Tatalaksana dan Prognosis Tumor

periampullar
Terapi Pembedahan
Prosedur Whipple (Pancreaticoduodenectomy)
Mortalitas rendah di pusat kesehatan besar (<5%)
Survival rate terbaik (>50% 5-year)
Morbiditas tinggi (25-65%)
Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier;
2011
GUT Online.Guidelines for the management of patients with pancreatic cancer
periampullary and ampullary carcinomas. Gut.2005;54(V):1-16
Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:
Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.
United States of America: W.B.Saunders; 2002. p5.5002-5026



Komplikasi prosedur whipple

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:
Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.
United States of America: W.B.Saunders; 2002. p5.5002-5026


Prognosis terapi whipple
Faktor
Ada/tdk nya Nodus limfatikus yg terlibat
Penyebaran lokal organ2 sekitar (cth pankreas)
Grade tumnor/ diffrensiasi


Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier;
2011

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:
Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.
United States of America: W.B.Saunders; 2002. p5.5002-5026



Eksisi Transduodenal (TDE)
Pertama kali dilakukan tahun 1898 oleh William
Halsted
Morbiditas lebih rendah (5-20%)
Lebih jrg berhasil (rekurensi, survival)
Hasil:
Belum ada studi dgn kualitas yg baik

Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier;
2011

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:
Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.
United States of America: W.B.Saunders; 2002. p5.5002-5026


Pembedahan Radikal VS Lokal
Pertimbangan:
Stage tumor (T1,T2)
Kondisi Pasien
Indikasi TDE:
Adenoma dgn high-grade dysplasia
Villous atau tubullovillous adenoma
Low-grade. Stage tumor tanpa tingkat komorbiditas
yg tinggi.

Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier;
2011

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:
Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.
United States of America: W.B.Saunders; 2002. p5.5002-5026


Faktor Prognosis TDE:
Penyebaran LN
Mudah/tdknya Operasi berjalan
Elevasi dr bilirubin

Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier;
2011

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:
Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.
United States of America: W.B.Saunders; 2002. p5.5002-5026


Pre-oprative Endoscopic Stenting
Pertimbangan pre-reseksi:
Menurunkan morbiditas (kontroversial)
Pada kasus prosedur operasi hrs diundur >10 hr
GUT Online.Guidelines for the management of patients with pancreatic cancer
periampullary and ampullary carcinomas. Gut.2005;54(V):1-16

Terapi Endoskopik
Snare Resection
Laser Ablation
Photodynamic irradiation


Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier;
2011

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:
Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.
United States of America: W.B.Saunders; 2002. p5.5002-5026


Eksisi Endoskopik
Kriteria
Adenomas <4 cm
Tdk ada striktur atau ekstenski ke ductal
Tdk ada ulser
Hasil dari biopsi 6x menunjukkan masa Benign
Tdk ada mortalitas, ttp ada kenaikan morbiditas
(10-27%)
Pendarahan
Pankreatitis
Varibel Rekurensi (5-25%)
Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier;
2011

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:
Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.
United States of America: W.B.Saunders; 2002. p5.5002-5026


Padolfi M, et al.. Endoscopic Treatment of Ampullary Adenomas. J Pancreas
(Online).2008;9(1):1-8


Flow Chart
Terapi Adjuvant

Kemoterapi (5-FluoroUracil)
[+doxirubicin+mitomycin C]
+/- XRT (45 Gy)

GUT Online.Guidelines for the management of patients with pancreatic cancer
periampullary and ampullary carcinomas. Gut.2005;54(V):1-16

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:
Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.
United States of America: W.B.Saunders; 2002. p5.5002-5026


Terapi Neoadjuvant
Radioterapi pre- dan post- op.
Improvement pd kontrol locoregional, ttp belum
ada perbaikan survival
Masih dlm masa penelitian

GUT Online.Guidelines for the management of patients with pancreatic cancer
periampullary and ampullary carcinomas. Gut.2005;54(V):1-16

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:
Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.
United States of America: W.B.Saunders; 2002. p5.5002-5026


Kemoterapi pd non-resectable
localised, metastatic , atau rekuren
Mestastasis survival rate 3-6bln, tergantung dr
luas penyebaran.
5-FU dan Mitomycin C terbaik
Gemcitabine digunakan pd adenocarcinoma

GUT Online.Guidelines for the management of patients with pancreatic cancer
periampullary and ampullary carcinomas. Gut.2005;54(V):1-16

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:
Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.
United States of America: W.B.Saunders; 2002. p5.5002-5026