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CASE MANAGEMENT, PRESENTATION, DISCUSSION AND SHARING OF INFORMATION ON PERIAMPULLARY CANCER

CASE MANAGEMENT, PRESENTATION, DISCUSSION AND SHARING OF INFORMATION ON PERIAMPULLARY CANCER. by Michael Angelo L. Suñaz, M.D. Department of Surgery Ospital ng Maynila Medical Center. CASE MANAGEMENT, PRESENTATION, DISCUSSION. O.V., 52/M LUCENA CITY. CHIEF COMPLAINT: ABDOMINAL PAIN.

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CASE MANAGEMENT, PRESENTATION, DISCUSSION AND SHARING OF INFORMATION ON PERIAMPULLARY CANCER

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  1. CASE MANAGEMENT, PRESENTATION, DISCUSSION AND SHARING OF INFORMATION ON PERIAMPULLARY CANCER by Michael Angelo L. Suñaz, M.D. Department of Surgery Ospital ng Maynila Medical Center

  2. CASE MANAGEMENT, PRESENTATION, DISCUSSION

  3. O.V., 52/M LUCENA CITY

  4. CHIEF COMPLAINT: ABDOMINAL PAIN

  5. HISTORY OF PRESENT ILLNESS: • 2 months PTA  Px underwent cholecystectomy, IOC, and t-tube insertion in another institution

  6. HISTORY OF PRESENT ILLNESS: • 6 weeks PTA the patient noted he had yellowish discoloration of his skin with associated right upper quadrant abdominal pain

  7. HISTORY OF PRESENT ILLNESS: • 6 weeks PTA consultation was done in another institution where t-tube replacement was performed

  8. HISTORY OF PRESENT ILLNESS: • 6 weeks PTA there was noted increase in the intensity of the abdominal pain and passage of black, tarry stool after t-tube replacement

  9. HISTORY OF PRESENT ILLNESS: • 4 weeks PTA  ERCP done and the noted perimampullary mass was biopsied.

  10. HISTORY OF PRESENT ILLNESS: • 3 weeks PTA  biopsy results revealed an adenocarcinoma

  11. HISTORY OF PRESENT ILLNESS: • 3 days PTA  abdominal CT Scan revealed a periampullary mass which was difficult to delineate from the pancreatic head

  12. HISTORY OF PRESENT ILLNESS: • Persistence of his condition as well the results of the abovementioned diagnostics prompted consultation and subsequent admission. • Pertinent (+): approximately 10% weight loss in the past 2 months

  13. PAST MEDICAL Hx: (+)HPN – UBP 130/80 HBP 160/100; maintained on Metoprolol with poor compliance • FAMILY Hx: No heredofamilial disease noted

  14. PERSONAL/SOCIAL Hx: - smoking history of 2.5 pack-years - consumed 2 bottles of beer per week for the past 10 years

  15. PHYSICAL EXAMINATION: G/S: conscious, coherent, not in cardiorespiratory distress BP= 110/70 CR=80 RR= 20 T=370C SHEENT: no jaundice; pink palpebral cojunctiva,anicteric sclera, No NAD, No CLAD, No TPC

  16. PHYSICAL EXAMINATION: C/L: SCE, no retractions, clear BS CVS: adynamic precordium, NRRR, no murmur Abdomen: flabby; (+) right subcostal surgical scar with t-tube in place; soft; no palpable masses

  17. PHYSICAL EXAMINATION: Extremities: no edema, atrophy or cyanosis noted; full and equal pulses on all extremities

  18. SALIENT FEATURES: • 52 y/o, M • Right upper quadrant abdominal pain • approximately 10% weight loss in the past 2 months • underwent cholecystectomy, IOC, and t-tube insertion in another institution 2 months PTA

  19. SALIENT FEATURES: • yellowish discoloration of the skin associated with right upper quadrant abdominal pain 6 weeks PTA • t-tube replacement 6 weeks PTA • increase in the intensity of the abdominal pain and passage of black, tarry stool after t-tube replacement

  20. RUQ abdominal pain and jaundice

  21. S/P Cholecystectomy, IOC, placement of t-tube RUQ abdominal pain and jaundice

  22. RUQ abdominal pain and jaundice S/P Cholecystectomy, IOC, placement of t-tube • Inflammatory/ Metabolic • Cirrhosis • Hepatitis Retained CBD Stone • Neoplastic Disease • Primary liver tumors • Metastases • Cholangiocarcinoma • Klatskin tumors • GB CA • Periampullary CA

  23. Clinical Diagnosis:

  24. BASES: • 52 y/o, M • Right upper quadrant abdominal pain • underwent cholecystectomy, IOC, and t-tube insertion 2 months PTA • yellowish discoloration of the skin associated with right upper quadrant abdominal pain 6 weeks PTA • increase in the intensity of the abdominal pain and passage of black, tarry stool after t-tube replacement

  25. Do I need a para-clinical diagnostic procedure? YES

  26. Paraclinical Diagnostic Procedures

  27. Paraclinical Diagnostic Procedures • ERCP with biopsy (9/29/07) • Normal esophagus and gastric mucosa • Fungating mass at the periampullary area. Pus noted extruding from the papilla. • Moderately dilated CBD, CHD, and right and left hepatic ducts • 0.5 filling defect at the distal CBD

  28. Paraclinical Diagnostic Procedures • Biopsy result (10/5/07) • Adenocarcinoma

  29. Paraclinical Diagnostic Procedures • Abdominal CT Scan (10/24/07) • Nodular soft tissue density in the periampullary region (66.1 x 49.5 x 40.6mm) • Hyperdense tubular structure, most likely a tube noted within the mass

  30. Paraclinical Diagnostic Procedures • Abdominal CT Scan (10/24/07) • Head of the pancreas difficult to delineate from the mass • Body and tail of the pancreas are unremarkable • Liver and spleen normal in size and homogeneity

  31. Paraclinical Diagnostic Procedures • Abdominal CT Scan (10/24/07) • GB not visualized • Biliary tree unremarkable • Kidneys normal in size, position, and configuration with good excretory function • Rest of the soft tissue, vascular, and osseous structures intact

  32. RUQ abdominal pain and jaundice S/P Cholecystectomy, IOC, placement of t-tube • Inflammatory/ Metabolic • Cirrhosis • Hepatitis Retained CBD Stone • Neoplastic Disease • Primary liver tumors • Metastases • Cholangiocarcinoma • Klatskin tumors • GB CA • Periampullary CA

  33. RUQ abdominal pain and jaundice S/P Cholecystectomy, IOC, placement of t-tube • Inflammatory/ Metabolic • Cirrhosis • Hepatitis Retained CBD Stone • Neoplastic Disease • Primary liver tumors • Metastases • Cholangiocarcinoma • Klatskin tumors • GB CA • Periampullary CA • Fungating mass at the periampullary region on ERCP • Nodular soft tissue density in the periampullary region on abdominal CT Scan

  34. RUQ abdominal pain and jaundice S/P Cholecystectomy, IOC, placement of t-tube • Inflammatory/ Metabolic • Cirrhosis • Hepatitis Retained CBD Stone • Neoplastic Disease • Primary liver tumors • Metastases • Cholangiocarcinoma • Klatskin tumors • GB CA • Periampullary CA • Fungating mass at the periampullary region on ERCP • Nodular soft tissue density in the periampullary region on abdominal CT Scan

  35. Periampullary Carcinoma Pancreas Ampulla of Vater CBD Duodenum

  36. Periampullary Carcinoma • Abdominal CT Scan • Head of the pancreas difficult to delineate from the mass • Body and tail of the pancreas are unremarkable • ERCP with biopsy • Fungating mass at the periampullary region • Pus noted extruding from the papilla Pancreas Ampulla of Vater CBD Duodenum

  37. Periampullary Carcinoma Pancreas Ampulla of Vater CBD Duodenum

  38. Periampullary Carcinoma Pancreas Ampulla of Vater CBD Duodenum Adenocarcinoma on biopsy Ampullary Adenocarcinoma

  39. Pretreatment Diagnosis:

  40. TREATMENT • PRETREATMENT DIAGNOSIS: Ampullary Adenocarcinoma

  41. TREATMENT • GOALS OF TREATMENT: • Curative extirpation of the tumor • Relieve biliary obstruction

  42. TREATMENT OPTIONS

  43. TREATMENT OPTIONS

  44. TREATMENT OF CHOICE STANDARD WHIPPLE RESECTION/ PANCREATICODUODENECTOMY

  45. PREOPERATIVE PREPARATION • Informed consent • Psychosocial support • Optimize patient’s health • Screen for any condition that will interfere with treatment • Prepare materials

  46. OPERATIVE TECHNIQUE • Patient supine under GETA • Asepsis/Antisepsis • Sterile drapes placed • Bilateral subcostal incision • Assessment of the abdomen for metastatic disease • Mobilization of the duodenum and the head of the pancreas with identification of the superior mesenteric vein • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513

  47. OPERATIVE TECHNIQUE • Mobilization of the stomach and proximal duodenum with transection of the proximal duodenum (or stomach) as soon as the decision of resection has been made • Skeletonization of the structures of the porta • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513

  48. OPERATIVE TECHNIQUE • Cholecystectomy and division of the common bile duct • Mobilization and division of the proximal duodenum • Transection of the neck of the pancreas and division of the remaining attachments of the specimen to the superior mesenteric and portal veins and the superior mesenteric artery • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513

  49. OPERATIVE TECHNIQUE • Reconstruction of gastrointestinal continuity • Correct sponge and instrument count • Layer by layer closure • DSD • Hines OJ, Reber HA: Periampullary cancer, in Cameron JL (ed): Current Surgical Therapy 9th Ed. Philadelphia, Mosby, 2008, pp 506-513

  50. OPERATIVE FINDINGS • Intraluminal mass located in the Ampulla of Vater with infiltration of the mucosal layer

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