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Advanced Surgical Techniques For Pancreatic Cancer

2013 GI Cancer Symposium. Advanced Surgical Techniques For Pancreatic Cancer. Dr. Janak Parikh, MD, MSHS November 2, 2013 St. John Providence Health System. 2013 GI Surgery Symposium. Overview. Background Basic Whipple Operation History Resection criteria

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Advanced Surgical Techniques For Pancreatic Cancer

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  1. 2013 GI Cancer Symposium Advanced Surgical Techniques For Pancreatic Cancer Dr. Janak Parikh, MD, MSHS November 2, 2013 St. John Providence Health System

  2. 2013 GI Surgery Symposium Overview • Background • Basic Whipple Operation • History • Resection criteria • Technique (Pylorus-Preservation vs. Classic) • Advanced Whipple Operation • Vascular resection/reconstruction • Laparoscopic Whipple • Robotic Whipple • Distal Pancreatectomy • Technique (w/ or w/o splenectomy, Appleby) • Minimally invasive (Laparoscopic, Robotic)

  3. 2013 GI Surgery Symposium Incidence and Mortality • 45,000 new cases in US in 2013 • 3% of malignancies in the United States • Fourth leading cause of cancer death in the United States

  4. 2013 GI Surgery Symposium Pancreatic Cancer • High incidence of regionally advanced and metastatic disease • Only 10-15% pts have resectable disease Head 60% Body/Tail 40%   20% resectable <5% resectable   20% 5-yr survival <15% 5-yr survival   <3% alive at 5 years Most patients are treated with palliative therapies

  5. Historical Context (1985-2008) 2013 GI Surgery Symposium Incidence and Mortality Rates 1985-2008 NCI’s SEER Program http://www.seer.cancer.gov/

  6. 2013 GI Surgery Symposium Fewer Than 1/3 Of Resectable Patients Receive Surgery

  7. 2013 GI Surgery Symposium Pancreatoduodenectomy—Whipple Operation History and Evolution

  8. 2013 GI Surgery Symposium History of Pancreatoduodenectomy George Hirschel (1914) OttorinoTenani (1922) Friedrich Trendelenburg (1882) Allan O. Whipple (1935) Walter Kausch (1909) Allesandro Codivilla (1898)

  9. 2013 GI Surgery Symposium “Whipple Operation” Allen Oldfather Whipple

  10. 1960’s – 1970’s High perioperative morbidity Hospital mortality – 25% Long term survival for pancreatic cancer – 5% Calls to abandon PD for pancreatic cancer 2013 GI Surgery Symposium Crile, Surgery Gyn Obstet 1970;130:1049-53

  11. Improving the Whipple Operation 2013 GI Surgery Symposium

  12. 2013 GI Surgery Symposium Pancreatic Surgery Is Safe At High-Volume Hospitals NEJM 2002;346(15):1128-37

  13. 2013 GI Surgery Symposium Long-Term Survival Better At High-Volume Hospitals P=0.001 High Volume Hospital Low Volume Hospital Fong, Ann Surg 2005; 242:540-7

  14. 2013 GI Surgery Symposium High-Volume Surgeons Have Better Outcomes

  15. 2013 GI Surgery Symposium Pancreatoduodenectomy—Whipple Operation Evolution of Operative Techniques

  16. 2013 GI Surgery Symposium Is Diagnostic Laparoscopy Necessary? • Used less often with the evolution of imaging quality. • Considered when: • Marked weight loss • Very high CA19-9 • Pain • Frail patient

  17. 2013 GI Surgery Symposium Steps of the Whipple • Abdominal exploration to r/o occult metastases. • Mobilization of duodenum and head of pancreas. • Check for aberrant anatomy. • Isolation of bile duct, GDA, pylorus. • Tunnel under neck of pancreas.

  18. 2013 GI Surgery Symposium The Resection

  19. 2013 GI Surgery Symposium The Reconstruction

  20. 2013 GI Surgery Symposium Pylorus Preserving vs. Classic Whipple?

  21. 2013 GI Surgery Symposium Theoretical Advantages • Pylous –preservation • More physiologic • Less dumping • Classic • Better tumor clearance

  22. 2013 GI Surgery Symposium Reality • You can do it however you want. • No difference in DGE • No difference in wt loss/wt gain • Everything evens out at around 6-8 weeks

  23. 2013 GI Surgery Symposium Methods of Reconstruction • Pancreatojejunostomy • Most common reconstruction • More physiologic • Pancreatogatrostomy • Lower leak rate • Access to PD • Techniques • Duct-to-mucosa • Invagination • Externalization

  24. 2013 GI Surgery Symposium Externalizing the Pancreatic-Enteric Anastomosis • Used by some for high-risk patients: • Soft gland • Small duct • Frail patient

  25. 2013 GI Surgery Symposium Palliation of Pain with Alcohol Splanchnicectomy Lillemoe, et al. Ann Surg 217:447-457, 1993

  26. 2013 GI Surgery Symposium Vascular Resection • Venous resection is acceptable to achieve an R0 resection. • Arterial resections not recommended. • Associated with increased blood loss, increased transfusions, increased OR time, and increased morbidity. • No difference in mortality

  27. 2013 GI Surgery Symposium Vascular Resection • Most require partial vein resection with primary repair. • Reconstruction options include: • Oversew or patch • end-to-end vs. interposition graft (internal jugular vein, left renal vein, PTFE) • Postop anticoagulation varies by surgeon: none, ASA/plavix, coumadin

  28. 2013 GI Surgery Symposium Methods of Reconstruction Tseng, JF, et. al. Pancreaticoduodenectomy With Vascular Resection: Margin Status and Survival Duration, J GASTROINTEST SURG 2004;8:935–950 Harrison, LE, et. al. Isolated Portal Vein Involvement in Pancreatic Adenocarcinoma A Contraindication for Resection? ANNALS OF SURGERY 1996 Vol. 224, No. 3, 342-349

  29. 2013 GI Surgery Symposium Methods of Reconstruction

  30. 2013 GI Surgery Symposium Venous Resection in Pancreas Cancer

  31. 2013 GI Surgery Symposium Minimally Invasive Pancreatoduodenectomy

  32. 2013 GI Surgery Symposium Benefits of Laparoscopic Surgery • Less post-operative pain • Less post operative ileus • Preserved immune function • Decreased stress response • Shorter hospital stay • Improved cosmesis • Decreased complications ? • Faster time to receipt of chemo?

  33. 2013 GI Surgery Symposium Drawbacks • Learning curve • Increased operative time • Laparoscopic U/S • ? Cost • ? Risk • ? Malignancy • Extent of resection • Adequate surgical margins • Lymph node basin dissection • Port site recurrence

  34. 2013 GI Surgery Symposium Laparoscopic Whipple • First performed in 1994 by Gagner and Pomp. • Coversion rate 40% • OR time 8.5h • Authors concluded no advantage

  35. 2013 GI Surgery Symposium Laparoscopic Whipple • 7 centers report more than 30 lap Whipples. • Feasibility established • Lower EBL, fewer wound complications, shorter LOS • Increased OR time (541 min vs 401min) • No difference pancreatic fistula rates, overall complications, DGE, or mortality.

  36. 2013 GI Surgery Symposium Laparoscopic Whipple

  37. 2013 GI Surgery Symposium Outcomes for Laparoscopic Whipple

  38. 2013 GI Surgery Symposium Robotic Whipple • Advantages vs. Laparoscopic Whipple: • Better visualization (3-D) • More precise suturing • Disadvantages • Steep learning curve • Longer operative time • Need for 2 experienced surgeons

  39. 2013 GI Surgery Symposium Robotic Whipple • Largest experience from U of Pitt (n=132). • 30-day mortality 1.5% • 90-day mortality 3.8% • Minor complications: 41% • Major complications: 21%

  40. 2013 GI Surgery Symposium Robotic Whipple • HJ leak: 2% • DJ leak: 6% • Bleeding: 3.7% • Pseudoaneurysm: 14.8% • Grade B fistula: 3.7% • Grade C fistula: 3.7%

  41. 2013 GI Surgery Symposium Robotic Whipple • Mean OR time 527 min (360min last 50) • Conversion: 8% • Reoperation: 3% • LOS: 10 days • Readmission: 28%

  42. 2013 GI Surgery Symposium Distal Pancreatectomy

  43. 2013 GI Surgery Symposium Body/Tail Cancers • Tend to present later and with larger tumors. • Most will be metastatic at time of presentation (10-15% surgical candidates). • Diagnostic laparoscopy performed for most (esp. w/ large tumors, high CA 19-9, debilitated patients)

  44. 2013 GI Surgery Symposium Is Splenectomy Necessary? • Splenectomy is required during resection for malignancy to obtain adequate lymph node harvest. • For premalignant or benign lesions, spleen-preservation attempted when possible. • Warshaw technique: splenic artery and vein ligation without removal of spleen

  45. 2013 GI Surgery Symposium Laparoscopic Approach Is Standard of Care • Associated with: • Decreased complication rate • Decreased blood loss • Shorter LOS • Higher splenic preservation rate

  46. 2013 GI Surgery Symposium Laparoscopic Distal Pancreatectomy

  47. 2013 GI Surgery Symposium Robotic Distal • 30-, 90-day mortality: 0% • Minor complications: 59% • Major complications: 13% • Grade B fistula: 12% • Grade C fistula: 4.8%

  48. 2013 GI Surgery Symposium Robotic Distal • OR time: 256 min • LOS: 6 days • Readmission: 28%

  49. 2013 GI Surgery Symposium Appleby Procedure • Originally described for locally advanced gastric cancer. • Involves en-bloc resection of celiac axis, body/tail of pancreas and spleen. • Allshould undergo neoadjuvanttherapy before attempting an Appleby procedure.

  50. 2013 GI Surgery Symposium Appleby: Plane of Resection Bonnet, S. et. al. Indications and surgical technique of Appleby's operation for tumor invasion of the celiac trunk and its branches. Journal de Chirurgie. Volume 146, Issue 1, February 2009, Pages 6–14

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