Perioperative management - Pylorus-preserving pancreaticoduodenectomy, according to Longmire-Traverso, robotically assisted

Fundamentals:

• The pylorus-preserving pancreatic head resection according to Traverso-Longmire is considered the current standard for malignant tumors of the pancreatic head.
• Despite the overall poor prognosis of these tumors, the surgery represents the only potentially curative procedure.
• In principle, the indication for pancreatic head resection exists for histologically confirmed malignancies and when there is sufficient suspicion of malignancy, provided that pre- and intraoperatively there is at least the prospect of resecting the tumor in toto, and the patient is in a general sufficient condition for this procedure.

Main Indication:

• The most common malignant tumor of the pancreas is ductal adenocarcinoma (85%), with the pancreatic head being affected in 65% of cases.

Other Indications:

• distal bile duct carcinoma
• ampullary carcinoma
• duodenal carcinoma
• large adenomas of the ampulla or near the ampulla in the duodenum
• benign/cystic tumors of the pancreatic head
• intraductal papillary mucinous neoplasm (IPMN) of the main and side ducts (with "high-risk stigmata") as well as the mixed type
• mucinous cystic neoplasm (MCN)
• solid-pseudopapillary neoplasm (SPN)
• chronic pancreatitis with complications, especially with distal bile duct stenosis
• so-called "dilemma" cases (when imaging and clinical presentation cannot reliably differentiate between inflammatory and malignant pancreatic head tumors)
• hereditary gastrinomas in MEN-1 disease (multiple duodenal gastrinomas)
• metastases in the pancreatic head
• pancreas divisum
• rare other pancreatic head tumors

The essential difference to the classical Kausch-Whipple operation is:

• Preservation of the pylorus of the stomach with its neurovascular supply
• In terms of mortality, morbidity, and oncological radicality, there is no difference
• Limiting for an R0 resection is not the gastric margin but the dorsal, retroperitoneal pancreas margin.

Potential advantages of the pylorus-preserving method are:

• a shorter operation time
• less blood loss
• Preservation of physiological gastric emptying: better function regarding absorption, food utilization, and postoperative weight gain

Specific considerations for indication:

Surgical Procedure and Extent of Resection:

-Operative approach dependent on:

• Tumor location
• Stage and classification
• pylorus-preserving vs. "classical" resection (house standard: Traverso-Longmire!)

Resectability Criteria:

From N1 or T3, perioperative chemotherapy is usually performed. Tumor conference! Borderline tumors

Locally limited pancreatic carcinoma or IPMN of the pancreatic head:

-pylorus-preserving pancreatic head resection according to Traverso-Longmire

- In case of R0 resection, adjuvant chemotherapy 4-12 weeks after surgery

- In case of R1, possibly radiochemotherapy

Locally advanced pancreatic carcinoma:

• Infiltration of the A. hepatica com. or the trunk (up to 180°): Borderline resectable: Neoadjuvant + exploration
• Resection not possible → (Radio-) Chemotherapy

Venous infiltration:

• 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 usually cannot differentiate between inflammatory adhesion and tumor infiltration.
• Patients seem to benefit from vascular resection if an R0 resection is successful.

Arterial infiltration:

• The resection and reconstruction of visceral arteries is a case-by-case decision to achieve an R0 resection given the currently insufficient study situation.

Preoperative bile duct drainage:

• The indication for resection is made by the surgeon promptly after diagnosis, especially if it is a potentially resectable finding in jaundiced patients.
• Only in patients with manifest secondary complications of jaundice (deranged 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, preoperative bile duct drainage, whether TPCD (transpapillary) or PTCD (percutaneous-transhepatic), is avoided due to increased postoperative morbidity.

Age and comorbidity:

• Comorbidity is another essential factor in the indication setting.
• Patients with severe cardiovascular comorbidities carry a significantly increased surgical risk.
• High age per se is no longer a contraindication for pancreatic head resection today.

Lymphadenectomy:

• Lymphadenectomy includes the regional lymph nodes at the duodenum and pancreatic head.
• An extension beyond this does not lead to an improvement in survival. Therefore, extended lymph node dissection is controversial due to an increased complication rate.
• Vascular skeletonization along the aorta and superior mesenteric artery with removal of nerve tissue can result in persistent gastric emptying disorders and severe diarrhea with malnutrition.

Indication for Robotic PPPD:

• Preoperative assessment of resectability is not always exact, as cross-sectional imaging is not one hundred percent reliable here.
• Even in open exploration, it is a challenge to correctly assess arterial infiltration.
• Especially in the early days of implementing robotic pancreatic head resection, the indication for robotic approach is seen in small tumors that have a good safety distance from the upper abdominal arteries and portal venous branches. If intraoperatively there is indeed a vascular infiltration, a conversion to an open approach should currently be performed. (Note: This approach is certainly in progress, and advances in robotics are also to be expected in the near future.)

Currently, resectability is assessed according to the so-called ABC criteria of resectability according to the International Association of Pancreatology (IAP) consensus:

According to: Isaji, S., et al., International consensus on definition and criteria of borderline resectable pancreatic ductal adenocarcinoma 2017. Pancreatology, 2018. 18(1): p. 2-11.

Alternative Procedures:

Regarding Access Route

• Open PPPD
• Laparoscopic PPPD

Regarding Extent of Surgery

• Classical Whipple with distal gastric resection
• Left pancreatic resection for tumor location in the body or tail
• Total pancreatectomy for infiltration of the entire pancreas

surgical-technical:

• Portal vein occlusion with pronounced collateral circulation
• Spleen vein occlusion with pronounced collaterals and presence of gastric varices

tumor-related unresectability:

• Tumor infiltration of supplying arteries of the liver (hepatic artery), inferior vena cava, aorta, small intestine (superior mesenteric artery, > 180°), celiac trunk (> 180°)
• Peritoneal carcinomatosis
• Liver metastases primarily from ductal pancreatic carcinoma (exceptions: oligometastasis within the framework of multimodal therapy concepts in studies)

tumor-related contraindications for primary surgical approach:

• Superior mesenteric artery contact > 180°
• Celiac trunk contact > 180°
• Infiltration of the common hepatic artery with contact to the proper hepatic artery or celiac trunk
• Infiltration of the superior mesenteric vein/portal vein and their tributaries without possibility of reconstruction
• For a CA 19-9 > 500 U/ml, a diagnostic laparoscopy should be performed to assess peritoneal carcinomatosis. Subsequently, after exclusion, a neoadjuvant concept can be pursued.

Note: The tumor-related contraindications listed last regarding the infiltration of the common hepatic artery, superior mesenteric artery apply primarily to the primary operation, as in individual cases after neoadjuvant (radio-)chemotherapy, even oligometastatic or arterially infiltrating tumors can be resected R0.

• The infiltration of the pylorus or distal stomach is a contraindication, as in these cases a classic pancreatic head resection according to Kausch-Whipple should be performed.
• In the case of continuous involvement of the pancreatic tail, a pancreatectomy is performed to ensure an R0 resection

patient-specific:

• acute florid pancreatitis
• liver cirrhosis Child B and C
• poor heart and lung function (NYHA status and GOLD status)
• ECOG status ≥ 2
• high-grade carotid stenoses before therapy

Note: the absolute age is no longer relevant, but rather the clinical condition of the patient (ECOG status, etc.)

(Relative) contraindications for a robotic approach (currently)

• Small/no safety margin to the upper abdominal arteries and portal venous branches
• Large space-occupying lesions over 5 cm
• accompanying pancreatitis

Currently, resectability is comprehensively assessed according to the so-called ABC criteria of resectability according to the International Association of Pancreatology (IAP) consensus:

According to: Isaji, S., et al., International consensus on definition and criteria of borderline resectable pancreatic ductal adenocarcinoma 2017. Pancreatology, 2018. 18(1): p. 2-11.

History/Clinical Findings:

• no characteristic leading symptom, nonspecific with loss of appetite, feeling of fullness, digestive disorders, fatty stools, weight loss, B symptoms
• Jaundice
• New onset diabetes mellitus
• Upper abdominal and back pain
• obstructive pancreatitis
• palpable tumor
• Previous surgeries
• Cholestasis, cholangitis, Courvoisier's sign (palpable enlarged tense elastic gallbladder)

Laboratory Diagnostics

• CBC, electrolytes, CRP, cholestasis markers, liver synthesis markers, kidney markers, albumin, lipase/amylase, blood glucose, OGTT (oral glucose tolerance test) or HbA1c, blood type, coagulation, 2-4 RBC units as per surgeon's discretion
• Tumor marker CA 19-9 (independent predictor of poorer overall survival)
• CEA (also and especially from endosonographically obtained cyst punctate)
• Genetics: PRSS1, SPINK1, PSTI, CFTR (in young patients to exclude hereditary genesis – strict indication due to high cost!)
• Hormone analysis if endocrine active neoplasms are suspected

Note: Pancreatic function diagnostics can use the following tests:

• Oral glucose tolerance test in previously unknown diabetes mellitus to assess endocrine pancreatic function
• HbA1c to assess endocrine pancreatic function
• Stool elastase for diagnosing exocrine pancreatic function

Imaging Diagnostics

• Transcutaneous Sonography: Basic diagnostics with good and non-invasive visualization of the pancreatic parenchyma, also allows detection of pancreatic duct dilation. Additional assessment of the portal vein system through color Doppler sonography. Ultrasound contrast agents can aid in differential diagnosis between inflammatory and tumorous, cystic tumor and pseudocyst. Furthermore, detection of cholestasis, cholecystolithiasis, liver metastases, ascites.
• CT Abdomen: For solid changes, a multiphase CT of the abdomen is best suited. CT can generally assess pancreatic masses, lymph node enlargements, perfusion of the superior mesenteric vein, portal vein, superior mesenteric artery, and celiac trunk, distant metastases, pancreatic calcifications, pancreaticolithiasis, distant metastasis
• CT Thorax: to exclude pulmonary metastasis
• MRI with MRCP (Magnetic Resonance Cholangiopancreatography): Non-invasive visualization of the bile and pancreatic duct systems. More sensitive than ERCP in detecting solid wall changes (so-called "mural nodules"). For cystic tumors, an MRI of the upper abdomen with MRCP is recommended, which is superior to CT in diagnostic potency. Additionally, MRI with MRCP better visualizes the spatial relationships between the tumor and pancreatic duct system. Furthermore, duct irregularities, stenoses, dilations, double-duct sign = simultaneous stenosis of the pancreatic duct and common bile duct, CBD stenosis, dilation, and pancreaticolithiasis can be detected.
• MRI with liver-specific contrast agent: Exclusion of hepatic metastasis
• Possibly CEUS ultrasound (contrast-enhanced ultrasound) for assessing liver lesions
• Possibly FDG-PET-CT: in suspected metastatic situation

Note: Visualization of the bile or pancreatic duct systems is only required in unclear cases. ERCP and MRCP are suitable for this. The "double-duct sign" (simultaneous stenosis/interruption of the pancreatic duct and common bile duct) is considered pathognomonic for carcinoma.

Endoscopic/Invasive Diagnostics

• Possibly EGD: histological confirmation possible in papillary carcinoma, exclusion or extent of duodenal polyps with stomach preservation, transpapillary secretion of viscous mucus highly suspicious for IPMN

Note: A histological confirmation of the tumor is not required preoperatively if there is sufficient suspicion of a tumor, but it is necessary before initiating neoadjuvant (radio)chemotherapy or palliative chemotherapy in the metastatic stage.

• Possibly Endosonography (EUS): clarification of gastric collateral pathologies and further depiction of the pancreas by endosonography to assess mural changes in cystic neoplasms for type diagnosis of these changes and for cyst puncture or biopsy confirmation, examiner-dependent, additionally: determination of local tumor extent and assessment of local lymph nodes (lymph nodes > 1 cm are suspicious for malignancy), possibly with puncture (fine needle aspiration of cyst fluid) and biopsy.
• Possibly Laparoscopy in suspected peritoneal carcinomatosis/CA 19-9 > 500 U/ml and/or proven ascites -> puncture with cytology
• ERCP: Due to possible complications (pancreatitis, bleeding, perforation), preferably only for therapeutic intervention, otherwise MRCP or EUS; interventional relief of the bile duct system only in unresectability or delay of surgery, otherwise immediate surgical intervention

Preoperative Functional Diagnostics

• depending on pre-existing conditions: ECG, echocardiogram, lung function

Special Preparation

• Blood group determination
• Provision of 2-4 cross-matched erythrocyte concentrates as per the surgeon's discretion
• Pyloric stenosis: preoperative gastric tube
• If necessary, stabilization of coagulation (e.g., Konakion® for 2-3 days preoperatively) in jaundiced patients.
• If necessary, improvement of liver function (e.g., DHC stenting): Only in patients with manifest secondary complications of jaundice (deranged plasma coagulation, liver synthesis disorder, reduced cellular defense), bilirubin >15 mg/dl, or in postponed surgery and jaundice

Preoperative Preparation

• Body care: shower the evening before
• Shaving: from the jugulum to the symphysis; legs in case of vein harvesting for vascular construction
• Preoperative nutrition: Eat lunch the day before, then small intestine absorbable diet (SAD), in case of reduced general condition and nutritional status (albumin < 30mg/dL) additionally high-calorie nutrition (3 days preoperatively), human albumin, iron (Ferrinject), vitamin B12, folic acid
• Thrombosis prophylaxis: See guideline Prophylaxis of venous thromboembolism (VTE)
• Premedication: Epidural catheter. Admission to intensive care unit. Central venous catheter
• Antibiotics: according to house standard, e.g., Cefuroxime 1.5g and Clont 500 mg or Rocephin (Ceftriaxone) 2g + Clont 500mg (repeat after 3 hours of surgery time)
• If necessary: Octreotide: (somatostatin analogue) 100 µg subcutaneously (2 ampoules) to be taken to the operating room, every 8 hours for 24 hours in case of oral fasting

Significant intervention, therefore pay special attention to the informed consent period (> 24h; better to inform during the initial consultation). Always with a drawing to illustrate the postoperative anatomy! 

General Complications

• Wound healing disorder
• Thromboembolism
• Pneumonia
• Lymphatic fistula
• Injury to adjacent structures (intestine, vessels, nerves, other organs)
• Extension of the operation at the surgeon's discretion
• Follow-up interventions
• Long-term intensive medical treatment in case of complications
• Bleeding/rebleeding, PPH = postpancreatectomy hemorrhage
• Allogeneic blood transfusions

Specific Complications

• Pancreatic fistula POPF = postoperative pancreatic fistula
• Gastric emptying disorder
• Bile leakage/bilioma
• Anastomotic insufficiency/stenosis
• Necrosis of the pancreatic remnant
• Endocrine and exocrine pancreatic insufficiency, possibly associated dietary changes
• Insulin-dependent diabetes mellitus (lifelong)
• Peptic ulcers of the jejunum
• Episodes of cholangitis with biliodigestive anastomosis
• Extension of the procedure up to pancreatomy +/- splenectomy

Note: Definition and classification of PPH, POPF, and DGE by the International Study Group of Pancreatic Surgery (ISGPS)

• Intubation anesthesia
• Central venous catheter (CVC)
• Arterial pressure measurement
• Restrictive intraoperative volume administration (3 anastomoses, long surgery time with 4-6 hours)
• Nasogastric tube
• Indwelling urinary catheter
• Perioperative antibiotic prophylaxis
• If necessary, administration of octreotide
• Intra- and postoperative analgesia with Epidural catheter (EDC)

Note: Follow the link to PROSPECT (Procedure specific postoperative pain management) or to the current guideline Treatment of acute perioperative and post-traumatic pain.

Positioning is done in the supine position on the large vacuum cushion. The left arm can be positioned outward. The use of the cushion eliminates the need for lateral supports. Due to the extreme Trendelenburg position at the beginning of the operation, padded shoulder supports are recommended to prevent slipping.

Note: The positioning is of particular importance due to the docking of the patient to the manipulator of the robot. There is a risk of injury if the patient slips.

Caution: Vacuum cushions may have leaks. Check again before sterile draping.

Important: In the procedure shown here, intraoperative repositioning is performed:

1.) After inserting the trocars, the operating table is positioned for the first step in maximum Trendelenburg and moderate right lateral position (see Figure 1).

Note: Only through this initial positioning can the region dorsal to the mesenteric root be cleanly prepared.

2.) After the first step, undocking and positioning in 15 degrees reverse Trendelenburg while maintaining the moderate right lateral position is performed (see Figure 2).

The surgical robot is brought in after each positioning and the robot arms are docked.

• The Surgeon ideally sits at the console with the ability to look at the patient and table assistant.
• The surgical robot (Patient Card) is brought to the patient from the right cranial side (X). With the Xi, the Patient Card can be variably brought to the patient, for example, straight at a right angle from the right.
• The table assistant stands or sits on the left side of the operating table.
• The anesthesia is located at the head of the patient.
• The instrumenting OR nurse is positioned to the right of the patient's legs with the table over the legs.

Robotic Instruments:

• Cardiere or Tip-Up Grasper,
• (Maryland bipolar Forceps),
• fenestrated bipolar Forceps,
• Camera (30°),
• monopolar Scissors,
• Vessel sealer,
• Linear stapler SureForm 60 with blue cartridge

Trocars:

Robotic

• Three 8 mm Robotic Trocars
• One 12 mm Robotic Trocar

Laparoscopic

• One 5 or 12 mm Assistant Trocar

Basic Instruments:

• 11 Scalpel
• Dissection Scissors
• Langenbeck Retractor
• Suction System
• Needle Holder
• Suture Scissors
• Forceps
• Compresses/Gauzes
• Swabs
• Suture material for the abdominal wall fascia in the area of trocars from 10 mm Vicryl 0 with UCLX needle, for the extraction incision PDS 0 or PDS 2/0. Subcutis (3-0 braided, absorbable), Skin (3-0 monofilament, absorbable)
• Veress Needle
• Backhaus Clamps
• Plaster

Additional Instruments

• Gas System for Pneumoperitoneum
• Laparoscopic Atraumatic Grasper
• Laparoscopic Swab on a Stick
• Laparoscopic Suction-Irrigation System
• Specimen Retrieval Bag
• Alexis Wound Protector Size S

Assistant Trocar:

• Clip Applier, if not robotic
• atraumatic Bowel Graspers,
• Suction with Irrigation,
• Swab on a Stick

Instrument Setting: Start: with “two left hands”

Arms X: 4,1,2,3,

• Port 1 (8mm) (Arm 4 at X): Cardiere or Tip-Up Grasper
• Port 2 (8 mm) (Arm 1 at X): bipolar Forceps
• Port 3 (8 mm) (Arm 2 at X): Camera
• Port 4 (12 mm) (Arm 3 at X): Monopolar Scissors/Vessel sealer/Sure Form 60

Preliminary Note: Postoperative care should be integrated into a fast-track concept as "enhanced recovery after surgery" (ERAS). This aims for rapid recovery and reduction of postoperative complications and hospital stay. Key points of the perioperative ERAS concept are:

• preoperative eutrophy and normovolemia with fluid intake up to 2 hours preoperatively,
• contemporary anesthesia management and use of regional techniques,
• largely avoiding drains and invasive access,
• minimally invasive blood-sparing surgical technique as much as possible,
• postoperative pain management with reduction of opioid requirement,
• early mobilization,
• early nutritional build-up, and
• timely discharge planning using discharge management.

In Detail:

• Monitoring: at least 1 night in an IMC/ICU then transfer to NST if medically possible, usually no postoperative ventilation.
• Venous Access: early removal of central venous catheter by the 3rd postoperative day, leave one peripheral line,
• Nasogastric Tube depending on reflux, usually removed on the morning of the 1st postoperative day
• Urinary Catheter: early removal if epidural analgesia <6ml/h, by the 3rd postoperative day
• Drain(s) removal: target drain removal after determination of pancreatic enzymes and serum-equivalent values on the 5th postoperative day
• Mobilization: early mobilization on the evening of the operation. Gradual resumption of physical activity, full load when symptom-free, e.g., on the day of surgery in the siesta chair, standing and walking in the room from the first day, mobilization in the corridor from the 2nd postoperative day
• Physiotherapy
• Breathing Exercises
• Nutritional Build-up: enteral nutrition via FNKJ from the 1st postoperative day with 20ml/h water/Intestamin, increase tube feeding in ICU according to ICU nutritional build-up scheme, sip drinking from the 1st day, increase according to findings: yogurt/high-calorie drink, then tea/soup/yogurt + high-calorie drink then: light full diet
• Infusion: 500-1000 ml on the first postoperative day, thereafter only if oral fluid intake is insufficient
• The prophylactic, perioperative use of somatostatin or its analogs to prevent pancreatic anastomosis leaks is controversially discussed. If used, then with "soft" pancreas: start intraoperatively early (single dose s.c. 100 µg) and for 3 to 5 days postoperatively (s.c. 3 × 100 µg).
• Antibiotics: without GG stent: single-shot intraoperatively, no further administration required, with previously inserted stent: extended antibiotics for 72h
• Thrombosis Prophylaxis: In the absence of contraindications: for moderate thromboembolic risk (surgical procedure > 30 min duration): low molecular weight heparin in prophylactic (usually "Clexane 40"), possibly in weight- or disposition risk-adapted dosing until full mobilization is achieved, physical measures, ATS
• Note: Follow the link to the current guideline on Prophylaxis of Venous Thromboembolism (VTE)
• Caution: when administering heparin, consider: kidney function, HIT II (history, platelet control),
• Possibly Bowel Regulation/Intestinal Activity: from the 1st postoperative day: Macrogol 1-3 sachets/day, by the 3rd day the first bowel movement should have occurred, maintain high-normal potassium, laxative regimen: 1. tea with Laxoberal/Dulcolax suppository, 2. prokinetics: MCP / Prostigmin i.v., 3. Neostigmine s.c. or iv, possibly Relistor with opioid administration
• Laboratory: on the 1st postoperative day, and then every 2-3 days with normal progression until discharge, immediately if clinical deterioration,
  • Blood sugar daily profiles
  • Pancreatic enzymes from drainage fluid before drain removal, e.g., on the 5th postoperative day
• Dressing every 2 days, with cutaneous suction dressing every 5 days
• Pancreatic Enzyme Substitution after nutritional build-up and dietary counseling
• Diabetological Adjustment for newly developed diabetes mellitus
• PPI Prophylaxis: initially i.v., then orally beyond discharge.
• Clips/Sutures: if not absorbable, remove after 10 days

Postoperative Analgesia:

• Note: Various scales are available for quantifying postoperative pain, allowing the patient to determine their own pain level multiple times a day, such as the NRS (numerical rating scale 0–10), the VAS (visual analog scale), or the VRS (verbal rating scale).
• Caution: Aim to largely avoid opioids and NSAIDs (adverse effects on bowel motility and anastomotic healing)
• Epidural Catheter removed by the anesthesia pain service on the 3rd postoperative day
• Basic Medication: Oral analgesia: 4x1g Novalgin/3x1 g Paracetamol, also combinable, e.g., fixed Novalgin and as needed Paracetamol as needed up to 3x/day
  • Administration of Novalgin: 1g Novalgin in 100 ml NaCl solution over 10 minutes as contraindicated iv, or 1 g as a tablet orally or 30-40 drops Novalgin orally
  • Administration of Paracetamol: 1g iv over 15 minutes every 8h, or 1g suppository every 8h rectally (Caution: consider anastomosis height1), or 1g as tablets orally
• Caution: The basic medication should be tailored to the patient (age, allergies, kidney function).
• As-needed Medication: For VAS >= 4 as needed Piritramid 7.5 mg as contraindicated or sc, or 5 mg Oxigesic acute
  • if pain persists postoperatively >= 4 administration of a sustained-release opioid (e.g., Targin 10/5 2x/day)
• Note: If pain occurs only during mobilization, an as-needed medication should be given 20 minutes before mobilization.
• Note: Follow the link to PROSPECT (Procedures Specific Postoperative Pain Management) and to the current guideline on the treatment of acute perioperative and post-traumatic pain and consider the WHO step scheme.

Discharge and Follow-up Care:

• Discharge: From the 7th postoperative day
• Work Incapacity: Individual sick leave – depending on the degree of recovery and type of activity, e.g., office work after 3 weeks post-op, physical work after 4 weeks post-op
• Follow-up Care:
  • Depending on histological findings and tumor board decision 
  • After R0 resection of pancreatic carcinoma in UICC stage I–III, adjuvant chemotherapy should be conducted for 6 months with ECOG 0-2
    • With an ECOG 0-1 with mFOLFIRINOX
    • With an ECOG > 1-2 Gemcitabine or Gemcitabine+Capecitabine 
  • For R1-resected pancreatic carcinoma, additive chemotherapy should be conducted for 6 months. 
• Discharge Letter: The discharge letter should include information on: diagnosis, therapy, course, histology, comorbidities, current medication, continuation of VTE prophylaxis, postoperative nutrition, tumor board decision
• Rehabilitation Treatment (AHB): register through social services