whipple procedure for ductal adenocarcinoma

Whipple Procedure for Whipple Procedure for DuctalDuctal AdenocarcinomaAdenocarcinoma

Not FutileNot Futile

BackgroundBackground

Approx 30,000 people Approx 30,000 people per year die of per year die of Pancreatic Pancreatic ductalductaladenocarcinomaadenocarcinomaFourth most Fourth most common cause of common cause of cancer death (in cancer death (in adults) representing adults) representing roughly 5% of roughly 5% of deathsdeaths

Whipple BackgroundWhipple Background

PancreaticoduodenectomyPancreaticoduodenectomy described in described in 1898 by Dr. 1898 by Dr. CodivillaCodivilla and by and by KaushKaush in in 19121912Whipple procedure named for Dr. Allen Whipple procedure named for Dr. Allen Whipple Whipple -- devised the procedure in 1935 devised the procedure in 1935 and later improved the techniqueand later improved the techniqueDr. Whipple performed 37 Dr. Whipple performed 37 pancreaticoduodenectomiespancreaticoduodenectomies in his career in his career

FutileFutileMain Entry: Main Entry: fufu··tiletile

Pronunciation: Pronunciation: \\��fyfyüü--ttəəll, , ��fyfyüü--��ttīī((--əə)l)l\\

Function: Function: adjectiveadjective

Etymology: Etymology: Middle French or Latin; Middle French, from Latin Middle French or Latin; Middle French, from Latin futilisfutilis brittle, pointless, brittle, pointless,

probably from probably from fufu-- (akin to (akin to funderefundere to pour) to pour) —— more at more at foundfoundDate: Date: circa 1555 circa 1555

1 :1 : serving no useful purpose serving no useful purpose :: completely ineffective completely ineffective <Dr. Lackey<Dr. Lackey’’s s efforts at poker are futile> 2 :efforts at poker are futile> 2 : occupied with trifles occupied with trifles :: frivolousfrivolous—— fufu··tiletile··lyly \\--ttəəll--(l)(l)ēē, , --��ttīī((--əə)l)l--llēē\\ adverbadverb—— fufu··tiletile··nessness \\--ttəəll--nnəəss, , --��ttīī((--əə)l)l--nnəəss\\ nounnoun

Adapted from Merriam-Webster Online Dictionary

StudiesStudies

Retrospective review of 194 patients with Retrospective review of 194 patients with ductalductaladenocarcinomaadenocarcinoma receiving Whipplereceiving WhippleCurative resection (R0) was significantly related Curative resection (R0) was significantly related to a favorable prognosis ( p < 0.0001)to a favorable prognosis ( p < 0.0001)Cumulative survival for curative resection: 5Cumulative survival for curative resection: 5--year year survival rate of 25.4%, a 7survival rate of 25.4%, a 7--year survival rate of year survival rate of 12.3%, and a 1012.3%, and a 10--year survival rate of 8.2% year survival rate of 8.2% Concluded Whipple is Concluded Whipple is ““as good as it getsas good as it gets”” ((ieie. . No survival benefit with other techniques)No survival benefit with other techniques)

Richter. World Journal of Surgery. 27(3):324-9, 2003 Mar

StudiesStudies48 patients with 48 patients with pylorouspylorous--preserving preserving pancreatoduodenectomypancreatoduodenectomy (PPPD) (PPPD) vsvs 61 patients with 61 patients with Whipple procedure for Whipple procedure for ductalductal adenocarcinomaadenocarcinomaPPPD survival: 3PPPD survival: 3--year survival rate was 20.8%, and the year survival rate was 20.8%, and the 55--year survival rate was 16.7%year survival rate was 16.7%

PPPD NOT performed on patients with direct PPPD NOT performed on patients with direct invasion to the duodenal bulb or pyloric ring or invasion to the duodenal bulb or pyloric ring or perigastricperigastric lymph node metastasislymph node metastasisAlso showed NO survival difference between PPPD and Also showed NO survival difference between PPPD and WhippleWhipple

Takada. Hepato-Gastroenterology. 44(18):1536-40, 1997 Nov-Dec.

StudiesStudies

12 patients with pylorus sparing 12 patients with pylorus sparing procedure, 9 patients with Whipple procedure, 9 patients with Whipple procedureprocedureSignificant increase in days of NG Significant increase in days of NG decompression and days to liquid diet for decompression and days to liquid diet for pylorus sparing procedurepylorus sparing procedureNO difference in morbidity, mortality, OR NO difference in morbidity, mortality, OR time or blood time or blood lossloss

Hayashibe. Journal of Surgical Oncology. 95(2):106-9, 2007 Feb 1.

StudiesStudies

Whipple procedure in 282 patientsWhipple procedure in 282 patientsPylorus preserving in 186 patientsPylorus preserving in 186 patientsTotal Total pancreatectomypancreatectomy in 21 patients, distal in 21 patients, distal pancreatectomypancreatectomy in 39 patientsin 39 patientsNo difference in morbidity or mortality No difference in morbidity or mortality between Whipple and pylorus preservingbetween Whipple and pylorus preserving

Bassi. Dig Surg. 2005;22(5):353-63.

MetaMeta--analysisanalysis490 patients in 6 studies490 patients in 6 studies244 with Whipple procedure, 246 with Pylorus 244 with Whipple procedure, 246 with Pylorus sparing proceduresparing procedurePylorus sparing procedure 72 minutes faster (P< Pylorus sparing procedure 72 minutes faster (P< 0.001) with 0.66 fewer units of transfused blood (P= 0.001) with 0.66 fewer units of transfused blood (P= 0.002)0.002)NO difference in hospital stay, NO difference in hospital stay, biliarybiliary leak, leak, pancreatic leak, gastric leak, or long term mortality pancreatic leak, gastric leak, or long term mortality Trend toward better gastric emptying and shorter Trend toward better gastric emptying and shorter NG tube use in Whipple procedureNG tube use in Whipple procedureConclusionConclusion-- Large well designed Large well designed study(sstudy(s) needed to ) needed to assess differencesassess differences

Karanicolas. Annals of Surgical Oncology. 14(6):1825-34, 2007 Jun.

MetaMeta--analysisanalysis

MetaMeta--analysis included 6 analysis included 6 RCTsRCTs and and screened 1235 abstractsscreened 1235 abstracts465 patients (236 Whipple, 229 Pylorus 465 patients (236 Whipple, 229 Pylorus

preserving)preserving)Revealed statistically significant decrease Revealed statistically significant decrease in operative time with pylorus preserving in operative time with pylorus preserving (30 to 105 minutes P=0.0004)(30 to 105 minutes P=0.0004)

Diener Ann Surg. 2007 February; 245(2): 187–200.


NO change in morbidity (47.6% pylorus NO change in morbidity (47.6% pylorus preserving, 52.2% Whipple, P=0.69)preserving, 52.2% Whipple, P=0.69)NO change in mortality (P=0.18)NO change in mortality (P=0.18)NO change in hospital stay (P=0.62)NO change in hospital stay (P=0.62)NO difference in NO difference in biliarybiliary leak (P=0.82)leak (P=0.82)NO difference in fistula rate (P=0.63)NO difference in fistula rate (P=0.63)Trend toward decreased delayed gastric Trend toward decreased delayed gastric emptying in Whipple (29.0% vs. 24.4%)emptying in Whipple (29.0% vs. 24.4%)



4 of 6 without power calculations (likely 4 of 6 without power calculations (likely underpowered) underpowered) 1 of 6 used intent to treat1 of 6 used intent to treatNo analysis of No analysis of neoadjuvantneoadjuvant therapy on therapy on resultsresults2 of 6 had blinded outcome assessor2 of 6 had blinded outcome assessorConclusion Conclusion –– Need for high powered study Need for high powered study with universal endpoint definitionswith universal endpoint definitions


Studies in MetaStudies in Meta--analysisanalysis

Trend to higher tumor positive resections with Trend to higher tumor positive resections with pylorus sparing (19 pylorus sparing (19 vsvs 12 patients), excluded all 12 patients), excluded all patients with positive patients with positive peripyloricperipyloric lymph nodes, or lymph nodes, or direct invasion of stomach/pylorus. direct invasion of stomach/pylorus. Randomization occurred AFTER determining Randomization occurred AFTER determining ability to treatability to treat2 patients were converted to standard Whipple 2 patients were converted to standard Whipple intraoperativelyintraoperatively>20% of patients lost to follow up>20% of patients lost to follow up

Tran. Ann Surg 2004; 240:738–45


3 patients converted to Whipple from 3 patients converted to Whipple from pylorus preserving procedurepylorus preserving procedureShorter OR time by 30 minutesShorter OR time by 30 minutesNo difference in leak rate or mortalityNo difference in leak rate or mortalitySignificant difference in delayed gastric Significant difference in delayed gastric emptying (P < 0.05), improved with emptying (P < 0.05), improved with WhippleWhipple

Lin. Hepatogastroenterology 2005; 52:1601–4


11 patients converted to Whipple from 11 patients converted to Whipple from pylorus sparing, and were excluded from pylorus sparing, and were excluded from the studythe studyNo data available on excluded patients, No data available on excluded patients, per authorper author>20% of patients lost to follow up>20% of patients lost to follow up

Seiler. Br J Surg 2005; 92:547–56

FutileFutileMain Entry: Main Entry: fufu··tiletile







Not FutileNot FutileMain Entry: Main Entry: fufu··tiletile







whipple procedure for ductal adenocarcinoma

Documents