1. Department of Pathology
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 MEMORIAM ALLEN O. WHIPPLE, M.D. 1881 - 1963

4. Periampullary Tumors (104)
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 Probe Bile Duct
Pancreatic resection margin
Bile duct margins
Probe Bile Duct
Dilated
Identified by surgeons with black suture

8. Dissect The Unfixed Specimen
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 Specimen Dissect The Unfixed
Open the bile duct extending to ampulla
Identify the main pancreatic duct

10. WHIPPLE SPECIMEN PANCREATIC 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)
- Pergastric
- Periduodenal

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

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

32. CHRONIC PANCREATITIS Gross Pathologic Features 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 5-year Survival Rate <5%
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

39. 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 CA

40. PANCREATIC CARCINOMA PATHOLOGY
Microscopic
Poorly formed glands in fibrotic stroma

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

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

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

44. PARK