Difference between revisions of "Pancreaticoduodenectomy"
From WikiAnesthesia
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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). | 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 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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=== 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 | ||
=== 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 | * 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 | |||
=== 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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|- | |- | ||
|Procedure | |Procedure | ||
| | |Pylorus resected | ||
|The pylorus is not resected | |The pylorus is not resected | ||
|- | |- | ||
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|- | |- | ||
|Surgical time | |Surgical time | ||
| | |4-7h | ||
| | |4-7h | ||
|- | |- | ||
|EBL | |EBL | ||
| | |200-800cc | ||
| | |200-800cc | ||
|- | |- | ||
|Postoperative disposition | |Postoperative disposition | ||
Revision as of 08:21, 14 March 2022
Pancreaticoduodenectomy
| Anesthesia type |
General |
|---|---|
| Airway |
ETT |
| Lines and access |
PIV x 2 |
| Monitors |
Standard |
| Primary anesthetic considerations | |
| Preoperative |
Mechanical bowel prep |
| Intraoperative |
Combined general + epidural |
| Postoperative |
PONV |
| Article quality | |
| Editor rating | |
| User likes | 1 |
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 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
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
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