A 65-year-old man with ductal adenocarcinoma in the head of the pancreas was operated elsewhere (laparotomy and biliary diversiobn) and he was considered inoperable. He was discharged and he came to see me for a second opinion. 6th postoperative day now. Analysis of CT scan was totally resectable. What to do next? Rush to the OR and perform a Whipple procedure or send him to neoadjuvant chemotherapy?
what was the operative finding that made the condition inoperable??
According to the surgeon, the tumor was too large to be removed. No extra pancreatic metastasis were found. No liver mets, no lymphnodes mets. Locally inoperable. Reviewing CT scan (performed one day before surgery, 7 days ago) it is clearly resectable. Ductal adenocarcinoma.
just go for it my friend ,if the CT shows clear , it is possible that he did not do much dissection and pulled back based on size .. so maybe not two bad adhesions
Agree with Mo, the surgeon's report was not so clear about dissection of the tumor and maybe one week may be soon enough to reoperate without much adhesions.
I think there is only one way: if there is resectable tumor, it has to be resected as soon as possible.
The resection of the tumor is the first and most importante step to do
Usually
1.the tumor size is not a key factor:
2. Artery involvement is a real key point:
3. Adhesions after by-pass surgery are not so heavy if there were no attepts to mobilize the tumor.
If the vein is involved, i think neoajuvant will be the best option
Best
I think an expert surgeon in this tumor is the first election to choose
This is actually a very rare situation With years af experience in pancreatic surgery I never had a situation like this one The resection is the best way to deal with this case
I agree with Dr Egorov that tumor size is not a key factor but this is the first surgeon opinion or excuse not to proceed with the resection. Anyway, review of the CT scan showed a 3.5 cm tumor with no arterial nor venous invasion whatsoever. Luckily the patient looked for a second opinion as soon after discharge and the timing for reoperation is optimal. Therefore we decided for immediate reoperation.
We agree with Dr Rodrigo that resection is the best alternative. We also agree with Dr Machado that this is a very rare situation. Usually the patient come after one month or more and at that time, hard adhesions are to be expected and normally we decide to perform neoadjuvant chemotherapy in this setting.
The are few selected indications for this technique but thinking on the possibility to perform later on a liver transplantations if it is needed
I believe that still dense adhesions are not yet formed , then reoperation my be the best for him if exploration confirmed the CT findings
The resection must be the first choice in hands of an expert surgeon, of course
Neo-adjuvant therapy to reduce tumour size / shrink the tumour followed by Resection
I think you may have already performed the resection What did you find ? What was the reason the first surgeon did not performed the resection? What was the pathological repot ?
If the resection is not possible, the best option would be the neb-adjuvant therapy, of course!
I agre with DR Rodrigo and folfirinox ar the presente time is the best option for neo adjuvante therapy
We decided to reoperate immediately. The operation took place exactly on the 7th postoperative day. We found only mild and soft adhesions with easy access to the head of the pancreas. The previous surgeon really tried hard to resect, portal tunnel was already done and it was easy to encircle the neck of the pancreas. There was a Roux en Y latero-lateral bilioenteric diversion. There was a rare vascular variation. The trunk of hepatic artery arised from the SMA and therefore the previous surgeon though that there was an invasion. However, as you may know, this variation runs vertically towards SMA and not horizontally, so there was no vascular invasion whatsoever. The resection was somehow easy and we perform a Whipple procedure with isolated pancreato-jejunal anastomosis.
The previous surgeon for sure Was not a pancreátic surgeon therefore was not able to recognize the vascular variation I would like to Know What was the patológic report
Pathological report not ready. Frozen section analysis showed clear margins. Here is the CT scan.
Good job! I did the same approach ! if the scan shows the tumor resectable ithe re-operation is mandatory !
Congratulations to all your team for the excellent approach and removal of the tumor. We are expecting the final results of the pathology findings
well done congrats,once a good CT shows no vascular invasion and previous surgeon did not find any mets,Resection is the ideal option.
Patient recovered well, apart from some delayed gastric emptying that resolved with conservative treatment. Final pathology T3N0(0/25).
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