Case Presentation 68yM referred for incidental finding of pancreatic head mass on CT scan for elevated PSA. No symptoms. Denied pruritus, jaundice, change in color of urine/stool, anorexia, or weight loss. PMH: HTN, BPH, strabismus PSH: appendectomy Medications: norvasc, tamsulosin NKDA SH/FH: negative
Physical and Labs AF VSS NAD No jaundice Abdomen soft, NT, ND, no hepatomegaly No palpable lymphadenopathy CBC 3.5/13/42/266 BMP 140/4.6/102/26/17/1.1/78 LFT 7.4/4.6/17/16/54/0.4 PT 10/PTT 26/INR 0.9
Imaging CT: 3.2cm cystic lesion with fine septation in head of pancreas, no lymphadenopathy MRI: 2.6x3.0cm cystic mass in head of the pancreas CXR: negative
EGD 3.5x3.5cm microcystic multiseptate lesion in the head of pancreas FNA unable to obtain fluid or cells
Operation Exploratory laparotomy, pylorus-preserving pancreaticoduodenectomy, cholecystectomy No obvious metastatic disease Large palpable mass in head of pancreas Uncomplicated dissection and resection JP drains to HJx1 and DJx2
Post-Operative Course POD#0-7 octreotide 100mcg SC tid POD#8 octreotide 100mcg SC bid POD#9 octreotide 100mcg SC qd POD#10 octreotide stopped
Post-Operative Course POD#2 fever, RLL opacity, started on antibiotics POD#5 transferred to floor POD#7 HJ drain removed POD#9 posterior PJ drain removed POD#11 diet started POD#13 anterior PJ drain removed POD#14 discharged home POD#22 Seen in clinic without complaints
Pathology Serous microcystic adenoma in head of pancreas Surgical margins negative Single peripancreatic node negative for tumor
Current Status of Whipple Procedure Christopher Turner 12.18.13
Questions 1. What is the role for routine prophylactic somatostatin (or its analogue) after a whipple procedure? 2. What are the preoperative criteria for resectability for a whipple procedure? 3. Is there an age limit for a whipple procedure?
Question #1 What is the role for routine prophylactic somatostatin (or its analogue) after a whipple procedure?
The Problem Pancreatic surgery is high risk Morbidity 30-60% Mortality 2-5% Major complication is postoperative leak or fistula
The Possible Solution Somatostatin and its analogues inhibit pancreatic exocrine secretions Decreased volume of secretions may decrease incidence of pancreatic leak or fistula
Funnel Plot for Perioperative Mortality More Less Vertical precise Horizontal axis Point studies = measure estimate axis (with = measure of from more fewer precision each of participants) treatment study of estimate plotted should of may effect of be effect be more close Vertical line added (ie (ie standard odds for to widely pooled ratio error scattered estimate or relative sample from risk) size) meta-analyses
Comparison of Intervention Somatostatin vs Octreotide No significant difference in any primary outcome
Comparison of Etiology Malignancy vs Pancreatitis No significant difference in any primary outcome
Comparison of Operation All vs Whipple No significant difference in any primary outcome
Conclusion Somatostatin analogues may reduce perioperative complications but do not reduce perioperative mortality Considering the lack of serious adverse effects, low costs and the potential benefit in reducing the proportion of people who developed any complication and in the number of people who developed pancreatic fistulas, somatostain analogues are recommended routinely for pancreatic surgery
Question #2 What are the preoperative criteria for resectability for a whipple procedure?
Staging System for Resectability Based on Vascular Involvement Resectable (all four are required) SMA Celiac Axis CHA SMV/PV Normal tissue plane between tumor and vessel Normal tissue plane between tumor and vessel Normal tissue plane between tumor and vessel Patent Borderline (only one required) Unresectable (only one required) Abutment Abutment Abutment Occlusion, reconstruction possible Encasement Encasement Encasement Occlusion, reconstruction not possible Abutment <180 Encasement >180
Rationale for PV/SMV Resection Tumors have access to the systemic circulation earlier in the disease than when large enough to involve the PV or SMV PV or SMV invasion does not itself carry a worse prognosis as compared with similar tumors without invasion
Rationale against SMA Resection SMA is surrounded by autonomic nerves Risk of perineural invasion and extension locally into retroperitoneum Resection results in midgut de-innervation and hyperperistalsis with rapid GI transit
Resectable Does not extend to SMV or SMA
Resectable Abuts SMV Does not extend to SMA
Borderline Resectable Does not extend to SMV Abuts SMA
Borderline Resectable Nearly complete occludes SMV Does not extend to SMA
Conclusion Unresectable tumors have at least one of the following Metastatic disease Occlusion of PV or SMV that cannot be reconstructed Encasement of SMA or CHA
Question #3 Is there an age limit for a whipple procedure?
The Problem Current median age at diagnosis of pancreatic cancer is 72y Some studies have recommended avoiding surgery over 70y due to high morbidity and mortality
The (Future) Problem US population is getting older Population over 65y will double within the next three decades Average life expectancy will increase from 75y in 1995 to 79y in 2025 Expected concomitant increase in incidence of cancer and cancer related mortality
The Possible Solution Improvement in outcomes have encouraged surgeons to approach the elderly as aggressive as younger patients Expanded selection criteria to elderly patients may be appropriate
Funnel Plot for Mortality >75y
Funnel Plot for Mortality >80y
Comparison Older (>75y) vs Younger Increased prevalance of pre-operative CAD in elderly (OR 2.45, 95% CI = 1.46 to 4.10, P < 0.0007)
Comparison Older (>80y) vs Younger Insufficient data to evalute differences in post-operative bleeding or length of stay
Conclusion Increased incidence of post-operative mortality and pneumonia among all patients >75y, as well as increased incidence of postoperative complications among patients >80y Additional randomized control trials studying post-pd operative outcomes with standardization of comorbidities is therefore necessary to confirm these conclusions
Summary Somatostatin analogues are recommended for routine use after pancreatic resection Resectability depends on metastatic disease and involvement of vasculature Elderly patients are at increased risk of mortality, pneumonia and complications, but no age limit for resection is currently recommended
Question #1 There is no sign of metastatic disease. Is this pancreatic adenocarcinoma resectable?
Question #1 There is no sign of metastatic disease. Is this pancreatic adenocarcinoma resectable?