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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_734_Библиотеки_им_академика_М_И_Перельмана.pdf
8 Chronic Pancreatitis: Resection
Fig. 8.4 Tail-dominant
disease with abscess
extending down psoas
muscle
129
Fig. 8.5 Disconnected duct with pseudocyst abutting posterior wall of stomach
whose disease is conned exclusively to the tail of the gland, thus preserving normal pancreatic parenchyma at the pancreatic head. In patients with disease throughout the gland, an erroneously offered distal pancreatectomy will only partially solve
their problem and lead to further sequelae of their disease.
Like patients with disease conned to the head of the pancreas, general indications for surgery include patients who have failed medical management, those with
debilitating abdominal pain with or without dependence on opioid analgesics, and
patients with failure to thrive. Most patients who undergo distal pancreatectomy for
chronic pancreatitis will be offered an open operation. In one series of patients only
6.2% of distal pancreatectomies performed for chronic pancreatitis at a high- volume
center were performed laparoscopically due to the degree of severe inammation
causing prohibitive risk for minimally invasive surgery. For this reason, electing to
offer laparoscopic or robotic surgery for chronic pancreatitis should be done only in
highly selected and carefully considered cases. It is the exception and not the rule.
130
Fig. 8.6 Same patient as Fig.8.5 after wall-opposing metal stent
J. C. DeLong and B. C. Visser
Suspicion forMalignancy
As stated earlier, it may not be possible to differentiate radiographic sequelae of
pancreatitis from a pancreatic mass. Mass effect from pancreatic cancer can be a
cause of pancreatitis [4]. A thorough history including weight loss chronicity, newonset diabetes mellitus, smoking, family history, or previous interventions should
be taken. Upper endoscopy with endoscopic ultrasound (EUS) may be useful for a
detailed examination of the pancreas parenchyma. Efforts to achieve a tissue diagnosis with ne needle aspiration are warranted given the higher complexity and
perioperative morbidity of a PD in the setting of CP.There are some cases where
malignancy cannot be ruled out and the diagnosis is made at the time of surgery due
to the difculty of determining pancreatic cancer histologically in the background
of chronic pancreatitis.
Perioperative Management
Workup of a patient with chronic pancreatitis begins with a detailed history and
physical exam. Approximately 20–30% of patients with acute pancreatitis will
develop recurrent pancreatitis and another 10% of patients will ultimately progress
to chronic pancreatitis. Questions including number of previous episodes, severity,
previous hospitalizations, pain-free periods, and time since last episode will establish the timeline. Many patients who progress to chronic pancreatitis experience
frequent or near-constant abdominal pain, so questions regarding the use of opioid
analgesics including how much and for how long the patient has been taking opioids
will be especially important for management in the postoperative period. Alcohol
consumption is the most common inciting factor for chronic pancreatitis which is
made worse by concurrent use of tobacco. A multidisciplinary approach to develop
a realistic plan for alcohol cessation is important because postoperative outcomes in
patients who continue to drink alcohol are poor.
8 Chronic Pancreatitis: Resection
131
A thorough patient history will also include questions regarding family history as
an increasing number of genetic mutations have been found to predispose patients
to chronic pancreatitis. This may be especially true in young patients or those with
no known inciting factors (i.e., idiopathic). Genetic mutations such as PRSS1,
SPINK-1, and CFTR among others are known to increase the risk of developing
pancreatitis especially when combined with what would otherwise be considered
modest alcohol consumption. Family history should also include questions regarding cancer in close relatives.
A common complication of chronic pancreatitis is failure to thrive, and poor
nutrition in the preoperative period is associated with worse outcomes. Due to the
location of the inammation and associated changes, some patients may be unable
to eat solid foods due to duodenal stricture or inammatory-mediated dysmotility.
Questions regarding quantity, composition, and frequency of meals, experience of
postprandial emesis, or tolerance of a liquid-only diet may be suggestive of this
problem. In patients with documented poor nutrition, enteral support in the form of
tube feeding may be indicated. Small, exible nasoenteric tubes with the weighted
tip of the tube positioned in the proximal jejunum may provide temporary support
in order to nutritionally optimize a malnourished patient prior to surgery.
Percutaneous gastrostomy tubes with the addition of a jejunal feeding tube may also
be appropriate for this indication. Enteric feeds are preferable to parenteral nutrition
and every effort should be made to nd an enteric solution. Of note, exocrine insufciency is common in chronic pancreatitis patients and the resultant diarrhea may
erroneously be attributed to tube feed intolerance.
Possible lab work for patients with chronic pancreatitis include prealbumin and
transferrin to determine nutritional status, cancer antigen 19–9 (CA 19–9) and carcinoembryonic antigen (CEA) if malignancy is being considered, IgG4 for autoimmune causes of pancreatitis, and genetic testing for genetic mutations such as
SPINK-1 and CFTR.A comprehensive metabolic panel (CMP) is useful to evaluate
renal function, evidence of liver disease from alcohol consumption, and in cases of
biliary stricture. A complete blood count (CBC) may reveal thrombocytopenia in
patients with portal hypertension. A phosphatidylethanol test (PeTH) may be useful
to conrm alcohol cessation. Routine serum amylase or lipase studies, which are
acutely elevated during cases of acute pancreatitis, are not useful in patients with
chronic pancreatitis.
High-quality axial imaging is essential for the management of this disease. Every
effort should be made to obtain all of the abdominal imaging studies that a patient
has received over the course of their disease. Reviewing these studies over time will
provide valuable information regarding the overall course and pace of progression.
New studies to obtain will include a contrast-enhanced triple phase computed
tomography (CT) scan. A standard pancreas protocol CT scan includes late arterial,
portal venous, and delayed phases. Special attention should be paid to the superior
mesenteric vein/portal vein conuence for stenosis or thrombosis as well as other
evidence of portal hypertension like splenomegaly or gastric varices.
Further information can be obtained from a secretin-enhanced magnetic resonance cholangiopancreatography (MRCP) which provides valuable information
132
J. C. DeLong and B. C. Visser
regarding ductal anatomy. Secretin stimulates the pancreas to secrete bicarbonaterich uid that improves the image resolution of T2-weighted images of the pancreatic duct resulting in an optimal non-invasive imaging of the pancreatic duct. In the
modern era, MRCP provides anatomical imaging and endoscopic retrograde cholangiopancreatography (ERCP) is reserved for endoscopic interventions such as
pancreatic duct stenting, balloon dilation, and sphincterotomy of the sphincter of
Oddi [5].
Procedure Steps
Open Whipple
1. After making an upper midline incision and opening fascia, take the falciform
off the anterior abdominal wall (this will be used later for ap coverage of the
gastroduodenal artery stump).
2. Explore the abdomen for evidence of unrecognized malignant disease. Given
chronic inammation, there may be extensive adhesions requiring lysis.
3. Ultrasound is useful to identify key vascular landmarks. Doppler mode con-
rms patency and ow within vessels such as the splenic vein.
4. Open the gastrocolic ligament outside of the gastroepiploic arcade. Continue
mobilization to the right taking down the hepatic exure of the colon.
5. Perform a wide Kocher maneuver all the way to the aorta. Chronic inamma-
tion replaces the typical thin, wispy plane with thick, brous tissue (Figs.8.7
and 8.8).
6. Dissect down to the superior mesenteric vein (SMV). This is accomplished by
lifting the stomach anteriorly and following the right gastroepiploic pedicle.
The right gastroepiploic vein drains into the SMV just inferior to the inferior
Fig. 8.7 Whipple Kocher
maneuver with chronic
inammation
8 Chronic Pancreatitis: Resection
Fig. 8.8 Thickened
adventitia over IVC after
Kocherization (Pancreas
and Duodenum retracted
anteriorly)
133
border of the pancreas. Follow this vein to expose the SMV.The right gastroepiploic vein is ligated and divided.
7. An attempt is then made to create a tunnel under the neck of the pancreas.
Depending on the degree of chronic inammation, this may not be feasible, and
perseverance may lead to uncontrolled bleeding in a deep hole with poor access
and exposure. Attempts at a traditional tunnel between the pancreas neck and
SMV/PV may not be possible.
8. Then turn to the infracolic compartment where the proximal jejunum is divided
a short distance from the ligament of Treitz with a GIA stapler. The mesentery
is divided with a vessel sealer down to the root staying close to the bowel and
avoiding the rst jejunal branch.
9. Then perform a top-down cholecystectomy.
10. Next, ligate the right gastric artery followed by the right gastroepiploic pedicle.
The duodenum is then divided with a linear stapler just distal to the pylorus.
Chronic inammation may prevent mobilization of the duodenum in which
case a classic Whipple with distal stomach transection is performed.
11. The gastroduodenal artery is then divided. We use a vascular stapler load for
even, consistent compression along the diameter of the vessel.
12. The neck of the pancreas is then divided. If a tunnel was able to be created, then
this is done in the standard fashion. However, if severe inammation precludes
this, then it may make sense to perform a progressive division of the neck in a
stepwise approach from above, slowly working down onto the portal vein. This
is done by making a little space, then dividing a little pancreas in an incremental
process.
13. A frozen section of the pancreatic margin is sent to pathology if there is any
concern for malignancy.
14. Next divide the bile duct. To prevent the spillage of bile, a bulldog can be placed
superiorly, and a silk tie is used to ligate the duct distally. A frozen section of
the bile duct is typically not done for this indication.
134
15. Next the uncinate is freed from the portal vein and superior mesenteric vein
using a combination of blunt dissection, vessel sealer, and silk ties. If possible,
vascular control should be obtained. A Kitner is a useful tool to peel the vein off
the specimen. Prolene repair sutures should be loaded and ready because the
avulsion of small venous branches can lead to signicant hemorrhage. If
bleeding does occur, lifting the specimen anteriorly against the PV/SMV can
slow or stop the bleeding to assist with obtaining control.
16. The uncinate dissection is nished by taking the specimen off of the superior
mesenteric artery (SMA). This is done using the vessel sealer and ties with
frequent palpation of the SMA pulse to avoid iatrogenic injury.
17. After the dissection is complete, the reconstruction is performed in the standard
fashion. We perform an end to side pancreaticojejunostomy using the Blumgart
technique. For the inner layer, we use 6–0 PDS on a BV needle. We place a
pancreatic stent through the anastomosis.
18. For the hepaticojejunostomy we use 5–0 PDS on an RB2 needle with inter-
rupted sutures in the standard end-to-side fashion.
19. For the duodenojejunostomy, we hand sew using 3–0 PDS.
20. Two 15 Fr closed suction drains are positioned, one next to the hepaticojejunos-
tomy and the other next to the pancreaticojejunostomy.
J. C. DeLong and B. C. Visser
MIS Whipple
In our practice, we offer minimally invasive pancreatoduodenectomy (Whipple)
procedures (for any indication) in carefully selected patients. In general, when a
patient presents with a history of chronic pancreatitis, our standard practice is to
offer an open operation. This is due to the increased difculty of dissection from
chronic inammation, distortion of normal tissue planes, and risk of uncontrolled
hemorrhage with limited access. Safety is paramount in these cases. It is our belief
that not all cases should be attempted robotically, and the successful implementation of minimally invasive techniques in pancreatic surgery starts with good patient
selection. We do offer minimally invasive pancreatic drainage procedures for
chronic pancreatitis, as the risk prole is considerably less than that with a pancreatic head resection. These procedures will be discussed in detail elsewhere in
the manual.
Open Distal Pancreatectomy
1. After the abdomen is prepped and draped, an upper midline incision is made
from the xiphoid process down to the umbilicus. A self-retaining retractor is set
up to maintain exposure.
8 Chronic Pancreatitis: Resection
135
2. The gastrocolic omentum is freed from the transverse colon, preserving the
blood supply to the omentum so it can be used later as a ap. A vessel sealer is
used to come around the splenic exure. Short gastric arteries are similarly
divided.
3. The stomach is then retracted anteriorly to gain access to the lesser sac. The
subsequent steps are determined by the conditions and specic indications for
distal pancreatectomy for chronic pancreatitis.
4. In the case of tail-dominant disease with an intact duct, the pancreas is mobilized
to get around the gland in an area just proximal to the diseased segment.
5. The splenic artery followed by the splenic vein can be taken with a vascular
staple load. The splenic vein is often fused to the back of the pancreas and cannot
be safely mobilized off the gland. It can be taken together with the pancreas with
a linear staple load.
6. The pancreas can typically be divided with a GIA black reinforced staple load.
In some cases, the gland is too thick or rm to be divided in this manner. In that
case, it can either be partially thinned with an energy device and then stapled or
divided using a vessel sealer. An attempt should be made to nd the duct and
close with absorbable suture.
7. The tail of the pancreas is mobilized out of the retroperitoneum and removed
along with the spleen. Considering the inammatory adhesions between the pancreatic parenchyma and the splenic vessels, spleen preservation is usually not
attempted. However, splenic vessel and spleen preservation should be considered as an option if technically feasible. Unlike for malignant tumors, where a
right-to-left dissection is preferred, when the indication for distal pancreatectomy is chronic pancreatitis, a left-to-right dissection is equally appropriate. The
safest and least distorted plane should be selected.
8. We often elect against drain placement, not because leaks are uncommon, but
rather because a contained pseudocyst is often easier to manage than a prolonged
pancreatic stula.
MIS Distal Pancreatectomy
Unlike in a minimally invasive Whipple procedure, where chronic pancreatitis adds
signicant technical complexity and often prohibitive risk, a minimally invasive
distal pancreatectomy in the setting of chronic pancreatitis is within the realm of
possibility. It is reasonable to attempt a laparoscopic or robotic distal pancreatectomy for this indication while understanding that these operations will typically be
harder than when the indication is for a tumor. It is our practice to offer splenic
preservation whenever possible. However, with chronic pancreatitis, this is often
not feasible, so a distal pancreatectomy and splenectomy is typically performed. In
addition, unlike for tumor indications where a right-to-left or “antegrade” dissection
is widely considered to be best practice, with chronic pancreatitis it is equally reasonable to use a left-to-right approach, as this may be a less hostile dissection plane.
136
J. C. DeLong and B. C. Visser
1. The patient is positioned supine and carefully secured to the table which is
positioned with a slight break to maximize the operative space. The abdomen
and left ank are prepped and draped, and the robot is positioned for docking
on the patient’s left.
2. Port placement is determined by body habitus, the predominant site of disease,
and surgical plan. In most cases, the camera port is placed slightly above and to
the right of the umbilicus. The remaining robotic trocars are placed 7cm apart
in a linear position.
3. A 2 cm incision is made below the umbilicus and a small wound protector
placed with a 12mm assistant trocar through that which is ultimately used for
specimen extraction. A 5mm port is also placed for liver retraction initially, and
later anterior stomach retraction to expose the lesser sac.
4. The robot is docked, and the camera is placed in arm 2 such that the surgeon has
1 left arm and 2 right arms.
5. The splenic exure of the colon is carefully taken down with the vessel sealer.
Inammation from chronic pancreatitis can make this difcult and meticulous
dissection is required to avoid colonic injury.
6. The stomach is lifted anteriorly and the gastrocolic omentum is opened close to
the gastroepiploic arcade so excessive omentum doesn’t hang down and obstruct
the view. Short gastric vessels are taken with the vessel sealer.
Note: in cases of splenic vein thrombosis, an effort should be made to preserve the short gastric vessels until the splenic artery has been divided, as
these vessels provide the only outow for the spleen. Alternatively, the
spleen can be embolized preoperatively.
7. The triangular-shaped “snake” liver retractor is repositioned under the stomach
with anterior retraction. An orogastric tube that was previously placed by anesthesia is positioned such that it is “bowing” along the greater curvature and
terminates in the gastric antrum. This creates a lip for the retractor to sit under
which prevents slipping of the stomach and maintains exposure.
8. Next the retroperitoneal plane behind the pancreas is developed starting from
the bottom to the top of the gland, and extending laterally. If this proves challenging, and neoplasm is not suspected as the etiology of the chronic pancreatitis, a left-to-right approach can be considered.
9. The splenic artery is next identied at the superior border of the pancreas and
divided with a vascular stapler.
10. The splenic vein will typically be fused to the back of the pancreas and isolation
is not often possible. It can instead be taken together with the pancreas.
11. Next the pancreas is divided with a linear stapler with a reinforced black staple
load. In order to use this staple load, the assistant trocar may need to be upsized
to a 15mm trocar. The stapler is closed and subsequently red very slowly over
the course of several minutes (at least 5).
12. The rest of the pancreas is subsequently freed from the retroperitoneum together
with the spleen. The specimen is kept intact during the dissection and ultimately
8 Chronic Pancreatitis: Resection
placed in a strong specimen bag and removed. The extraction site may need to
be extended depending on the size of the specimen.
13. The surgical site is inspected for hemostasis. The liver retractor is taken down
and the trocars are removed.
137
Pitfalls andPearls
While once considered to be the gold standard surgical resections for patients with
chronic pancreatitis, pancreatoduodenectomy and distal pancreatectomy have less
of a role in the management of chronic pancreatitis in the modern era of pancreas
surgery. This is partly due to increased surgical options for pancreatitis, particularly
the drainage procedures, but also due to the recognition of improved outcomes and
growing enthusiasm for total pancreatectomy with islet cell autotransplantation
(TPIAT) [6]. This is particularly true among patients with early to mid-stage disease, where there remains a sufcient number of islet cells for the procedure to be
benecial. However, these treatments are currently limited to specialized centers
making access a signicant limitation to this strategy.
Given the difculty of the operation, chronicity of disease, and comorbidities in
this patient population, complications after pancreatic resection for chronic pancreatitis are common. In fact, approximately one third of patients experience a signicant complication (Clavian-Dindo Grade >/= to 3). Examples of the types of
complications that are seen include clinically relevant postoperative pancreatic stula (CR-POPF), surgical site infection, new onset diabetes, persistent opioid use,
percutaneous drains, return to the operating room, readmission, and death. CR-POPF
is higher in patients operated on for pancreatic necrosis, pseudocyst, or disconnected
left pancreatic duct remnant than in patients who undergo distal pancreatectomy for
neoplasm [7]. The development of new-onset diabetes in patients undergoing distal
pancreatectomy for chronic pancreatitis is seen in 19–46% of patients.
Pearls
1. Surgical resection for chronic pancreatitis is harder than when the indication for
surgery is a tumor. This is particularly true with a Whipple.
2. MIS techniques for chronic pancreatitis should be attempted with caution but
may be appropriate for some patients undergoing distal pancreatectomy. If a
patient with pancreatic head-dominant disease has mild inammation to the
degree that an MIS Whipple could be reasonably feasible, then TPIAT may be
the superior surgical option.
3. Vascular pitfall for distal pancreatectomy is the celiac artery, for Whipple it is
the superior mesenteric vein.
138
J. C. DeLong and B. C. Visser
4. Unlike when the indication for surgery is tumor, a distal pancreatectomy can be
performed left-to-right or right-to-left, depending on the most favorable
conditions. Extending the resection deeper into the retroperitoneum (e.g.,
through Gerota’s fascia) may also provide a less hostile plane.
5. In a left-to-right dissection when the spleen and pancreas are lifted anteriorly,
you have better appreciation of the position of the celiac artery.
6. Splenic vein thrombosis is common. Do not divide short gastric vessels until
the splenic artery has been taken. Alternatively, a splenectomy can be performed
as a separate specimen. Dividing short gastric vessels prior to the splenic artery
in the setting of splenic vein thrombosis leads to signicant venous oozing in
the operative eld.
7. The splenic vein may not be able to be divided off the back of the pancreas to
be taken separately so it can be taken together with the pancreas in the same
staple load.
8. Sometimes the tissue of the pancreas may be too hard to divide even with the
thickest staple load. The options in this scenario are to clamp, divide, and oversew (if open) or to thin out the front of the gland and then staple (whether MIS
or open).
9. The decision to drain for a distal pancreatectomy is based on surgeon prefer-
ence and judgment, but in our practice we rarely leave a surgical drain (unless
the GI lumen has been opened during the case) because it is our belief that in
the setting of a leak a pseudocyst (no drain) is preferable to a pancreatic stula
(drain).
10. In a Whipple, creating the entire tunnel under the neck of the pancreas is often
not feasible and persistence can result in bleeding with limited access. In the
setting of profound chronic inammation, it can make sense to divide the pancreas in a stepwise approach whether from above or below, progressively
exposing the vein.
11. When performing a Whipple for CP, if the head of the gland is very adherent to
the SMV and PV (after division of the neck), consider obtaining proximal, distal, and splenic vein control prior to persisting with blunt (ie Kittner) dissection.
12. In a pacemaker situation, if the tail of the gland is very atrophic, completion of
the pancreaticojejunostomy is not necessary in all cases. An atrophic pancreatic
remnant can be closed using a linear stapler (but leaves a small amount of endocrine function).
References
1. Gurusamy KS, Lusuku C, Halkias C, Davidson BR.Duodenum-preserving pancreatic resec-
tion versus pancreatoduodenectomy for chronic pancreatitis. Cochrane Database Syst Rev.
2016;2(2):CD011521. https://doi.org/10.1002/14651858.CD011521.pub2. PMID: 26837472;
PMCID: PMC8278566
2. Diener MK, Hüttner FJ, Kieser M, Knebel P, et al., ChroPac Trial GroupPartial pancreato-
duodenectomy versus duodenum-preserving pancreatic head resection in chronic pan-