Pancreaticoduodenectomy

Resection of:

• Distal stomach
• Duodenal loop and DJ flexure
• Distal CBD
• Head and uncinate process of pancreas

History

• First described 1909 (Kausch)
• First successful resection 1935 (Whipple)
• First performed in one stage 1941 (Trimble)

Pre-op:

• No absolute upper age limit, but need to be very careful >75yo

Controversies

• Pylorus-preserving (conservative) vs non-pylorus-preserving (conventional)
  • No RCTs have suggested superiority of pylorus-preserving approach
• Pancreaticojejunostomy vs pancreatogastrostomy
  • Some studies have reported fewer fistulas and leaks with pancreatogastrostomy, but this was not reproduced in RCTs
• Somatostatin analogues to reduce pancreatic fistula
  • Mixed results when used perioperatively
• Extent of lymphadenectomy
  • No evidence to suggest improved survival after extended lymphadenectomy
• Laparoscopy/robotics
  • Similar outcomes for certain high-volume, experienced surgeons, but not widely adopted due to being very hard
  • Open Whipple remains standard of care
• Antecolic vs retrocolic duodenojejunostomy
  • Antecolic may improve gastric emptying

Technique

• Bilateral subcostal is best, but midline can also be used
• Exploration for metastatic disease - abort if found
• Trial dissection:
  • Enter lesser sac by taking omentum off transverse colon
  • Kocher manoeuvre to level of left lateral aortic border, which confirms that the tumour is resectable
  • Identify infra-pancreatic SMV by following middle colic vein down. Make a tunnel behind pancreas, anterior to portal vein, to confirm it can be freed from PV.
  • Divide lesser omentum
  • Now make a tunnel in front of PV from above, joined to inferior tunnel behind neck of pancreas

• Conservative pancreaticoduodenectomy
  • Right gastric artery and GDA ligated and divided, after confirming collateral circulation through CHA
  • First part of duodenum separated from pancreas - mobilise the pylorus and proximal 6cm of duodenum
  • Divide CBD
  • Divide proximal duodenum (3cm distal to pylorus)
  • Mobilise ligament of Treitz to allow jejunum to come up into the supracolic compartment
  • Divide distal duodenum
  • Divide pancreatic neck under vision
    • Stapler
    • Protect PV posteriorly
  • Separate head and uncinate process of pancreas from PV and SMV (moving from left to right, peeling the disconnected pancreatic head off the vessels)
• Reconstruction (16.14A above)
  • Pancreatic neck to jejunum (double layer duct to mucosa)
  • Bile duct to jejunum (single layer end to side)
  • Duodenal stump to jejunum (two layer end to side, 25cm distal to biliary anastomosis)
• Drains adjacent to joins
• Feeding jejunostomy in patients with pre-operative malnutrition

Post-op care:

• BGL management - needs insulin infusion
  • Should switch to subcut insulin on day 1 post-op
• NGT placed intra-operatively
  • Likely removed day 1
• Incentive spirometry
• Some surgeons would advocate for prokinetics from early on
• Drains usually left in place until day 4 or 5, with a drain tube lipase/amylase prior to removal

Complications

• Perioperative mortality
  • <2% at high-volume centres
• Overall morbidity 30-50%
• Haemorrhage
  • Early bleeding usually results from a failure to achieve adequate haemostasis that is best managed by return to OT
  • Late bleeding is usually the result of an inflammatory process that causes vascular erosion and formation of arterial pseudoaneurysm formation
    • Most commonly GDA stump, followed by hepatic artery, SMA and splenic artery.
    • Treated effectively endovascularly - either transcatheter arterial embolization (85% successful) or stent-graft placement or both
• Delayed gastric emptying - 15%
  • Functional gastroparesis
  • Controversial whether pylorus-preserving operations affect this
  • Typically presents with inability to tolerate solid foods or prolonged NGT requirement
  • Need to exclude mechanical obstruction due to leak/abscess/stricture - CT +/- gastroscopy +/- contrast swallow
  • Management
    • Discontinuation PO intake
    • Resumed NGT decompression
    • Jejunal feeds
    • Prokinetics
    • Nutritional support
    • CT to exclude intra-abdominal complication including abscess
• Wound infection - 7%
• Pancreatic fistula - 12%
  • Risks:
    • Soft, fatty glands
  • Presentation
    • Transient anastomotic leak
    • Intra-abdominal abscess
    • Frank fistula formation
  • Defined as drain tube lipase/amylase > 3 times ULN on day 3 or later, regardless of output volume. Divide into grades A B and C based on severity to guide management.
  • Grade A: little to no clinical impact, no specific intervention. Sometimes elect to remove drain incrementally over successive days to prevent fistula formation. Normal diet, don't delay discharge.
  • Grade B or C: drain intra-abdominal collections, restrict PO intake, nutritional support, Long-active somatostan analogues may reduce output - debated. Empiric antibiotics if concern for infection. 90% of fistulae close spontaneously, generally within 4 weeks.
    • Indications for re-exploration: severe clinical instability, sepsis, organ dysfunction. Can need repair or revision of PJ anastomosis.
• Bile leak - 2%
• Pneumonia - 1%
• Pancreatitis - 1%
• Cardiac events - 3%
• Intra-abdominal abscess - 6%
• Pancreatic insufficiency
  • Unpredictable, but rare for those with a normal gland