Perioperative management - Pylorus-preserving duodenohemipancreatectomy according to Traverso-Longmire with T-drainage (pp-Whipple)

• Tumors of the pancreatic head (carcinomas, adenomas, cystic tumors etc.)
• Chronic pancreatitis with complications (e.g. CBD stenosis, pancreatic lithiasis, pancreatic duct dilatation)
• Unclear space-occupying lesions in the pancreatic head
• Distal bile duct carcinoma
• Ampullary carcinoma, large adenomas of the papilla or periampullary in the duodenum
• Metastases in the pancreatic head

Preoperative

• Confirmed infiltration of the vessels (superior mesenteric vein, portal vein, superior mesenteric artery, celiac trunk)
• Known metastasizing tumor
• Portal vein thrombosis or other diseases with pronounced venous collateral circulations (liver cirrhosis)

Intraoperative

• Vascular infiltration, then possibly only bypass operation
• Tumor infiltrates up to the pancreatic tail, then pancreatectomy
• Pronounced local inflammation
• Very soft pancreas, then pancreatectomy

Imaging Diagnostics Mandatory

• Ultrasound: Space-occupying lesion in the pancreas, duct dilatation, cysts, cholestasis, cholecystolithiasis
• CT Abdomen: Space-occupying lesion in the pancreas, lymph node enlargement, free perfusion of superior mesenteric vein, portal vein, superior mesenteric artery and celiac trunk, distant metastases, calcifications in the pancreas, pancreatolithiasis
• MRCP = Magnetic Resonance Cholangiopancreatography: Cysts, duct irregularities, -stenoses, -dilatation, Double Duct Sign = simultaneous stenosis of the pancreatic duct
  and common bile duct, CBD stenosis, -dilatation, pancreatolithiasis

Imaging Diagnostics Optional

• Endosonography: Space-occupying lesion in the pancreas, if necessary with puncture and biopsy, cysts
• ERCP: see MRCP, if necessary with papillotomy and stenting of the CBD

Pancreas Function Diagnostics

• Oral Glucose Tolerance Test in case of previously unknown diabetes mellitus to assess the endocrine pancreas function
• HbA1c to assess the endocrine pancreas function
• Stool Elastase for the diagnosis of exocrine pancreas function

Laboratory Diagnostics

• Tumor marker CA 19-9
• Tumor marker CEA (especially from cyst puncture obtained endosonographically)
• If necessary, genetics: PRSS1, SPINK1, PSTI, CFTR (in young patients to exclude a hereditary genesis – strict indication, as cost-intensive!)

• Blood group determination
• Provision of 4 cross-matched red blood cell concentrates
• If necessary, stabilization of coagulation (e.g., Konakion® )
• If necessary, improvement of liver function (e.g. DHC stenting in jaundice)

General

• Wound healing disorder
• Thromboembolism
• Lymphatic fistula
• Injury to internal organs (intestine, liver, stomach, spleen)
• Follow-up procedures

Specific

• Bleeding/Rebleeding: PPH = postpancreatectomy hemorrhage
• Pancreatic fistula: POPF = postoperative pancreatic fistula
• Gastric emptying disorder: DGE = delayed gastric emptying
• Bile leakage/Bilioma
• Anastomotic insufficiency/stenosis: Pancreaticojejunostomy/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 for this