Pancreatic Surgery


Complications, risks, and consequences

Estimated frequency

Most significant/serious complications

Infectiona overall

5–20 %

 Subcutaneous/wound

5–20 %

 Intra-abdominal/liver bed/pelvic

0.1–1 %

 Liver (hepatitis; abscess)

0.1–1 %

 Cholangitis

1–5 %

 Systemic

0.1–1 %

 Late postsplenectomy sepsis (vaccination)

<0.1 %

Bleeding/hematoma formationa

 Wound

1–5 %

 Anastomotic; raw surfaces

1–5 %

 Portal, superior mesenteric, splenic vessels

0.1–1 %

 Injury to vena cava/renal vessels

0.1–1 %

 Gastrointestinal hemorrhage

1–5 %

Injury to the bowel or blood vessels

1–5 %

 Gastric/duodenal/small bowel/colonic

Splenic injury/removala

>80 %

Bile leak/collection

20–50 %

Biliary fistula/stenosis

5–20 %

Insertion of T tubea

20–50 %

Unresectability of malignancy/involved resection marginsa

Individual

Pancreatitis/pancreatic injury/pancreatic cyst/pancreatic fistulaa

5–20 %

Anastomotic breakdown

1–5 %

Small bowel or gastro- or pancreaticocutaneous fistulaa

1–5 %

Entero-pancreatic fistula

1–5 %

Intolerance of large meals (necessity for small frequent meals)

1–5 %

Diarrhea (neurogenic; enzyme deficiency)

1–5 %

Islet failure and diabetes (consequent insulin therapy)

5–20 %

Pancreatic failure and enzyme replacement

5–20 %

Coagulopathy

1–5 %

Multisystem organ failure (renal, pulmonary, cardiac failure)a

1–5 %

Mortalitya

1–5 %

Rare significant/serious problems

Bile/hepatic duct injury

0.1–1 %

Liver injury

0.1–1 %

Biliary obstruction (all causes)a

0.1–1 %

 [Ischemia/stenosis]

0.1–1 %

Gastric/small bowel ischemiaa

 (devascularization; SMA, coeliac ligation)*

0.1–1 %

Small bowel ischemia

0.1–1 %

Small bowel obstruction (early or late)a [ischemic stenosis/adhesion formation]

0.1–1 %

Nutritional deficiency – anemia, B12 malabsorption

0.1–1 %

Seroma/lymphocele formation

0.1–1 %

Vascular injury and false aneurysm formation

0.1–1 %

Renal/adrenal injury

0.1–1 %

Thoracic duct injury (chylous leak, fistula)

0.1–1 %

Aspiration pneumonitis

0.1–1 %

Portal venous thrombosisa

0.1–1 %

Deep venous thrombosis

0.1–1 %

Operative cholangiograma

 Dye reaction/cholangitis/pancreatitis/radiation exposure

<0.1 %

Biliary ascites

<0.1 %

Possibility of colostomy/ileostomy (very rare)a

<0.1 %

Less serious complications

Pain/tenderness [rib pain (sternal retractor), wound pain]

 Acute (<4 weeks)

>80 %

 Chronic (>12 weeks)a

5–20 %

Paralytic ileusa

>80 %

Wound dehiscence

0.1–1 %

Muscle weakness (atrophy due to denervation esp. subcostal incision)

1–5 %

Wound scarring (poor cosmesis/wound deformity)

1–5 %

Incisional hernia formation (delayed heavy lifting/straining)

0.1–1 %

Nasogastric tubea

1–5 %

Blood transfusion

<0.1 %

Wound drain tube(s)a

>80 %


aDependent on underlying pathology, anatomy, surgical technique, and preferences





Perspective


See Table 9.1. Many of the complications are relatively minor in nature and related to wound infection and minor bleeding; however, major complications may occur, including intra-abdominal bleeding, intra-abdominal abscess, peritonitis, pancreatitis, pancreatic fistula, systemic sepsis, respiratory failure, renal failure, and multisystem organ failure, leading to prolonged intensive care and possibly mortality.


Major Complications


The major complication of distal pancreatectomy is infection usually related to pancreatic leak from the transected pancreatic duct. The leak rate can be significantly reduced (10 % vs. 35 %) when the pancreatic duct is directly ligated*. With current interventional radiological drainage techniques, reoperation for infection is unusual. CT scan of the abdomen and pelvis should be used early for a suspected infected collection. Early intra-abdominal sepsis frequently manifests itself as respiratory distress. Another sequela of intra-abdominal sepsis is intra-abdominal bleeding. If fluid coming out of an intra-abdominal drain turns bloody, it may represent a sentinel bleed most commonly from a pseudoaneurysm that has developed from the stump of the splenic artery. Angiography is necessary as an emergency study with embolization or stenting as the therapeutic intervention of choice, if possible, based upon arterial anatomy. Delayed gastric emptying is another complication that can prolong hospitalization. Although frequently multifactorial in nature, causes should be sought out such as intra-abdominal sepsis, electrolyte abnormalities, pancreatitis, pancreatic leak, abscess, and technical problems. Placement of a feeding jejunostomy tube at the time of surgery can help manage this problem, but one must ensure that the distal gut is functioning adequately before feeding via this route. A pancreatic fistula can be a significant problem. Respiratory infection and failure are common difficulties, and renal failure is another possible complication, often secondary to sepsis. Systemic infection and multisystem organ failure may supervene and are major causes of morbidity, prolonged hospitalization, and mortality.


Consent and Risk Reduction



Main Points to Explain



  • Infection


  • Bleeding


  • Risk of organ injury


  • Risk of leakage/fistula


  • Risk of stoma


  • Risk of further surgery


  • Risk of death



Pancreaticoduodenectomy (Including Whipple’s Procedure)



Description


General anesthesia is used. The goal of pancreaticoduodenectomy is to remove tumors in the periampullary region, including the head of pancreas, typically retaining the distal pancreas. The operation proceeds in a clockwise fashion consisting of six steps. At each step resectability is assessed. One is not committed to the resection until the last step when the pancreas is divided. Step 1 is to perform a Cattell-Braasch maneuver and expose the superior mesenteric vein. In this step the right colon is mobilized and the mesenteric attachment to the retroperitoneum is divided from the terminal ileum to the ligament of Treitz. This frees up the third and fourth portions of the duodenum. The lesser sac is opened via the gastrocolic omentum and the transverse colon is separated from the duodenum and stomach. The inferior edge of the pancreas is dissected out, as is the superior mesenteric vein as it courses under the neck of the pancreas, avoiding traction on the gastrocolic vein. Step 2 is to perform an extended Kocher maneuver where the duodenum and head of pancreas are dissected off the vena cava and aorta. At the completion of this step, tumor involvement of the major vessels can be assessed, as well as the origin of the superior mesenteric artery. Step 3 is to perform the portal dissection. A cholecystectomy is performed. The common bile duct is encircled and divided. A frozen section analysis of the bile duct margin is performed; if positive, more bile duct can be removed. The gastroduodenal artery is then dissected out and divided after clearly identifying its origin from the common hepatic artery. The portal vein is identified directly under the gastroduodenal artery. The portal vein is freed up at the neck of the pancreas superiorly and the entire neck of the pancreas is mobilized off the vein, taking great care not to damage the small venous tributaries entering the right side of this structure. Step 4 is to divide the stomach. Where the stomach is divided depends on whether a pylorus-preserving procedure, an antral-preserving procedure, or a classical Whipple procedure with antrectomy is performed. Step 5 is to divide the small bowel at the proximal jejunum. The ligament of Treitz is completely mobilized below the transverse mesocolon, and the small bowel, to be resected as part of the specimen, is rotated under the mesenteric vessels. Step 6 is to divide the pancreas in the region of the pancreatic neck. A frozen section analysis is performed over the pancreatic body margin, and if positive, additional pancreas is resected. Once the pancreas is divided, the superior mesenteric vein and portal vein are mobilized off the uncinate portion of the pancreas and divided along the medial border of the superior mesenteric artery. Extreme care is needed at this point as lateral traction on the head of pancreas may pull the superior mesenteric artery to the right side of the corresponding major vein. Reconstruction occurs in a counterclockwise fashion. Initially an end-to-side pancreaticojejunostomy is performed first, followed by the biliary anastomosis (usually an end-to-side choledochojejunostomy), and, finally, evidence leans towards performing a gastrojejunostomy in an antecolic fashion. It is thus distanced from the pancreas and may reduce the incidence of delayed gastric emptying. The pancreatic anastomosis can either be an invagination of the pancreas or a direct duct-to-mucosal anastomosis. The gastrojejunostomy can either be a loop or Roux-en-Y reconstruction. Partial pancreatectomy of the head of pancreas without duodenectomy is uncommon and restricted to situations where either benign disease is present or small tumors are localized to the head region only. Total pancreatectomy is uncommonly performed because of the severe endocrine and metabolic consequences that are often experienced and associated high morbidity and mortality. It may be used in some centers for multifocal secreting endocrine tumors, chronic pancreatitis, and intraductal papillary mucinous neoplasia, all of which are often associated with serious endocrine and metabolic disturbances as part of the disease processes. This may be performed with or without duodenectomy.


Anatomical Points


The major anatomical point that is important with pancreaticoduodenectomy is related to the hepatic arterial supply. Accessory or replaced right hepatic arteries arise off the superior mesenteric artery and course along the upper part of the uncinate, posterior and lateral to the common bile duct. Accessory or replaced left hepatic arteries arise off the left gastric artery and less commonly come into play during resection. Occasionally, the entire common hepatic trunk comes off the superior mesenteric artery. In this case it usually courses up in between the portal vein and the common bile duct. Usually these vessels can be preserved as part of the resection.


Table 9.2
Pancreaticoduodenectomy (including Whipple’s procedure) estimated frequency of complications, risks, and consequences


























































































































































































Complications, risks, and consequences

Estimated frequency

Most significant/serious complications

Infectiona overall

5–20 %

 Subcutaneous/wound

5–20 %

 Intra-abdominal/liver bed/pelvic

0.1–1 %

 Liver (hepatitis; abscess)

0.1–1 %

 Cholangitis

1–5 %

 Mediastinitisa

<0.1 %

 Systemic

0.1–1 %

 Late postsplenectomy sepsis (vaccination)

<0.1 %

Bleeding/hematoma formationa

 Wound

1–5 %

 Anastomotic; raw surfaces

1–5 %

 Portal, superior mesenteric, common hepatic, splenic vessels

0.1–1 %

 Injury to vena cava/renal vessels

0.1–1 %

 Gastrointestinal hemorrhage

1–5 %

Injury to the bowel or blood vessels

1–5 %

 Gastric/duodenal/small bowel/colonic/renal/adrenal

Bile leak/collection

20–50 %

Biliary fistula/stenosis

5–20 %

Postoperative acute pancreatitis

2–30 %

Pancreatic leak/fistula

5–40 %

Small bowel obstruction (early or late)a [ischemic stenosis/adhesion formation]

1–5 %

Diabetes (consequent insulin therapy)

>80 %

Pancreatic enzyme replacement

>80 %

Unresectability of malignancy/involved resection marginsa

Individual

Anastomotic breakdown

5–20 %

Enterocutaneous fistulaa

1–5 %

Diarrhea (neurogenic; enzyme deficiency)

5–20 %

Nutritional deficiency – anemia, B12 malabsorption

5–20 %

Seroma/lymphocele formation

20–50 %

Thoracic duct injury (chylous leak, fistula)

20–50 %

Coagulopathy

1–5 %

Reflux esophagitis/pharyngitis/pneumonitis

1–5 %

Delayed gastric emptying

20–50 %

Bilious vomiting

5–20 %

Dumping syndrome

5–20 %

 Early dumping (vasomotor)

 Late dumping (osmotic)

Intolerance of large meals (necessity for small frequent meals)

50–80 %

Multisystem organ failure (renal, pulmonary, cardiac failure)a

5–20 %

Mortalitya,b

5–20 %

Rare significant/serious problems

Aspiration pneumonitisa

0.1–1 %

Portal venous thrombosisa

0.1–1 %

Deep venous thrombosisa

0.1–1 %

Biliary obstructiona

0.1–1 %

Bile/hepatic duct injury

0.1–1 %

Liver injury

0.1–1 %

Bile duct ischemia/stenosisa

0.1–1 %

Gastric/small bowel ischemia

 (Devascularization; SMA, coeliac artery injury)a

0.1–1 %

Jejunal fistula

0.1–1 %

Biliary ascites

<0.1 %

Operative cholangiogram

 Dye reaction/cholangitis/radiation exposure

<0.1 %

Possibility of colostomy/ileostomya

<0.1 %

Less serious complications

Pain/tendernessa [rib pain (sternal retractor), wound pain]

 Acute (<4 weeks)

>80 %

 Chronic (>12 weeks)

5–20 %

Paralytic ileusa

>80 %

Wound dehiscence

0.1–1 %

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Mar 23, 2017 | Posted by in ABDOMINAL MEDICINE | Comments Off on Pancreatic Surgery

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