Decisions Periamp

Management Decisions in Operable Periampullary carcinoma Dr H V Shivaram

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Diagnostic lap.for periamp & pancreatic ca.J.gastrointest.surgery 2002;6:75-81

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],“ Anaesthesia for Whipple’s Procedure” IJA 2003; 47(2): 150-151)

What Incision for Whipple’s? Bilateral sub costal Midline vertical Transverse

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[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],1.Results of Pancreaticoduodenectomy in Patients With Periampullary Adenocarcinoma; Annals of Surgery • Volume 248, Number 1, July 2008 2.Resected periamp.ca: 5 yr.survivors and their 6 to 10 yr follow up ;Riall et al ; surgery 2006;140:764-772

[object Object],[object Object],[object Object],[object Object],Guidelines for the management of patients with pancreatic cancer, Pancreatic Section of the British Society of Gastroenterology, periampullary and ampullary carcinomas; Gut 2005;54:1-16

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Classical Whipple’s Pylorus Preserving PD

Pylorus preserving PD : Will it affect oncological radicality ? Advantages : less blood loss, less time consuming Wt. gain & nutritional status Disadvantages : ? delayed gastric emptying no difference in morbidity, mortality & survival Randomised prospective trial of PPPD Vs. classic PDJ.gastroint.surgery 2004;443-452 Cochrane database 2008

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[object Object],[object Object],[object Object],[object Object],[object Object],Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinomad—part 3: Update on 5-year survival Journal J.GI Surg.vol.9.no.9;Dec.2005

Vascular resections ? Venous - Yes (adherence/invasion) Arterial – No Systematic review of outcome of synchronous portal-superior mesenteric vein resection during pancreatectomy for cancer . Br J Surg. 2006 Jun;93(6):662-73 “ By the time of tumour involvement of the portal vein cure is unlikely, even with radical resection” Reconstruction: mobilisation splenic vein transection Lt.renal vein

Pre-op.CBD stenting – will it affect decision making ? 1.Effect of pre-op biliary stenting on immediate outcome after PD; Br.J.Surg 2005;92;356-361 2.The effect of preoperative biliary stenting on postoperative complications after pancreaticoduodenectomy . American Journal of Surgery , Volume 186 , Issue 5 , Pages 420 - 425 ,[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],1.Meta-analysis of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy: Brit.J.Surg 2006;vol.93;929 - 936 2.Pancreaticojejunostomy versus pancreaticogastrostomy: systematic review and meta-analysis American Journal of Surgery - Volume 193, Issue 2 (February 2007 .

[object Object],[object Object],[object Object],[object Object],[object Object],1.Comparison of Wirsung-jejunal duct-to-mucosa and dunking technique for pancreatojejunostomy after pancreatoduodenectomy Hepatobiliary Pancreat Dis Int. 2005 Aug;4(3):450-5 2. Binding Pancreatojejunostomy ;ANZ journal of surgery; vol 78;issue S1 , A68 - A80 3. Polypropylene mesh-reinforced pancreaticojejunostomy for periampullar neoplasm : World J Gastroenterol 2007 December 7; 13(45): 6072-6075

stitches are applied to a fairly thick pancreatic parenchyma and seromuscle layers of the jejunal wall of the posterior part of the anastomosis

Stents or no stents ? Small duct , soft pancreas Internal stent

An Antecolic Roux-En-Y type reconstruction decreased Delayed Gastric Emptying after Pylorus-Preserving Pancreatoduodenectomy J Gastrointest Surg (2008) 12:1812 ,[object Object],[object Object],[object Object]

Feeding Jejunostomy ? 1.Feeding jejunostomy: is there enough evidence to justify its routine use? Dig Surg. 2004;21(2):142-5. 2.T-tube jejunostomy feeding after pancreatic surgery: a safe adjunct ; Asian J Surg. 2004 Apr;27(2):80-4 Disadvantages : Tube related : blockage, dislodgement, pericatheter leakage and peritonitis Feeds related : transient diarrhoea, abdominal distension, nausea or vomiting and pain Advantages : cost effevtive enteral nutrition superior

Drains ? How many ? Type ? when to remove ? Is intraabdominal drainage necessary after pancreaticoduodenectomy? J.gastroint.surg . vol 2; no.4 August 1998

Decisions Periamp

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