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“Blind pancreatectomy ”

Simposio : “ Pancreatic Cancer: Surgical Treatment, 2013” Roma, 26 marzo 2013. Marco Catarci Dipartmento di Chirurgia. “Blind pancreatectomy ”. Helical CT. SSO-AHPBA Consensus Conference, Ann Surg Oncol 2009. Diagnosi cito-istologica preoperatoria. Linee guida.

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“Blind pancreatectomy ”

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  1. Simposio: “Pancreatic Cancer: Surgical Treatment, 2013” Roma, 26 marzo 2013 Marco Catarci DipartmentodiChirurgia “Blind pancreatectomy”

  2. Helical CT SSO-AHPBA Consensus Conference, Ann SurgOncol 2009

  3. Diagnosi cito-istologica preoperatoria • Lineeguida For patients expected to undergo surgery with radical intent, a previous biopsy is not necessary, and even preoperative percutaneous sampling should be avoided. Biopsy proof of malignancy is not required before surgical resection and a non-diagnostic biopsy should not delay surgical resection when the clinical suspicion for pancreatic cancer is high However, a preoperative diagnostic biopsy may not be needed in a fit patient with a potentially resectable pancreatic lesion that is highly suspected of malignancy.

  4. Blindpancreatectomy • 50-70% in letteratura Camp ER et al., American Surgeon 2004 Sasson AR et al., American Journal ofSurgery 2006

  5. Chirurgia del pancreas

  6. Diagnosi cito-istologica preoperatoria • Lineeguida Attempts should be made to obtain a tissue diagnosis during the course of investigative endoscopic procedures. Failure to obtain histological confirmation of a suspected diagnosis of malignancy does not exclude the presence of a tumour, and should not delay appropriate surgical treatment. Avoid transperitoneal biopsy in patients with potentially resectabletumours If EUS is being done, try and obtain tissue diagnosis Try to obtain histological confirmation of cancer in all patients being referred for chemotherapy and/or radiotherapy, and preferably in patients being referred for palliative care Many surgeons are reluctant to proceed with pancreaticoduodenectomy in the absence of cytologic or histologic confirmation of disease. For those surgeons, EUS-guided or CT-guided FNA is a reasonable alternative.

  7. Diagnosi cito-istologica preoperatoria • Fattore tempo Giorno 0 diagnosi istologica Giorno 5 preospedalizzazione Giorno 10-15 intervento chirurgico programmazione del 2° tentativo programmazione del 3° tentativo attesa per l’E.I. attesa per l’E.I. attesa per l’E.I. Giorno 14 3° tentativo Giorno 21 Giorno 0 1° tentativo Giorno 7 2° tentativo

  8. Diagnosi cito-istologica preoperatoria • Metodiche • 1. CPRE • brushing • biopsia 2. EUS • EUS-FNA 3. Biopsia percutanea • ECO/TC-guidata

  9. Br J Surg 2009; 96:5-20

  10. CITOLOGIA TIROIDEA CITOLOGIA PANCREATICA Panc1. NON DIAGNOSTICO Panc2. NEGATIVO PER CELLULE MALIGNE Panc 3. INCONCLUSIVO/INDETERMINATO (atipie epiteliali lievi-moderate) Panc4. SOSPETTO DI MALIGNITA’ Panc5. POSITIVO PER CELLULE MALIGNE Tir 1. NON DIAGNOSTICO Tir 2. NEGATIVO PER CELLULE MALIGNE Tir 3. INCONCLUSIVO/INDETERMINATO (Proliferazione Follicolare) Tir 4. SOSPETTO DI MALIGNITA’ Tir 5. POSITIVO PER CELLULE MALIGNE • Diagnosi citologica preoperatoria • Perchè no?

  11. Diagnosi citologica preoperatoria • CBM Roma – 01/2011-02/2012 23.4% 69%

  12. SENSIBILITA’: 80% SPECIFICITA’: 100% • Diagnosi citologica preoperatoria • CBM Roma Quadro atipico/inconclusivo (Panc3) VALUTAZIONE DEL K-RAS Tada M. et al., Am J Gastr 2002 K-RAS: negativo RISULTATO NEGATIVO PER NEOPLASIA

  13. EUS-FNA • SFN Roma Dr. Marco Bianchi - UOC Gastroenterologia Dr. L. Coppola – UOC AnatomiaPatologica

  14. Diagnosi cito-istologica preoperatoria • Fattorepatologo

  15. EUS-FNA • Inchiestanazionalesu 26 centri; • 953 lesionisolide e 330 lesionicistiche del pancreas Bianchi M, et al. 2013 in press

  16. IPMN centrali IPMN misti IPMN periferici

  17. IAP guidelines 2012 • IPMN centrali/misti • IPMN centrale/misto senza sintomi/noduli • e con Wirsung < 1 cm – Pz anziano EUS + FNA Nodulo murale, ispessimento parietale, citologia positiva per cellule atipiche/maligne Esame ″negativo″ o “non diagnostico” FOLLOW-UP stretto CHIRURGIA Tanaka M, et al. Pancreatology 2012; 12:183-197

  18. IAP guidelines 2012 • IPMN periferici • Resezione chirurgica se (high-riskstigmata): • Sintomi maggiori (ittero) • Noduli parietali vascolarizzati • Citologia positiva per cellule maligne/atipiche • (Diametro > 3 cm, rapida crescita) Tanaka M, et al. Pancreatology 2012; 12:183-197

  19. Blindpancreatectomy • Conclusioni • La blindpancreatectomy è uno standard in molte linee guida, ma in assenza di evidenza (grado C) • L’elevata morbilità della chirurgia pancreatica resettiva e l’aumento delle controversie medico-legali suggeriscono di effettuare almeno un tentativo di diagnosi citopatologica • EUS+FNAcritica nelle lesioni cistiche • L’esecuzione sistematica di EUS + FNA è l’unico modo di ottenere un ambiente multidisciplinare adeguato

  20. “God put the pancreas posteriorly is that so surgeons wouldn’t mess with it “ Allen O. Whipple (1881-1963)

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