3. carcinoma head ofcarcinoma head of
pancreaspancreas
Malignant
Obstructive Jaundice
Carcinoma
Head of Pancreas
Periampullary
Carcinoma
Cholangiocarcinoma Carcinoma
Gallbladder
4. USG + CECTUSG + CECT
ResectableResectable UnresectableUnresectable No massNo mass
detecteddetected
ReassessReassess
ResectibilityResectibility
ResectResect
(Whipple Procedure)(Whipple Procedure)
PalliationPalliation
ChemotherapyChemotherapy
RadiotherapyRadiotherapy
PainPain JaundiceJaundice Du ObstructionDu Obstruction
ERCP orERCP or
EUSEUS
MalignantMalignant
EvaluateEvaluate
FurtherFurther
ResectResect
(Whipple Procedure)(Whipple Procedure)
5. resectibility vs.resectibility vs.
unresectibilityunresectibility
Findings contraindicating
resection :
Liver/Visceral metastasis (any
size)
Peritoneal implants
Celiac lymph node involvement
Invasion of transverse mesocolon
Hepatic hilar lymph node
involvement
Arterial Invasion – Venous
Occlusion
Findings not
contraindicating
resection:
Invasion of duodenum or
distal stomach
Involvement of
peripancreatic lymph node
6. resectionresection
Only shot at Cure (but recurrence is common)
At presentation – only 15% resectable
Two techniques –
- Standard Whipple Procedure
- Modified Whipple (PPPD)
Pancreatic Ca.
Resection Palliation
7. kausch - whipplekausch - whipple
procedureprocedure
3 phases –
- Assessment phase
- Resection phase
- Reconstruction phase
Pancreatic Ca.
Resection Palliation
Assessment
Resection
Reconstruction
Sir Allen Oldfather Whipple
(1881-1963)
Important Landmarks
- 1909 – Kausch first performed Pancreatoduodenectomy
- 1935 – Whipple perfected the technique (two-stage)
- 1941 – One-stage procedure was described
- 1978 – Traverso and Longmire introduced PPPD
8. a. assessmenta. assessment
Why Reassess???
Specificity of CECT for Resectibility = 80%... Why?
Laparoscopy or Laparotomy???
Gen. Anesthesia – Midline/Bilateral Subcostal incision
Look for –
- Metastasis
- Inoperable LN involvement
- Kocher Maneuver
- Aberrant Right Hepatic Artery
Pancreatic Ca.
Resection Palliation
Assessment
Resection
Reconstruction
10. b. resectionb. resection
Viscera removed
- Distal 1/3rd
of Stomach (not in PPPD)
- Duodenum
- Proximal 10 cm of jejunum
- Head, Neck and Uncinate Process of Pancreas
- Gallbladder with
cystic duct and CBD
- Regional Lymph Nodes
Pancreatic Ca.
Resection Palliation
Assessment
Resection
Reconstruction
11.
12. c. reconstructionc. reconstruction
3 steps –
- Pancreatico-jejunostomy
- Hepatico-jejunostomy
- Gastro-jejunostomy
Pancreatic Ca.
Resection Palliation
Assessment
Resection
Reconstruction
13. PPPD vs. WhipplePPPD vs. Whipple
Advantages of
PPPD
Prevention of Reflux
Prevents marginal ulceration
Normal Acid Secretion and
Hormone Release
Improved gastric function
Better Weight Gain
Disadvantages of
PPPD
Compromise with the resection
margin
Delayed Gastric Emptying
Pancreatic Ca.
Resection Palliation
14. complicationscomplications
Common Complication
• Delayed Gastric Emptying (19%)
• Pancreatic Fistula (14%)
• Wound Infection/Sepsis (10%)
• Hemorrhage (intraop. or postop.)
Other Complications
• Intra-abdominal Abscess
• Cholangitis
• Pneumonia
• Bile Leak
• Pancreatitis
• Marginal Ulcer
(upto 40% of cases)
Pancreatic Ca.
Resection Palliation
15. palliationpalliation
• 85% cases unresectable at presentation
• Not curative
• Aimed at improving the quality of life
• Three major problems –
- Pain
- Jaundice
- Duodenal Obstruction
Pancreatic Ca.
Resection Palliation
Pain
Du Obstruction
Jaundice
16. a. paina. pain
• Medical – Opioids ; NSAIDs
• Celiac Plexus Nerve Block
(Percutaneous - USG or CT Guided)
(Transgastric or Laparotomic)
Pancreatic Ca.
Resection Palliation
Du Obstruction
JaundicePain
25. periampullary carcinomaperiampullary carcinoma
• Distal CBD carcinoma
• Ampullary Carcinoma
• Duodenal Carcinoma (surrounding Ampulla)
- Prognosis is better
- Management – similar to Ca head of Pancreas
26. 5 year survival5 year survival
Ca head of PancreasCa head of Pancreas
3%
Periampullary CaPeriampullary Ca
30%
prognostic markers
- CA 19-9
- CA 494