Department of Pathology 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

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)

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

WHIPPLE PROCEDURE Reconstruction Pancreatico jejunostomy Choledocho jejunostomy Gastrojejunostomy -

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

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

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

WHIPPLE SPECIMEN PANCREATIC CA Pathologic Features Gross Effacement of lobules Invasive CA Fibrosis

WHIPPLE SPECIMEN Periampullary Tumors Pancreatic tumors Bile duct tumors Ampullary tumors Duodenal tumors

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

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

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

ENDOSCOPY DUODENAL CA Endoscopic Appearance 3 cm polypoid, ulcerating CA

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

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

ENDOSCOPY AMPULLARY CA - EARLY Endoscopic Appearance 1.5 polypoid CA

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

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

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

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

WHIPPLE PROCEDURE BILE DUCT CA Pathologic Features Gross Protuberant ampulla

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

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

ANATOMY AND FUNCTIONS OF THE PANCREAS Endocrine Exocrine

PANCREAS Anatomy Head Body Tail

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

PANCREATIC DUCTAL ANATOMY AND ANATOMIC RELATIONSHIP OF THE PANCREAS

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

CHRONIC PANCREATITIS Causes Alcohol abuse Obstruction Cystic fibrosis Hereditary Tropical

CHRONIC PANCREATITIS Gross Pathologic Features Fibrosis Dilated ducts Calcified concretions

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

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

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

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%

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

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

PANCREATIC CARCINOMA PATHOLOGY Microscopic Poorly formed glands in fibrotic stroma

METASTATIC PANCREATIC CA TO LIVER Hematogenous Metastases Portal vein Hepatic artery

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

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

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