Pancreaticoduodenectomy

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

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

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