2. By AMGAD FOUAD Professor Of Surgery Gastroenterology Center Gastroenterology Center Mansoura University. Factors Affecting survival after pancreatico duodenectomy

3. Pancreatic cancer is the fourth most common cause of cancer related mortality in the western world It accounts for 10 % of all cancers of the digestive tract. ( Moossa & Stabile 1995 )

4. Most patients with pancreatic cancer present late in the course of the disease and have locally extensive disease ± Metastasis

5. Overall only up to 20 % of patients are candidates for resection and have potential for curative surgery this late presentation is a combination of delays related to: Patient presentation Physician misdiagnosis Lack of screening programs (Moossa& Gamagami, 1995)

6. In the management of periampulary tumors, resection is the only liklihood for cure and pancreaticoduodenectomy continues to be the surgical procedure of choice (Watanapa, et al 1992 ) (Watanapa, et al 1992 )

7. Although a low mortality rate has been achieved, the incidence of morbidity still high even in recent reports. (Rosso et al 2006 )

8. Ampulary carcinoma has a relatively better prognosis and a 5–year survival rates approaching 50 % Whereas Pancreatic cancer has a less favourable prognosis and a 5- year survival rate < 25 % ( Sarmiento & Sarr, 2001 )

9. Many factors have been identified to be associdted with a more favourable prognosis and a better survival after pancreaticoduodenectomy ( Fung et al, 2002)

10. Aim of the work Evaluation of different prognostic factors that may influence the overall survival after pancreaticoduodenectomy in patients with periampulary tumours.

11. Patients and Methods Retrospective study GEC – Mansoura University Series 154 patients. Sep 2001 → April 2004

12. Patient evaluation Thorough history Clinical examination Complete laboratory work up Radiological eval : US US CT CT

13. Pancreaticoduodenal resection classic whipple with Pancreateco–gastrostomy Gastro- jejunostomy Hepatico- jejunostomy

15. All Specimen Were Histologically Examined Site of origin Degree of diff. LN status. Safety margins.

16. Results

17. GEC Mansoura University Series 154 Patients 97 ♂ ( 62.9 % ) 57 ♀ ( 37.1 % ) Age : Mean 52 ± 11 Y Median 53 Y Range 34 – 80 Y

18. Patient Presentations %NoPresentation 97.476.629.26.413.618.215011845102128JaundicePain Loss of wt Bleeding ( GIT) VomitingDM

19. Preop Lab Data RangeMedian Mean ±SD 4.8-30.4-4520-44320-64150-1003-1236-3830.2-28.71000-1.33.95.260641006792.534 39±0.4 9 ± 9.8 84 ± 77 116 ± 142 93 ±10.4 6.2 ±2.5 94.2 ± 65.3 3.8 ± 5.3 99 ± 187 Albumin ( g/ dL) Bilirubin ( mg/ dl ) AST ( U/ dL) ALT( U/dl ) Proth.Conc. WBC (1000 /mm 3( ِ Amylase ( U/ml ) CEA ( ng/ mL) CA 19-9 ( U/ml) Ast : Aspartate Transaminase, ALT : Alanine Transaminase, CEA : Carcinoemberyonic Antigen CA 19 -9 : Carbohydrate Antigen 19 -9

20. CT Findings ( 154 patients ) PercentNo 7.812 No Mass 92.2142 Solid Mass 7613.62.6117214Site Pancreas head AmpularyDoudenal 34±262918-150 Size (mm) Mean ±SD MedianRange

22. Pathological Features after PD in 154 patients with periampulary carcinoma Duodenal Distal CBD PancreaticAmpulary 106.520138655.83824.7NumberPercent 3.7 ±1.5 5-24.1 2.7 ±0.9 5-22.3 3.8 ± 1.6 2.5.54.3 2.1±0.6 1-42 Tumour Diameter (cm) Mean± SD RangeMedian 2 (25%) 4 (50%) 2 (25%) 2 (25%) 10 (50%) 6 (30%) 4 (20%) 4 (20%) 46 (53.4%) 26 (30.3%) 14 (16.3%) 26.3 24 (63.1%) 10 (53.4%) 4 (10.6%) Tumor Differentiation WellModPoor - 4 (20 %) 4 (20 %) 3 (3.5 %) 1 (2.6 %) Margin Status +ve - 10 (50 %) 24 (27.9 %) 6 (15.7 %) LN + ve

25. 1,2,3 Years survival of studied cases according to different P value 3 Year % 2Year % 1Year % Factors P = 0.021 69.245.943.386.667.57010097.293.3Age Below 50 Y Below 50 Y 50- 60Y 50- 60Y Above 60 Above 60 P = 0.023 44.157.5706072.0981.8808095.310090100Site Pancreatic Pancreatic Ampullary Ampullary Distal CBD Distal CBD Duodenum Duodenum P = 0.01 53.815.276.122.998.389.4LN Negtive Negtive Positive Positive P = 0.001 59.342.13078.171.056010097.380Stage one one Two Two Three Three P = 0.024 55.543.425.077.769.558.310095.683.3Differen well well Mod. Mod. Poor Poor P = 0.021 32.352.158.876.0885.297.8 Platelet Count < (300) 10 9 L < (300) 10 9 L > (300) 10 9 - L > (300) 10 9 - L P = 0.027 64.253.332.185.77062.210096.692.8 Tumor Marker CEA < 5 ngm CEA < 5 ngm CEA 5-55 ng CEA 5-55 ng CEA> 55 ngm CEA> 55 ngm P = 0.031 64.745.131.188.276.463.610096.694.7 CA 19-9 < 375u/ml/ > 375 – 1000 U / ml > 375 – 1000 U / ml CA19-9 > 1000 CA19-9 > 1000

26. Median Survival Of Studied Cases According To Different Factors Significance Range ( months ) Median ( months ) Factors P=0.047 23-46 23-46 19 – 37 3423Age Below 50 Y Below 50 Y 50- 60Y 50- 60Y Above 60 Above 60 P = 0.001 23- 53 19-374230 Size of the tumor < 3 cm < 3 cm > 3 cm > 3 cm P= 0.008 27-48’0-214116Margin Negative Margin Negative Margin Positive Margin Positive Margin P=0.00921-4215-323922LN Negtive Negtive Positive Positive P =0.03 14-3728-4218-3716-3922362527Site Pancreatic Pancreatic Ampullary Ampullary Distal CBD Distal CBD Duodenum Duodenum P =0.075 25-4318-313624 Blood trrans. < 3 units < 3 units > 3 units > 3 units P= 0.002 25-43 19- 38 5-23393117Differen well well Mod. Mod. Poor Poor P = 0.041 22-4015-313428 Platelet Count < (300) 10 9 L < (300) 10 9 L > (300) 10 9 - > (300) 10 9 - P= 0.037 214417-354031 Tumor Marker CEA < 5 ngm CEA < 5 ngm CEA 5-55 ng CEA 5-55 ng CEA> 55 ngm CEA> 55 ngm P= 0.029 21-4111-343829 CA 19-9 < 375u/ml/ > 375 – 1000 U / ml > 375 – 1000 U / ml CA19-9 > 1000 CA19-9 > 1000

27. Median recurrence free survival according to different factors: SignificanceRangeMedianFactors P=0.47(23-46)months(19-37)months 34 months 23 months Age Below 50Y Above 50y P=0.001 (23-53) months (10-37) months 42 months 30 months Size of the tumor <3cm>3cm P=0.008 (27-48) months (0-21) months 41 months 16 months Margin (Negative margin) (Positive margian) P=0.009 (21-42) months (15-35) months 39 months 22 months LNNegativePositive P=0.03 (14-37) months (28-42) months (18-37) months (16-39) months 22 month 36 month 25 month 27 month SitePancreaticAmpullary Distal CBD Duodenum

28. SignificanceRangeMedianFactors P=0.075 (25-43) months (18-31) months 36 months 24 months Blood trrans. <3units>3units P=0.002 (25-43) months (19-38) months (5-23) months 39 months 31 months 17 months DifferenWellModPoor P=0.041 (22-40) months (15-31) months 34 months 28 months Platelet count <(300)109-L >(300) 109 –L P=0.037P=0.029 (21-44) months (17-35) months (21-41) months (11-34) months 40 months 31 months 38 months 29 months Tumor marker CEA <5ngm CEA >5ngm CA19.9 <375 U\ml >375 u\ml

31. Conclusion Periampulary carcinoma represents a major therapeutic challenge to surgeons. Despite resent improvement in Hospital mortality and morbidity, the long-term survival after pancreaticoduodenectomy is still disappointing and many factors should be considered to improve the outcome

32. We believe that, the age of the patient, the site of origin of the tumor, cellular differentiation, the pathological tumour stage, the resection margin and the amount of blood transfusion all are important prognostic factors and should be considered in selecting patients eligible to surgical resection