Difference between revisions of "Pancreaticoduodenectomy"

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| anesthesia_type = General
| anesthesia_type = General
| airway = ETT
| airway = ETT
| lines_access = PIV x 2 <br/> ART
| lines_access = Large bore IV
| monitors = Standard <br/> 5-lead EKG <br/> ABP <br/> +/- CVP
Arterial line
| considerations_preoperative = Mechanical bowel prep <br/> ERAS
± Central line
| considerations_intraoperative = Combined general + epidural<br/> Goal-directed fluid therapy <br/> Glucose control <br/> Blood transfusion management <br/> Lung protective ventilation <br/> Avoid hypothermia
| monitors = Standard
| considerations_postoperative = PONV <br/> ERAS <br/> Goal-directed fluid therapy <br/> Early NG, foley, and drain removal <br/> Early PO nutrition <br/> Glycemic control<br/> Non-opioid analgesia <br/> DVT PPx <br/> Pulmonary rehab <br/> Early ambulation
5-lead ECG
ABP
± CVP
| considerations_preoperative = Mechanical bowel prep
ERAS
| considerations_intraoperative = Combined general ± epidural
Goal-directed fluid therapy
Glucose control
Blood transfusion management
Lung protective ventilation
Avoid hypothermia
| considerations_postoperative = PONV
ERAS
Goal-directed fluid therapy
Early NG, foley, and drain removal
Early PO nutrition
Glycemic control
Non-opioid analgesia
DVT prophylaxis
Pulmonary rehabiliation
Early ambulation
}}
}}


The Pancreaticoduodenectomy is also known as the Whipple Procedure, after Dr. Allen Whipple. This is the most commonly performed surgery to remove pancreatic tumors, and is typically done for patients who have tumors located in the head of the pancreas or adjacent regions. The procedure is anatomically complicated, and there may be anatomical variations among the various involved blood vessels and ducts in the area. Even after pancreatic resection, the 5-year survival rate is only 15-20% (compared with 5% without surgery).  
A '''pancreaticoduodenectomy''' (also known as a '''Whipple Procedure''' after Dr. Allen Whipple) is the most commonly performed surgery to remove pancreatic tumors, and is typically done for patients who have tumors located in the head of the pancreas or adjacent regions. The procedure is anatomically complicated, and there may be anatomical variations among the various involved blood vessels and ducts in the area. Even after pancreatic resection, the 5-year survival rate is only 15-20% (compared with 5% without surgery).
 
A standard whipple consists of resection of head of pancreas, gallbladder, part of duodenum, pylorus of the stomach, and lymph nodes near the pancreatic head. The surgeon reconnects the remaining pancreas and digestive organs so that pancreatic digestive enzymes, bile, and stomach contents will flow into the SI during digestion. Pyloric-sparing whipples are a variant of this procedure.  


== Preoperative management ==
== Preoperative management ==
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|-
|-
|Pulmonary
|Pulmonary
|
|Many pancreatic cancer patients have been heavy smokers, increased risk of pulmonary complications
|-
|-
|Gastrointestinal
|Gastrointestinal
|
|Check if patient has had a bowel prep, they may be dry
|-
|-
|Hematologic
|Hematologic
|
|Assess for anticoagulation and possible contraindications to an epidural. DVTs/PEs are major common complications of pancreatic cancer patients
|-
|-
|Renal
|Renal
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|-
|-
|Endocrine
|Endocrine
|
|80% have either diabetes or impaired glucose tolerance. Diabetics are at increased risk of MI, CVA, renal infarction
|-
|-
|Other
|Other
|
|Pancreatitis patients tend to be hypotensive and hypovolemic
More than 80% of pancreatic cancers are diagnosed in patients >65y/o with comorbidities.
|}
|}


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* CBC, BMP, LFTs, coags
* CBC, BMP, LFTs, coags
* EKG in any patient with risk factors for CAD
* EKG in any patient with risk factors for CAD
*Type and Screen, have 2 units of pRBC on hold


=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
* A-line setup
* Have insulin available in the room


=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
* Many are ERAS pathway
*Strongly consider acetaminophen, gabapentin, celecoxib, particularly if epidural is not used


=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
* Preoperative epidural placement is common
*TAP block can be administered if there is no epidural placement


== Intraoperative management ==
== Intraoperative management ==


=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
* A-line, 2 large-bore PIVs
* CVP is not as common anymore
* NG tube should be placed and taped for postop


=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
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=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
* Regular glucose checks and insulin infusion titration should occur throughout the procedure
*Consider epidural maintainance for intraop pain if BP tolerates (e.g. bupivacaine 0.125% 5-10 mL/hr)
*Consider ketamine bolus (0.5 mg/kg) and infusion (0.2-0.3 mg/kg/hr), especially if epidural is not used


=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
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=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
* ICU


=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
* Epidural can be used for postoperative pain management


=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
* Pulmonary complications occur following pancreatic resections in 25% of patients. Pulmonary recruitment is important with upper abdominal surgery
** Pneumonia
** Failure to wean from ventilator
** Post-extubation respiratory failure represents mortality rate of 1-5%
** Patients with pulmonary disease account for 40% of postoperative complications and 20% of deaths
* Delayed gastric emptying: Usually at 7-10 days the stomach begins to recover function
* Pancreatic fistula
* Bowel leakage from anastomosis
* Hemorrhage
* Abscess
* Pancreatogenic diabetes: Following pancreatic resection, insulin receptors are peripherally upregulated and patients are more sensitive to insulin. Patient is more prone to large swings in glucose.


== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
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|+
|+
!
!
!Variant 1
!Standard Whipple
!Variant 2
!Pylorus Preserving Whipple
|-
|-
|Unique considerations
|Procedure
|
|Pylorus resected
|
|The pylorus is not resected
|-
|-
|Position
|Position
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|-
|-
|Surgical time
|Surgical time
|
|4-7h
|
|4-7h
|-
|-
|EBL
|EBL
|
|200-800cc
|
|200-800cc
|-
|-
|Postoperative disposition
|Postoperative disposition
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[[Category:Surgical procedures]]
[[Category:Surgical procedures]]
[[Category:General surgery]]
[[Category:Pancreatic surgery]]

Latest revision as of 18:47, 15 September 2022

Pancreaticoduodenectomy
Anesthesia type

General

Airway

ETT

Lines and access

Large bore IV Arterial line ± Central line

Monitors

Standard 5-lead ECG ABP ± CVP

Primary anesthetic considerations
Preoperative

Mechanical bowel prep ERAS

Intraoperative

Combined general ± epidural Goal-directed fluid therapy Glucose control Blood transfusion management Lung protective ventilation Avoid hypothermia

Postoperative

PONV ERAS Goal-directed fluid therapy Early NG, foley, and drain removal Early PO nutrition Glycemic control Non-opioid analgesia DVT prophylaxis Pulmonary rehabiliation Early ambulation

Article quality
Editor rating
In development
User likes
1

A pancreaticoduodenectomy (also known as a Whipple Procedure after Dr. Allen Whipple) is the most commonly performed surgery to remove pancreatic tumors, and is typically done for patients who have tumors located in the head of the pancreas or adjacent regions. The procedure is anatomically complicated, and there may be anatomical variations among the various involved blood vessels and ducts in the area. Even after pancreatic resection, the 5-year survival rate is only 15-20% (compared with 5% without surgery).

A standard whipple consists of resection of head of pancreas, gallbladder, part of duodenum, pylorus of the stomach, and lymph nodes near the pancreatic head. The surgeon reconnects the remaining pancreas and digestive organs so that pancreatic digestive enzymes, bile, and stomach contents will flow into the SI during digestion. Pyloric-sparing whipples are a variant of this procedure.

Preoperative management

Patient evaluation

System Considerations
Neurologic
Cardiovascular
Pulmonary Many pancreatic cancer patients have been heavy smokers, increased risk of pulmonary complications
Gastrointestinal Check if patient has had a bowel prep, they may be dry
Hematologic Assess for anticoagulation and possible contraindications to an epidural. DVTs/PEs are major common complications of pancreatic cancer patients
Renal
Endocrine 80% have either diabetes or impaired glucose tolerance. Diabetics are at increased risk of MI, CVA, renal infarction
Other Pancreatitis patients tend to be hypotensive and hypovolemic

More than 80% of pancreatic cancers are diagnosed in patients >65y/o with comorbidities.

Labs and studies

  • CBC, BMP, LFTs, coags
  • EKG in any patient with risk factors for CAD
  • Type and Screen, have 2 units of pRBC on hold

Operating room setup

  • A-line setup
  • Have insulin available in the room

Patient preparation and premedication

  • Many are ERAS pathway
  • Strongly consider acetaminophen, gabapentin, celecoxib, particularly if epidural is not used

Regional and neuraxial techniques

  • Preoperative epidural placement is common
  • TAP block can be administered if there is no epidural placement

Intraoperative management

Monitoring and access

  • A-line, 2 large-bore PIVs
  • CVP is not as common anymore
  • NG tube should be placed and taped for postop

Induction and airway management

Positioning

Maintenance and surgical considerations

  • Regular glucose checks and insulin infusion titration should occur throughout the procedure
  • Consider epidural maintainance for intraop pain if BP tolerates (e.g. bupivacaine 0.125% 5-10 mL/hr)
  • Consider ketamine bolus (0.5 mg/kg) and infusion (0.2-0.3 mg/kg/hr), especially if epidural is not used

Emergence

Postoperative management

Disposition

  • ICU

Pain management

  • Epidural can be used for postoperative pain management

Potential complications

  • Pulmonary complications occur following pancreatic resections in 25% of patients. Pulmonary recruitment is important with upper abdominal surgery
    • Pneumonia
    • Failure to wean from ventilator
    • Post-extubation respiratory failure represents mortality rate of 1-5%
    • Patients with pulmonary disease account for 40% of postoperative complications and 20% of deaths
  • Delayed gastric emptying: Usually at 7-10 days the stomach begins to recover function
  • Pancreatic fistula
  • Bowel leakage from anastomosis
  • Hemorrhage
  • Abscess
  • Pancreatogenic diabetes: Following pancreatic resection, insulin receptors are peripherally upregulated and patients are more sensitive to insulin. Patient is more prone to large swings in glucose.

Procedure variants

Standard Whipple Pylorus Preserving Whipple
Procedure Pylorus resected The pylorus is not resected
Position
Surgical time 4-7h 4-7h
EBL 200-800cc 200-800cc
Postoperative disposition
Pain management
Potential complications

References

Top contributors: Barrett Larson, Olivia Sutton, Tony Wang and Chris Rishel

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