Pancreaticoduodenectomy

Pancreaticoduodenectomy

Anesthesia type	General
Airway	ETT
Lines and access	PIV x 2 ART
Monitors	Standard 5-lead EKG 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 PPx Pulmonary rehab Early ambulation
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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).

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

Regional and neuraxial techniques

• Preoperative epidural placement is common

Procedure variants

	Standard Whipple	Pylorus Preserving Whipple
Procedure	Resection of head of pancreas, gallbladder, part of duodenum, pylorus of the stomach, and lymph nodes near the pancreatic head. Surgeon reconnects the remaining pancreas and digestive organs so that pancreatic digestive enzymes, bile, and stomach contents will flow into the SI during digestion	The pylorus is not resected
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications