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

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

3. 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.

4. AIM
--To review Whipple`s procedures for presumed but unproven malignant tumors
METHODS
period
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

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

6. 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 !

7. Algorithm to evaluate suspected pancreatobiliary malignancy

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

9. 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 %

10. Clinicopathologic features and imaging findingsNo
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

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

12. 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

13. 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

14. 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.

15. THANK YOU!