Gastro 55 Pancreas Whipples procedure

  1. Criteria for Resectable tumor
    • Absence of extrapancreatic disease
    • Patent SMV-PV confluence
    • No direct tumor extension to hepatic artery, celiac axis or SMA.
  2. Criterial for borderline Resectable pancreatic carcinoma
    Three types by Katz

    • Type A
    • Tumor artery abutment of ≤180 degree of circumference3 of SMA or celiac axis.
    • Tumor abutment or encasement (>180 degree) of short segment of HA (usually at origin of GDA)
    • Short segment occlusion of SMV, PV or SMV-PV confluence with suitable PV above and SMV below for reconstruction.

    • Type B
    • CT findings suspicious but not diagnostic of metastatic disease.

    • Type C
    • Marginal performance status as well as those with severe pre-existing co-
  3. Criterial for locally advanced tumors
    • Encasement (>180 degree) of adjacent arteries.
    • Occluded SMV-PV with no technical option for resection and reconstruction.
    • Locally advanced tumors should not be considered for operation.
  4. Pylorus Preserving Whipples?
    • The distal third of the stomach is not removed to avoid the complications related to gastrectomy. 
    • The line of rescetion is 2 cm distal to the pylorus.
  5. Extended Whipple’s operation?
    When growth has involved superior mesenteric vessels and adjacent lymph nodes—a wider clearance is possible by resecting a segment of superior mesenteric vessels with bypass graft and dissection of adjacent lymph nodes.
  6. Outline the steps of Whipple’s procedure. [TU 2073]
    Short note on Cattel braasch maneuver. [TU 2067/2] 

    Step 1 - To isolate infrapancreatic SMV and separate colon and its mesentery
    • - Lesser sac entered and hepatic flexure of colon taken down
    • - Inferior body of pancreatic is identified at level of proximal body of gland, visceral peritoneum and root of mesentery is incised from this point, in lateral direction heading towards junction of 2nd and 3rd portion of duodenum in an effort to expose anterior wall of SMV. SMV is exposed at the inferior border of neck of pancreas adjacent to uncinate process. [Tunnel of love – tunnel between pancreatic neck and SMV]
    • - Middle colic vein and gastro-epiploic vein may require ligation
    • - When need of venous resection is anticipated, Catell and Brasch Maneuver to mobilize entire right colon and root of small bowel mesentery. This involves incision of visceral peritoneum to the ligament of Treitz and allow anterior reflection of colon off the duodenum and pancreatic head.
    • [Note – Mattox maneuver is left sided medial visceral rotation]
  7. Step 2 - Kochers maneuver
    • - Begin at transverse portion (third part) of duodenum by identifying the inferior vanacava.
    • - Moblize the duodenum and pancreatic head off of the IVC In cephaloid direction, thereby removing all soft tissue anterior to IVC.
    • - Right gonadal vein usually preserved, if possible as it serves as a good landmark to help prevent inadvertent injury to the underlying ureter (which is usually posterior and slightly lateral to gonadal vain)
    • - Kochers maneuver is continued to the left lateral border of aorta.
  8. Step 3 -  Portal dissection
    • - Begins with identifying CHA by large LN which commonly sits anteriorly the vessel.
    • - CHA is followed distally to allow identification, ligation and division of right gastric artery and gastroduodenal artery. This allows CHA-proper hepatic artery to be mobilized cephaloid and medial off of the underlying anterior surface of portal vein.
    • - PV is always identified prior to division of CHD.
    • - CHD is divided at the level of cystic duct.

    • Anatomic variations
    • o Anomalous location of right and left hepatic artery
    • o Replaced or accessory right hepatic artery arising from proximal SMA may course posterolateral to PV
    • o Rarely, entire CHA may arise from SMA.
  9. Step 4 - Transection of stomach
    • - Stomach transected at the level of third or fourth transverse vein on the lesser curvature and on confluence of gastroepiploic vein on the greater curvature
    • - Terminal branches of left gastric artery are ligated and divided along the lesser curvature of the stomach prior to gastric transection.
  10. Step 5 -  Transection of Jejunum
    • - Ligation and division of mesentery
    • - Loose attachment of ligament of Treitz are taken down
    • - 4th and 3rd portion of the duodenum are mobilized by dividing their short mesenteric vessels
    • - Jejunum transected 10cm distal to ligament of Treitz.
  11. Step 6 -  Resection of pancreatic head and removal of specimen
    • - Most difficult part of operation
    • - Traction sutures are placed on superior and inferior border of pancreas – pancreas is transected at the level of PV.
    • - Specimen separated from SMV by ligation and division of small venous tributaries to the uncinate process and pancreatic head.
    • - Complete removal of Uncinate process from SMV is required for mobilization of SMV-PV confluence and subsequent identification of the SMA.
    • - Failure of complete mobilization of SMV-PV confluence results in
    • o Risk of injury to SMA
    • o Risk of positive margin due to incomplete removal of uncinate process and mesenteric soft tissue adjacent to SMA.

    • o In addition, without complete mobilization of the SMV, it is difficult to expose the SMA-a maneuver necessary for direct ligation of the inferior pancreaticoduodenalartery (lPDA) or arteries. Mass ligation of the IPDA(s) with mesenteric soft tissue is a major cause of postoperative hemorrhage as this vessel retracts from its poorly placed tie or ligature; again often a preventable complication.
    • o Proper mobilization of SMV involves identification of jejunal branches of SMV. This branch originates from right posterolateral aspect of SMV (at the level of uncinate process), travels posterior to SMA and enters the medial aspect of jejunal mesentery. Jejunal branch gives 1-2 venous tributaries to the uncinate process, these tributaries should be divided. Injury to distal SMV at this level or tangential laceration in its jejunal branch, it is difficult to control bleeding and probably represent the most frequent cause of iatrogenic SMA injury as one attempts to suture venous injury prior to full exposure to SMA.
    • o Once, uncinate process is separated from the distal SMV, medial retraction of SMV-PV confluence allows one to expose SMA.
    • o The specimen is then separated from the right lateral wall of SMA, which is dissected to its origin of aorta.
    • o Direct origin of SMA avoids iatrogenic injury and ensures direct ligation to IPDA.
  12. Steps of reconstruction in Whipple's procedure?
    1. Two layered, end-side, duct-mucosa retrocolic pancreaticojejunostomy is performed with stent (if pancreatic duct is not dilated) or without stent. When stent is used, (4-5 cm long), is sewn to pancreatic duct with a single absorbable monofilament suture.

    2. Hepaticojejunostomy A single-layer biliary anastomosis is performed using interrupted 4-0 or 5-0 absorbable monofilament sutures. An interrupted technique is utilized to avoid purse-stringing of the anastomosis. It is important to align the jejunum with the bile duct to avoid tension on the pancreatic and biliary anastomoses.

    3. An antecolic. end-to-side gastrojejunostomy is constructed in two layers. Starting from the greater, 6 to 8 cm of the gastrlc staple line is removed. A posterlor row of  silk sutures is followed by a full-thickness inner layer of running monofilament sutures: the anterior row of silk sutures completes the anastomosis.
  13. Controversy in Whipple's procedure?
    • The technique of PD has evolved greatly making a tumour that would have been considered unresectable previously, now a resectable one. Although the extensive literature provides an excellent guidance, it often creates a situation of great confusion. Rather than changing one's technique frequently by following recently published data much of which is contradictory we would recommend following a set practice of resection, reconstitution and the use of drains etc. and making minor adjustments in special cases to achieve the optimal results. Our practice should not follow blindly what is described to be the ‘best’ reported but the procedure which is most appropriate for the individual patient.
    • The controversies are
    • 1. The use of diagnostic laparoscopy
    • 2. The resection procedure
    • 3. Techniques of reconstruction
    • 4. The use of drains and a feeding jejunostomy

    1. The use of diagnostic laparoscopy - DL should be considered only in a patient with large tumours (>4 cm)10 which are locally advanced on cross sectional imaging and in patients with ascites.

    2. The resection procedure –

    • A. Standard PD vs. pylorus preserving PD (PPPD) –PPPD poses a risk of an inadequate removal of lymph nodes around the pylorus and an increased tumour positivity rate at the duodenal margin and a PPPD should be avoided when the primary tumour is in the duodenal mucosa. There is reduction in
    • operative time and blood loss with PPPD compared with the standard operation but there was no difference in morbidity,
    • mortality & overall survival. 

    • B. The superior mesenteric artery (SMA) first approach - SMA is exposed at an early stage of the operation to determine resectability before any irreversible step is taken. Six
    • different approaches for the arterial first technique have been described.
    • a. Posterior approach from the retroperitoneum
    • b. Medial uncinate approach efrom the uncinate process
    • c. Mesenteric approach from the infracolic region medial to the duodenojejunal flexure
    • d. Left posterior approach from the infracolic retroperitoneum lateral to the duodenojejunal flexure
    • e. Inferior supracolic approach from the supracolic region
    • f. Superior approach e through the lesser sac
    • Thus, for locally advanced pancreatic tumours the arterial first technique not only helps in early determination of the resectability, it may also be associated with a shorter operative time and intraoperative blood loss without significantly worse outcomes.

    C. The role of extended lymphadenectomy - Extended lymphadenectomy with PD has failed to show any survival benefit and is accompanied by an increase in operative time and morbidity. It is therefore not recommended for periampullary tumours

    D. Venous reconstruction - Patients with venous involvement can achieve survival comparable to patients without venous involvement with venous reconstruction.

    E. Arterial reconstruction - arterial involvement still remains a contraindication for PD.

    • 3. Techniques of reconstruction
    • A. Pancreaticojejunostomy vs. pancreaticogastrostomy - taking a decision of which procedure to perform during operation depending on the texture of the pancreatic parenchyma, the size of the main pancreatic duct and the individual surgeon's preference. 

    B. Conventional vs. isolated roux loop pancreaticojejunostomy - IPJ does not appear to offer any advantage over conventional PJ.

    • C. Invagination vs. duct to mucosa pancreaticojejunostomy –
    • Invagination - remains the preferred technique in cases with a soft pancreas or a small pancreatic duct.
    • Duct to mucosa PJ – technically challenging to perform in cases with a small duct & a soft pancreas.

    D. The role of pancreatic duct stents - external drainage of PJ anastomosis in high risk patients reduces the incidence of a post operative pancreatic fistula.

    E. The gastrojejunal anastomosis: Antecolic vs retrocolic - GJ should be routed according to the surgeon preference.

    4. The use of drains and a feeding jejunostomy

    A. Drains - Since a soft pancreas, a pancreatic duct size of <3 mm or greater operative blood loss are associated with an  increased risk of pancreatic fistulae, investigators have started using selective drain placement in high risk patients.

    B. Feeding jejunostomy - most surgeons still prefer feeding jejunostomies as a method for maintaining nutrition
  14. Tributaries of SMV?
    • Mesenteric venous arcades (jejunal and ilieal veins)
    • ileocolic vein
    • right colic vein
    • inferior pancreaticoduodenal vein
    • gastrocolic trunk of Henle 
    • - right gastroepiploic vein
    • - middle colic vein
    • - anterior superior pancreaticoduodenal vein

    Middle colic vein and right gastroepiploic vein need to be cut to expose SMV.
  15. What should be done before ligating GDA?
    GDA occlusion to see the flow in distal hepatic artery using doppler - to ensure that hepatic flow is not dependent on collateral retrograde flow from SMA through GDA.
  16. Tampere Binding PJ?
    • Purse string suture in Jejunum 
    • No suture in Pancreas
  17. Pancreatic fistula Definition (ISGPS)?
    Output via intraoperatively placed drain or percutaneous drain of any measurable volume on or after 3 days with drain amylase level >3 times

    POPF A - Transient fistula, no clinical impact, requires little change in management or deviation from normal clinical pathway, no delay in hospital discharge, managed by slow removal of operatively placed drain. 

    POPF B - Requires change in management, keep NPO, Start TPN, May require repositioning of drain, If fever and leukocytosis - add Ab, delay in discharge (discharge with drain), if invasive procedure is needed, the POPF grade shifts to POPF C. 

    POPF C - Major change in clinical management, NPO, TPN,IV Ab, Somatostatin Analogue, Percutaneous drain, If sepsis or organ dysfunction - exploration

    POPF B and C are also called as clinically significant fistula. 

    • Note -
    • Soft, non fibrotic pancreas is  at more risk to develop fistula. 
    • In ampullary and distal cholangiocarcinoma, pancreas soft so more chance of fistula.
    • In pancreatic carcinoma, pancrease is firm, so, chance of POPF is more.
  18. The 2016 Update of the International Study Group (ISGPS) Definition and Grading of Postoperative Pancreatic Fistula?
    The former "grade A postoperative pancreatic fistula" is now redefined and called a "biochemical leak," because it has no clinical importance and is no longer referred to a true pancreatic fistula.

    Postoperative pancreatic fistula grades B and C are confirmed but defined more strictly.

    Grade B requires a change in the postoperative management; drains are either left in place >3 weeks or repositioned through endoscopic or percutaneous procedures.

    Grade C postoperative pancreatic fistula refers to those postoperative pancreatic fistula that require reoperation or lead to single or multiple organ failure and/or mortality attributable to the pancreatic fistula.
  19. Delayed gastric emptying Definition (ISGPS)?
    A - NG Tube required - 4–7 days or reinsertion POD >3

    B - NG tube required - 8–14 days or reinsertion POD > 7

    C - NG tube required - 14 days or reinsertion POD > 14

    DGE can also be defined as Unable to tolerate solid oral intake by POD - 7(Grade A), 14 (Grade B)  and 21 days (Grade C)
  20. Definition of PPH (ISGPS)?
    • Time of onset
    • - Early hemorrhage (24 h after the end of the index operation)
    • - Late hemorrhage (24 h after the end of the index operation)

    • Location
    • - Intraluminal (intraenteric, eg, anastomotidc suture line at stomach or duodenum, or pancreatic surface at anastomosis, stress ulcer, pseudoaneurysm)
    • - Extraluminal (extraenteric, bleeding into the abdominal cavity, eg, from arterial or venous vessels, diffuse bleeding from resection area, anastomosis suture lines, pseudoaneurysm)

    • Severity of Hemorrhage
    • Mild
    • - Small or medium volume blood loss (from drains, nasogastric tube, or on ultrasonography, decrease in hemoglobin concentration 3 g/dl)
    • - Mild clinical impairment of the patient, no therapeutic consequence, or at most the need for noninvasive treatment with volume resuscitation or blood transfusions (2-3 units packed cells within 24 h of end of operation or 1-3 units if later than 24 h after operation)
    • - No need for reoperation or interventional angiographic embolization; endoscopic treatment of anastomotic  bleeding may occur provided the other conditions apply
    • Severe
    • - Large volume blood loss (drop of hemoglobin level by 3 g/dl)
    • - Clinically significant impairment (eg, tachycardia, hypotension, oliguria, hypovolemic shock), need for blood transfusion (3 units packed cells)
    • - Need for invasive treatment (interventional angiographic embolization, or relaparotomy)
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Gastro 55 Pancreas Whipples procedure