pancreatitis 25%
– Tropical Pancreatitis 10%
– Alcoholic Pancreatitis 5%

11. Oncogenes in pancreatic cancer
• K ras
• P 53
• P 16
• DPC 4

12. Pancreatic Neoplams
Primary Secondary
Exocrine Endocrine
Epithelial Mesenchymal
Ductal Acinar
Benign Intermediate Malignant
Solid Cystic
Ductal Adenocarcinoma

13. Periampullary
carcinoma
• Any tumor within 2
cm from the duodenal
papilla is defined as
periampullary cancer.
Ca terminal PD
Distal CBD
Ampullary tumor
Duodenal tumor

15. Site
• Pancreatic head-2/3rd
• Remaining part 1/3rd

16. Clinical presentation
• Mid epigastric pain radiating to back
• Weight loss
• Fatigue
• Anorexia
• Symptoms are vague and hence the
delayed presentation

17. Clinical presentation
• Painless progressive jaundice 50-60%
• Pruritus
• Staetorrhea
• Malabsorption
• New onset of Diabetes in older patients

18. Clinical presentation
• Jaundice is a late presentation in uncinate
process growth
• Severe back pain indicate irresectablity
and an omnious sign

19. Physical findings
• Palpable GB (Courvoisier’s law)
• Hepatomegaly
• Icterus
• Scratch marks
• Ascites
• Mass
• Virchow’s node
• Pelvic deposit
• Trousseau’s sign

20. Assessment
• Confirm the diagnosis
• Stage the disease
• Assess the operability
• General assessment for surgery

21. Investigation
• CBC
• LFT
• RFT
• Coagulation profile
• CXR
• ECG
• Echo

22. USG
• Cheap
• Level of obstruction
• Cause of obstruction
• Liver metastasis
• Ascites

23. USG
• Operator dependent
• Miss small metastasis
• Cannot assess operability

24. CT
• “Pancreatic protocol CT” is the gold
standard of investigation to stage the
disease and assess the operability
– Triple phase CT
– Closer cuts
– Water used as an intraluminal contrast
– Helical or multislice

27. “Operability is assessed in the office
of the surgeon and not in the
Operating room”

28. CT
• Advantages
– Available easily
– Surgeons are familiar with CT
– Excellent in giving details of operability
• Disadvantages
– May miss liver mets less than 1 cm
– Miss peritoneal mets
– Radiation

29. MRI
• Advantages
– No radiation
– Avoids contrast
– Single investigation that gives all the
information needed
• Disadvantages
– Cost & availability
– Surgeons are unfamiliar

30. MRI
ONE STOP SHOP

31. Role of Biopsy
Not mandatory

32. Why not a biopsy
• May upstage the disease
• Complications of biopsy
• Has a very low negative predictive value

33. Role of Biopsy
• Tissue diagnosis is indicated in cases which
are found inoperable by imaging
• Biopsy is indicated when Neoadjuvant
chemotherapy is planned

34. What biopsy
• Ideally it should be
done under EUS
guidance
– Targeted
– No tumor seeding
– No complications
like fistula

35. ERCP
Double duct sign
Not routinely done in
pancreatic
Cancer
Preop biliary drainage
Atypical lower CBD
obstruction

36. PET
• It is useful in differentiating pancreatic
cancer from chronic Pancreatitis
• Extra pancreatic disease

37. EUS
• Ideal method to evaluate
lower CBD obstruction
• Guided FNAC
• Vascular invasion
• EUS+FNAC= sensitivity of
90% and specificity of 95%

38. Angiography
No longer used

39. Barium studies – only historical
• Pad sign – widening of C loop
• Reverse 3 sign or Frostberg sign

40. Tumor markers
• CA 19-9
• CEA
• CA 125
• CA 50
• SPAN-1
• DUPAN-2

41. Staging
• TX primary tumor cannot be assessed
• T0 no evidence of primary tumor
• T1 confined to pancreas
T1a less than 2 cm
T1b more than 2 cm
• T 2 tumor extend to involve the bile
duct, duodenum and peripancreatic
tissue
• T3 involvement of stomach, spleen, colon,
vessels

42. Staging
• NX nodes cannot
be assessed
• N0 no evidence
of nodes
• N1 regional
nodes present
• MX cannot be
assessed
• M0 no metastasis
• M1 distant
metastasis

43. Stage grouping
• Stage I
– T1 N0 M0
– T2 N0 M0
• Stage II
– T3 N0 M0
• Stage III
– Any T N1 M0
• Stage IV
– Any T Any N M1

44. Prognosis
• Tumor size
• Node positivity
• Type of resection (R0 or R1)
• Ploidy

45. Operability
• Ca head 20%
• Ca body&tail 3%
• Ampullary 80%

46. Preop preparation
• Vitamin K
• Hydration
• Correction of electrolytes
• Preop nutrition

47. Surgery for pancreatic Ca
• Ca head Pancreaticoduodenectomy
• Ca body & Tail Distal Pancreatectomy
• Periampullary Pancreaticoduodenectomy

48. Pancreaticoduodenectomy
Pancreaticoduodenectomy offers the surgeon the only
chance to cure a patient with carcinoma of the head of
the pancreas and periampullary region

49. Pancreaticoduodenectomy
• Walter Kausch was the first to successfully
perform pancreaticoduodenectomy in Berlin
1912
• Allen Whipple popularized the operation in
US in 1935
• Now this operation is called Kausch-
Whipple procedure

50. Pancreaticoduodenectomy
• This operation suffered a very bad
reputation due to the operative mortality of
over 25% and morbidity of over 50%
• Some authorities have even suggested that,
this operation be abandoned

51. What made whipple safe
• Better surgical technique
• Anaesthesia
• Improvement in postoperative care
• Concept of high volume center and
clinical pathways

52. Pancreaticoduodenectomy
Despite the reduction in the operative
mortality to less than 5%, the morbidity
continues to be hovering around 40%

53. Whipple – 6 well defined operative steps
1. Cattle Brasch maneuver
2. Extended Kocherization
3. Portal Dissection, division
of Bile duct
4. Division of Stomach
5. Division of Jejunum
6. Pancreatic Neck
transection

54. Reconstruction after Classical Whipple’s operation
Hepaticojejunostomy
Gastrojejunostomy
Pancreaticojejunostomy

55. Pylorus preserving Pancreaticoduodenectomy

56. Controversies
• Preop biliary drainage
• Preop imaging, CT vs. MR vs. EUS
• Role of biopsy
• Diagnostic laparoscopy
• PJ vs. PG
• Classical Whipple vs. PPPD
• Vascular resections
• Extended lymphadenectomy
• Drainage

57. Controversies
• Role of octreotide
• Order of reconstruction
• Adjuvant therapy
• Palliative resections
• Palliative bypass

58. Preop biliary drainage
• For
– Reduce the mortality and morbidity of surgery
– Improves the liver function
– Reduces the bleeding
– Improves the nutrition
– Buys time

59. Preop biliary drainage
• Against
– Does not reduce the mortality and morbidity
– More infectious complications
– It takes 6 weeks for the improvement of hepatic
microsomal functions
– Makes the duct small and fibrotic – adds to
technical difficulty

60. Preop biliary drainage -
consensus
• Indicated
– Cholangitis
– Impending renal failure
– Surgery is likely to be delayed
– Bilirubin of more than 20 mg%
– Nutritionally very poor
– Neoadjuvant chemotherapy is planned

61. Preop biliary drainage -
consensus
Routine preop biliary
drainage is not
recommended and there is
no evidence to support it

62. Diagnostic laparoscopy
• 30% of patients found operable by imaging
are found to have small liver mets or
peritoneal mets, on diagnostic laparoscopy
Warshaw et al

63. Diagnostic laparoscopy
With the advent of high
quality CT, Helical and
Multislice, occult peritoneal
and liver metastasis are
documented in only 10% in
some series

64. PJ vs. PG
• Merits of PG
– Stomach is in proximity to pancreatic stump
– Better vascularity
– Acid in stomach inactivates enzymes
– Absence of enterokinase
– Even if leak occurs the enzymes are not
activated and hence fatal bleeding do not occur

65. PJ vs. PG
• Two randomized controlled trials fail to
demonstrate superiority of one method over
the other
• Dilated duct, texture of pancreas and
surgeon’s experience are more important
than the viscera used for drainage

66. Classical Vs PPPD
• PPPD is oncologically as radical as classical
whipple except for tumors encroaching on
the D1 and pylorus
• RCTs have failed to show any significant
benefit of PPPD over classical whipple

67. Vascular
involvement
• Resection of SMV is
accepted provide it
enables to perform R0
resections
• Involvement of SMA is
a contraindication for
resection

68. Extended
lymphadenectomy
• Studies have shown that
extended
lymphadenectomies can
be done with acceptable
morbidity
• Extended
lymphadenectomy do not
improve the survival

69. Octreotide
• There have been totally six RCT across the
Atlantic, three from Europe ( Buchler et al, Beger
et al , Pedrazolli et al) and three from US ( Yeo et
al, Sarr et al and Lowy et al)
• The European trials favor use of octreotide and the
American trials do not favor
• Recently published meta analysis of these trials
have shown a benefit of octreotide in reducing the
complications

70. Adjuvant therapy
• Chemotherapy
• Radiotherapy
• Chemo radiotherapy

71. Adjuvant therapy
• The ESPAC trial has shown that the only
factor that positively affect the long term
survival is administration of adjuvant
chemotherapy
• Ideally all patients undergoing surgery for
cancer pancreas should be given adjuvant
chemotherapy

72. Palliative resections – Is it
acceptable

73. Palliation
• Jaundice (pruritus)
• Duodenal obstruction
• Pain
• Bleeding

74. Palliative bypass
• Options of by-pass
– Choledochojejunostomy ( Loop or Roux en Y)
– Cholecystojejunostomy
– Hepaticojejunostomy

75. Palliative bypass-prophylactic GJ
• The current recommendation is to perform
a prophylactic GJ along with the biliary
bypass even if there is no gastric outlet
obstruction

76. Laparoscopy in palliation
• Depending on the expertise of the surgeon,
procedures can be done with laparoscopy

77. Palliation of pain
• Neurolysis ( 20 ml of absolute alcohol
injected on either side of the celiac axis to
destroy the celiac ganglia)
– At laparotomy
– CT guided
– EUS guided
– Thoracoscopic splanchnectomy

78. Surgery has reached the zenith

79. Thank You