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

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Presentation on theme: "Advanced Surgical Techniques For Pancreatic Cancer Dr. Janak Parikh, MD, MSHS November 2, 2013 St. John Providence Health System 2013 GI Cancer Symposium."— Presentation transcript:

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

2 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) 2013 GI Surgery Symposium

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

4 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 2013 GI Surgery Symposium

5 Historical Context ( ) Incidence and Mortality Rates NCI’s SEER Program GI Surgery Symposium

6 Fewer Than 1/3 Of Resectable Patients Receive Surgery

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

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

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

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 Crile, Surgery Gyn Obstet 1970;130: GI Surgery Symposium

11 Improving the Whipple Operation 2013 GI Surgery Symposium

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

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

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

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

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

17 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 GI Surgery Symposium

18 The Resection 2013 GI Surgery Symposium

19 The Reconstruction 2013 GI Surgery Symposium

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

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

22 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 2013 GI Surgery Symposium

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

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

25 Palliation of Pain with Alcohol Splanchnicectomy Lillemoe, et al. Ann Surg 217: , GI Surgery Symposium

26 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 2013 GI Surgery Symposium

27 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 2013 GI Surgery Symposium

28 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, GI Surgery Symposium

29 Methods of Reconstruction 2013 GI Surgery Symposium

30 Venous Resection in Pancreas Cancer AuthorN Op Mort. Vessel Invasion1 yr. survival Median Survival Ishikawa356%86%n.r.9 Takahashi*7917%61%38%14 Roder310%77%20%8 Tseng1412%n.r.72%23 Harrison585%n.r.59%13 Yekebas1364%73%58%15 I.U.733%65%71% GI Surgery Symposium

31 Minimally Invasive Pancreatoduodenectomy 2013 GI Surgery Symposium

32 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? 2013 GI Surgery Symposium

33 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 2013 GI Surgery Symposium

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

35 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 GI Surgery Symposium

36 Laparoscopic Whipple 2013 GI Surgery Symposium

37 ConvLapOp TimeCompLOSPanc AuthorYearN (%)Recon (%)(Min) (%) (days)Can (%) Gagner Dulucq Palanivelu Pugliese Kendrick Outcomes for Laparoscopic Whipple 2013 GI Surgery Symposium

38 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 2013 GI Surgery Symposium

39 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% 2013 GI Surgery Symposium

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

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

42 Distal Pancreatectomy 2013 GI Surgery Symposium

43 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) 2013 GI Surgery Symposium

44 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 2013 GI Surgery Symposium

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

46 Laparoscopic Distal Pancreatectomy 2013 GI Surgery Symposium

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

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

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

50 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 6–14Volume 146, Issue GI Surgery Symposium

51 Surgical Outcomes in GI Surgery Symposium

52 NMortalityMorbidity Overall11752%38% 1970’s2330%- 1980’s655%30% 1990’s5142%31% 2000’s5731%45% 1423 Pancreaticoduodenectomies for Pancreatic Cancer Winter JM, et al. J Gastrointest Surg 2006, 10: Pancreatic Surgery Is Safe 2013 GI Surgery Symposium

53 Long-Term Survival Remains Poor AuthorYearNMedian survival 5 year survival 10 year survival Predictors Ahmad mo19%-Adj tx Cleary mo15%4%Stage, grade Winter mo18%11%Size, LN, margin, grade Han mo12%-Stage, margin Ferrone %5%Stage, Margin 2013 GI Surgery Symposium

54 Paradigm Shift? Neoadjuvant therapy for all patients with pancreatic adenocarcinoma. Potential benefits: –Avoid surgery in patients with widely micrometastatic disease –Down-size tumor to avoid vein resection –Examination of tumor biology 2013 GI Surgery Symposium

55 Paradigm Shift? Opposition: –Resectable patients progress to unresectable –Complications of chemo prevent/delay surgery, increase complications 2013 GI Surgery Symposium

56 Pre-Operative Therapy Selects Patients Better than Upfront Surgery ●Avoids surgery in patients with rapidly progressive disease (unfavorable tumor biology).  Avoids surgery in patients unable to tolerate the stress of pre-operative therapy (those revealed to be unfit). *Evans DB, et al. JCO, 2008 ProtocolRegimenNumber of pts Resection Rate Overall Survival MDA * Gem/XRT8674%34 mo MDA ^ Gem/Cis Gem/XRT 9066%31 mo ^ Varadhachary GR, et al. JCO, 2008 ●Surgery was avoided in 25-35% of the patients; their median survival was 7-10 mo. ●Local failure occurred in 10-25% of patients undergoing resection; suggesting radiation may have a role in preoperative setting GI Surgery Symposium

57 Pancreatic Cancer in 2013 Surgery can be done safely Venous resection acceptable for R0 rxn. Minimally invasive distal pancreatectomy should be standard of care. Minimally invasive Whipple feasible, safe at selected centers. Need better systemic therapy to impact long-term survival GI Surgery Symposium

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

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