Tatalaksana dan Prognosis Tumor periampullar

Terapi Pembedahan
Prosedur Whipple (Pancreaticoduodenectomy)
Mortalitas rendah di pusat kesehatan besar (<5%) Survival rate terbaik (>50% 5-year) Morbiditas tinggi (25-65%)

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In: Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed. United States of America: W.B.Saunders; 2002. p5.5002-5026 Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier; 2011 GUT Online.Guidelines for the management of patients with pancreatic cancer periampullary and ampullary carcinomas. Gut.2005;54(V):1-16

Komplikasi prosedur whipple

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In: Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed. United States of America: W.B.Saunders; 2002. p5.5002-5026

Prognosis terapi whipple

Faktor
Ada/tdk nya Nodus limfatikus yg terlibat Penyebaran lokal organ2 sekitar (cth pankreas) Grade tumnor/ diffrensiasi

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In: Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed. United States of America: W.B.Saunders; 2002. p5.5002-5026 Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier; 2011

Eksisi Transduodenal (TDE)

Pertama kali dilakukan tahun 1898 oleh William

Halsted Morbiditas lebih rendah (5-20%) Lebih jrg berhasil (rekurensi, survival) Hasil:
Belum ada studi dgn kualitas yg baik

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In: Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed. United States of America: W.B.Saunders; 2002. p5.5002-5026 Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier; 2011

Pembedahan Radikal VS Lokal

Pertimbangan:
Stage tumor (T1,T2) Kondisi Pasien

Indikasi TDE:
Adenoma dgn high-grade dysplasia Villous atau tubullovillous adenoma Low-grade. Stage tumor tanpa tingkat komorbiditas

yg tinggi.
Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In: Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed. United States of America: W.B.Saunders; 2002. p5.5002-5026 Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier; 2011

Faktor Prognosis TDE:

Penyebaran LN

Mudah/tdknya Operasi berjalan

Elevasi dr bilirubin

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In: Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed. United States of America: W.B.Saunders; 2002. p5.5002-5026 Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier; 2011

Pre-oprative Endoscopic Stenting

Pertimbangan pre-reseksi: Menurunkan morbiditas (kontroversial) Pada kasus prosedur operasi hrs diundur >10 hr

GUT Online.Guidelines for the management of patients with pancreatic cancer periampullary and ampullary carcinomas. Gut.2005;54(V):1-16

Terapi Endoskopik
Snare Resection

Laser Ablation
Photodynamic irradiation

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In: Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed. United States of America: W.B.Saunders; 2002. p5.5002-5026 Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier; 2011

Eksisi Endoskopik
Kriteria
Adenomas <4 cm Tdk ada striktur atau ekstenski ke ductal Tdk ada ulser Hasil dari biopsi 6x menunjukkan masa Benign

Tdk ada mortalitas, ttp ada kenaikan morbiditas

(10-27%)
Pendarahan Pankreatitis
Sohn T.A., C.J.. Pancreatic and Periampullary Yeo Varibel Rekurensi (5-25%) Carcinoma (Nonendocrine). In: Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed. United States of America: W.B.Saunders; 2002. p5.5002-5026 Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier; 2011

 Flow Chart

Padolfi M, et al.. Endoscopic Treatment of Ampullary Adenomas. J Pancreas (Online).2008;9(1):1-8

Terapi Adjuvant
Kemoterapi (5-FluoroUracil)

[+doxirubicin+mitomycin C] +/- XRT (45 Gy)

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In: Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed. United States of America: W.B.Saunders; 2002. p5.5002-5026 GUT Online.Guidelines for the management of patients with pancreatic cancer periampullary and ampullary carcinomas. Gut.2005;54(V):1-16

Terapi Neoadjuvant
Radioterapi pre- dan post- op.

Improvement pd kontrol locoregional, ttp belum

ada perbaikan survival Masih dlm masa penelitian

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In: Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed. United States of America: W.B.Saunders; 2002. p5.5002-5026 GUT Online.Guidelines for the management of patients with pancreatic cancer periampullary and ampullary carcinomas. Gut.2005;54(V):1-16

Kemoterapi pd non-resectable localised, metastatic , atau rekuren

Mestastasis survival rate 3-6bln, tergantung dr

luas penyebaran. 5-FU dan Mitomycin C terbaik Gemcitabine digunakan pd adenocarcinoma

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In: Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed. United States of America: W.B.Saunders; 2002. p5.5002-5026 GUT Online.Guidelines for the management of patients with pancreatic cancer periampullary and ampullary carcinomas. Gut.2005;54(V):1-16