Difference between revisions of "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

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Latest revision as of 19:47, 15 September 2022

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

@@ Line 1: / Line 1: @@
+{{Infobox surgical procedure
+| anesthesia_type = General
+| airway = ETT
+| lines_access = Large bore IV
+Arterial line
+± Central line
+| monitors = Standard
+-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
+}}
+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<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
+{| class="wikitable"
+|+
+!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<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
+* 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<!-- 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. --> ===
+* 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. --> ===
+* Preoperative epidural placement is common
+*TAP block can be administered if there is no epidural placement
+== 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. --> ===
+* 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. --> ===
+=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
+=== 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. --> ===
+== Postoperative management ==
+=== 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. --> ===
+* Epidural can be used for postoperative pain management
+=== 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). --> ==
+{| class="wikitable wikitable-horizontal-scroll"
+|+
+!
+!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 ==
+[[Category:Surgical procedures]]
+[[Category:General surgery]]
+[[Category:Pancreatic surgery]]