3. Introduction
• Pancreaticoduodenectomy involves removal of the
pancreatic head, duodenum, gallbladder, and bile duct
with or without removal of the gastric antrum
• Pancreatic resection ranks as one of the most
complicated and technically challenging surgical
procedures
• Alessandro Codivilla performed the first
pancreaticoduodenectomy in 1898.
• Whipple performed the first anatomic one-stage
pancreaticoduodenectomy for a tumor of the head of
the pancreas in 1940
4. TECHNIQUES OF RESECTION
Indication
• pancreatic ductal adenocarcinoma(MC) in the
head of pancreas.
• distal common bile duct cholangiocarcinoma
• adenocarcinoma of the ampulla of Vater
• duodenal adenocarcinoma
• IPMN
• neuroendocrine tumors
• Chronic pancreatitis
• blunt or penetrating trauma to the
pancreaticoduodenal region.
5. PREOPERATIVE PLANNING
• complete medical history
• thorough physical examination
• Laboratory evaluation
-CBC
-electrolyte panel
- liver function tests
-coagulation profile
-tumor markers [CA 19-9 & CEA)]
-serum albumin
• Patient Education
9. PREOPERATIVE PLANNING
• EUS allows for direct ultrasound imaging of
the periampullary region through the walls of
the gastric antrum and duodenum.
• It offers real-time imaging of the tumor and
surrounding lymph nodes, can determine the
relationship of the tumor to the visceral
vasculature, and provides the ability to obtain
tissue via ultrasound guided-FNA
10. Patient Preparation
• clear liquid diet on the day prior to surgery.
• An endotracheal tube, nasogastric tube, urinary
catheter, and appropriate monitoring lines are
placed.
• Prophylactic subcutaneous heparin (5,000 units)
to prevent deep venous thrombosis.
• Prophylactic antibiotics are administared within
30 minutes of the incision.
• The operation is performed in the supine
position.
11. Technique- Resection steps
• A midline incision
• Thorough exploration for
occult metastasis
• The duodenum is widely
kocherized by releasing it
from the
retroperitoneum.
This allows for palpation
of the tumor and
determination of its
relationship to the SMA
12. Technique- Resection steps
• The gallbladder is resected via the
"dome down" technique
• The gastrohepatic ligament is
partially divided
• Further dissection within the
hepatoduodenalligament allows
for identification of the proper
hepatic artery and its branches
• The common hepatic duct is
divided
• A bulldog vascular clamp is placed
on the proximal common hepatic
duct to limit bile spillage
14. • Transection of the duodenum is performed 2
to 3 cm distal to the pylorus
15. • The pancreatic head and
uncinate process are further
mobilized and the right
gastroepiploic artery and vein
are ligated.
• Creation of the tunnel
posterior to the pancreatic
neck, in the avascular vertical
plane of the SMV-PV axis.
• A Penrose drain is passed
through this tunnel, to elevate
the pancreatic neck.
16. • The pancreatic neck
is then divided with
electrocautery over
the Penrose drain
• The location of the
pancreatic duct is
identified during
neck transection by
looking for a small
gush of clear
pancreatic juice
17. • The proximal jejunum is
transacted approximately
10 to 15 em distal to the
ligament of Treitz
• This dissection is continued
onto the mesentery of the
fourth portion of the
duodenum
• The pancreatic head and
uncinate process are now
gently separated from the
right lateral border of the
PV and SMV, and
subsequently the SMA.
18. • The specimen is then
removed
• The specimen is marked (by
suture and marking pen) to
identify the bile duct,
pancreatic neck, and
retroperitoneal soft-tissue
margins and is sent for
intra-operative frozen
section analysis of the
margins and pathologic
examination of the tumor
• The peritoneal defect at the
ligament of 'Ii'aitz is closed
with inteiTUpted 3-0 silk
sutures to prevent internal
herniation
19. Technique-Reconstruction Phase
• A defect is made in the
transverse mesocolon to
the right of the middle colic
vessels, through which the
proximal jejunal limb is
delivered
• The pancreatic remnant is
mobilized for a distance of
2 cm ventrally off the
splenic vein, to facilitate
creation of the invaginated
pancreaticojejunostomy
• The end-to-side
invaginated
pancreaticojejunostomy is
performed
20. • The goal is to achieve full jejunal
mucosal invagination, and
pancreatic capsule to jejunal
serosa apposition
• The inner layer of continuous 3-
0 polyglactin suture is placed in
a locking fashion on the
posterior aspect of the
anastomosis
• converted to a simple running
suture for the inner anterior
layer
• The outer anterior layer of
interrupted 3·0 silk sutures is
placed as a vertical mattress.
21. • The completed end-to-side invaginated
pancreaticojejunostomy with the caudal half
of the anastomosis (Dunking)
22. Other techniques of PE
Basic principle of safe PE
• careful handling of the pancreatic tissues
• a tension-free adaptation
• good perfusion
• no distal obstruction
Mesh end-to-end
pancreatojejunostomy
pancreatogastrostomy
duct-to-mucosa end-to-side
pancreatojejunostomy is
without seromuscular
incision
23. Reconstruction Phase-
hepaticojejunostomy
• a small jejunotomy on the antimesenteric border of the jejunum
• The end to side anastomosis is created using interrupted 4-0, 5-0, or
6-0 monofilament absorbable suture
• the posterior row of sutures is placed and tied placement of the
anterior row of sutures
24. Reconstruction phase-
duodenojejunostomy
• performed 10 to 15 em
distal to the
hepaticojejunostomy.
• It is performed in a two
layer, end to side fashion.
• The inner rows are sewn
in a continuous locking
fashion posteriorly, and as
a Connell stitch anteriorly
with 3-0 polyglactin
suture
25. Classic PD
• For classic PD
reconstruction, several
centimeters of the gastric
staple line from the lesser
curvature of the stomach
are imbricated with 3-0 silk
Lembert sutures.
• The remaining gastric
staple line is then resected
to facilitate performance of
a Hofmeister type end-to-
side gastrojejunostomy
27. Drains position and closure
• The right-sided drain is placed in the
subhepatic space and posterior to the RUQ
jejunal loops (the neoduodenum)
• the left-sided drain is placed through the
gastrocolic ligament and a few cm cephalad to
the PJ
• The fascia is closed with running 2-0 nylon or
polypropylene suture
28. Post-operative management
• Patients are routinely placed in an ICU
• ERAS Protocol is followed for evidence based practice.
• Analgesia-Mid-thoracic epidurals are recommended
showing superior pain relief and fewer respiratory
complications compared with intravenous opioids.
• Postoperative nausea and vomiting-metoclopramide and
early removal of NG tube
• dexamethasone at induction or a serotonin receptor
antagonist (e.g., ondansetron, tropisetron) at the end of
surgery
• Postoperative glycaemic control-Treatment of
hyperglycaemia with intravenous insulin in the intensive-
care setting improves outcomes but hypoglycaemia
remains a risk
29. Post-op fluid management
• Fluid Balance-near-zero fluid balance must be
achieved
• 0.9% saline leads to renal oedema, reduced flow
velocity in the renal artery, renal cortical tissue
perfusion, and an overall increase in
postoperative complications when compared
with balanced crystalloids
• To avoid unnecessary fluid overload, vasopressors
should be considered for intra- and postoperative
management of epidural-induced hypotension.
30. Perianastomotic Drains
• Early drain removal after 72 h may be
advisable in patients at low risk (i.e., amylase
content in drain <5000 U/L, firm pancreas,
wide pancreatic duct) for developing a
pancreatic fistula.
• patients with a soft pancreas and narrow
duct-> leave this drain in situ slightly longer
31. Somatostatin analogues
• Recent meta-analysis involved 17 trials with 1457
patients undergoing PD concluded that the use of
somatostatin analogues reduced the crude rate
of pancreatic fistulas, but that the rate of
clinically significant fistulas as well as the overall
major morbidity and mortality remained
unchanged
• Beneficial effect of somatostatin commonly
believed to be present in cases with
acknowledged risk factors (soft pancreas, small
pancreatic duct)
32. • Urinary drainage- removal of transurethral
catheter on postoperative day 1 to be superior in
terms of infection rates and did not lead to an
increased rate of recatheterisation when
compared with removal on day 3-5
• Stimulation of bowel movement-recommended
the use of laxatives postoperatively-to support
early start of normal bowel function.
• Chewing gum has been shown to be safe and
beneficial in restoring gut activity
33. Postoperative artificial nutrition- Early oral intake in this
patient group has been shown to be feasible and safe
• Enteral or parenteral nutritional support will often be
necessary if major complications develop
• Enteral tube feeding delivers artificial nutrients, but is a
nonvolitional intervention that bypasses the cephalic-vagal
digestive reflex and carries significant risks.
Mobilisation
• Patients should be mobilized actively from the morning of
the first postoperative day and encouraged to meet the
daily targets for mobilisation
• Analgesia must be adequate not only for rest, but also for
early mobilisation.
34. Systematic audit
• Systematic audit is essential to determine
clinical outcome and to establish the
successful implementation and continued use
of a care protocol
• There are also indications that audit per se
improves clinical results through feedback
35. Take Home Message
• Pancreatic resection is now an accepted form of
therapy for a large spectrum of pancreatic
diseases, both benign and malignant
• These improvements in overall outcome are a
result of advances in surgical technique, patient
selection, perioperative care, and diagnostic
imaging
• The management of patients with pancreatic
diseases is best done with a multispecialty
approach, with the surgeon in a central and
coordinating role.
distal bile duct cholangiocarcinoma, adenocarcinoma of the ampulla of Vater, and duodenal adenocarcinoma. Less common indications for pancreaticoduodenectomy include neuroendocrine tumors, gastrointestinal stromal tumors, intraductal papillary mucinous neoplasms, sarcomas, and isolated metastatic lesions in the head of the pancreas
complete medical history, with special emphasis on a past history of chronic pancreatitis, or a family history of gastrointestinal cancer. A thorough physical examination may note scleral or cutaneous icterus if the patient has common bile duct obstruction. Significant weight loss is not an uncommon finding. Enlarged left supraclavicular (V1rchow's) or periumbilical (Sister Mary Joseph's) lymph nodes or a perirectal tumor mass (Blumer's shelf) represent uncommon findings of disease dissemination. Laboratory evaluation should include complete blood count, electrolyte panel, liver function tests, coagulation profile, tumor markers [carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA)], and serum albumin measuremant to assess nutritional status.
EUS with FNA is an efficient and safe method for obtaining a tissue diagnosis to allow referral for protocol-based chemotherapy or chemoradiation therapy. In patients with clearly resectable periampullary abnormalities, a preoperative tissue diagnosis is not required in most cases, as the results of FNA (whether positive or negative) often do not alter the decision to proceed to surgical resection, and the low but measurable risk. of procedure-related complications (pancreatitis, perforation, and bleeding) may delay surgical intervention
The gastroduodenal artery (GDA) is identified within the hepatoduodenalligament and is test clamped prior to its division, to ensure maintenance of proper hepatic artery flow to the liver
The distal staple line is invaginated with
3-0 silk Lambert sutures, as this will serve as the jejunal limb for reconstruction
A jejunotomy is then made smaller than the horizontal pancreatic
remnant width, as the small bowel will stretch during the creation of the anastomosis
5 French pediatric feeding tube is placed temporarily in the pancreatic duct, to avoid compromising it during suture placement
jejunotomy on the antimesenteric border of the jejunum, approximately 5 to 10 em distal to the completed pancreaticojajunostomy
It is performed in a two layer, end to side fashion, using interrupted 3-0 silk Lembert sutures for the outer posterior and anterior rows.
Somatostatin and its synthetic analogues (e.g., octreotide) reduce splanchnic blood flow and the release of pancreatic exocrine secretion
Postoperative artificial nutrition Most patients tolerate normal oral intake soon after elective PD. Early oral intake in this patient group has been shown to be feasible and safe
