[The periampullary carcinoma. Clinical and therapeutic alternatives]

An analysis of the diagnosis difficulties in periampullary carcinoma (PAC) is done, the consequences being the possible therapeutically insufficiencies.

During 10 years (1990-1998) 54 patients have been operated on for a PAC. Sex ratio: 34 males (63%)/20 females (37%). The pick of frequency was in the decade 61-70 years (20 patients) with extremes ages between 20 and 80 years. The main symptom was the cholestatic progressive jaundice with or without neoplasic pain (39 patients--72%). The intermittent jaundice was present only to 7 patients (13%) and the clinical forms without jaundice were manifested to other 8 (15%); superaded colangitic syndrome was present to 17 patients (31%). Other concomitances manifestations of the neoplasic disease were record to 23 cases (43%). Historical evolution of the illness until the cholestatic jaundice appearance was under 2 month to 23 cases, between 2 and 4 months to 24 patients and not sure determined to other 8. The biological preoperative investigations confirmed the clinically evident biliary retention syndrome in 85% of the cases and not yet clinically visible to other 15% of the cases. The ultrasonography was the most conclusive method from the imaging examinations because it have suggested the diagnostic of PAC to 43.5% from the patients submitted to this exploration. Computed tomography was diagnosis relevant only for the in site-regional invasion of the tumors or for the nodes or systemic metastases. Endoscopy and the endobiopsy proved to be valuable especially associated with ERCP (our experience regarding ERCP is not conclusive yet). Therefore the real preoperative diagnostic was established to 11 patients (20%), and for the rest of the cases there have been another presumptive preoperative diagnosis: cancer of the pancreatic head (11 patients), retentive jaundice without determined origin (24 patients), others (8 patients). Intraoperative exploration detected the periampullary tumor through palpation in 30 (55%) cases, through palpation and exploratory duodenectomy in 8 (15%) cases and/or by accessory signs (hydropic gallbladder, dilatation of the main biliary duct etc.). Organic metastases or duodenal stenosis was present in nine cases (6 with nodes metastases). The practiced surgery was: Whipple operations (in one--the majority--or two steps)--35 cases (65%); palliative surgery for biliary drainage 16 (30%) cases; others 3 (6%) cases. The postoperative staging of pT parameter (in situ or ex situ dimensional determined) reveled: pT1-12 patients; pT2--9 patients; pT3--14 patients; pT4--19 patients. Histopathological examinations confirmed the diagnostic of periampullary adenocarcinoma (32 patients) or carcinoma (3 patients) for the 35 patients with resectional operations. The determination of the tissular origin of the periampullary tumor was initially possible only in 11 (31%) operative specimens. A secondary study with many repeated sections in the wax included blocks specified the histogenesis of the tumors to other 10 patients, therefore for a total of 21 cases. We think that this histogenetically diagnosis aspect is important only for some predictive appreciations regarding the outcome of the operated patients and not for the elected therapeutically surgical method.

The globally perioperative mortality was 8 (15%) patients. Three from this deceased were a consequence of palliative surgery applied to patients with advanced stages of neoplasic disease. The medium outcome for patients submitted to Whipple operation--in course of evaluation--is between 32 and 41 months to the patients which we can followed. For the patients with palliative operations the same distant survival is between 12 and 24 months.