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Edward L. Lee, M.D. Professor & Chairman Department of Pathology Howard University College of Medicine. PERIAMPULLARY TUMORS AND THE DISSECTION OF THE WHIPPLE RESECTION. IN MEMORIAM ALLEN O. WHIPPLE, M.D. 1881 - 1963. WHIPPLE PROCEDURE. PERFORMED FOR Periampullary Tumors (104).

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edward l lee m d professor chairman department of pathology howard university college of medicine
Edward L. Lee, M.D.

Professor & Chairman

Department of Pathology

Howard University

College of Medicine

whipple procedure
WHIPPLE PROCEDURE

PERFORMED FOR

Periampullary Tumors (104)

  • Pancreatic CA -70
  • Ampullary CA -20
  • Duodenal CA -10
  • Distal bile duct CA -4

Chronic pancreatitis (38)

whipple procedure pancreaticoduodenectomy
WHIPPLE PROCEDURE (PANCREATICODUODENECTOMY)

Specimen

  • Distal stomach
  • Duodenum
  • Head of pancreas
  • Distal bile duct
  • Gallbladder
  • Proximal jejunum
whipple procedure6
WHIPPLE PROCEDURE

Reconstruction

  • Pancreatico jejunostomy
  • Choledocho jejunostomy
  • Gastrojejunostomy -
whipple specimen
WHIPPLE SPECIMEN

Frozen Section

  • Pancreatic resection margin
  • Bile duct margins

Probe Bile Duct

  • Dilated
  • Identified by surgeons with black suture
whipple specimen8
WHIPPLE SPECIMEN

Dissect The Unfixed Specimen

  • Open the stomach along greater curvature
  • Open the duodenum along the border opposite the pancreas

- Duodenal mucosa looks

dusky because the blood

supply is ligated earlier

in the operation

whipple specimen9
WHIPPLE SPECIMEN

Dissect The Unfixed

Specimen

  • Open the bile duct extending to ampulla
  • Identify the main pancreatic duct
whipple specimen pancreatic ca
WHIPPLE SPECIMENPANCREATIC CA

Pathologic Features

Gross

  • Effacement of lobules
  • Invasive CA
  • Fibrosis
whipple specimen11
WHIPPLE SPECIMEN

Periampullary

Tumors

  • Pancreatic tumors
  • Bile duct tumors
  • Ampullary tumors
  • Duodenal tumors
whipple specimen12
WHIPPLE SPECIMEN

Record Dimensions

  • Stomach
  • Duodenum
  • Pancreatic head
  • Margins
  • Lymph nodes (10)
whipple specimen pancreatic ca13
WHIPPLE SPECIMEN PANCREATIC CA

Describe The Tumor

  • Size
  • Color
  • Consistency
  • Cysts
  • Relationship to anatomic sites
  • Distance from margins
  • Obstruction of ducts
  • Remainder of pancreatic parenchyma
whipple specimen14
WHIPPLE SPECIMEN

Sections (20)

  • Resection Margins

- Pancreatic

- Uncinate process

- Gastric

- Duodenal

- Common bile duct

  • Tumor

- Tumor and common bile

- Tumor and pancreatic duct

- Tumor and pancreatic parenchyma

  • Uninvolved pancreas
  • Ampulla
  • Lymph nodes (10)

- Common bile duct

- Pergastric

- Periduodenal

- Pancreatic

endoscopy duodenal ca
ENDOSCOPY DUODENAL CA

Endoscopic Appearance

  • 3 cm polypoid,

ulcerating CA

whipple specimen duodenal ca
WHIPPLE SPECIMEN DUODENAL CA

Pathologic Features

Gross

  • 3 cm polypoid, ulcerating CA
whipple specimen duodenal ca17
WHIPPLE SPECIMEN DUODENAL CA

Pathologic Features

Micro

  • Ulcerating Adeno CA
  • Invades pancreas

Prognosis

5 – year survival rate –30%

endoscopy ampullary ca early
ENDOSCOPYAMPULLARY CA - EARLY

Endoscopic Appearance

  • 1.5 polypoid CA
whipple specimen ampullary ca early
WHIPPLE SPECIMEN AMPULLARY CA - EARLY

Pathologic Features

Gross

  • 1.5 cm mass
whipple specimen ampullary carcinoma early
WHIPPLE SPECIMEN AMPULLARY CARCINOMA - EARLY

Pathologic Features

Micro

  • Adeno CA
  • Confined to mucosa

Prognosis

5 – year survival rate - good

whipple specimen ampullary carcinoma advanced
WHIPPLE SPECIMEN AMPULLARY CARCINOMA - ADVANCED

Pathologic Features

Gross

  • 2 cm polypoid

ulcerating CA

whipple specimen ampullary carcinoma advanced22
WHIPPLE SPECIMEN AMPULLARY CARCINOMA - ADVANCED

Pathologic Features

Gross

  • Invasive adeno CA
  • Tumor invades pancreas

Micro

  • Invasive adeno CA
  • Tumor invades pancreas

Prognosis

5 – year survival rate - 34%

whipple procedure bile duct ca
WHIPPLE PROCEDURE BILE DUCT CA

Pathologic Features

Gross

  • Protuberant ampulla
whipple procedure bile duct ca24
WHIPPLE PROCEDURE BILE DUCT CA

Pathologic Features

Gross

  • Mass in distal bile duct
  • 3 cm papillary CA
whipple procedure bile duct ca25
WHIPPLE PROCEDURE BILE DUCT CA

Pathologic Features

Gross

  • Invasive papillary CA

Micro

  • Invasive papillary CA
  • Metastasis to lymph node

Prognosis

5 – year survival rate – 15%

pancreas
PANCREAS

Anatomy

  • Head
  • Body
  • Tail
pancreas28
PANCREAS

Histology

Exocrine

  • Acinar cells
  • Ducts

Endocrine

  • Islet cells
    • Insulin
    • Glucagon
    • Somatostatin
    • Pancreatic polypeptide
pancreatitis
“Acute”

Inflammation

Edema

Fat Necrosis

Hemorrhage

PANCREATITIS
  • “Chronic”
  • Inflammation
  • Destruction of exocrine glands
  • Destruction of endocrine glands
  • Fibrosis
chronic pancreatitis
CHRONIC PANCREATITIS

Causes

  • Alcohol abuse
  • Obstruction
  • Cystic fibrosis
  • Hereditary
  • Tropical
chronic pancreatitis32
CHRONIC PANCREATITIS

Pathologic Features

Gross

  • Fibrosis
  • Dilated ducts
  • Calcified concretions
chronic pancreatitis33
CHRONIC PANCREATITIS

Pathologic Features

Micro

  • Fibrosis
  • Atrophy of acini
  • Dilated ducts with concretions
complications of chronic pancreatitis
COMPLICATIONS OF CHRONIC PANCREATITIS
  • Pseudocysts
  • Duct obstruction
  • Malabsorption
  • Steatorrhea
  • Secondary diabetes
  • Carcinoma
neoplasms of the pancreas
NEOPLASMS OF THE PANCREAS

Cystic Neoplasms

  • Serous cystadenomas
  • Mucinous cystic neoplasms
  • Intraductal papillary mucinous neoplasms

Solid Neoplasms

  • Pancreatic ductal adenocarcinoma
  • Endocrine tumors
pancreatic carcinoma
PANCREATIC CARCINOMA

Clinical Features

  • Fourth leading cause of cancer death in U.S.
  • 30,000 patients diagnosed and die from it
  • Genetic disease: mutations in K-RAS, p53

5-year Survival Rate <5%

pancreatic ductal adenocarcinomas
PANCREATIC DUCTAL ADENOCARCINOMAS

Diagnosis

  • ERCP (endoscopic retrograde cholangio- pancreatography)
  • Fine needle aspiration biopsy
  • Ct scan
  • CA-19-9
pancreatic ductal carcinomas
PANCREATIC DUCTAL CARCINOMAS

Risk Factors

  • Tobacco abuse
  • Chronic pancreatitis
  • Hereditary pancreatitis
  • Diet (high in fats and meats)
  • Chemical carcinogen exposure
  • Pancreatic Intraepithelial Neoplasias (PanINs)

Pan INs 1 2 3 CA

pancreatic carcinoma pathology
PANCREATIC CARCINOMA PATHOLOGY

Microscopic

  • Poorly formed glands in fibrotic stroma
metastatic pancreatic ca to liver
METASTATIC PANCREATIC CA TO LIVER

Hematogenous

Metastases

  • Portal vein
  • Hepatic artery
whipple procedure42
WHIPPLE PROCEDURE

Complications

  • Post Op Mortality Rate

- 2 - 5%

  • Morbidity Rate

- 20 - 50%

  • Leakage

- Pancreaticojejunal

anastomosis (15%)

- Choledochojejunal

anastomosis (7%)

whipple procedure43
WHIPPLE PROCEDURE

Cost

  • $34,000 to $92,000
  • High-volume centers

- Lower hospital cost

- Shorter hospital stay

- Lower morbidity