Kimberly Kirkwood, M.D. Professor of Pancreatic and GI Surgery. Risk Factors

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1 : What Can Surgeons Do to Maximize Survival? Kimberly Kirkwood, M.D. Professor of Pancreatic and GI Surgery UCSF Postgraduate Course, General Surgery Maui, HI March 22, 2011 In 2010: New Cases: 43,140 (trend: significantly increasing) Deaths: 36,800 (85%) Median Age at Dx: 72 yrs Risk: 1 in 71 men and women; 1.4% lifetime risk Risk Factors Smoking: 3x risk (packs,yrs) Diabetes: Genetics:?cause or effect 5-10% known germ line mutation; another 10% suspected Role of EUS Rosch 1995 GI Endosc Clinics N Amer NONE! 69 yo man persistent epigastric discomfort after pancreatitis 1

2 EUS is Essential to evaluate: suspected lesions isodense on CT ( fullness, ground glass, granularity, hypodense ) patients with high clinical suspicion, nl CT (jaundice without CDS, epig. discomfort/wt. loss) cystic lesions >2cm Useful to bx the primary tumor if surgery is not 1 st Rx (? Less peritoneal spread than with CT-guided?) Unnecessary in most patients with resectable PDA! EUS We re seeing more: Older Patients (3x) 86 yo woman with abdominal discomfort, anorexia and 8 lb wt. loss/2 mos, alb 3.4 mg/dl Median Survival (all ages): Stent Alone vs. Resection 6-9 mos. 18 mos.* 5 Year Survival 0 30% *Elizabeth Holly, UCSF 2006 Candidacy: Fit (walks 2miles/dy until recently) Goal: 60 th wedding anniversary, 11 mos. away Unlikely to achieve without resection Whipples in Older Patients: Lessons Learned Whipple uncomplicated, R0 Epidural could not be placed, OA ICU: fentanyl, MA4 but Confused, no commands, head CT negative Avoid narcotics/sedatives: Delirium grimace with just tylenol POD 2: ketorolac 15mg (nl Cr, u.o.) Cr: 0.9 to 2.4 mg/dl in 2dys: Hi Risk ATN Confusion better after 3 weeks, SNF x 3wks Walker: Hi Risk Functional Impairment Surgical jejunostomy x 2mos: Hi Risk Malnutrition Danced at their 60 th Anniversary Party! in Older Patients Higher incidence of postoperative complications (70 vs. 56%): PNA (13 vs. 5%) Cardiac events (13 vs. 0.5%) ICU stay (47% vs. 20%) ATN (7 vs. 2%) Delayed Functional Recovery 200 pts. UCSF v. 3,000 pts. CA, 15% >75 yrs. Mortality: CA 10%; UCSF 3% 2

3 We re Seeing More: Locally Advanced: Responders to Chemotherapy! Does CA Predict Metastatic Disease? Probably especially trends 56 yo f. cp, DM, erratic bs x 6mos, worse abd pain, CA U/ml Combination CTX x 9mos Less pain, wt. gain CA U/ml prognostic? Patients with hi CA 19-9 (>182) had worse OS & clearly benefit from CTX (adjuvant) nl is better but approx. 10% general pop. Lewis Ag negative Decline in CA 19-9 associated with improved resectability and overall survival 56 yo woman after 9 mos combination CTX Post C/XRT, CA 19-9 from 192 to 35 U/ml Pain improved, weight stable DM: hi stable doses insulin We re Seeing More: Neoadjuvant Responders 59yo man jaundice, 10# wt. loss, U/ml CT: multiphase, 1.25mm cuts, cor/sag recons Total Pancreatectomy, short seg.smv patch angioplasty T2N1 (1/25 direct invasion) Prolonged los due to gastroparesis, pna? Role of BS swings 1 year out, NED, lower insulin doses, off narcotics 3

4 Neoadjuvant Rx for borderline/la tumors Truly localized diz. is rare Best way to ensure delivery of ctx is to give it up front 3-4 mo. window into tumor biology and response to ctx Also, window into patient performance under Tx stress Neoadjuvant Responder: 59yo man jaundice, 10# wt. loss, U/ml Re-Staging: fine toothed comb Clinically good, 19-9 nl or significantly decreased Look for unusual patterns of diz: PET Diagnostic laparoscopy: liver surface,peritoneal <5mm CT: localized disease, scar vs. tumor? Portal Vein Resection? YES! Many series show equivalency to standard Whipple: Improved survival vs. non-operative mgmt; median 20 mos. Lyon: 5/30 pts. pv/smv or cha reconstruction; > 5yrs out Tended to be younger (mean 61) all R0 all adjuvant CTX +/- XRT Vascular Reconstruction Prefer 1 blood vessel (bv) Prep the groins! Pedicle the tumor on the bv Heparin GI surgeon cuts it out, vascular surgeon sews it up Typically primary closure pending margins sv, ij patch or segment Our pt, Whipple, R0 resection, long vein patch Home after 9 dys T2NO/62, A&W, NED 2 years out Anatomy of the Superior Mesenteric Vein With Special Reference to the Surgical Management of First-order Branch Involvement at Pancreaticoduodenectomy. Katz, Matthew; Fleming, Jason; Pisters, Peter; Lee, Jeffrey; Evans, Douglas Annals of Surgery. 248(6): , December DOI: /SLA.0b013e f0 3 4

5 Lymph Node Retrieval: Does It Matter? Expertise and Systems of Care Survival after Whipple improved with: Surgeon Volume: > 5/yr; >100 career Hospital Volume: >17/yr Somewhat Surprisingly, Total # lymph nodes retrieved >15 predicted improved OVERALL survival after Whipple resection Survival after Whipple improved with: General Surgery Residency GI Fellowship Interventional Radiology onsite Clearly Resectable, Fit Resect UCSF 5-year Survival: 42% : Current Approach Initial Staging: (19-9, PET/CT) Borderline 19-9 <1000, Fit Clinically stable + LA: Rad. Resp. Bor: nonprogres. Borderline + hi 19-9 or co-morbid Or Locally advanced BX (eus or ct): pda CTX x 3-4 cycles Re-Stage LA:Inadequate Local response C/XRT Progression Or unfit Non- Surgical Rx Thank You! Kimberly Kirkwood, M.D. Professor of Pancreatic and GI Surgery UCSF Medical Center 400 Parnassus Avenue Room A-655, Box 0338 San Francisco, CA Appts. (415) ; fax (415) Physicians (415) Kim.Kirkwood@ucsfmedctr.org 5