Perioperative management - Pancreaticoduodenectomy, pylorus-preserving, partial (OP according to Traverso)

• Treatment of potentially resectable malignancies of the pancreatic head, the papilla, and the distal bile duct.
  Rare indications: Duodenal carcinomas, benign or cystic tumors, chronic pancreatitis, or so-called "dilemma" cases (when imaging and clinical presentation cannot reliably differentiate between inflammatory and malignant pancreatic head tumors).
  In principle, the indication for pancreatic head resection exists in cases of malignancies or sufficient suspicion of malignancy whenever there is at least the prospect of resecting the tumor in toto pre- and intraoperatively, and the patient is in a general condition adequate for this procedure.

• The indication for resection should be made promptly by the surgeon, especially in potentially resectable findings in jaundiced patients. Only in patients with manifest secondary complications of jaundice (decompensated plasma coagulation, liver synthesis disorder, reduced cellular defense, purulent cholangitis) should preoperative endoscopic bile duct drainage be considered to gain time and create a better starting situation for the operation. In all other cases, preoperatively placed bile duct drainage, whether TPCD (transpapillary) or PTCD (percutaneous-transhepatic), should be avoided due to increased postoperative morbidity.
  In the case of infiltration of large veins (superior mesenteric vein, splenic vein, or portal vein), resection should be pursued, if necessary with vascular reconstruction, as preoperative diagnostics often cannot differentiate between inflammatory adhesion and tumor infiltration.
  Comorbidity is another essential factor in determining the indication. Patients with severe cardiovascular comorbidities carry a significantly increased surgical risk; however, advanced age in itself is no longer a contraindication for pancreatic head resection today.

• Pancreatic head malignancies with proven: Distant metastases, vascular infiltration (encasement in imaging >180°) of the superior mesenteric artery, hepatic artery, celiac trunk
• Patients with severe cardiovascular comorbidities, for whom anesthesia alone poses a risk (e.g., NYHA III constellation with high-grade carotid stenoses)

• Medical history (pain, steatorrhea, jaundice, newly onset diabetes, episodes of pancreatitis)
• Clinical examination (jaundice, Courvoisier's sign, palpable tumor, palpable lymph nodes, previous surgeries)
• Laboratory tests (clinical chemistry, blood count, cholestasis values, liver synthesis values, coagulation, tumor markers CA 19.9, CEA)
• Chest X-ray (lung RH)
• CT or MRI with the question: potentially resectable local finding, arterial and venous vascular infiltration (hepatic artery, superior mesenteric artery, celiac trunk, portal vein), ascites, distant metastasis (liver), vascular supply of the liver/upper abdomen (e.g., anomalies such as atypical right hepatic artery)

• Icteric patients: parenteral administration of Vitamin K (Konakion) for 2-3 days preoperatively regardless of the Quick value. Only in patients with manifest secondary complications of jaundice (deranged plasma coagulation, liver synthesis disorder, reduced cellular defense) preoperative endoscopic bile duct drainage
• Gastric outlet stenosis: preoperative insertion of a gastric tube for 3 days for "gastric toning"

Significant intervention, therefore pay special attention to the informed consent period (>24h; better to inform already during the initial consultation).
Always explain with an operative drawing to clarify the postoperative anatomy!
Consequences of the intervention: Exocrine/endocrine insufficiency, possibly associated dietary changes, biliary reflux (Whipple), peptic ulcers of the jejunum, episodes of cholangitis with biliodigestive anastomosis, pancreatitis,
Bleeding, foreign blood transfusions necessary in about 50%
Anastomotic insufficiencies, revision surgeries, long-term intensive medical treatment in case of complications
“Usual complications”: Thrombosis, pulmonary embolism, pneumonia, injury to adjacent structures (intestine, vessels, nerves, other organs), extension of the surgery at the discretion of the surgeon

• Intubation anesthesia
• Postoperative analgesia with epidural catheter
• Restrictive intraoperative volume administration (3 anastomoses, long surgery time with 4-6 hours)
• If red blood cell transfusion is necessary, preferably only after the resection phase

• Supine position
• Left arm abducted
• Right arm adducted

The surgeon stands on the right side, the first assistant on the left side, and during the operation, there may be a change of sides. The scrub nurse stands at the foot end.

• Retention system for the rib arch (e.g., according to Stuhler)
• Clip applicator
• Bipolar scissors helpful
• Stapler devices

postoperative analgesia: Pain management in the first 48-72 hours using epidural catheter (opioid and local anesthetic) and peripherally acting analgesics (e.g., Ibuprofen, Paracetamol, Metamizole orally). Then switch to oral analgesia according to established hospital protocol (e.g., Targin 10 1-0-1 + Ibuprofen 600 1-1-1). Follow the link to PROSPECT (Procedures Specific Postoperative Pain Management). Follow the link to the current guideline Treatment of acute perioperative and post-traumatic pain.

medical follow-up treatment: The prophylactic, perioperative use of somatostatin or its analogs to prevent pancreatic anastomosis leakage is still controversially discussed. If used, then in “soft” pancreas: start early intraoperatively (single dose s.c. 100 µg) and continue for five days postoperatively (s.c. 3×100 µg). Proton pump inhibitor (e.g., Pantoprazole 1 × 40 mg/day, in pancreato-gastrostomy due to the risk of erosion bleeding 2×40 mg). Patients with pancreato-gastrostomy should take a PPI (e.g., Pantoprazole 40mg 0-0-1) for life. The gastric tube is regularly removed on the 1st postoperative day, except in pancreato-gastrostomy (indicator of erosion bleeding) at the earliest on the 2nd day (if the secretion is unremarkable). Central accesses and bladder catheter should be removed by the 3rd postoperative day if the course is uncomplicated. Thrombosis prophylaxis: In the absence of contraindications, due to the high risk of thromboembolism (major abdominal surgery for malignancy), low molecular weight heparin should be administered prophylactically, possibly in weight- or disposition risk-adapted dosage until full mobilization is achieved. The continuation of drug thromboembolism prophylaxis for e.g., 6 weeks is discussed. Note: Kidney function, HIT II (history, platelet control) Follow the link to the current guideline Prophylaxis of venous thromboembolism (VTE).

mobilization: Early mobilization in the evening of the surgery day. Physiotherapy: Pneumonia prophylaxis (physiotherapy, breathing exercises) Diet progression: Diet progression starts from the 1st postoperative day with tea, later with yogurt, pureed food, and, if well tolerated, from the 4th postoperative day with a full diet. Bowel regulation: Supportive measures in case of bowel sluggishness. Incapacity for work: Varies individually