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General Surgery
Cancers of the Periampullary Region and the Pancreas
Built from Maingot's Abdominal Operations
What’s inside
22 sections · 160 slides
Overview
- Scope of this presentation
What periampullary cancer means
Four tumours, one small piece of anatomy
- Definition of periampullary cancer
- Rationale for grouping the four cancers
- Anatomical origins of periampullary cancer
- Early attempts at resection
- Establishment of pancreaticoduodenectomy
- ~2%
Incidence and epidemiology
How common, where, and in whom
- Burden of pancreatic cancer in the United States
- Geographic trends and demographic distribution
Pathology
What the tumours are made of
- Adenocarcinoma as the dominant histology
- Site of origin of periampullary adenocarcinoma
- Uncommon tumours of the periampullary region
- Distribution of pancreatic ductal adenocarcinoma
- Pancreatic endocrine and cystic neoplasms
Risk factors
What is proven, what is weak, what is myth
- Established and weak environmental risk factors
- Evidence linking cigarette smoking to pancreatic cancer
- Dietary associations
- Exposures with little or no established risk
- Chronic pancreatitis and diabetes as risk factors
- Risk factors for the non-pancreatic periampullary cancers
- Hereditary syndromes predisposing to pancreatic cancer
- Familial pancreatic cancer and polyposis syndromes
Genetic alterations
What sequencing the tumour genome showed
- Genomic tools applied to cancer
- The pancreatic cancer genome project
- Frequency of the commonest gene alterations
- Genetics of ampullary adenocarcinoma
Clinical presentation
Symptoms, signs and laboratory findings
- Aim of the workup and timing of symptoms
- Symptoms of obstructive jaundice
- Mechanism of obstructive jaundice
- Pain and gastric outlet obstruction
- Subtle presentations and presentation by site
- Physical findings on examination
- Physical signs of advanced disease
- Laboratory findings in biliary obstruction
- CA 19-9 and molecular markers
Imaging studies
Choosing the test that answers the question
- Imaging modalities and the shift to noninvasive tests
- Choosing an imaging test
- Role of right upper quadrant ultrasonography
- Multidetector spiral CT in diagnosis and staging
- Dilated intrahepatic bile ducts on CT
- Double-duct sign on CT
- Pancreatic mass lying against the superior mesenteric artery
- Three-dimensional CT vascular reconstruction
- Portal and superior mesenteric veins on three-dimensional CT
- Superior mesenteric artery on three-dimensional CT
- Magnetic resonance imaging and cholangiopancreatography
- Hypodense pancreatic head mass on contrast-enhanced MRI
- Dilated bile and pancreatic ducts on magnetic resonance cholangiopancreatography
- Endoscopic retrograde cholangiopancreatography
- Indications for ERCP in periampullary cancer
- Pancreatic and bile duct obstruction on ERCP
- Completion cholangiogram after endoscopic stenting
- Percutaneous cholangiography and positron emission tomography
- Complete obstruction of the common bile duct on percutaneous cholangiography
- Upper endoscopy and endoscopic ultrasound
- Pancreatic head mass without vascular invasion on endoscopic ultrasound
Tissue diagnosis
When a biopsy changes the plan and when it does not
- Tissue diagnosis before curative resection
- Situations that do require tissue before treatment
- Safety and yield of biopsy by site
Preoperative biliary decompression
Should the duct be drained before operating
- Indications for preoperative biliary decompression
- Evidence on preoperative biliary stenting
Preoperative staging
Deciding who should go to the operating room
- Purpose and limits of staging imaging
- Accuracy of three-dimensional CT in predicting resectability
- Radiological signs of unresectability
- Arguments for and against routine staging laparoscopy
- Selective use of endoscopic ultrasound and laparoscopy
- Clinicopathologic staging systems
Pancreaticoduodenectomy
The Whipple procedure, step by step
- Sequence of pancreaticoduodenectomy
- Incision, exposure and assessment of resectability
- The Kocher maneuver
- Bimanual palpation of the uncinate process
- Relation of the uncinate process to the mesenteric vessels
- Order of dissection and division of the bile duct
- Gastroduodenal artery clamp test and division of the jejunum
- Classic Whipple and pylorus-preserving variants
- Exposure of the superior mesenteric vein
- Developing the retropancreatic tunnel
- Division of the pancreatic neck
- Dissection of the uncinate process
- Marking the resection margins
- Order of reconstruction
- Standard reconstruction after pancreaticoduodenectomy
- Options for pancreatic reconstruction
- Pancreaticogastrostomy reconstruction
- Controversies in pancreatic reconstruction
- Duct-to-mucosa anastomosis and duct stents
- Invagination technique and pancreaticogastrostomy
- Biliary and gastric anastomoses
- Drains and postoperative management
Distal pancreatectomy
For cancer of the body or tail
- Role of splenectomy with distal pancreatectomy
- Exposure and entry into the lesser sac
- Exposure of the pancreatic body and tail
- Control of the splenic artery and vein
- Transection of the pancreas and fistula prevention
- Cancer of the body of the pancreas
Operative palliation
When cure is impossible but the abdomen is already open
- Indications for operative palliation
- The three problems palliation must solve
- Operative palliation of obstructive jaundice
- Technique of palliative hepaticojejunostomy
- Anatomy after palliative bypass
- Prophylactic gastrojejunostomy for duodenal obstruction
- Technique of palliative gastrojejunostomy
- Operative chemical splanchnicectomy for pain
- Technique of alcohol celiac plexus block
Nonoperative palliation
Stents, blocks and analgesia
- Proportion suitable for cure and routes of biliary drainage
- Plastic and self-expanding metallic biliary stents
- Selecting a stent and treating duodenal obstruction
- Distal bile duct obstruction treated by metal stenting
- Nonoperative palliation of pain
Complications of resection
What goes wrong and how often
- 1.4%
- Commonest complications after pancreaticoduodenectomy
- Delayed gastric emptying
- Postoperative pancreatic fistula
- Complications after distal pancreatectomy
Long-term survival
What resection actually achieves
- Composition of a resected periampullary series
- Five-year survival by site of origin
- Interpretation of survival and features of five-year survivors
- Survival after resection of pancreatic cancer by tumour location
- Survival by resection margin and lymph node status
- Survival by tumour size and differentiation
- Survival after 1423 pancreaticoduodenectomies
- Prognostic factors in resected pancreatic cancer
- Survival after resection of ampullary adenocarcinoma
- Molecular prognosis and hospital volume
Adjuvant therapy
Treatment given after resection
- Current state of adjuvant therapy
- The GITSG adjuvant trial
- Multiagent regimens and the gemcitabine comparison
- The ESPAC-1 trial
- The CONKO-001 trial
- Survival with and without postoperative chemoradiation
- Adjuvant therapy for non-pancreatic periampullary cancers
Neoadjuvant therapy
Treatment given before resection
- Theoretical advantages of neoadjuvant therapy
- The Duke University neoadjuvant series
- The M.D. Anderson neoadjuvant programme
- Preoperative chemoradiation trials for resectable pancreatic cancer
- Preoperative chemoradiation trials at a single cancer centre
- Reading the neoadjuvant trial results
Novel agents in pancreatic cancer
Targeting the molecular defects
- Rationale for targeted agents
- Basis and attractions of immune-based therapy
- Phase I trial of a GM-CSF-secreting tumour vaccine
- Bevacizumab in advanced pancreatic cancer
- K-ras and farnesyltransferase inhibition
- The epidermal growth factor receptor family
- Trastuzumab in Her-2-positive pancreatic cancer
- Erlotinib combined with gemcitabine
Conclusion
What to carry away
- Summary of management principles
- 15-20%
- Pathway from presentation to treatment
References
Sources cited in this topic
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- Maingot's Abdominal Operations, 12th Edition