The retroperitoneal resection margin: An independent prognostic factor in periampullary carcinoma

Mohanasundaram Avudaiappan, MS, Thakur D Yadav, MS, Vikas Gupta, Mch, Ashim Das, MD, Rakesh Kochhar, DM, Saroj K Sinha, DM, Anupam Lal, MD. PGIMER,CHANDIGARH

INTRODUCTIONS:The retroperitoneal resection margin is most common margin microscopically involved by tumor in resectable periampullary carcinomas. The aim of the study was to evaluate outcome in patients who have undergone  pancreaticoduodenectomy in terms of  retroperitoneal resection margin is an independent prognostic factor in periampullary carcinoma. The aim of the study is to determine: 1) The total incidence of positive SMA margin in resected pancreaticoduodenectomy specimen. 2) To see how it correlate with the type of periampullary carcinoma( head of pancreas,distal bile duct,duodenal and ampullary).

METHODS AND PROCEDURES:46 patients of periampullary adenocarcinoma undergone surgery were included in our study.Two senior surgeons were involved in the study denude at least 4cm  of SMA and  they had followed the same protocol for all patients.The SMA margin  marked with methylene blue.Specimen cut and origin  of the tumour  documented on the table by surgeon.  A detailed gross examination of the specimen carried out. At first,the components of the specimen  assessed and then the exact location of the tumour  identified i.e. ampullary,pancreatic head,distal cholangio,duodenal. The bile duct resection margin,pancreatic resection margin and the retroperitoneal resection margin  sampled. The reteroperitoneal margin was identified directly adjacent to the proximal 3-4 cm of the SMA. Samples of multiple areas of tumour including the adjacent non-tumorous areas  submitted for paraffin section(5-BO section).Pathologic evaluation of the specimen includes:1)Histology of tumour,2)Differentiation,3)Origin of tumour,4)Vascular,lymphatic and perineural invasion-presence or not,5)The status of resection margins of common bile duct,pancreatic margin and the retroperitoneal margin,6)lymph node status. We had done minimum followup of five months after surgery.34 patients completed minimum  postop period of 5 months followup.Two  patients had lost in followup Associations between histological factor evaluated by chi-square test.Survival curves were calculated by the Kaplan meier method.

RESULTS: In our study cholangiocarcinoma(34.8%) was the predominat component of periampullary carcinoma. Retroperitoneal margin was involved in six (13%) cases.Among that three cases were cholangio carcinoma and three cases were carcinoma head of pancreas.Mean survival of these patients is 11.58 months,Patients with retroperitoneal margin positive had mean survival of 7.5 months,comparing to mean survival of 11.39 months of retroperitoneal margin negative patients.Among all cases carcinoma head of pancreas had poor survival with mean survival of 7.7 months.

CONCLUSIONS: In  our study we had found that: 1) Cholangiocarcinoma was the most common type of periampullary carcinoma 2) Carcinoma head of pancreas had the poor survival comparing to the other periampullary malignancies 3) Retroperitoneal  margin involvement was the independent poor prognostic factor for survival.

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