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Edward L. Lee, M.D. Professor & Chairman Department of Pathology Howard University College of Medicine

Edward L. Lee, M.D. Professor & Chairman Department of Pathology Howard University College of Medicine. PERIAMPULLARY TUMORS AND THE DISSECTION OF THE WHIPPLE RESECTION. IN MEMORIAM ALLEN O. WHIPPLE, M.D. 1881 - 1963. WHIPPLE PROCEDURE. PERFORMED FOR Periampullary Tumors (104).

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Edward L. Lee, M.D. Professor & Chairman Department of Pathology Howard University College of Medicine

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  1. Edward L. Lee, M.D. Professor & Chairman Department of Pathology Howard University College of Medicine

  2. PERIAMPULLARY TUMORS AND THE DISSECTION OF THE WHIPPLE RESECTION

  3. IN MEMORIAMALLEN O. WHIPPLE, M.D. 1881 - 1963

  4. WHIPPLE PROCEDURE PERFORMED FOR Periampullary Tumors (104) • Pancreatic CA -70 • Ampullary CA -20 • Duodenal CA -10 • Distal bile duct CA -4 Chronic pancreatitis (38)

  5. WHIPPLE PROCEDURE (PANCREATICODUODENECTOMY) Specimen • Distal stomach • Duodenum • Head of pancreas • Distal bile duct • Gallbladder • Proximal jejunum

  6. WHIPPLE PROCEDURE Reconstruction • Pancreatico jejunostomy • Choledocho jejunostomy • Gastrojejunostomy -

  7. WHIPPLE SPECIMEN Frozen Section • Pancreatic resection margin • Bile duct margins Probe Bile Duct • Dilated • Identified by surgeons with black suture

  8. WHIPPLE SPECIMEN Dissect The Unfixed Specimen • Open the stomach along greater curvature • Open the duodenum along the border opposite the pancreas - Duodenal mucosa looks dusky because the blood supply is ligated earlier in the operation

  9. WHIPPLE SPECIMEN Dissect The Unfixed Specimen • Open the bile duct extending to ampulla • Identify the main pancreatic duct

  10. WHIPPLE SPECIMENPANCREATIC CA Pathologic Features Gross • Effacement of lobules • Invasive CA • Fibrosis

  11. WHIPPLE SPECIMEN Periampullary Tumors • Pancreatic tumors • Bile duct tumors • Ampullary tumors • Duodenal tumors

  12. WHIPPLE SPECIMEN Record Dimensions • Stomach • Duodenum • Pancreatic head • Margins • Lymph nodes (10)

  13. WHIPPLE SPECIMEN PANCREATIC CA Describe The Tumor • Size • Color • Consistency • Cysts • Relationship to anatomic sites • Distance from margins • Obstruction of ducts • Remainder of pancreatic parenchyma

  14. WHIPPLE SPECIMEN Sections (20) • Resection Margins - Pancreatic - Uncinate process - Gastric - Duodenal - Common bile duct • Tumor - Tumor and common bile - Tumor and pancreatic duct - Tumor and pancreatic parenchyma • Uninvolved pancreas • Ampulla • Lymph nodes (10) - Common bile duct - Pergastric - Periduodenal - Pancreatic

  15. ENDOSCOPY DUODENAL CA Endoscopic Appearance • 3 cm polypoid, ulcerating CA

  16. WHIPPLE SPECIMEN DUODENAL CA Pathologic Features Gross • 3 cm polypoid, ulcerating CA

  17. WHIPPLE SPECIMEN DUODENAL CA Pathologic Features Micro • Ulcerating Adeno CA • Invades pancreas Prognosis 5 – year survival rate –30%

  18. ENDOSCOPYAMPULLARY CA - EARLY Endoscopic Appearance • 1.5 polypoid CA

  19. WHIPPLE SPECIMEN AMPULLARY CA - EARLY Pathologic Features Gross • 1.5 cm mass

  20. WHIPPLE SPECIMEN AMPULLARY CARCINOMA - EARLY Pathologic Features Micro • Adeno CA • Confined to mucosa Prognosis 5 – year survival rate - good

  21. WHIPPLE SPECIMEN AMPULLARY CARCINOMA - ADVANCED Pathologic Features Gross • 2 cm polypoid ulcerating CA

  22. WHIPPLE SPECIMEN AMPULLARY CARCINOMA - ADVANCED Pathologic Features Gross • Invasive adeno CA • Tumor invades pancreas Micro • Invasive adeno CA • Tumor invades pancreas Prognosis 5 – year survival rate - 34%

  23. WHIPPLE PROCEDURE BILE DUCT CA Pathologic Features Gross • Protuberant ampulla

  24. WHIPPLE PROCEDURE BILE DUCT CA Pathologic Features Gross • Mass in distal bile duct • 3 cm papillary CA

  25. WHIPPLE PROCEDURE BILE DUCT CA Pathologic Features Gross • Invasive papillary CA Micro • Invasive papillary CA • Metastasis to lymph node Prognosis 5 – year survival rate – 15%

  26. ANATOMY AND FUNCTIONS OF THE PANCREAS Endocrine Exocrine

  27. PANCREAS Anatomy • Head • Body • Tail

  28. PANCREAS Histology Exocrine • Acinar cells • Ducts Endocrine • Islet cells • Insulin • Glucagon • Somatostatin • Pancreatic polypeptide

  29. PANCREATIC DUCTAL ANATOMY AND ANATOMIC RELATIONSHIP OF THE PANCREAS

  30. “Acute” Inflammation Edema Fat Necrosis Hemorrhage PANCREATITIS • “Chronic” • Inflammation • Destruction of exocrine glands • Destruction of endocrine glands • Fibrosis

  31. CHRONIC PANCREATITIS Causes • Alcohol abuse • Obstruction • Cystic fibrosis • Hereditary • Tropical

  32. CHRONIC PANCREATITIS Pathologic Features Gross • Fibrosis • Dilated ducts • Calcified concretions

  33. CHRONIC PANCREATITIS Pathologic Features Micro • Fibrosis • Atrophy of acini • Dilated ducts with concretions

  34. COMPLICATIONS OF CHRONIC PANCREATITIS • Pseudocysts • Duct obstruction • Malabsorption • Steatorrhea • Secondary diabetes • Carcinoma

  35. NEOPLASMS OF THE PANCREAS Cystic Neoplasms • Serous cystadenomas • Mucinous cystic neoplasms • Intraductal papillary mucinous neoplasms Solid Neoplasms • Pancreatic ductal adenocarcinoma • Endocrine tumors

  36. PANCREATIC CARCINOMA Clinical Features • Fourth leading cause of cancer death in U.S. • 30,000 patients diagnosed and die from it • Genetic disease: mutations in K-RAS, p53 5-year Survival Rate <5%

  37. PANCREATIC DUCTAL ADENOCARCINOMAS Diagnosis • ERCP (endoscopic retrograde cholangio- pancreatography) • Fine needle aspiration biopsy • Ct scan • CA-19-9

  38. PANCREATIC DUCTAL CARCINOMAS Risk Factors • Tobacco abuse • Chronic pancreatitis • Hereditary pancreatitis • Diet (high in fats and meats) • Chemical carcinogen exposure • Pancreatic Intraepithelial Neoplasias (PanINs) Pan INs 1 2 3 CA

  39. PANCREATIC CARCINOMA PATHOLOGY Microscopic • Poorly formed glands in fibrotic stroma

  40. METASTATIC PANCREATIC CA TO LIVER Hematogenous Metastases • Portal vein • Hepatic artery

  41. WHIPPLE PROCEDURE Complications • Post Op Mortality Rate - 2 - 5% • Morbidity Rate - 20 - 50% • Leakage - Pancreaticojejunal anastomosis (15%) - Choledochojejunal anastomosis (7%)

  42. WHIPPLE PROCEDURE Cost • $34,000 to $92,000 • High-volume centers - Lower hospital cost - Shorter hospital stay - Lower morbidity

  43. PARK

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