Pancreatic resections

Pancreatoduodenectomy

• Whipple’s – en bloc resection of pancreatic head, duodenum, CBD, distal stomach and lymph nodes.
• Technique/steps:
  • Mobilisation of right colon exposing 3^rd/4^th part of duodenum, with extended kocherisation performed.
  • Allows palpation of tumour in head of pancreas and exposes left renal vein.
  • Aortocaval and portal vein nodal packages are dissected with respective vessels skeletonised.
  • Resectability is finally assessed; if extensive involvement of confluence of PV/SMV may render unresectable
    • Short segments of PV can be resected
  • Relationship of tumour to first jejunal branch of SMV is critical determinant; if involved, unlikely be able to reconstruct SMV
  • Remaining porta hepatis is dissected.
  • Cholecystectomy facilitates higher ligation of bile duct
    • transected just proximal to insertion of cystic duct.
  • CBD mobilised distally and hepatico-duodenal ligament dissected along its length, taking care to preserve PV and CHA.
  • Gastroduodenal artery ligated.
  • Care not to damage an aberrant right hepatic artery.
• Conventional Whipple
  • Distal stomach resected – nodes along greater and lesser curve included
  • Stomach transected at antrum along with omentum.
  • Proximal jejunum along with mesentery is transected and mobilised duodenum and jejunum delivered back under ligament of Treitz.
  • After uncinate process has been dissected from SM vessels, pancreas is transected between four stay sutures (to help with haemostasis marginal arteries). If any doubt of pancreatic margin, should be sent for frozen section.
  • Reconstruction with biliary anastomosis, followed by pancreatic and gastric.
  • Pancreatico-jejunostomy and pancreatico-gastrostomy are most common techniques for pancreatico-enteric reconstruction.
  • Choledocho-jejunostomy end-to-side. These are usually two-layered mucosa-to-mucosa anastomoses.
• Complications:
  • Most significant cause is pancreatic fistula (7-18%)
  • Mostly dealt with conservatively or drain placement. Minority (<5%) require re-laparotomy.

Pylorus-preserving pancreatico-duodenectomy (PPPDR)

• Intact pylorus limits nutritional deficiencies, dumping and bile reflux.
• No difference in overall survival, morbidity or mortality.
• Whipple’s associated with less delayed gastric emptying.
• PPPDR results in less operating time, intraoperative blood loss and transfusions.
• Right gastric artery preserved.
• Duodenum transected at least 2 cm distal to pylorus.
• Reconstruction with duodenojejunostomy or gastrojejunostomy.

Extended lymphadenectomy

• Aortocaval nodal and left gastric
• Increased number of lymph nodes for staging/prognosis
• Increased postoperative morbidity.
• No difference in overall survival.

Distal pancreatectomy

• For body and tail.
• Majority have spleen resected to achieve en bloc clearance.
• Vaccinated preoperatively for encapsulated organisms – haemophilus influenza B, Neisseria meningitidis and streptococcus pneumoniae.

Total pancreatectomy

• Some suggest pancreatic cancer is multicentric disease.
• Could avoid risk of pancreatico-enteric leaks and remove potential undetected synchronous disease in other part of gland.
• Low survival benefit

Central pancreatectomy

• Role limited.
• Historically for chronic pancreatitis and traumatic injuries.
• Higher rates of pancreatic anastomotic leak