Neoplastic Lesions Duodenum Ampulla Distal Common Bile Duct and Exocrine Pancreas

At the time of presentation, pancreatic carcinoma is beyond resection in more than 80% of patients. Also, given the advanced age of presentation in the vast majority of patients, over 95% of cases are treated palliatively. However, if the patient is fit, the tumour is less than 3 cm, does not involve major vessels and has not metastasised then a curative procedure may be considered.

Although the type of operation will depend on the site and size of tumour, the curative procedure of choice for duodenal, ampullary, distal common bile duct and pancreatic tumours is a standard Kausch-Whipple pancreaticoduodenectomy (PD) - "Whipple's procedure".

This procedure involves a transverse subcostal incision and initial exploration to assess oper-ability. It then involves the en bloc resection of the pancreatic head (with a variable amount of body depending on the location and size of the tumour), distal two thirds of the stomach, duodenum (and proximal 10 cm of jejunum), gall bladder and common bile duct (Figure 3.4a), which may be extended proximally for distal common bile duct tumours. There are many methods (up to 70!) of reconstruction after PD. One of the most popular is the formation of the following (Figure 3.4b):

I. Pancreaticojejunostomy (end to end).

II. Hepaticojejunostomy (end to side) - anastomosis of the hepatic duct to the jejunum.

III. Gastrojejunostomy (end to side).

IV. Jejunojejunostomy (side to side) - this decompresses the proximal jejunal loop and reduces jejuno-gastric reflux.

If there is involvement by tumour of the body and tail, the procedure can be modified to a total PD, which includes resection of the body and tail of the pancreas plus or minus the spleen.

For some small ampullary and periampullary (i.e., head of pancreas, distal common bile duct and duodenum) tumours, a pylorus-preserving PD is performed. This is essentially identical to a standard PD except that the distal stomach and proximal 3 cm of duodenum are left in situ thus retaining the food storage and release functions of the stomach.

A distal pancreatectomy consists of resection of the body and tail of the pancreas, usually including the spleen. This procedure may be used for tumours which are thought to be benign (e.g., cystadenoma) in the distal pancreas.

In all the above procedures, the pancreatic resection margin should be sent for frozen section examination to ensure adequate excision.

Figure 3.4. Whipple's procedure - (a) limits of resection and (b) reconstruction anastomoses.

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