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Grand CLARO HOTEL

MAKASSAR, October 25, 2019

Ibrahim Labeda

TIPS AND TRICKS OF

PANCREATICO DUODENECTOMY

1 2 3 4

5

Introduction THE CLASSIC operation OF

PANCREAS

Complications Approach classification

Contra indication

OUTLINE of Presentation

CONCLUSIONS

1. Surgeons using a command

and control style of

leadership

2. Single provider–based care

1. A team based approach

2. Collaborative leadership

skills

Surgical care benefits from the

collaboration of : • Surgeons, Anesthesiologists

• Internists, Radiologists

• Pathologists, Radiation oncologists

• Nurses, Pharmacists

• Social workers, Therapists

• Hospital staff, Administrators.

Romantic

ERA Modern

ERA

Hill AL et al. In : Schwartz’s Principles of Surgery, Tenth Ed, 2015 Adapted by Labeda I, 2019

HISTORICAL

PERSPECTIVE

Introduction

4 C :

• Communication

• Collaboration

• Critical thinking and Problem solving

• Creativity and Innovation

Surgeons Team :

• Patient Outcomes : ↑

• Medical Errors : ↓

• Patients Satisfaction : ↑

1 Ranks as one of the most

complicated &

technically challenging surgical

procedures 2 It is technically demanding

3 Given its associated high complication rate

4 Patients are often of advanced age

5 With suboptimal performance status

6 Sometimes due to comorbid conditions : jaundice &

malnourishment.

Blumgart’s. Surgery of the Liver, Biliary tract and Pancreas, 6th Ed, 2016

Pancreatic Resection :


Pancreatic Cancer Operations

Laparoscopic

PD (1990)

Postoperative morbidity : 60% Mortality : 25%

Patients would be better served with bypass and other

palliative-type procedures

Crile, 1970-1980 In the late

1960s

For high-volume PD centers.

Mortality : 3%. Morbidity rate :

30% - 40%.

Currently

(2005 - )

By Nakao, 1993

Pancreatic Cancer Operations

Factors that have contributed were : • Understanding of pancreatic disease, • Higher-quality diagnostic imaging, • Better patient selection, • The development of interventional

radiology and endoscopy • Improvements in perioperative care

all have contributed as well.

The standard surgical treatment for : • tumors of the pancreatic head • proximal bile duct • duodenum and ampulla and • represents the only hope of cure

in cases of malignancy.

Pancreaticoduodenectomy

(PD)


Early series on pancreatic operations for cancer published in

Bailey & Love’s. Short Practice of Surgery, 2018

Pancreaticoduodenectomy (Whipple Procedure)

Pylorus-Preserving Pancreaticoduodenectomy

DIAGNOSIS

Pancreas in Schwartz’s Principle of Surgery, 11th Edition,

2019

Contraindication of PD Pancreas in Schwartz’s Principle of Surgery, 11th Edition,

2019

Annals of Pancreatic Cancer, 2019, 2,14

Diagram showing the six approaches to

the superior mesenteric artery:

S, Superior approach

A, Anterior approach

P, Right posterior approach

L, Left posterior approach

R, Right/ medial uncinate approach

M, Mesenteric approach/inferior infracolic

approach

VARIOUS ARTERY-FIRST APPROACHES IN OPEN PDS

ARTERY-FIRST PANCREATODUODENECTOMY

World J Gastrointest Oncol 2014 September 15; 6(9): 344-350

These techniques prioritize the

dissection of the origin of SMA

Allowing :

• Complete

lymphadenectomy

• Safe dissection of the SMA

• Accurate identification of

anatomic variations such as

a HA originating in the

SMA.

Pessaux et al • Have reported several surgical

techniques and approaches,

• All termed “artery-first”.

• All these techniques prioritize

artery dissection to identify

arterial involvement

• Thus assess whether the tumor is

resectable before taking the

irreversible step to operate

ARTERY-FIRST PANCREATODUODENECTOMY


For patients with intraoperative arterial complications • have longer operative time • higher transfusion rate • more postoperative complications

The randomized trials published do not recommend radical lymphadenectomy as a standard approach for pancreatic ductal adenocarcinoma.

1. POSTERIOR APPROACH


Pessaux et al described the posterior approach to the SMA

Indication :

• For resection of posteromedial tumors of the head and neck

• Periampullary tumors extending from the body to the head

of the pancreas.

1. POSTERIOR APPROACH


Advantage :

• To allows early dissection of the posterior pancreatic capsule

• To identification of SMA involvement

• To Identification an anomalous RHA

• To facilitates en bloc resection of the portal vein (PV)/SMV if they

are involved.

Disadvantage :

• It is difficult to perform in patients presenting with peripancreatic

inflammation

• adhesions around the pancreatic head

• In obese patients

JOP. J Pancreas (Online) 2015 Jan 31; 16(1):41-44.

In conclusion : This study confirmed that limiting blood loss and avoiding prolonged surgeries should be goals for duration during surgery were lower after right posterior- approach PD, probably due to the more discernible route of the IPDA artery from the SMA, early ligation of the IPDA, and reduced congestion of the pancreatic head.

JOP. J Pancreas (Online) 2015 Jan 31; 16(1):41-44.

Conclusions : Early hind right approach is advocated in selected cases of PD to improve locoregional vascular control and determine, safely and early, whether there is mesopancreas involvement

2. Inferior Supracolic/Anterior Approach


Hirota et al using a “no-touch isolation technique” Advantage • To avoid compression of the tumor

• To avoid the spread of malignant cells within the abdominal

cavity

• For tumors of the lower edge of the pancreas

• To facilitates retroperitoneal dissection especially

• in locally advanced tumors receiving neoadjuvant therapy

Conclusions : SHT is a feasible and Safe technique with acceptable short-term outcomes. We propose the use of this procedure to standardize en block dissection around the SMA.

3. Hanging maneuver


Pessaux et al combined the posterior and anterior

technique

which they termed the “hanging maneuver”

They recommend this approach especially

• In patients with preoperative suspicion of

involvement of the SMA

• In patients receiving neoadjuvant therapy for locally

advanced disease

• In obese patients

• When the RHA originates in the SMA

In conclusion : Independently of the surgeon’s preferred

approach, the spread and standardization of superior

mesenteric artery first dissection seems of utmost

importance in order to reduce R1 resections, increase

survival and improve the transmission of high level

oncological practice.

JOP. J Pancreas (Online) 2011 Jul 8; 12(4):429-430

In conclusion : For us, the hanging

maneuver is very interesting to facilitate

and standardize the complete resection of

the retroportal lamina. This technique

could improve RO resection rate and more

generally oncological outcomes


Weitz et al described the approach from the transverse

mesocolon

Advantage :

• Is useful in patients with locally advanced tumors

• Suspected infiltration of the SMA at the origin of the aorta

• Malignant tumors in the uncinate pancreas

Disadvantage :

• It is difficult to perform in obese patients

• If the origin of the SMA is high.

4. Inferior infracolic / mesenteric approach

In conclusions : The mesenteric approach • Might reduce blood loss during PD by early ligation of vessels to the leading to low

frequency of transfusion. • Might Increase the R0 rate for R-PDAC patients • Decrease in the recurrence rate and • Improvement of the survival rate • However, this procedure alone may not be sufficient to increase R0 rate, decrease

recurrence rate, and improve survival in BR-PDAC patients. • Therefore, effective multidisciplinary treatment is essential to improve survival in BR-PDAC

patients.


5. Right / medial uncinate approach

Hackert et al : “ Uncinate process first” Adavantage : • Is recommended in uncinate tumors

• in cases with suspected involvement of the SMV or

SMA.

• Early ligation of the IPDA

Disadvantage :

It does not allow early identification of an anomalous

RHA

The “Uncinate process first” : Can serve as an additional approach in modern pancreatic surgery Conclusions : The new approach facilitates the

initial dissection of the IPDA at the right side of the SMA, reducing intraoperative blood loss

Hepatogastroenterology, 2015 Jun;62(14):1037-40


6. Left Posterior approach Presented by Kurosaki et al Superior mesenteric vessels are dissected first

Clockwise from the left

• To allows en bloc dissection of the SMV pedicle

• A clear understanding of the anatomy

• To detect an aberrant RHA

• To predicts the involvement of the margins in the SMA level.

Advantage :

• Be useful in tumors of the posterior part of the head of

pancreas

• In tumors in the uncinate process

JOP. J Pancreas (Online) 2011 May 6; 12(3):220-229


7. Superior approach

Advantage :

• Is useful for resection of tumors on the upper edge of

pancreas

• When involvement of the common HA (CHA)

• Suspected involment of surrounding lymph nodes

Disadvantage :

• Difficult to perform in patients presenting a low origin of the

SMA


Conclusions In select patients, SMA-first approaches LPD is a safe and effective

procedure when performed by experienced pancreatic surgeons, with

advanced laparoscopic skills to achieve the similar oncological outcome

comparable to those of OPD in high volume pancreatic center.

It may become a promising and even favored approach for these patients

with advanced pancreatic cancer given potential benefits of early

laparoscopic evaluation of the resectability and less blood loss during

pancreatic transection.


Comparative Studies of The Different Approach

CLASSICAL

PD

Figueras, Cir Esp, 2008, 83

POST ARTERY FIRST-

APPROACH


Comparative Studies of The Different Approach Dumitrascu, Langenbecks Arch Surg, 2010, 395

〉 CLASSICAL

PD

POST ARTERY FIRST-

APPROACH

NO

SIGNIFICANT

DIFFRENCES


Comparative Studies of The Different Approach Srikhande, Langenbecks Arch Surg, 2011, 396

〉 CLASSICAL

PD

UNCINATE ARTERY FIRST-

APPROACH NO

SIGNIFICANT

DIFFRENCES


Comparative Studies of The Different Approach Kuroseki, JOP, 2011

CLASSICAL

PD

LEFT POSTERI

OR APPROA

CH

NO

SIGNIFICANT

DIFFRENCES


Maingots Abdominal Operations, 13th Editions, 2019

COMPLICATIONS FEMALE, 48 yo, po

:PPPD

29 November 2011

Postoperative recovery

Mayor Fistula

21 Desember 2016

Female, 18 yo, D. Adenoca Pancreas T. Pyloric Preserving Pancreatico Duodenectomy March 2013

Foto kontrol Pebruari 2019

CASE 2. HEAD of PANCREATIC TUMOR

Female, 20 yo. PA. Adeno Ca. Pancreas

Postop PD, 27 Oktober 2016

Postop PD, 9 Desember 2018

CASE 3. HEAD of PANCREATIC TUMOR


Maingots Abdominal Operations, 13th Editions, 2019

PANCREATIC TUMOR IN WAHIDIN SUDIROHUSODO HOSPITAL

Makassar, Juli 2017 – Juli 2019

AGE

DEWASA (26-45 Tahun)

LANSIA AWAL (46-54 Tahun)

LANSIA AKHIR (55-64 Tahun)

MANULA (> 64 Tahun)

[VALUE]

[VALUE]

[VALUE]

[VALUE]

SEX

LAKI-LAKI

PEREMPUAN

[VALUE]

[VALUE]

PROFESSION

PNS

Wiraswasta

Pensiunan

Petani

IRT

4

11

6

3

10

ETHNIC

LUWU

BOLANGO

BUGIS

MAKASSAR

TORAJA

JAWA

TOLAKI

BATAK

MALUKU

BUTON

BATAM

[VALUE]

[VALUE]

[VALUE]

[VALUE]

[VALUE]

[VALUE]

1

[VALUE]

[VALUE]

[VALUE]

[VALUE]

DIAGNOSIS

Tumor Caput Pankreas

Tumor Ampulla vater

Tumor Duodenum

[VALUE]

[VALUE]

[VALUE]

TYPE OF OPERATION

Whipple

PPPD

Double Bypass

Laparatomi Biopsi

Konservatif

[VALUE]

[VALUE]

[VALUE]

[VALUE]

[VALUE]

PATOLOGI ANATOMI

Adenocarcinoma

Acinic cell carcinoma

Cysta Adenoma Mucinosum

malignant mesechimal tumor

fatty liver

11

7

1

1

1

CONCLUSIONS • Surgical resection remains the only therapy that

offers potential for long-term survival. • Median survival following resection is :16 to 20

months • Patients who do not undergo resection is 6 to 12

months • Ten (10% - 20%) of patients can be true 5-year

survivors after resection

• Effective multidisciplinary treatment is essential to

improve survival in Pancreaticoduodenal cancer

patients.

TERIMA KASIH

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