RADICAL WHIPPLE`S PANCREATODUODENECTOMY FOR CHRONIC PANCREATITIS C. Lupascu, Ana Trofin, M. Zabara, Oana Apopei, Corina Lupascu-Ursulescu

INTRODUCTION PD –treatment of choice for suspected pancreatic head cancer and periampullary malignancies Perioperative mortality 1-5 % Perioperative morbidity ~ 40 % The only potential cure for pancreatic ADK (the 4-th leading cause of cancer related death in Europe)

INTRODUCTION Preoperative histologic diagnosis—essential for surgical management in malignancies Advances in imaging—improval of preoperative diagnosis less emphasis on preoperative tissue diagnosis Major series of Whipple`s procedure for presumed cancer still report 5-10 % ultimately benign disease.

AIM --To review Whipple`s procedures for presumed but unproven malignant tumors METHODS period 2007-2015 From 122 Whipple`s procedures 11 (9 %)—chronic pancreatitis at the final HP report Patients with diagnosis of CP undergoing resection for relief of pain--excluded

DEMOGRAPHIC DATA Category Number (%) Gender M 6(54 %) F 5 (46 %) Past medical history pancreatitis 5(46%) diabetes 2(17%) Social history smoking 7(68 %), alcohol 5(46%)

MRCP, ERCP ± brushing, CT, PET-CT ALGORITHM TO EVALUATE A PATIENT WITH SUSPECTED PANCREATOBILIARY MALIGNANCY CA 19-9 levels, serologic date MRCP, ERCP ± brushing, CT, PET-CT Percutaneous image guided FNA risk to disseminate the tumor EUS ±FNA Intraop . Tru-cut biopsy and frozen section Before the decision for surgery is made !

Algorithm to evaluate suspected pancreatobiliary malignancy

Presenting symptom Jaundice 7 (77 %) Abdominal pain 4 (30 %) Weight loss 3 (22 %) Upper digestive bleeding 2 (18 %) Gastric outlet obstruction 2 (18 %) Cholangitis 2 (18 %)

Imaging modalities of patients with benign disease CT spiral 11 100% MRI with or without MRCP 8 88,5% ERCP 4 33,5 % ERCP +brushing ± transpapillary biopsy EUS with FNA 1 9,2 %

Clinicopathologic features and imaging findings No Clinical features Imaging findings Pathology 1 Jaundice Periampullary mass Chronic pancreatitis with regional lymphadenitis 2 Jaundice, pancreatitis, pain Pancreatic duct stricture with upstream dillatation Focal active pancreatitis 3 Jaundice, weight loss Pancreatic head mass Pseudotumoral pancreatitis 4 Ascending cholangitis CBD stricture /dilation Focal sclerosing pancreatitis with CBD stricture 5 Ascending colangitis CBD stricture / dilation Chronic pancreatitis with pancreatic ductal stone 6 Jaundice, pain, weight loss CBD stricture Choledocal cyst with chronic cholangitis and granulomatose pancreatitis 7 Gastric outlet obstr, jaundice Duodenal ulcerated mass Cystic duodenal wall displasia and chronic pancreatitis 8 Jaundice, pain CBD stricture and dilation Autoimmune chronic pancreatitis 9 Duodenal bleeding Active duodenal bleeding Chronic pancreatitis due to duodenal diverticula 10 Duodenal (transpapillary) bleeding, weight loss Pancreatic head mass with active bleeding Pancreatic head pseudoaneurysm on chronic pancreatitis 11 Jaundice, gastric outlet obstr CBD stricture /dilation, duodenal obstruction Periduodenal pancreatitis

RESULTS Mortality - myocardial infarction 1 (9%) Morbidity 4 (35 %) - stump pancreatitis 1 - anastomotic leakage 2 - intaaabdominal bleeding 1 Mean operative time 245 min Mean blood loss 550 ml Mean hospital stay 12 day

DISCUSSION Report of 11 patients of a series of 122 Whipple`s operation for presumed but unproven malignant disease All patient had radiological, endoscopic, intraop. findings consistent with malignancy Preop. tissue diagnosis - only 1 case Improved availability of imaging techniques has not been mirrored by improval of preop tissue diagnosis

DISCUSSION Image guided FNA has 90 % sensitivity rate but risk of transcoelomic tumoral seeding The current series includes pathological entities of pancreatitis, mimicing pancreatic cancer Pancreatic cancer has a 5 year overall survival < 4 %. Whipple`s procedure—only treat. with curative potential

CONCLUSION Increasing availability of preop EUS- FNA might reduce the need for Whipple`s operation in benign disease Despite, given the lack of any definitive test to preop. separate malignant from benign disease, Whipple`s op is reasonable, since is the only chance to improve survival in pancreatic cancer.

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