Research Article| Volume 172, ISSUE 5, P432-438, November 1996

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Reoperative pancreaticoduodenectomy for periampullary carcinoma

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      We have noted a continued increase in the number of patients referred to our institution for presumed or biopsy-proven periampullary carcinoma following an “exploratory” laparotomy during which tumor resection was not performed. Although previous work has demonstrated the safety of reoperative pancreati-coduodenectomy PD), the need to avoid non-therapeutic laparotomy in these patients is obvious. In the current study, we sought to determine why PD was not performed at the initial operation.


      Using the prospective pancreatic cancer database, we identified all patients who underwent reoperative PD at our institution between June 1990 and October 1995. Radiologic imaging prior to reoperation was standardized and based on thin-section, contrast-enhanced computed tomography (CT); helical CT was used in more recent cases. Pathologic data were obtained, and initial outside operative reports were reviewed to determine why a PD was not performed at the initial procedure.


      Twenty-nine patients underwent reoperative PD. Resection was not performed at the initial laparotomy because of the surgeon's assessment of local unresectability (17 patients), lack of a tissue diagnosis of malignancy (9), misdiagnoses (2), and error in intraoperative management (1). In the 17 patients deemed to have unresectable disease, successful reoperative PD required vascular resection in 10. All 10 of these patients had resection with negative microscopic margins of excision. Of the 9 patients who did not have resection owing to diagnostic uncertainty, all 9 had undergone multiple intraoperative biopsies interpreted as negative for malignancy; 6 of 9 had carcinoma confirmed on permanent-section analysis of the biopsy specimens. Four patients suffered major complications from intraoperative large-needle biopsy.


      Detailed preoperative imaging and a clearly defined operative plan would have allowed successful resection at the initial operation in 27 of 29 patients who underwent reoperative PD. Avoidable patient morbidity and the cost of unnecessary surgery argue strongly against “exploratory” surgery in patients with presumed periampullary neoplasms.
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        • Fuhrman GM
        • Charnsangavej C
        • Abbruzzese JL
        • et al.
        Thin-section contrast-enhanced computed tomography accurately predicts the resectability of malignant pancreatic neoplasms.
        Am J Surg. 1994; 167: 104-113
        • Robins DB
        • Katz RL
        • Evans DB
        • et al.
        Fine-needle aspiration of the pancreas: in quest of accuracy.
        Acta Cytol. 1995; 39: 1-10
        • Sung JJY
        • Chung S
        Endoscopic stenting for palliation of malignant biliary obstruction, A review of progress in the last 15 years.
        Dig Dis Sci. 1995; 40: 1167-1173
        • Evans DB
        • Winchester DJ
        • Lee JE
        Laparoscopic cholecystoje-junostomy.
        in: MacFadyen BV Ponsky JL Operative Laparoscopy and Thoracoscopy. Raven Press, New York1996: 343-358
        • Evans DB
        • Staley CA
        • Lee JE
        • et al.
        Adenocarcinoma of the pancreas: recent controversies, current management, and future therapies.
        GI Cancer. 1996; 1: 149-161
        • Parker SL
        • Tong T
        • Bolden S
        • Wingo PA
        Cancer statistics.
        CA Cancer J Clin. 1996; 46: 19
        • Rooij PD
        • Rogatko A
        • Bennan MF
        Evaluation of palliative surgical procedures in unresectable pancreatic cancer.
        Br J Surg. 1991; 78: 1053-1058
        • Lillemoe KD
        • Sauter PK
        • Pitt HA
        • et al.
        Current status of surgical palliation of periampullary carcinoma.
        Surg Gynecol Obstet. 1993; 176: 1-10
        • Tyler DS
        • Evans DB
        Reoperative pancreaticoduodenectomy.
        Ann Surg. 1994; 2: 211-221
        • Staley CA
        • Lee JE
        • Cleary KR
        • et al.
        Preoperative chemoradiation, pancreaticoduodenectomy, and intraoperative radiation therpy for adenocarcinoma of the pancreatic head.
        Am J Surg. 1996; 171: 118-125
        • Evans DB
        • Lee JE
        • Pisters PWT
        Pancreaticoduodenectomy (Whipple operation) and total pancreatectomy for cancer.
        in: Nyhus LM Baker RJ Fischer JF Mastery of Surgery. 3rd ed. Little, Brown and Co, Boston1996
        • Evans DB
        • Termuhlen PM
        • Byrd DR
        • et al.
        Intraoperative radiation therapy following pancreaticoduodenectomy.
        Ann Surg. 1993; 218: 54-60
        • Staley CA
        • Cleary KA
        • Abbruzzese JA
        • et al.
        Need for standardized pathologic staging of pancreaticoduodenectomy specimens.
        Pancreas. 1996; 12: 373-380
        • Gastrointestinal Tumor Study Group
        A multi-institutional comparative trial of radiation therapy alone and in combination with 5-fluorouracil for locally unresectable pancreatic carcinoma.
        Ann Surg. 1979; 189: 205-208
        • Klempnauer J
        • Ridder GJ
        • Bektas H
        • Pichlmayr R
        Surgery for exocrine pancreatic cancer — who are the 5-and 10-year survivors?.
        Oncology. 1995; 52: 353-359
        • Nitecki SS
        • Sarr MG
        • Colby TV
        • van Heerden JA
        Long-term survival after resection for ductal adenocarcinoma of the pancreas, Is it really improving?.
        Ann Surg. 1995; 221: 59-66
        • Willet CG
        • Lewandrowski K
        • Warshaw AL
        • et al.
        Resection margins in carcinoma of the head of the pancreas: implications for radiation therapy.
        Ann Surg. 1993; 217: 144-148
        • Yeo CJ
        • Cameron JL
        • Lillemore KD
        • et al.
        Pancreaticoduodenectomy for cancer of the head of the pancreas: 201 patients.
        Ann Surg. 1995; 221: 721-733
        • Geer RJ
        • Brennan MF
        Prognostic indicators for survival after resection of pancreatic adenocarcinoma.
        Am J Surg. 1993; 165: 68-73
        • Trede M
        • Schwall G
        • Saeger H
        Survival after pancreatico-duodenectomy, 118 consecutive resections without an operative mortality.
        Ann Surg. 1990; 211: 447-458
        • Alvarez C
        • Livingston EH
        • Ashley SW
        • et al.
        Cost-benefit analysis of work-up for pancreatic cancer.
        Am J Surg. 1993; 165: 53-60
        • Cusack JC
        • Furhman GM
        • Lee JE
        • Evans DB
        Management of unsuspected tumor invasion of the superior mesenteric-portal venous confluence at the time of pancreaticoduodenectomy.
        Am J Surg. 1994; 168: 352-354
        • Fuhrman GM
        • Leach SD
        • Staley CA
        • et al.
        Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence.
        Ann Surg. 1996; 223: 154-162
        • Evans DB
        • Lee JE
        • Leach SD
        • et al.
        Vascular resection and intraoperative radiation therapy during pancreaticoduodenectomy: rationale and technique.
        Adv Surg. 1996; 29: 235-262
        • Leach SD
        • Lowy AM
        • Fuhrman GM
        • et al.
        Pancreatic malignancy involving the superior mesenteric-portal vein confluence is not a contraindication to pancreaticoduodenectomy.
        Gastroenterology. 1995; 108: A1228