By AMGAD FOUAD Professor Of Surgery Gastroenterology Center Gastroenterology Center Mansoura...

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AMGAD FOUADAMGAD FOUAD Professor Of SurgeryProfessor Of Surgery

Gastroenterology CenterGastroenterology CenterMansoura University.Mansoura University.

Factors Affecting survival Factors Affecting survival after pancreatico after pancreatico duodenectomy duodenectomy

Pancreatic cancer is the fourth most Pancreatic cancer is the fourth most

common cause of cancer related common cause of cancer related

mortality in the western worldmortality in the western world

It accounts for It accounts for 10 %10 % of all cancers of of all cancers of

the digestive tract.the digestive tract.

( Moossa & Stabile 1995( Moossa & Stabile 1995 ))

Most patients with pancreatic Most patients with pancreatic

cancer present late in the course cancer present late in the course

of the disease and have locally of the disease and have locally

extensive disease extensive disease ±± Metastasis Metastasis

Overall only up to Overall only up to 20 %20 % of patients are of patients are

candidates for resection and have potential candidates for resection and have potential

for curative surgery this late presentation for curative surgery this late presentation

is a combination of delays related to: is a combination of delays related to:

Patient presentation Patient presentation

Physician misdiagnosis Physician misdiagnosis

Lack of screening programs Lack of screening programs

(Moossa& Gamagami , 1995)(Moossa& Gamagami , 1995)

In the management of periampulary In the management of periampulary

tumors , resection is the only liklihood for tumors , resection is the only liklihood for

cure and pancreaticoduodenectomy cure and pancreaticoduodenectomy

continues to be the surgical procedure of continues to be the surgical procedure of

choice choice

(Watanapa , et al 1992 )(Watanapa , et al 1992 )

Although a low mortality rate Although a low mortality rate

has been achieved , the has been achieved , the

incidence of morbidity still high incidence of morbidity still high

even in recent reports .even in recent reports .

(Rosso et al 2006 )(Rosso et al 2006 )

Ampulary carcinoma has a relatively Ampulary carcinoma has a relatively better prognosis and a better prognosis and a 5–year5–year survival rates approaching survival rates approaching 50 %50 %

WhereasWhereas

Pancreatic cancer has a less Pancreatic cancer has a less favourable prognosis and a favourable prognosis and a 5- year5- year survival rate survival rate < 25 %< 25 %

( Sarmiento & Sarr, 2001 )( Sarmiento & Sarr, 2001 )

Many factors have been identified to Many factors have been identified to

be associdted with a more favourable be associdted with a more favourable

prognosis and a better survival after prognosis and a better survival after

pancreaticoduodenectomy pancreaticoduodenectomy

( Fung et al, 2002)( Fung et al, 2002)

Aim of the work Aim of the work

Evaluation of different prognostic Evaluation of different prognostic

factors that may influence the overall factors that may influence the overall

survival after survival after

pancreaticoduodenectomy in patients pancreaticoduodenectomy in patients

with periampulary tumours . with periampulary tumours .

Patients and Methods Patients and Methods

Retrospective study Retrospective study

GEC – Mansoura University GEC – Mansoura University

Series 154 patients .Series 154 patients .

Sep 2001 → April 2004Sep 2001 → April 2004

Patient evaluation Patient evaluation

Thorough history Thorough history

Clinical examination Clinical examination

Complete laboratory work up Complete laboratory work up

Radiological eval : Radiological eval :

US US

CT CT

Pancreaticoduodenal Pancreaticoduodenal resection resection

classic whipple classic whipple with with

• Pancreateco–gastrostomy

• Gastro- jejunostomy

• Hepatico- jejunostomy

All Specimen Were All Specimen Were Histologically Examined Histologically Examined

Site of originSite of origin

Degree of diff.Degree of diff.

LN status.LN status.

Safety margins.Safety margins.

ResulResults ts

GEC Mansoura University GEC Mansoura University

Series 154 Patients Series 154 Patients

97 ♂ ( 62.9 % )97 ♂ ( 62.9 % )

57 ♀ ( 37.1 % )57 ♀ ( 37.1 % )

Age :Age :

Mean 52 ± 11 Mean 52 ± 11 YY

Median 53 Median 53 YY

Range 34 – 80 Range 34 – 80 Y Y

Patient Presentations Patient Presentations

Presentation Presentation No No %%

Jaundice Jaundice

Pain Pain

Loss of wtLoss of wt

Bleeding Bleeding

( GIT)( GIT)

VomitingVomiting

DMDM

150150

118118

4545

1010

2121

2828

97.4 97.4

76.676.6

29.229.2

6.46.4

13.613.6

18.218.2

Preop Lab Data Preop Lab Data

Mean ±SDMean ±SDMedian Median Range Range

Albumin ( g/ dL)Albumin ( g/ dL)Bilirubin ( mg/ dl )Bilirubin ( mg/ dl )AST ( U/ dL)AST ( U/ dL)ALT( U/dl )ALT( U/dl )Proth.Conc.Proth.Conc.WBC (1000 /mmWBC (1000 /mm33((

GِGِAmylase ( U/ml )Amylase ( U/ml )CEA ( ng/ mL)CEA ( ng/ mL)CA 19-9 ( U/ml)CA 19-9 ( U/ml)

3939±±0.40.49 9 ± 9.8 ± 9.884 ± 7784 ± 77

116 ± 142 116 ± 142 93 ±10.493 ±10.46.2 ±2.56.2 ±2.5

94.2 ± 65.394.2 ± 65.33.8 ± 5.3 3.8 ± 5.3 99 ± 187 99 ± 187

3.93.95.25.260606464

1001006679792.52.53434

4.8-34.8-30.4-450.4-4520-44320-44320-64120-64150-10050-1003-123-12

36-38336-3830.2-28.70.2-28.71000-1.31000-1.3

Ast : Aspartate Transaminase , ALT : Alanine Transaminase , CEA : Carcinoemberyonic Antigen CA 19 -9 : Carbohydrate

Antigen 19 -9

CT Findings ( 154 patients )CT Findings ( 154 patients )

No No Percent Percent

No MassNo Mass12127.87.8

Solid Mass Solid Mass 14214292.292.2

Site Site Pancreas head Pancreas head

Ampulary Ampulary

Doudenal Doudenal

117117

2121

44

7676

13.613.6

2.62.6

Size (mm)Size (mm)Mean ±SDMean ±SD

Median Median

RangeRange

34±2634±26

2929

18-15018-150

Pathological Features after PD in 154 patients with Pathological Features after PD in 154 patients with periampulary carcinoma periampulary carcinoma

Ampulary Ampulary Pancreatic Pancreatic Distal CBDDistal CBDDuodenal Duodenal

NumberNumber

PercentPercent

3838

24.724.7

8686

55.855.8

2020

1313

1010

6.56.5

Tumour Diameter Tumour Diameter

(cm)(cm)

Mean± SDMean± SD

RangeRange

MedianMedian

2.12.1±±0.60.6

1-41-4

22

3.8 3.8 ±± 1.6 1.6

2.5.52.5.5

4.3 4.3

2.7 2.7 ±±0.90.9

5-25-2

2.32.3

3.7 3.7 ±±1.51.5

5-25-2

4.14.1

Tumor Tumor

DifferentiationDifferentiation

Well Well

ModMod

PoorPoor

26.326.3

24 24 (63.1%)(63.1%)

10 10 (53.4%)(53.4%)

4 4 (10.6%)(10.6%)

46 46 (53.4%)(53.4%)

26 26 (30.3%)(30.3%)

14 14 (16.3%)(16.3%)

10 10 (50%)(50%)

6 6 (30%)(30%)

4 4 (20%)(20%)

2 2 (25%)(25%)

4 4 (50%)(50%)

2 2 (25%)(25%)

Margin Status +ve Margin Status +ve 1 1 (2.6 %)(2.6 %)3 3 (3.5 %)(3.5 %) 4 4 (20 %)(20 %)--

LN + veLN + ve6 6 (15.7 %)(15.7 %)24 24 (27.9 %)(27.9 %)10 10 (50 %)(50 %)--

1,2,3 Years survival of studied cases according to different 1,2,3 Years survival of studied cases according to different

FactorsFactors1Year %1Year %2Year %2Year %3 Year3 Year % %P valueP value

AgeAge Below 50 YBelow 50 Y 50- 60Y50- 60Y Above 60Above 60

10010097.297.293.393.3

86.686.667.567.57070

69.269.245.945.943.343.3

P = 0.021P = 0.021

Site Site Pancreatic Pancreatic Ampullary Ampullary Distal CBDDistal CBD DuodenumDuodenum

95.395.31001009090

100100

72.0972.0981.881.880808080

44.144.157.557.570706060

P = 0.023P = 0.023

LNLN Negtive Negtive PositivePositive

98.398.389.489.4

76.176.122.922.9

53.853.815.215.2

P = 0.01P = 0.01

Stage Stage one one TwoTwo Three Three

10010097.397.38080

78.178.171.0571.05

6060

59.359.342.142.13030

P = 0.001P = 0.001

DifferenDifferen well well Mod.Mod. PoorPoor

10010095.695.683.383.3

77.777.769.569.558.358.3

55.555.543.443.425.025.0

P = 0.024P = 0.024

Platelet CountPlatelet Count < (300) 10< (300) 109 9 LL

>> (300) 10 (300) 109 - L9 - L85.285.297.897.8

58.858.876.0876.08

32.332.352.152.1

P = 0.021P = 0.021

Tumor MarkerTumor Marker CEA < 5 ngmCEA < 5 ngm CEA 5-55 ngCEA 5-55 ng CEA> 55 ngmCEA> 55 ngm

10010096.696.692.892.8

85.785.77070

62.262.2

64.264.253.353.332.132.1

P = 0.027P = 0.027

CA 19-9 < CA 19-9 < 375u/ml/375u/ml/ > 375 – 1000 U / > 375 – 1000 U / mlml CA19-9 > 1000CA19-9 > 1000

10010096.696.694.794.7

88.288.276.476.463.663.6

64.764.745.145.131.131.1

P = 0.031P = 0.031

Median Survival Of Studied Cases According To Median Survival Of Studied Cases According To Different Factors Different Factors

FactorsFactorsMedian ( months ) Median ( months ) RangeRange ( months ) ( months ) Significance Significance AgeAge Below 50 YBelow 50 Y 50- 60Y50- 60Y Above 60Above 60

34342323

23-46 23-46 19 – 3719 – 37

P=0.047P=0.047

Size of the tumorSize of the tumor < 3 cm< 3 cm > 3 cm> 3 cm

42423030

23- 53 23- 53 19-3719-37

P = 0.001P = 0.001

MarginMargin Negative MarginNegative Margin Positive MarginPositive Margin

41411616

27-48’27-48’0-210-21

P= 0.008P= 0.008

LNLN Negtive Negtive PositivePositive

39392222

21-4221-4215-3215-32

P=0.009P=0.009

Site Site Pancreatic Pancreatic Ampullary Ampullary Distal CBDDistal CBD DuodenumDuodenum

2222363625252727

14-3714-3728-4228-4218-3718-3716-3916-39

P =0.03P =0.03

Blood trrans. Blood trrans. < 3 units< 3 units > 3 units> 3 units

36362424

25-4325-4318-3118-31

P =0.075P =0.075

DifferenDifferen well well Mod.Mod. PoorPoor

393931311717

25-4325-4319- 3819- 385-235-23

P= 0.002P= 0.002

Platelet CountPlatelet Count < (300) 10< (300) 109 9 LL

>> (300) 10 (300) 109 -9 -34342828

22-4022-4015-3115-31

P = 0.041P = 0.041

Tumor MarkerTumor Marker CEA < 5 ngmCEA < 5 ngm CEA 5-55 ngCEA 5-55 ng CEA> 55 ngmCEA> 55 ngm

40403131

2144214417-3517-35

P= 0.037P= 0.037

CA 19-9 < 375u/ml/CA 19-9 < 375u/ml/ > 375 – 1000 U / ml> 375 – 1000 U / ml CA19-9 > 1000CA19-9 > 1000

38382929

21-4121-4111-3411-34

P= 0.029P= 0.029

Median recurrence free survival according to Median recurrence free survival according to different factors:different factors:

FactorsFactorsMedianMedianRangeRangeSignificance Significance AgeAge Below 50YBelow 50YAbove 50yAbove 50y

34 months34 months23 months23 months

(23-46)months(23-46)months(19-37)months(19-37)months

P=0.47P=0.47

Size of the tumorSize of the tumor<3cm<3cm>3cm>3cm


(23-53) months(23-53) months(10-37) months(10-37) months

P=0.001P=0.001

MarginMargin(Negative (Negative margin)margin)(Positive (Positive margian)margian)



P=0.008P=0.008

LNLNNegativeNegativePositivePositive



P=0.009P=0.009

SiteSitePancreaticPancreaticAmpullaryAmpullaryDistal CBDDistal CBDDuodenumDuodenum

22 month22 month36 month36 month25 month25 month27 month27 month

(14-37) months(14-37) months(28-42) months(28-42) months(18-37) months(18-37) months(16-39) months(16-39) months

P=0.03P=0.03

FactorsFactorsMedianMedianRangeRangeSignificance Significance

Blood trrans.Blood trrans.<3units<3units>3units>3units



P=0.075P=0.075

DifferenDifferenWellWellModModPoorPoor

39 months39 months31 months31 months17 months17 months

(25-43) months(25-43) months(19-38) months(19-38) months(5-23) months(5-23) months

P=0.002P=0.002

Platelet countPlatelet count<(300)109-L<(300)109-L>(300) 109 –L>(300) 109 –L



P=0.041P=0.041

Tumor markerTumor markerCEA <5ngmCEA <5ngmCEA >5ngmCEA >5ngmCA19.9CA19.9<375 U\ml<375 U\ml>375 u\ml>375 u\ml





P=0.037P=0.037

P=0.029P=0.029

Conclusion Conclusion

Periampulary carcinoma represents a Periampulary carcinoma represents a

major therapeutic challenge to surgeons . major therapeutic challenge to surgeons .

Despite resent improvement in Hospital Despite resent improvement in Hospital

mortality and morbidity , the long-term mortality and morbidity , the long-term

survival after pancreaticoduodenectomy is survival after pancreaticoduodenectomy is

still disappointing and many factors should still disappointing and many factors should

be considered to improve the outcome be considered to improve the outcome

We believe that , the age of the patient , the We believe that , the age of the patient , the

site of origin of the tumor, cellular site of origin of the tumor, cellular

differentiation , the pathological tumour stage differentiation , the pathological tumour stage

, the resection margin and the amount of , the resection margin and the amount of

blood transfusion all are important prognostic blood transfusion all are important prognostic

factors and should be considered in selecting factors and should be considered in selecting

patients eligible to surgical resection patients eligible to surgical resection

By AMGAD FOUAD Professor Of Surgery Gastroenterology Center Gastroenterology Center Mansoura...

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