Perioperative management - Pylorus-preserving pancreaticoduodenectomy (pp Whipple) with T-drain (PPPD)

• Tumors of the pancreatic head (carcinomas, adenomas, cystic tumors etc.)
• Chronic pancreatitis with complications (e.g., CHD stenosis, pancreatolithiasis, pancreatic duct dilation)
• Unidentified mass in the pancreatic head
• Distal bile duct carcinoma
• Papillary carcinoma, large adenomas of the papilla or in the duodenum near the papilla
• Metastases in the pancreatic head

Preoperative

• Confirmed invasion of the vessels (superior mesenteric vein, portal vein, superior mesenteric artery, celiac trunk)
• Known metastatic tumor
• Portal vein thrombosis and other diseases with marked venous collateral circulation (liver cirrhosis)

Intraoperative

• Vascular invasion, then possibly only enteric bypass surgery
• Tumor invasion to the pancreatic tail, then pancreatectomy
• Marked local inflammation
• Very soft pancreas, then total pancreatectomy

Diagnostic imaging diagnostics mandatory

• Ultrasonography Pancreatic mass, ductal dilation, cysts, cholestasis, cholecystolithiasis
• Abdominal CT scan Pancreatic mass, lymph node enlargement, unhindered perfusion of superior mesenteric vein, portal vein, superior mesenteric artery and celiac trunk, distant metastases, pancreatic calcifications, pancreatolithiasis
• MRCP = magnetic resonance cholangiopancreatography: Cysts; irregularities, stenoses, dilation of the pancreatic duct, double duct sign = concurrent stenosis of the pancreatic duct and CHD, stenosis or dilation of CHD, pancreatolithiasis

Diagnostic imaging – optional

• Endosonography: Pancreatic mass, possibly needle biopsy; cysts
• ERCP: see MRCP, possibly with papillotomy and stenting of the CHD

Functional diagnostic work-up of the pancreas

• Oral glucose tolerance test in undiagnosed diabetes mellitus for assessment of endocrine pancreatic function
• HbA1c to assess endocrine pancreatic function
• Fecal elastase for diagnostic work-up of exocrine pancreatic function

Diagnostic lab studies

• Tumor marker CA 19-9
• Tumor marker CEA (particularly in EUS guided needle biopsy of cysts)
• Possibly genetics: PRSS1, SPINK1, PSTI, CFTR (in young patients to rule out hereditary origin - strict indication because of the high expense!)

• Blood typing
• Allocation of 4 packed RBCs
• Possibly stabilizing the coagulation (e.g. Konakion® (vitamin K1))
• Possibly improving the liver function (e.g. CHD stenting in icterus)

General

• Secondary healing
• Thromboembolism
• Lymph fistula
• Injury of internal organs (bowel, liver, stomach, spleen)
• Redo procedures

Specific:

• Bleeding/secondary bleeding: PPH = postpancreatectomy hemorrhage
• Pancreatic fistula: POPF = postoperative pancreatic fistula
• Gastric emptying disorder: DGE = delayed gastric emptying
• Bile leakage/bilioma
• Suture line failure/stenosis: Pancreatojejunostomy/-gastrostomy, hepaticojejunostomy, gastro-/duodenojejunostomy
• Residual pancreatitis
• Necrosis of the pancreatic remnant
• Endocrine and exocrine pancreatic insufficiency
• Insulin-dependent diabetes mellitus (lifelong)

Definition and classification of PPH, POPF and DGE by the International Study Group of Pancreatic Surgery (ISGPS), see literature references