Periampullary Tumors. Charles M. Vollmer Jr., MD Professor of Surgery Director of Pancreatic Surgery. Resident s Teaching Conference July 20, 2017

Transcription

1 Periampullary Tumors Charles M. Vollmer Jr., MD Professor of Surgery Director of Pancreatic Surgery Resident s Teaching Conference July 20, 2017

2 What are the periampullary tumors?

3 What is their expected survival?

4 How do they present?

5 How do you manage jaundice?

6 Role of a biopsy?

7 Our job is to ask two questions Can we do it?

8 Staging Assessment of resectability by CT- Angiography or MRI M,N,T Absence of metastasis Distant lymph node involvement Local relationships of tumor

9 Three Classes of Tumors Clearly Resectable

10 Three Classes of Tumors Clearly Unresectable (LA)

11 Three Classes of Tumors Borderline Resectable Or is it Borderline Unresectable??? Hmmh???

12 What is Borderline Unresectability?

13 What is Borderline Resectability?

14 How do we manage this?

15 Two Tools For This Neoadjuvant Therapy Promise not yet fulfilled. Vascular Resections Veins - Yes Arteries - Rarely

16 A word about nutrition?

17 Our job is to ask two questions Should we do it?

18 High-Acuity Surgery Hurdles Co-morbidities Diabetes Metabolic Syndrome: HTN, Obesity It s CANCER Immunosuppression Prothrombotic state Malnutrition Age

19 Prediction Models ASA Charlson POSSUM Hopkins NSQIP (Surgical Calculator) FOTB

20 Counterindications O 2 Dependency Wheelchairs Cirrhosis Dementia

21 Pancreatic Surgery The Volume Effect Birkmeyer JD et al. N Engl J Med 2002

22 Lets go to the OR!

23 Laparoscopy anyone?

24 What s the first step?

25 Staging

26 HPB Malignancy Problem Operability Resectability

27 Staging Laparoscopy Considered Resectable Pre-Op % False-Negative Rate Resected Total Laparoscopy Lap US Laparotomy Conclusion: Patients can be spared useless laparotomy

28 Laparoscopic Staging Does EVERY patient need it? Is it still relevant today? Probably Not. Absolutely (maybe)

29 What s the purpose of the Kocher?

30 How do you find the SMV?

31

32 What lurks in Tiger Country? The Portal Triad

33 What is the Node of Importance?

34 Classical or PPPD? Why is/was the stomach resected for this operation?

35 Why resect the proximal jejunum?

36 How do we remove the head of the pancreas?

37 Dissection off the Vessels

38

39 Vein Resections

40 How much Lymphadenectomy?

41

42 How do you deal with this?

43 What constitutes pancreatic fistula risk?

44 How do we mitigate pancreatic fistula?

45 The KISS Principle

46 Afferent Limb Reconstruction - Pancreaticojejunostomy - Hepaticojejunostomy - Duodenojejunostomy Common Hepatic Duct Pancreatic Anastomosis

47 Antecolic vs Retrocolic

48 A Team Effort Interventional Endoscopy Pathology Radiology Medical Pancreatology Anesthesia Critical Care Interventional Radiology Nursing Social Work

49 Your Pathway To Recovery From Pancreatic Surgery Labs Pain Control Medications Antibiotics Nutrition Day of Operation POD #1 POD #2 POD #3 POD #4 POD #5 POD #6 POD #7+ Discharge CBC Chem 7 LFTs (AST/ALT/Bili/Amylase/Lipase) PT/PTT/INR Epidural Analgesia or Patient Controlled Analgesia (PCA) Pain Team Consult Anticoagulation: SQ Heparin 5000u q8h Ulcer Prophylaxis: Pepcid 20 mg IV BID Fistula Protection: Octreotide150 µg SQ q8h (Selectively - based on risk) Home Medications in IV form (Beta blockers, Synthroid, etc) Pre-operative Ancef & Flagyl; If PCN allergy then: Vancomycin + Flagyl + Gentamicin NPO IVF (Lacted 125/hr) CBC Chem 7 LFTs (AST/ALT/Bili/Amylase/Lipase) Epidural/PCA +/- IV Ibuprofen or Toradol (if renal function ok) Heparin 5000u SQ q8h Pepcid 20 mg IV BID Octreotide: 150 µg SQ q8h Home Medications IV CBC N/A N/A CBC Chem7 Blake Drain Amylase (after dinner) Epidural/PCA +/- IV Ibuprofen or Toradol Heparin 5000u SQ q8h Pepcid 20 mg IV BID Octreotide: 150 µg SQ q8h Home Medications IV Epidural/PCA +/- IV Ibuprofen or Toradol Cap epidural at midnight Heparin 5000u SQ q8h Pepcid 20 mg IV BID Octreotide: 150 µg SQ q8h Home Medications IV Remove Epidural PCA:(Morphine or Dilaudid) Heparin 5000u SQ q8h Zantac 150 PO BID Reglan 10mg PO q6h Colace/Senna PO Octreotide: 150 µg SQ q8h Pertinent Home Medications PO Oral pain medication (Dilaudid or Percocet) +/- Tylenol or Ibuprofen Heparin 5000u SQ q8h Zantac 150 PO BID Reglan 10mg PO q6h Colace/Senna PO Octreotide: 150 µg SQ q8h Pertinent Home Medications PO Vaccinations (x3) - if post-splenectomy N/A Oral pain medication (Dilaudid or Percocet) +/- Tylenol or Ibuprofen Heparin 5000u SQ q8h Zantac 150 PO BID Reglan 10 mg PO q6h Colace/Senna PO Octreotide: 150 µg SQ q8h Pertinent Home Medications PO N/A N/A N/A N/A N/A N/A N/A NPO IVF (Lactated 125/hr) Ice chips IVF (D5 1/2nl Urinary Foley Catheter (Placed in OR) Foley Catheter Foley Catheter (D/C if no Epidural) Respiratory O2 by Nasal Cannula Nasal Cannula (Wean O2) Endocrine Tubes, Drains & Lines Fingersticks q6h Sliding Scale Insulin NG Tube Blake drain +/-Central Line Intermittent Compression Devices (ICDs) +/- Pancreatic stent OR Wound Dressing Incentive spirometer (10x/hr while awake) Fingersticks q6h Sliding Scale Insulin NG Tube (Remove for Distals) Blake drain +/-Central Line ICDs +/- Pancreatic stent OR Wound Dressing D/C Nasal Canula (Wean O2) Clear sips IVF (D5 1/2nl Foley Catheter (if Epidural) Clear Liquids Decrease IVF D/C Foley (6h after Epidural is capped) Regular diet (Drebin); GI soft (Vollmer) Boost/Ensure /Glucerna Shakes Heplock fluids Regular diet Boost/Ensure /Glucerna Shakes N/A Oral pain medication (Dilaudid or Percocet) +/- Tylenol or Ibuprofen Heparin 5000u SQ q8h Zantac 150 PO BID Reglan 10 mg PO q6h Colace/Senna PO Commode Commode Commode IS 10x/hr IS 10x/hr IS 10x/hr IS 10x/hr IS 10x/hr IS 10x/hr Fingersticks q6h Sliding Scale Insulin Remove NG Tube (Whipples) Blake drain +/-Central Line ICDs +/- Pancreatic stent Remove OR Wound Dressing Activity Bedrest Out of bed to chair Out of bed to chair Ambulate 1-3x Work with PT/OT Fingersticks q6h Sliding Scale Insulin Blake drain Remove Central Line (if 2 peripheral IVs) ICDs +/- Pancreatic stent Incision exposed to air Out of bed to chair Ambulate 1-3x Work with PT/OT Fingersticks q6h Sliding Scale Insulin Endocrine consult if sugars elevated Blake drain IVs ICDs +/- Pancreatic stent Incision exposed to air Out of bed to chair Ambulate 3-5x Work with PT/OT Fingersticks BID Sliding Scale Insulin Supplemental Insulin PRN Blake drain IVs ICDs +/- Pancreatic stent Incision exposed to air Out of bed to chair Ambulate all day Work with PT/OT Fingersticks BID Sliding Scale Insulin (May d/c if regular diet and glucose is normal) Supplemental Insulin PRN Remove Blake drain (If Drain Amy <300) Otherwise, if >300, high volume, or sinister appearance, check with the attending. +/- Pancreatic stent Incision exposed to air Out of bed to chair Ambulate all day Work with PT/OT Octreotide: 150 µg SQ q8h Pertinent Home Medications PO Regular diet Boost/Ensure /Glucerna Shakes Fingersticks BID Sliding Scale Insulin (May d/c if regular diet and glucose is normal) Supplemental Insulin PRN +/- Pancreatic stent Remove staples (unless on steroids) Out of bed to chair Ambulate all day Work with PT/OT Pain Control Oral Dilaudid or Percocet + Tylenol or Ibuprofen Medications Bowel Regimen: Colace/Senna Ulcer Prophylaxis: Zantac x 6months GI Motility: Reglan until office followup Enzymes: Creon 2-3 pills/meal (If panc stent -stays in 4-6 weeks) Antibiotics As necessary for acquired infections Diet Regular meals plus nutrition shakes (smaller, more frequent meals) Respiratory Use your Incentive Spirometer at home Diabetes Management +/- Glucometer Supplemental Insulin, as required Wound Care Packing BID (if necessary) Visiting Nurse to remove staples (if necessary) Drain Care Pancreatic stent to gravity bag (if necessary) Blake Drain to bulb suction (if necessary) Activity Frequent walking Climbing stairs Progress physical activity as tolerated

50 Today s Whipple Procedure Safer than ever esp. high volume centers Operative Mortality 1-2% Morbidity 20-25% Anastomotic Leak/Fistula 15% Long-Term Recovery 3 Months Diabetes (25%) Exocrine Insufficiency (25%) Ultimately, the quality of life (and palliation) is quite good, overall

51 Penn Outcomes Operability = Resectability Time 4-6 hours Leaks: 10% Reoperation: 4% ICU use: 9% Transfusion Rate: 13% Mortality: 1.5% LOS: Average 7-8 days Readmission Rate: 18% Simplify: Clinical Pathway (2/3 follow on course)

52 Predictors of Survival It s about tumor biology Preop Intraop Postop Pathology Coagulopathy Blood Loss ICU Admission Differentiation Dementia Blood Transfusion Duration of Stay Tumor Size Patient s Physiology Margins Sepsis T-Stage Charlson Score POSSUM Operative Ulcer N-Stage ASA Score Adjuvant Therapy # Positive Nodes LN ratio AJCC Stage LVI PNI

53 Adjuvant Therapy Chemo? XRT?

54 GI Disconnection The Whipple Procedure Biliary Disconnection Pancreatic Disconnection Lymphadenectomy Fierce Vascular Disconnection Reconstruction

55

56 Satisfaction of a Cancer Survivor

57 Surgery for Pancreatic Cancer Charles M. Vollmer Jr., MD Associate Professor of Surgery Director of Pancreatic Surgery 3 rd Focus on Pancreatic Cancer June 20, 2014

58 Underutilization of Surgery 28.6% of Clinical Stage 1 received surgery!!!!!!!!!! Most were resectable (96%) Why so few???? Unidentified Reason (52%) 38% Not offered & 14% unknown Refused Surgery (4%) Contraindications (9%) Comorbidities (6%) Predictors Medicare, Older, Black, Lower income, Less educated, Head Lesions, LV/Community Hospitals Bilimoria KY et al. Annals of Surgery, 2007