Allen Shieh

English 11 AP / IM - 6
3/4/16

Procedural Diagnosis and Surgical Treatment

for Periampullary Cancer

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INTRODUCTION
Witnessing the touching joy expressed by a patient who has post-operatively won the
tough battle against pancreatic cancer is an amazingly humbling spectacle. However gripping,
situations like these are unfortunately uncommon1. As of 2006, 33,730 Americans have been
diagnosed with pancreatic cancer (PC), of which 32,300 will die from the disease (World
Pancreatic 1). Comparatively, 45,200 people have been diagnosed with PC in 2013, of which
38,460 will die from it (Wolfgang Recent 319). Despite these alarmingly and seemingly
gigantic proportions, there has been much advancement in treatment options for patients to take
advantage of. In order to formally inform the general public and those with some medical
background of this massive concern, this report will mainly focus on defining the characteristics
and developmental stages of all cancers and then transition to treatment options for patients who
unfortunately bear a specific type of PC, known as periampullary cancers.
Generally defined, cancer itself is the rapid multiplication of cells caused by a mutation
in a patients genes within some specified area, such as the tissue of an organ, of the human body.
Cancer can either be deleterious (i.e. a malignant tumor) to a patients health or not deleterious
(i.e. a benign tumor). Indicative of the lower stages of cancer2, benign cancers stay in the
location of their growth3 and do not necessarily affect patients well-being, with regard to major
loss of bodily functions depending on the tissues and organs affected. On the other hand,
1

Statistical data provided is relevant to United States citizens.

There are four stages of cancer as denoted by the numbering system, one of the current methods of
staging cancer. Such methods and explanations are located in the following pages of this report.
2

stay in the location of their growth describes benign cancers non-metastatic conditions, which will
similarly be more thoroughly explained in the following pages.

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malignant tumors are indicative of the upper stages of cancer and may either grow in their own
locations or grow and metastasize to other areas of the body through a persons blood system
and/or lymphatic system (Research How Cancer Can Spread). Although cancerous cells
differentiate themselves from normal cells based on their increased ability to cause harm and
their inclination to rapidly multiply due to a mutation in the cells genetic codes, they too have a
similarity to normal cells as they grow and maintain sustenance by relying on a constant supply
of oxygen and other nutrients, provided by the cancer patient. This nourishment of the cancerous
cells is only possible if they stay in direct contact with a blood system. Now contrasting to
normal cells, cancer cells accommodate for this

requirement by sending out signals, called

angiogenic factors, to neighboring blood vessels to stimulate the growth of blood vessels for the
tumor (Research Grow 2). Therefore, this powerful ability and aforementioned properties
characterize cancer cells to be much more harmful than normal cells, posing an immense threat
to the lives of cancer patients.
Although tumors can be both benign and malignant, this report will focus on the
malignancies of four specialized types of periampullary cancer, so that related surgical treatment
methods can be discussed later on. These malignant tumors appear in the hepaticopancreatic
ampulla, otherwise referred to as the Ampulla of Vater, or hepaticopancreatic duct of the head of
the pancreas4. Anatomically, this site is where three key parts, the common bile duct, pancreatic
duct, and duodenum 5, coverage (Griffin Management 1) to form the Ampulla. In this location,
4 All

references (i.e. hepaticopancreatic ampulla, Ampulla of Vater, and hepaticopancreatic duct) to this
duct on the pancreas head define the same anatomical part.
5

The duodenum is part of the small intestine and is the site where the stomach adjoins to the small
intestine. Also, this body part is one of the key areas for attention during surgical treatment.

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these types of cancers are classified as periampullary cancers and are treated by one highly
powerful6 operation, a pancreaticoduodenectomy (PD) or the Whipple operation, provided the
following measures of precaution are carried out appropriately to determine a pancreatic cancer
patients eligibility for potentially curative pancreatic cancer surgery.
DIAGNOSIS
In diagnosing periampullary cancers, there is a handful of the most common presenting
symptoms to look for, which indicate problems in the gastro-intestinal system, otherwise known
as the GI tract. These symptoms include painless jaundice, light colored stool, dark urine,
abdominal pain, digestive issues, and weight loss not resulting from dieting or exercise (Griffin
Management 6). If a patient were to deal with one or more of these signs, diagnostic testing
and imaging is highly recommended to properly diagnose pancreatic cancer if apparent. In order
to properly assess if a patient has resectable7 cancer, which is predominantly characterized by a
malignant tumors encasement of a blood vessel8 or presence of metastases, some images must
be taken into consideration from the slices9 of imaging evaluation. Imaging evaluation mainly
relies on two things: a computed tomography (CT scan), which has a sensitivity of 91% for
properly assessing and imaging a patient, and magnetic resonance imaging (MRI) (Griffin
Management 8). Aside from imaging evaluation, non-imaging evaluation mainly relies on
The author of this paper regards the Whipple operation as powerful because of its low post-operative
(post-op) mortality rates discussed later on.
6

Resect, resectable, and resectability all define the surgical action of removing some body part, also
named as a specimen. Furthermore, in terms of cancer surgery, resect usually refers to the removal of a
tumor and other related masses.
8

This concept of vessel/vascular encasement will be explained later on.

slices refer to the numerous cross-sectional human body images a scan (such as a CT scan) will take.

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preoperative biopsies which take necessary samples of the affected site into consideration.
Nonetheless in both cases, either or both forms of evaluation are carried out to provide essential,
additional information concerning a cancers stage and resectability.
Among the specifications for cancer staging is the consideration for vessel involvement10.
Major vascular involvement accompanies the aforementioned idea of angiogenesis, as tumors
must reach out and send angiogenic factors to nearby blood vessels for their sustenance, which is
dependent on mainly oxygen and glucose. Because of this fact, the blood vessels and the cancers
have a chance to be intertwined and are thus, at times inseparable, rendering the patients case of
vessel-involved PC to be inoperablea significant factor when considering a patients eligibility
for tumor resection through PD.
Relative to imaging evaluation, on imaging tests, vascular involvement is seen as the
absence of fat between a tumor and a neighboring blood vessel11 (Wolfgang Personal), where
the color white denotes a major blood vessel, and the color dark gray indicates a tumor if it is
surrounded by adjacent black areas, which illustrate normal fat tissue. Since a patients eligibility
for the Whipple operation is majorly based off of his or her cancers vascular involvement, it is
important to know whether or not the patients cancer has encased a blood vessel through these
types of scans so that the surgical procedures may be modified or repudiated if necessary.

Because only a select few medical centers may be qualified for specialized vessel-involved pancreas
cancer removal techniques such as the Applebys procedure, this report will assume vessel-involved
cancers as predominantly unresectable to suit the wider range of surgical capabilities.
10

11

See Diagram 1 (Sandone).

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Alongside the knowledge of vascular involvement of a patients PC is the requirement to

assess for the correct cancer stage classification, which may delineate more information
regarding tumor size and spread for a patients healthcare team 12. There are two systems for
cancer staging. The first of which is TNM, which classifies the progression of cancer by Tumor,
Node, and Metastasis (Research Stages 3), whereas the second of which is the number
system13, which stages cancer with a range from Stage 1 through Stage 4 14. In order to
characterize cancer stages more clearly, the following are further details for the analysis of each
stage of pancreatic cancer. Firstly, Stages 1 and 2 are the earliest stages of cancer and detail
cancers that are most likely able to be treated with the combination of curative surgical treatment
and neoadjuvant and/or adjuvant chemotherapy or chemoradiotherapy. Additionally, these stages
also have no vessel involvement and no possibility to be metastatic, the ability of cancerous cells
to essentially break off from their initial, primary tumor and travel throughout a patients
bloodstream and/or lymphatic system to then grow as a secondary tumor on some other bodily
structure. Following this, Stage 3 is the most controversial stage when considering patient
eligibility for potentially curative surgical resection. At this stage, the patient has two
dramatically different outcomes from two dramatically different classifications: pancreatic
cancer can be either borderline resectable or locally advanced. The classification borderline
resectable details minimal to no vessel involvement and is therefore most likely to lead to

12

A multidisciplinary approach to healthcare for a cancer patient is the most widely-used, comprehensive,
and definitive method for the highest level of care (Wolfgang Pancreatic Cancer Surgical Techniques
7).
13

This report will utilize the number system for staging cancer.

14

Stage 1 is the least disseminated, in terms of cancerous cell spread, as compared to Stage 4 cancer
being the most disseminated.

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surgical resection15, whereas the term locally advanced details pancreatic cancer that has
extensive vascular involvement within is boundaries and may present the patients case to be
inoperable. Lastly, Stage 4 is the most advanced stage in terms of cancer characteristics and
treatment options, as only palliative systemic therapy in the form of chemotherapy and end-oflife care remains. Furthermore, whether or not vessel involvement is apparent, metastasis from
the primary pancreatic tumor disqualifies a patient for an operation. Therefore, it is evident that a
patients PC at Stages 1 and 2 would be expected to be treated by PD and just as a patients PC at
Stage 4 would be expected to be treated with systemic therapy, while PC at Stage 3 should be
given the most careful consideration when determining eligibility for PD treatment because of its
potential to be either borderline resectable or locally advanced.
Once a patient has shown the aforementioned possible signs of periampullary cancer,
undergone the correct number and range of imaging evaluations, and has been examined for
vascular encasement, he or she may then proceed to be considered as a potential candidate for
the Whipple operation. Generally speaking in the scope of surgical treatment, there are two
possibilities a patient with pancreatic cancer may encounter, as 20% of cases fall into the
potentially resectable16 category and the rest fall into the unresectable category. This is because
of clinical staging specifications previously mentioned. (Wolfgang Pancreatic 11). However, if
the previous conditions of staging are met and the patient is eligible for surgical treatment for his
or her periampullary cancer, then he or she would undergo a PD. In order to treat certain PCs,
15 A borderline

resectable cancer case has the possibility of being canceled due to initial abdominal
reassessment, as detailed below.
16

potentially resectable denotes the possibility that upon initial incision for surgery, the surgical team
may find additional information that may disqualify the patient from further curative surgery.

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there are a handful of surgeries named pancreatectomies, which either remove part or all of the
pancreas. Among these are surgeries that range from the most risky to not-as-risky. Examples
include a total pancreatectomy, distal pancreatectomy, segmental pancreatectomy, and a
pancreaticoduodenectomy, or Whipple operation, the primary focus of this report. Even this
operation has another well-known alternative. Aside from the conventional PD, the only
variation is the option for a pylorus preserving PD (PPPD) is available, which protects the
pylorus17 and keeps it intact by way of the alternative PD.
PD METHODOLOGY
PD is divided into three general steps. The first of which is a preliminary abdominal
reassessment for metastasis. Normally, surgeons first make an incision vertically from the lower
end of the sternum, otherwise known as the xiphoid process, to right below the navel. Following
the initial cut, several self-retaining retractors placed around the peritoneal18 cavity perpetually
expose the abdominal region so that further exploration for metastatic reassessment can take
place. Reassessment includes the physical palpation of both the visceral and parietal peritoneal
tissue linings to check for any anomaly, such as metastatic lesions for example.
The second of which is the mobilization of neighboring structures and the actual tumor
resection. Main anatomical parts to be resected include the pancreatic head, duodenum, distal
common bile duct, and gallbladder. Following this, the gastroduodenal artery is either ligated
twice or suture-ligated and then divided (Griffin Management 17). Then, the gallbladder is

17

The pylorus joins the end of the stomach to the duodenum.

18

The peritoneum is a thin, sheath-like layer that covers all organs (parietal) and cavity linings (visceral)

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resected by both ligating and dividing the cystic duct. Afterwards, the stomach is transected
proximally to the antrum, the jejunum is divided below the Ligament of Treitz, the pancreatic
neck is examined to identify the pancreatic duct, and the head of the pancreas and duodenum are
then retracted laterally (Griffin Management 18).
The third and final of which is the reconstruction and anastomoses of the gastrointestinal
system. There are three anastomoses to be performed: pancreatecticojejunostomy (PJ),
hepaticojejuostomy (HJ), and gastrojejunostomy (GJ) (Wolfgang Recent 334). The PJ must be
undertaken carefully, as it is the most susceptible to leakage. Absorbable sutures must be used for
an end-to-side duct-to-mucosa anastomosis (Griffin Management 19). The HJ is done a little
below the PJ and must use one layer of absorbable sutures. The GJ is completed below the HJ
and requires two layers of absorbable sutures, the inner and outer layers (Toronto Pancreaticoduodenectomy). Once the patient is closed, after the procedure detailed above, he or she taken
to the ICU for post-operative care.
Throughout history, the Whipple operation has continuously been refined to ensure as
low a mortality rate as possible, as the past 20 years have shown a decrease in Whipple operation
complications (Huang Quality). Furthermore, 35-45% of cases represents the quantity of
reported surgical complications. Some of these complications include Delayed Gastric Emptying,
which describes the condition where the patient cannot successfully empty his or her stomach,
and the most common of which, Postoperative Pancreatic Fistula (PPF), which can be presented
by transient anastomotic leak, intra-abdominal abscess, and frank fistula formation (Griffin
Management 23). PPF occurs because of certain risk factors like a small pancreatic duct or soft

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gland. Furthermore, the future of the Whipple operation continues to be defined, as more
technologically advanced alternatives like the robotic, minimally-invasive, and laparoscopic
Whipple are more safely in practice (Weiss Robotic Whipple Procedure).
CONCLUSION
Summarized, patients must undergo some combination of imaging evaluations and/or
specimen resection, otherwise known as a biopsy, in order to properly diagnose his or her
pancreatic cancer. Those with PC at Stages 1 and 2 are most likely to be eligible for curative
surgical resection because of the absence of tumor growth and spread as seen in the patients
preliminary scans, whereas PC at Stage 4 is unfortunately only treated by systemic
chemotherapy, as well as other forms of systemic treatment, because of the lack of treatment
options. Proper consideration of all aspects determines final patient eligibility to undergo surgical
treatment of a PD for a pancreatic cancer occurring in the periampullary region. This condition is
especially true for a patients PC at Stage 3, as it can exist as either borderline resectable or
locally advanced, with respect to major vascular involvement.
As for a summary of PD methodology, the Whipple operation is broadly divided into
three distinct phases. At the start, the surgeons of the surgical team perform initial abdominal reexploration to reassess for any missed metastasis before proceeding into the procedure. Second,
they mobilize key organs and other structures along with the main tumor resection. Third, the
reconstruction of these structures follows before closing. In conclusion, given proper
consideration for the diagnosis of a periampullary pancreatic cancer through specific criteria for
imaging evaluation and cancer staging, a patient may be eligible for the much esteemed Whipple
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operation, a surgical treatment alternative to cure cancer. Therefore, for the methodology of the
Whipple operation and its following information on complications and statistics on patient
prognoses, if a patient is eligible to undergo surgical treatment, detailed in the steps above, it is
highly likely for him or her to receive a great post-operative prognosis with much hope.

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Appendix

(Dia. 1) The red arrow is pointing to the light gray mass (tumor) surrounded by the cancer
patients dark gray areas (Sandone Encasement).

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(dia. 2) - Pictured above is a pancreaticoduodenectomy (aka PD or Whipple operation) for

periampullary cancer. The left image shows the resection lines, while the right image depicts the final
anastomomoses of structures (Wolfgang Pancreatic Cancer: Surgical Techniques).

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