Pancreatectomy

Pancreatectomy

Anesthesia type	General ± Epidural
Airway	ETT
Lines and access	PIV x2 Arterial line
Monitors	Standard 5-lead ECG Temperature ABP
Primary anesthetic considerations
Preoperative	Electrolyte disturbances Diabetes management
Intraoperative	Hypovolemia Glucose management
Postoperative
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A pancreatectomy can be indicated for conditions such as pancreatic stones, cysts, benign or malignant tumors, ductal obstructions, or chronic pancreatitis. It can be classified as total, where the entire organ is removed, often along with the spleen, gallbladder, local lymph nodes, the common bile duct, and portions of the small intestine and stomach, or partial, where the pancreas is resected from the mesenteric vessels distally, leaving the head and uncinate process intact.

Preoperative management

Patient evaluation

System	Considerations
Airway
Neurologic
Cardiovascular
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine	Diabetes is common in these patients, glucose management should be considered
Other	Electrolyte derangements and hypovolemia common in patients with pancreatitis

Labs and studies

• CBC
• Electrolytes
  • Especially K+, serum glucose, BUN, Cr
• Coagulation panel
• LFTs
• Urinalysis
• EKG
• CXR
• TTE is commonly requested

Operating room setup

• Have insulin available for glucose management
• Have pressor (usually norepinephrine) available for management of hypotension

Regional and neuraxial techniques

• Epidurals are common to manage postoperative pain
• If epidural is not performed, TAP blocks can be an alternative

Intraoperative management

Monitoring and access

• Arterial line
• 2 large bore IVs

Positioning

• Supine

Postoperative management

Disposition

• Floor vs. ICU

Pain management

• Epidural is common for postoperative pain management
• TAP blocks are an alternative for patients who cannot receive epidurals

Potential complications

• Endocrine and exocrine insufficiency
• Wound infection
• Duodenal necrosis
• Diabetes
• Hemorrhage

Procedure variants

	Total	Near-Total (Child's Procedure)	Partial (Distal)
Indications	Pancreatic stones, cysts, ductal obstruction, benign or malignant tumor, chronic pancreatitis	When underlying disease has functionally destroyed the pancreas or when lesser procedures have failed to provide adequate pain relief	Tumor or pancreatitis
Surgical procedure	Entire organ removed, usually with spleen, gallbladder, local lymph nodes, CBD, portions of SI and stomach. Remaining distal stomach is anastomosed to a portion of the SI	Removal of entire pancreas except rim of tissue along the lesser curvature of the duodenum, which makes it unnecessary to reconstruct the bile duct	Resection of the pancreas from the mesenteric vessels distally, leaving the head and uncinate process intact
Surgical time	3-6h	3-6h
EBL	300-500cc	300-500cc
Postoperative disposition
Pain management
Potential complications