by amgad fouad professor of surgery gastroenterology center gastroenterology center mansoura...
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AMGAD FOUADAMGAD FOUAD Professor Of SurgeryProfessor Of Surgery
Gastroenterology CenterGastroenterology CenterMansoura University.Mansoura University.
Factors Affecting survival Factors Affecting survival after pancreatico after pancreatico duodenectomy duodenectomy
Pancreatic cancer is the fourth most Pancreatic cancer is the fourth most
common cause of cancer related common cause of cancer related
mortality in the western worldmortality in the western world
It accounts for It accounts for 10 %10 % of all cancers of of all cancers of
the digestive tract.the digestive tract.
( Moossa & Stabile 1995( Moossa & Stabile 1995 ))
Most patients with pancreatic Most patients with pancreatic
cancer present late in the course cancer present late in the course
of the disease and have locally of the disease and have locally
extensive disease extensive disease ±± Metastasis Metastasis
Overall only up to Overall only up to 20 %20 % of patients are of patients are
candidates for resection and have potential candidates for resection and have potential
for curative surgery this late presentation for curative surgery this late presentation
is a combination of delays related to: is a combination of delays related to:
Patient presentation Patient presentation
Physician misdiagnosis Physician misdiagnosis
Lack of screening programs Lack of screening programs
(Moossa& Gamagami , 1995)(Moossa& Gamagami , 1995)
In the management of periampulary In the management of periampulary
tumors , resection is the only liklihood for tumors , resection is the only liklihood for
cure and pancreaticoduodenectomy cure and pancreaticoduodenectomy
continues to be the surgical procedure of continues to be the surgical procedure of
choice choice
(Watanapa , et al 1992 )(Watanapa , et al 1992 )
Although a low mortality rate Although a low mortality rate
has been achieved , the has been achieved , the
incidence of morbidity still high incidence of morbidity still high
even in recent reports .even in recent reports .
(Rosso et al 2006 )(Rosso et al 2006 )
Ampulary carcinoma has a relatively Ampulary carcinoma has a relatively better prognosis and a better prognosis and a 5–year5–year survival rates approaching survival rates approaching 50 %50 %
WhereasWhereas
Pancreatic cancer has a less Pancreatic cancer has a less favourable prognosis and a favourable prognosis and a 5- year5- year survival rate survival rate < 25 %< 25 %
( Sarmiento & Sarr, 2001 )( Sarmiento & Sarr, 2001 )
Many factors have been identified to Many factors have been identified to
be associdted with a more favourable be associdted with a more favourable
prognosis and a better survival after prognosis and a better survival after
pancreaticoduodenectomy pancreaticoduodenectomy
( Fung et al, 2002)( Fung et al, 2002)
Aim of the work Aim of the work
Evaluation of different prognostic Evaluation of different prognostic
factors that may influence the overall factors that may influence the overall
survival after survival after
pancreaticoduodenectomy in patients pancreaticoduodenectomy in patients
with periampulary tumours . with periampulary tumours .
Patients and Methods Patients and Methods
Retrospective study Retrospective study
GEC – Mansoura University GEC – Mansoura University
Series 154 patients .Series 154 patients .
Sep 2001 → April 2004Sep 2001 → April 2004
Patient evaluation Patient evaluation
Thorough history Thorough history
Clinical examination Clinical examination
Complete laboratory work up Complete laboratory work up
Radiological eval : Radiological eval :
US US
CT CT
Pancreaticoduodenal Pancreaticoduodenal resection resection
classic whipple classic whipple with with
• Pancreateco–gastrostomy
• Gastro- jejunostomy
• Hepatico- jejunostomy
All Specimen Were All Specimen Were Histologically Examined Histologically Examined
Site of originSite of origin
Degree of diff.Degree of diff.
LN status.LN status.
Safety margins.Safety margins.
ResulResults ts
GEC Mansoura University GEC Mansoura University
Series 154 Patients Series 154 Patients
97 ♂ ( 62.9 % )97 ♂ ( 62.9 % )
57 ♀ ( 37.1 % )57 ♀ ( 37.1 % )
Age :Age :
Mean 52 ± 11 Mean 52 ± 11 YY
Median 53 Median 53 YY
Range 34 – 80 Range 34 – 80 Y Y
Patient Presentations Patient Presentations
Presentation Presentation No No %%
Jaundice Jaundice
Pain Pain
Loss of wtLoss of wt
Bleeding Bleeding
( GIT)( GIT)
VomitingVomiting
DMDM
150150
118118
4545
1010
2121
2828
97.4 97.4
76.676.6
29.229.2
6.46.4
13.613.6
18.218.2
Preop Lab Data Preop Lab Data
Mean ±SDMean ±SDMedian Median Range Range
Albumin ( g/ dL)Albumin ( g/ dL)Bilirubin ( mg/ dl )Bilirubin ( mg/ dl )AST ( U/ dL)AST ( U/ dL)ALT( U/dl )ALT( U/dl )Proth.Conc.Proth.Conc.WBC (1000 /mmWBC (1000 /mm33((
GِGِAmylase ( U/ml )Amylase ( U/ml )CEA ( ng/ mL)CEA ( ng/ mL)CA 19-9 ( U/ml)CA 19-9 ( U/ml)
3939±±0.40.49 9 ± 9.8 ± 9.884 ± 7784 ± 77
116 ± 142 116 ± 142 93 ±10.493 ±10.46.2 ±2.56.2 ±2.5
94.2 ± 65.394.2 ± 65.33.8 ± 5.3 3.8 ± 5.3 99 ± 187 99 ± 187
3.93.95.25.260606464
1001006679792.52.53434
4.8-34.8-30.4-450.4-4520-44320-44320-64120-64150-10050-1003-123-12
36-38336-3830.2-28.70.2-28.71000-1.31000-1.3
Ast : Aspartate Transaminase , ALT : Alanine Transaminase , CEA : Carcinoemberyonic Antigen CA 19 -9 : Carbohydrate
Antigen 19 -9
CT Findings ( 154 patients )CT Findings ( 154 patients )
No No Percent Percent
No MassNo Mass12127.87.8
Solid Mass Solid Mass 14214292.292.2
Site Site Pancreas head Pancreas head
Ampulary Ampulary
Doudenal Doudenal
117117
2121
44
7676
13.613.6
2.62.6
Size (mm)Size (mm)Mean ±SDMean ±SD
Median Median
RangeRange
34±2634±26
2929
18-15018-150
Pathological Features after PD in 154 patients with Pathological Features after PD in 154 patients with periampulary carcinoma periampulary carcinoma
Ampulary Ampulary Pancreatic Pancreatic Distal CBDDistal CBDDuodenal Duodenal
NumberNumber
PercentPercent
3838
24.724.7
8686
55.855.8
2020
1313
1010
6.56.5
Tumour Diameter Tumour Diameter
(cm)(cm)
Mean± SDMean± SD
RangeRange
MedianMedian
2.12.1±±0.60.6
1-41-4
22
3.8 3.8 ±± 1.6 1.6
2.5.52.5.5
4.3 4.3
2.7 2.7 ±±0.90.9
5-25-2
2.32.3
3.7 3.7 ±±1.51.5
5-25-2
4.14.1
Tumor Tumor
DifferentiationDifferentiation
Well Well
ModMod
PoorPoor
26.326.3
24 24 (63.1%)(63.1%)
10 10 (53.4%)(53.4%)
4 4 (10.6%)(10.6%)
46 46 (53.4%)(53.4%)
26 26 (30.3%)(30.3%)
14 14 (16.3%)(16.3%)
10 10 (50%)(50%)
6 6 (30%)(30%)
4 4 (20%)(20%)
2 2 (25%)(25%)
4 4 (50%)(50%)
2 2 (25%)(25%)
Margin Status +ve Margin Status +ve 1 1 (2.6 %)(2.6 %)3 3 (3.5 %)(3.5 %) 4 4 (20 %)(20 %)--
LN + veLN + ve6 6 (15.7 %)(15.7 %)24 24 (27.9 %)(27.9 %)10 10 (50 %)(50 %)--
1,2,3 Years survival of studied cases according to different 1,2,3 Years survival of studied cases according to different
FactorsFactors1Year %1Year %2Year %2Year %3 Year3 Year % %P valueP value
AgeAge Below 50 YBelow 50 Y 50- 60Y50- 60Y Above 60Above 60
10010097.297.293.393.3
86.686.667.567.57070
69.269.245.945.943.343.3
P = 0.021P = 0.021
Site Site Pancreatic Pancreatic Ampullary Ampullary Distal CBDDistal CBD DuodenumDuodenum
95.395.31001009090
100100
72.0972.0981.881.880808080
44.144.157.557.570706060
P = 0.023P = 0.023
LNLN Negtive Negtive PositivePositive
98.398.389.489.4
76.176.122.922.9
53.853.815.215.2
P = 0.01P = 0.01
Stage Stage one one TwoTwo Three Three
10010097.397.38080
78.178.171.0571.05
6060
59.359.342.142.13030
P = 0.001P = 0.001
DifferenDifferen well well Mod.Mod. PoorPoor
10010095.695.683.383.3
77.777.769.569.558.358.3
55.555.543.443.425.025.0
P = 0.024P = 0.024
Platelet CountPlatelet Count < (300) 10< (300) 109 9 LL
>> (300) 10 (300) 109 - L9 - L85.285.297.897.8
58.858.876.0876.08
32.332.352.152.1
P = 0.021P = 0.021
Tumor MarkerTumor Marker CEA < 5 ngmCEA < 5 ngm CEA 5-55 ngCEA 5-55 ng CEA> 55 ngmCEA> 55 ngm
10010096.696.692.892.8
85.785.77070
62.262.2
64.264.253.353.332.132.1
P = 0.027P = 0.027
CA 19-9 < CA 19-9 < 375u/ml/375u/ml/ > 375 – 1000 U / > 375 – 1000 U / mlml CA19-9 > 1000CA19-9 > 1000
10010096.696.694.794.7
88.288.276.476.463.663.6
64.764.745.145.131.131.1
P = 0.031P = 0.031
Median Survival Of Studied Cases According To Median Survival Of Studied Cases According To Different Factors Different Factors
FactorsFactorsMedian ( months ) Median ( months ) RangeRange ( months ) ( months ) Significance Significance AgeAge Below 50 YBelow 50 Y 50- 60Y50- 60Y Above 60Above 60
34342323
23-46 23-46 19 – 3719 – 37
P=0.047P=0.047
Size of the tumorSize of the tumor < 3 cm< 3 cm > 3 cm> 3 cm
42423030
23- 53 23- 53 19-3719-37
P = 0.001P = 0.001
MarginMargin Negative MarginNegative Margin Positive MarginPositive Margin
41411616
27-48’27-48’0-210-21
P= 0.008P= 0.008
LNLN Negtive Negtive PositivePositive
39392222
21-4221-4215-3215-32
P=0.009P=0.009
Site Site Pancreatic Pancreatic Ampullary Ampullary Distal CBDDistal CBD DuodenumDuodenum
2222363625252727
14-3714-3728-4228-4218-3718-3716-3916-39
P =0.03P =0.03
Blood trrans. Blood trrans. < 3 units< 3 units > 3 units> 3 units
36362424
25-4325-4318-3118-31
P =0.075P =0.075
DifferenDifferen well well Mod.Mod. PoorPoor
393931311717
25-4325-4319- 3819- 385-235-23
P= 0.002P= 0.002
Platelet CountPlatelet Count < (300) 10< (300) 109 9 LL
>> (300) 10 (300) 109 -9 -34342828
22-4022-4015-3115-31
P = 0.041P = 0.041
Tumor MarkerTumor Marker CEA < 5 ngmCEA < 5 ngm CEA 5-55 ngCEA 5-55 ng CEA> 55 ngmCEA> 55 ngm
40403131
2144214417-3517-35
P= 0.037P= 0.037
CA 19-9 < 375u/ml/CA 19-9 < 375u/ml/ > 375 – 1000 U / ml> 375 – 1000 U / ml CA19-9 > 1000CA19-9 > 1000
38382929
21-4121-4111-3411-34
P= 0.029P= 0.029
Median recurrence free survival according to Median recurrence free survival according to different factors:different factors:
FactorsFactorsMedianMedianRangeRangeSignificance Significance AgeAge Below 50YBelow 50YAbove 50yAbove 50y
34 months34 months23 months23 months
(23-46)months(23-46)months(19-37)months(19-37)months
P=0.47P=0.47
Size of the tumorSize of the tumor<3cm<3cm>3cm>3cm
42 months42 months30 months30 months
(23-53) months(23-53) months(10-37) months(10-37) months
P=0.001P=0.001
MarginMargin(Negative (Negative margin)margin)(Positive (Positive margian)margian)
41 months41 months16 months16 months
(27-48) months(27-48) months(0-21) months(0-21) months
P=0.008P=0.008
LNLNNegativeNegativePositivePositive
39 months39 months22 months22 months
(21-42) months(21-42) months(15-35) months(15-35) months
P=0.009P=0.009
SiteSitePancreaticPancreaticAmpullaryAmpullaryDistal CBDDistal CBDDuodenumDuodenum
22 month22 month36 month36 month25 month25 month27 month27 month
(14-37) months(14-37) months(28-42) months(28-42) months(18-37) months(18-37) months(16-39) months(16-39) months
P=0.03P=0.03
FactorsFactorsMedianMedianRangeRangeSignificance Significance
Blood trrans.Blood trrans.<3units<3units>3units>3units
36 months36 months24 months24 months
(25-43) months(25-43) months(18-31) months(18-31) months
P=0.075P=0.075
DifferenDifferenWellWellModModPoorPoor
39 months39 months31 months31 months17 months17 months
(25-43) months(25-43) months(19-38) months(19-38) months(5-23) months(5-23) months
P=0.002P=0.002
Platelet countPlatelet count<(300)109-L<(300)109-L>(300) 109 –L>(300) 109 –L
34 months34 months28 months28 months
(22-40) months(22-40) months(15-31) months(15-31) months
P=0.041P=0.041
Tumor markerTumor markerCEA <5ngmCEA <5ngmCEA >5ngmCEA >5ngmCA19.9CA19.9<375 U\ml<375 U\ml>375 u\ml>375 u\ml
40 months40 months31 months31 months
38 months38 months29 months29 months
(21-44) months(21-44) months(17-35) months(17-35) months
(21-41) months(21-41) months(11-34) months(11-34) months
P=0.037P=0.037
P=0.029P=0.029
Conclusion Conclusion
Periampulary carcinoma represents a Periampulary carcinoma represents a
major therapeutic challenge to surgeons . major therapeutic challenge to surgeons .
Despite resent improvement in Hospital Despite resent improvement in Hospital
mortality and morbidity , the long-term mortality and morbidity , the long-term
survival after pancreaticoduodenectomy is survival after pancreaticoduodenectomy is
still disappointing and many factors should still disappointing and many factors should
be considered to improve the outcome be considered to improve the outcome
We believe that , the age of the patient , the We believe that , the age of the patient , the
site of origin of the tumor, cellular site of origin of the tumor, cellular
differentiation , the pathological tumour stage differentiation , the pathological tumour stage
, the resection margin and the amount of , the resection margin and the amount of
blood transfusion all are important prognostic blood transfusion all are important prognostic
factors and should be considered in selecting factors and should be considered in selecting
patients eligible to surgical resection patients eligible to surgical resection