Pancreaticoduodenectomy

Indications Malignant lesions involving the head of pancreas, ampulla of Vater, distal end of the common bile duct, or duodenum. Absence of metastasis. Absence of arterial involvement. Refractory severe pain from chronic pancreatitis. Refractory to medical therapy. Repeat hospital admissions. Majority of disease limited to the head of the pancreas.

Contraindications Absolute Evidence of metastatic disease. Evidence of para-aortic nodes outside the field of dissection. Involvement of the aorta or vena cava. Involvement of the superior mesenteric artery, hepatic artery, or celiac axis. Relative Cardiopulmonary comorbidities.

Informed Consent Survival following resection of periampullary and pancreatic lesions depends on the site of the primary tumor and stage. The overall 5-year survival rate is 20–30% but may be significantly better in patients with limited disease burden. Using prognostic modeling, a patient with a well- differentiated small tumor (1 cm) and no nodal involvement would have a 50% 5-year survival. A patient with a poorly differentiated lesion > 4 cm and 10 positive lymph nodes would have an estimated 10% 3-year survival rate. Expected Benefits To remove malignancies involving the head of the pancreas, ampulla, distal common bile duct, or duodenum while restoring continuity of the biliary-pancreatic system. Potential Risks Surgical site infections (superficial or deep, abscess). Bleeding. Pneumonia. Cardiovascular events. Venous thromboembolism. Delayed gastric emptying (15–40% of patients). Anastomotic leak (most commonly from the pancreaticojejunal anastomosis). Abscess. Biloma. Pseudocyst. Pancreatic fistulas. Incomplete resection and positive margins.

Equipment General surgery instrument tray. Self-retaining abdominal retractor to aid exposure. A surgical energy device (eg, harmonic scalpel or LigaSure) is useful for dividing the jejunal mesentery. Gastrointestinal anastomosis (GIA) stapler. Thoracoabdominal (TA) stapler.

Patient Preparation Assessment of tumor resectability. Fine-cut (3-mm) pancreatic protocol CT. MRI and magnetic resonance cholangiopancreatography (MRCP) can be useful to clarify the relationship of the tumor to the blood vessels and biliary system. Endoscopic retrograde cholangiopancreatography (ERCP) should be reserved for patients with obstructive jaundice and no mass noted on CT. ERCP with stent placement may be used for deeply jaundiced patients. Endoscopic ultrasound (EUS) is helpful in assessing lymph node involvement and relationship to the major vasculature. Assessment of cardiovascular risk.

Patient Positioning The patient should be supine. The entire abdomen is shaved and prepped. The abdomen is entered through a midline incision or bilateral subcostal "Chevron" incision, depending on surgeon preference.

Procedure The procedure can be divided into three stages: assessment of resectability, resection, and reestablishment of continuity. Figure 15–1: The round ligament and falciform ligaments are divided to provide adequate exposure. A Kocher maneuver is performed initially to expose the proximal duodenum and pancreas and ensure that no direct extension of the tumor involves the aorta or inferior vena cava. The duodenum is retracted medially under tension, and the peritoneum is incised along the lateral edge of the duodenum. The retroperitoneum is entered carefully to avoid injury to the vena cava. The gastrocolic omentum is divided and the lesser sac is entered to expose the anterior surface of the pancreas. The right and transverse colon is reflected completely down to expose the entire inferior portion of the pancreas. During this step the gastroepiploic vein is ligated and divided, and the middle colic vein can also be divided if necessary to facilitate exposure of the inferior border of the pancreas. A cholecystectomy is performed in the standard fashion. After appropriate exposure, the resectability of the lesion is assessed. Figure 15–2: The hepatoduodenal ligament is dissected to expose the common bile duct and hepatic artery. The anterior surface of the portal vein is usually identified by careful dissection between the common bile duct and hepatic artery. The gastroduodenal artery should also be identified along the anterior surface of the pancreas, beneath the first portion of the duodenum, and its takeoff from the common hepatic artery should be carefully identified. The portal vein is freed from the posterior surface of the neck of the pancreas using careful blunt dissection. The middle colic vein should be identified and followed down to the inferior border of the pancreas to help identify the superior mesenteric vein, as shown in Figure 15–1. Additional careful dissection should be performed to create a "tunnel" under the neck of the pancreas, demonstrating that the plane between the neck of the pancreas and the portal vein and superior mesenteric vein is free and that there is no evidence of tumor involvement. Alternatively, the right and transverse colon can be extensively mobilized, allowing identification of the superior mesenteric vein as it crosses over the third portion of the duodenum and goes under the neck of the pancreas. No further dissection, and more specifically, no structures should be divided prior to confirming that the vein is free of tumor involvement, unless the surgeon is prepared to proceed with en bloc vein resection. Figure 15–3: The antrum of the stomach is stapled and divided using the landmarks of a Billroth I hemigastrectomy. The hepatic artery within the hepatoduodenal ligament is palpated and dissected free to identify the gastroduodenal and right gastric vessels, which can be doubly ligated and divided. Prior to division of the gastroduodenal artery, it is important to briefly occlude this artery ("pinch test") while palpating the hepatic artery to confirm that there is no decrease in the hepatic arterial flow. On occasion, in individuals with a celiac stenosis or other congenital arterial anomalies, the majority of the hepatic arterial blood flow may come via collateral vessels through the gastroduodenal artery. Although rare, hepatic necrosis can occur in these patients following division of the gastroduodenal artery. In such cases, a Whipple procedure is contraindicated unless hepatic arterial flow can be reestablished via other mechanisms, including possible arterial bypass or endovascular intervention. The proximal stomach is packed away in the left upper quadrant, and the distal stomach is retracted inferiorly and to the right to aid exposure of the common bile duct. The common bile duct is divided and the distal end is ligated using a silk suture. The proximal common bile duct can be occluded temporarily with a Bulldog clamp. Figure 15–4: The duodenum is dissected free from the ligament of Treitz. Multiple small feeding arteries and veins in the duodenal mesentery must be clamped and tied to minimize bleeding or sealed using a surgical energy device (eg, harmonic scalpel, LigaSure). The proximal jejunum is divided about 10 cm distal to the ligament of Treitz using a GIA stapler, and the jejunal mesentery is divided between clamps and ligated with silk sutures down to the level of the ligament of Treitz. The divided end of the jejunum can then be delivered beneath the mesentery of the small bowel. Figure 15–5: Hemostatic transfixion sutures are placed both inferiorly and superiorly in the pancreas body on either side of the line of planned transection. The pancreas can be divided using electrocautery or sharply with a scalpel. The pancreatic duct is identified, and any bleeding vessels are suture ligated with 4-0 or 5-0 Prolene. Figure 15–6: The uncinate process is dissected free from the superior mesenteric vein. The superior and inferior pancreaticoduodenal veins are ligated and divided along with all other small branches that enter the lateral superior mesenteric and portal vein. Figure 15–7: The superior mesenteric vein is retracted medially, exposing the retropancreatic tissue. The retropancreatic attachments to the uncinate process are then divided. Either a TA stapler or traditional clamping and tying can be used. Clamping and tying is preferred for resection of malignancies. The TA stapler is preferred for benign disease. The specimen, which should now be entirely free, should be sent for pathologic and frozen section examination of the biliary and pancreatic margins. The retroperitoneal margin should be inked by the surgeon prior to sending the specimen for pathologic examination. Figure 15–8: The jejunal limb is delivered up to the right upper quadrant in a retrocolic fashion through an avascular window in the transverse mesocolon. The pancreaticojejunostomy is performed using an end-to-side anastomosis. The outer layer of the pancreaticojejunostomy is performed using interrupted 3-0 or 4-0 silk sutures between the capsule of the pancreas and the seromuscular layer of the jejunum. The inner layer of the anastomosis is performed using interrupted absorbable suture (4-0 or 5-0 PDS or Vicryl) between the pancreatic duct and a full-thickness layer of jejunum. Occasionally, a sterile 5 or 8 French pediatric feeding tube with extra side holes cut into it can be used to stent the pancreatic-jejunal anastomosis. The choledochojejunostomy is subsequently performed in an end-to-side fashion using a singled layer of interrupted absorbable suture, such as 4-0 or 5-0 PDS or Vicryl. The defect in the mesocolon is closed surrounding the delivered limb of jejunum to avoid internal herniation. The gastrojejunostomy is then completed with an antecolic loop of jejunum and creation of a two-layered hand-sewn anastomosis. The outer layer of the anastomosis is performed using interrupted seromuscular 3-0 silk sutures and the inner layer is a full-thickness running layer of 3-0 Vicryl or other absorbable suture. The abdomen is copiously irrigated and two drains are placed within the abdominal cavity in apposition to the biliary and pancreatic anastomoses. The midline incision is then closed using standard techniques. Figure 15–1 Figure 15–2 Figure 15–3 Figure 15–4 Figure 15–5 Figure 15–6 Figure 15–7 Figure 15–8

Postoperative Care Nothing by mouth with nasogastric tube decompression. Oral diet is advanced following removal of the nasogastric tube and once ileus has resolved, usually within 48–72 hours postoperatively. Monitoring of abdominal drain fluids for evidence of a biliary or pancreatic leak.

Potential Complications Delayed gastric emptying. Pancreatic leak. Surgical site infections. Gastroduodenal artery pseudoaneurysm.

Pearls and Tips If metastatic disease is suspected but cannot be confirmed using radiologic studies or EUS, consider diagnostic laparoscopy prior to formal laparotomy. Diagnostic laparoscopy can detect carcinomatosis and some liver metastases, but it is not helpful in determining blood vessel or retroperitoneal involvement. No organs should be divided and no irreversible maneuvers performed until resectability is confirmed. If a patient has significant involvement of the portal vein or superior mesenteric vein, consider preoperative chemotherapy and radiation prior to an attempt at resection. Portal vein or superior mesenteric vein involvement does not render a patient's tumor unresectable, and an aggressive surgical approach with vein resection and reconstruction should be considered in appropriate patients. Perform a "pinch test" (eg, occlusion of the gastroduodenal artery) prior to division of the gastroduodenal artery to confirm that there is no significant arterial flow to the hepatic artery via collaterals through the gastroduodenal artery.

References Brennan MF, Kattan MW, Klimstra D, Conlon K. Prognostic nomogram for patients undergoing resection for adenocarcinoma of the pancreas. Ann Surg. 2004;240:293–298.[PubMed: 15273554] [Full Text] Nakeeb A, Lillemoe KD, Yeo CJ, Cameron JC. Neoplasms of the Exocrine Pancreas. In: Mulholland MW, Lillemoe KD, Doherty GM, et al, eds. Greenfield's Surgery: Scientific Principles & Practice, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:861–879. Simeone DM. Complications of Pancreatic Surgery. In: Mullholand MW, Doherty GM, eds. Complications in Surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:469–472.