Perioperative management - Pylorus-preserving pancreaticoduodenectomy (pp Whipple) with T-drain (PPPD) - general and visceral surgery
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Indications
- 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
Contraindications
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
Preoperative diagnostic work-up
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!)
Special preparation
- 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)
Informed consent
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
Anesthesia
Positioning
Operating room setup
Special instruments and fixation systems
Postoperative management
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