Periampullary tumors

Dr. M Muzzammil Resident W3

Objectives

To know Anatomy of Ampullary region What are Periampullary Tumors How WHO classified PAT. What are Clinical Features To know TNM staging of PAT How to in estige PAT To know a!out Management of PAT

ampullary region

The Ampulla of "ater is a flasklike ca ity into which !oth the common !ile and pancreatic ducts open# $n %&' of patients( the ampulla is the termination of common !ile duct alone and the pancreatic duct enters the duodenum separately( ad)acent to the ampulla#

ampullary region

The ampulla is *#+ cm long or less( tra erses the duodenal wall( opens into the duodenal lumen through ,ma)orduodenal papilla ,papilla of "ater.urrounded !y the pancreas and duodenum# The area within & cm of the ampulla is called periampullary region

Anatomy o ampullary region

!p"incter o oddi

Arterial supply

Arterial supply

#enous drainage

#enous drainage

$ymp"atic drainage

$ymp"atic system

Periampullary tumors

Periampullary tumors arise within & cm of the ampulla and include/ pancreatic head tumors( 0ower common !ile duct tumors( Ampullary tumors( 1uodenal tumors Periampullary cancers account for +' of all gastrointestinal cancers

W"o classi ication o periampullary tumors

%pit"elial Tumors a# 2enign 3 Adenoma !# Pre4malignant 3 1ysplasia c# Malignant 3 Adenocarcinoma

periampullary tumors

!tromal Tumors a# 5astrointestinal .tromal Tumors ,5$.T!# 0ipomas Malignant $ymp"omas !econdary Tumors

PAT originating rom pancreas

&enign
.erous cystadenoma Acinar cell cystadenoma

Premalignant lesions
Mucinous cystic neoplasm intraepithelial neoplasia

Malignant lesions
1uctal adenocarcinoma '()* Mucinous adenocarcinoma

Pancreatic tumor

PAT originating rom common bile duct

They are adenocarcinomas in 6+' of cases# +maging indings are, *#4 $nfiltrati e4narrowing with an irregular and thickened duct tra)ectory &#4 Polypoid or papilary intraluminal( rare#

PAT originating rom t"e duodenum

1uodenal Adenocarcinoma 5$.T/ They are mesenchymal tumors of the gastrointestinal tract that can !e/ 2enign/ Malignant Adenomas illosus type tu!ular type

T-MOR! O. T/% AMP-$$A O. #AT%R

The benign tumors include Adenomas, Gastrointestinal stromal tumors (GISTs) , Lipomas, Neuroendocrine tumors. Malignant: Adenocarcinomas

Ampullary tumor

staging o tumors

Tumor si7e and location Histologic diagnosis The presence or a!sence of hepatic or peritoneal metastasis or ascites Presence of e8tapancreatic tumor e8tension Presence or a!sence of suspicious lymph nodes in peripancreatic( periportal or celiac region with option of !iopsy "ascular encasement 3 portal ein( .MA( .M"( hepatic artery

T0M 1lassi ication periampullary tumor

# T 4 Primary Tumour T9# No e idence of primary tumour T*# Tumour limited to ampulla of "ater or sphincter of Oddi T&# Tumour in ades duodenal wall T:# Tumour in ades pancreas T%# Tumour in ades peripancreatic soft tissues( or other ad)acent organs or structures

T0M 1lassi ication

N 4 Regional $ymp" 0odes N9# No regional lymph node metastasis N*# ;egional lymph node metastasis M 2 Distant Metastasis M9# No distant metastasis M*# 1istant metastasis

Prevalence o periampullary cancers

Cancer of the head of the pancreas )3*243*5 Ampullary cancer in 6)*27)*5 2iliary cancer in 63* 1uodenal cancer in 63*.

Prognosis of periampullary tumor 5year survival

1uodenal carcinoma 3 77* to )3* Ampullary carcinoma 3 38* to )3*. 1istal cholangiocarcinoma 3 78* Pancreatic adenocarcinoma 9 )* $n ampullary and periampullary tumors 4 margin status(

resected lymph node status and degree of tumor differentiation significantly influence outcome#

1linical .eatures

<aundice =pigastric 1iscomfort Pruritis 1ark >rine Pale .tool Anore8ia Weight 0oss 2ack Pain Palpa!le 0i er ? 5#2

1linical .eatures

.igns Of $ntra4a!dominal Malignancies( such as/

Palpa!le Mass Ascites .upracla icular 0ypmh Nodes

+nvestigations

$ab +nvestigations C2C .@>@C@= 0FTAs Coagulation profile .erum amylase Total Protein A@5 ;atio >rinalysis .erum Ca CA *646

Radiological
-ltrasound,

Whether or not C21 and pancreatic duct dilated# Mass in Pancreas M=T. in 0i er

1T2!1A0

Tumor .i7e Tumor .taging Hepatic or Peritoneal Metastasis .tomach ? duodenal in ol ement 0ymph Node Metastasis distant from pancreatic Head $n ol ement of .uperior Mesenteric Hepatic or celiac arteries $n ol ement of Portal ein

MR+ : MRA can gi e more confirmatory information compara!le to CT( regarding "ascular in ol ement#

Periampullary tumor with dou!le duct sign and distended g!

Peritoneal mets

1a "ead o pancreas unresectable tumor due to involvment o smv

%R1P

O!structi e <aundice cholangitis .mall ampullary lesions 1istressing Pruritis 1elay !@w diagnosis ? surgery For the !illiary stenting For 2iopsy

%-!

Tumors B*4&cm not detected !y CT4.CAN .taging of tumor FNAC Tissue !iopsy "ascular $n asion

management

All jaundiced patients must be kept in good state of nutrition and hydration. Blood clotting deficiencies must be corrected. Cardio pulmonary and renal functioning carefully assessed.

management
Palliation

o pancreatic cancer

Relieve jaundice and treat biliary sepsis .urgical !iliary !y pass .tent placement Percutaneous transhepatic drainage +mprove gastric empyting .urgical gastroenterostomy 1uodenal stent

management

Pain relie Use of analegsia Coeliac plexus block !ymptoms relie and ;uality o li e Encourage for normal activities Enzymes replacement for steatorrhea Treat diabetes chemotherapy

curative surgical treatment

Options available are: A. Whipple procedure (Pancreatico-duodenectomy) B. Pylorus Preserving Pancreaticoduodenectomy

The main advantage of this technique is that the pylorus preserved and thus normal gastric emptying.

!urgical management

Pancreaticoduodenectomy ,Wipple procedure- is regarded as the standard treatment for periampullary cancers =ndoscopic ampullectomy is typically reser ed for !enign ampullary lesions

Wipple procedure

+t consists o removal o /
distal half of the stomach the gall !ladder and its cystic duct the common !ile duct the head of the pancreas( duodenum regional lymph nodes#

Reconstruction consists o

Pancreatico)e)unostomy Hepatico)e)unostomy 5astro)e)unostomy

W"ipple procedure

1ontraindications to W"ipple

0i er metastases or implants on the hepatic serosa $n asion of the !ase of the colonic mesentery $n asion of the hepatoduodenal ligament $n asion of the hepatic( or superior mesenteric arteries

1ontraindications to W"ipple

$n ol ement of the porta hepatis Metastases to the portal ein Fi8ation !y tumor of duodenum and pancreas to underlying structures Metastases to aorta or ena ca a

!tep 6 smv

2ilateral .u!costal incision#,Che ronCs $ncision

Midline incision

fle8ure of the colon is taken down The inferior !order of the pancreas is identified

The

.M" is e8posed at the inferior !order of the neck of the pancreas( ad)acent to the uncinate process

!tep 7 2 <oc"erize

A Kocher maneuver has been performed to mobilize the duodenum, first identifying the inferior vena cava (IVC) at the level of the proximal portion of the transverse segment of the duodenum

then mobilize the duodenum and pancreatic head off of the IVC in a upward direction

!tep 3 9 Porta /epatis

Identification of the common hepatic artery

Identification and ligation and division of the right gastric artery and the gastroduodenal artery

The portal vein is always identified prior to division of the common hepatic duct and gall bladder

!tep 8 2 Antrum

The antrum of the stomach is resected !y di iding the stomach at the le el of the third or fourth trans erse ein on the lesser cur ature

!tep ) 2 =ejunum

<e)unum is then transected appro8imately *9 cm distal to the ligament of Treit7

!tep > 2 Pancreas

The pancreatic head and uncinate process are separated from the superior mesenteric4portal ein confluence

The pancreas has !een transected at the le el of the portal ein

!tep 4 9 Pancreaticojejunostomy

The pancreatic remnant is mo!ili7ed from the retroperitoneum and splenic ein for a distance of & to : cm

The transected )e)unum is !rought up retrocolic through incision in the trans erse mesocolon to the left of the middle colic essels

A two4layer( end4to4side( duct4to4mucosa panceatico)e)unostomy is performed o er a small .ilastic stent

!tep ( 2 /epaticojejunostomy

A one4layer( end4to4side hepatico)e)unostomy is performed

distal to the pancreatico)e)unostomy

!tep ? 2 @astrojejunostomy
An antecolic( end4to4side gastro)e)unostomy is constructed

The distance !etween the !iliary and gastric anastomoses should !e at least +9 cm pre enting !ile reflu8 cholangitis

feeding )e)unostomy tu!e may !e placed distal to the gastro)e)unostomy

Postoperative complications

Pancreatic fistula 3 leak from the pancreatico)e)unostomy Anastomotic leakage 1elayed gastric emptying .eptic complications 3 intraa!dominal a!scess A!dominal hemorrhage 1e elopment or worsening of dia!etes Medical pro!lems 3 respiratory distress( pneumonia( pulmonary em!olus( throm!oem!olic complications,1"T-( renal dysfunction( M$ and cere!ro ascular accidents( hepatic and meta!olic pro!lems#

Pyloris sparing A"ipple procedure

Pyloris sparing vs standard A"ipple procedure

study pu!lished in &9*9 , D trials( +E% patients - showed that operati e time for PPP1 was E& minutes faster with &F% ml less !lood loss compared to standard Whipple# Garanicolas et al#H Annals of .urgical Oncology *%,D-/ *F&+4:%#

Pyloris sparing vs standard A"ipple procedure

Another study pu!lished in &99E ,&&9 pts - F9pts undergone through PPP1 showed no significant difference in mor!idity( hospital mortality( or sur i al !etween PPP1 and standard Whipple procedure# I Operati e time and intraoperati e !lood loss was greater in patients undergoing .W# 1iener et alH Annal of .urgery &%+ ,&-/ *FE4&99#

Pyloris sparing vs standard A"ipple procedure

A meta4analysis pu!lished in &99F including &F&& patients ,*::+ .W and *%FE PPP1-# I Patients undergoing PPP1 had a shorter operati e time and reJuired less !lood transfusions compared to the .W group# I There were no differences in postoperati e complications or sur i al rates !etween the two groups# $J!al et alH =uropean < of .urgical Oncology :% ,**-/ *&:E4%+#

-nresectable tumors

In locally unresectable or metastatic cancer, both chemoradiotherapy and chemotherapy can be applied

Fluoropyrimidines, cisplatin, and gemcitabine are the most commonly used drugs in periampullary carcinoma

n a Th

u o kY