Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана
.pdf
Pancreatoduodenectomy (Whipple Procedure)
https://t.me/med1917
515
3 Description oftheProcedure
3.1 Staging Laparoscopy
Given the high likelihood of unresectable tumor in pancreatic cancer, some surgeons may perform a staging laparoscopy at the start of the case to evaluate for
radiographically occult metastatic disease. This may be done routinely or selectively based on prognostic risk factors such as high CA19-9, tumor size, or suspicious radiographic ndings. Laparoscopy can reduce the number of patients
undergoing unnecessary laparotomy to 20% from 41% of patients evaluated with
computed tomography (CT) scan alone [11]. We prefer entering the abdomen
through a 5mm vertical incision at the inferior edge of your planned laparotomy
incision. If suspicious lesions are identied, another laparoscopic port is placed to
allow for biopsy.
3.2 Entry
If the laparoscopy is negative, the midline port site is extended to a vertical midline
incision. Alternatively, the operation can be performed via subcostal incision. At
this point, the surgeon may further inspect the peritoneum and organ surfaces for
carcinomatosis taking care to evaluate the Ligament of Treitz and transverse mesocolon. The liver is also palpated and intraoperative ultrasonographic evaluation may
be used selectively. If metastatic disease is not identied, the surgeon may proceed
with the planned operation. We prefer using a wound protector and self-retaining
Thompson Retractor for exposure.
3.3 Accessing theLesser Sac
We begin our dissection by entering the lesser sac via division of the gastrocolic
ligament. The stomach is retracted anteriorly and the dissection is continued towards
the splenic exure and stopping before division of the short gastric vessels. Next,
the gastroepiploic vein trunk is identied and ligated (Fig.1) to provide access to
the superior mesenteric vein (SMV).
516
https://t.me/med1917
Fig. 1 The Gastroepiploic
Trunk. The lesser sac is
entered to expose the
pancreas and right
gastroepiploic trunk.
Ligation of this vessel
provides access to the
superior mesenteric vein
K. McElroy and J. B. Rose
3.4 Kocherization
A Kocher maneuver is performed to access the posterior aspect of the pancreatic
head and gain control of major vessels in an emergency or if tumor involvement is
suspected. This is accomplished by dividing the lateral, right-sided retroperitoneal
attachments from the duodenum. An avascular plane posterior to the pancreas is
identied and divided to separate the pancreas from Gerota’s fascia and the inferior
vena cava. Care should be taken to protect the right gonadal vein. The kocherization
is typically extended until the left renal vein is identied entering into the inferior
vena cava. We prefer not to extend the mobilization through the Ligament of Treitz
at this point as herniation of small bowel through this defect can be bothersome. The
superior mesenteric artery (SMA) is palpated to determine tumor involvement and
resectability. If a SMA rst approach is being considered for borderline resectable/
locally advanced disease, then a wide medial visceral rotation (i.e. Cattell-Braasch
maneuver) should be performed at this point.
3.5 Creation ofRetropancreatic Tunnel
The inferior border of the pancreas is dissected and a tunnel is developed inferiorly
behind the pancreatic neck. The middle colic vein and other colonic tributaries are
conrmed to be free of tumor involvement and can be selectively ligated if needed.
Attention is then turned to the superior pancreatic border.
The right gastric artery is identied and ligated at the level of the gastric antrum.
This can then be dissected to its origin to aid in identifying the proper and common
Pancreatoduodenectomy (Whipple Procedure)
https://t.me/med1917
Fig. 2 Retracting the right
gastric artery. This allows
for identication of the
common and proper
hepatic arteries and
ultimately the origin of the
gastroduodenal artery for
subsequent ligation
Fig. 3 The retropancreatic
neck tunnel. The superior
and inferior borders of the
pancreas are dissected to
develop a tunnel behind the
pancreatic neck in
preparation for division
517
hepatic arteries (Fig.2). The common hepatic artery lymph node (station 8A) is
identied and resected to provide access to the underlying gastroduodenal artery
(GDA). Prior to ligating the GDA, the surgeon must test clamp the artery to conrm
ow in the left and right hepatic arteries. This test clamping does not prove the ves-
sel in question is the GDA, but rather is intended to identify a signicant celiac stenosis resulting in hepatic ow being dependent on a patent GDA.The surgeon
should always conrm that the putative GDA is not the common or proper hepatic
artery through careful dissection. Once conrmed, the GDA is then ligated. This
provides access to the portal vein posteriorly.
The superior aspect of the retropancreatic tunnel is then developed and connected to the inferior portion of the tunnel dissected previously. This tunnel allows
for encirclement the pancreatic neck and it can be lifted away from the portal vein
and SMV posteriorly (Fig.3). If the surgeon is unable to create either plane, a superior mesenteric artery rst approach can be considered if the vein is felt to be
reconstructable.
518
https://t.me/med1917
K. McElroy and J. B. Rose
3.6 Cholecystectomy andDuct Ligation
The “critical view of safety” technique is utilized to remove the gallbladder. The
cystic plate is dissected free and two and only two structures are identied entering
the gallbladder. This view is conrmed from a lateral and medial aspect. Once the
critical view has been achieved, the fundus is taken down via a top down technique.
The cystic duct and artery are again identied, ligated, and divided. The gallbladder
is sent as a separate specimen. A tunnel under the common hepatic duct is generated
taking care to stay anterior to the portal vein. Division of the bile duct is performed
generally above the cystic duct insertion. The distal bile duct is ligated to prevent
enteric spillage into the operative eld.
3.7 Enteric Division
For a classic Whipple approach, the stomach is divided at the level of the “crow’s
feet” with a linear stapler. If the surgeon’s preference is to perform a pyloruspreserving Whipple, then proximal duodenal division is done instead. Next the jejunum is divided distal to the Ligament of Treitz with a linear stapler. The proximal
jejunum is mobilized off its mesentery down to the uncinate process and passed
through a retroperitoneal defect partially created during the Kocher maneuver.
3.8 Resection ofPancreatic Head
At this point all antecedent resection is reconstructable without completing a
Whipple and the surgeon should take time for a nal assessment of resectability.
Silk stay sutures are placed at the medial and lateral borders of the inferior and
superior pancreas (Fig. 4). The pancreatic neck is then divided. We prefer sharp
Fig. 4 Pancreatic neck
dissection. Silk stay
sutures are placed at the
medial and lateral borders
of the inferior and superior
pancreas prior to
transection. These provide
tension and hemostasis
Pancreatoduodenectomy (Whipple Procedure)
https://t.me/med1917
Fig. 5 The surgical
specimen. This should
include the stomach
antrum (classic Whipple),
duodenum, proximal
jejunum, distal biliary tree,
and pancreatic head
519
transection of the pancreatic neck with a scalpel to avoid thermal injury to the pancreatic duct. Hemostasis is obtained, again taking care to avoid thermal injury to the
pancreatic duct. The pancreatic neck is mobilized off the portal and superior mesenteric veins, Lastly, the head and uncinate are carefully dissected off the superior
mesenteric artery using a vessel sealing device and ties. We prefer to limit clips in
the area as the artifact created by them on cross sectional imaging can limit detection of local recurrence in the future. Care must be taken during the uncinate dissection to adequately ligate the inferior pancreaticoduodenal artery, protect the rst
jejunal tributary, and protect an aberrant right hepatic artery if present.
The surgical specimen is then removed from the operative eld and should
include the gastric antrum (classic Whipple), duodenum, proximal jejunum, distal
biliary tree, and pancreatic head (Fig.5). The specimen is then passed off the operative eld and can be sent for frozen analysis if requested. We do not routinely send
pancreatic neck margins as additional resection of a grossly negative margin does
not appear to improve survival [12].
3.9 Pancreatic Anastomosis
After hemostasis is obtained, reconstruction is begun with a pancreaticoenterotomy
(Fig. 6). Many techniques for pancreatic anastomosis have been described (e.g.
duct-to-mucosa, invagination, or pancreatogastrostomy), but without clear superiority of any singular method. Ultimately surgeons should utilize a technique they feel
most comfortable with. We prefer a slight modication to the approach rst
described by Dr. Blumgart; whereby an interrupted duct-to-mucosa anastomosis is
supported by 2–3 transpancreatic and seromuscular mattress sutures to approximate
the pancreas stump and the jejunum [13, 14]. The jejunal stump is typically brought
in a retrocolic fashion to the right of the middle colic vessels for this method of
reconstruction. In patients with a thickened root of the mesentery, passing the limb
in a retroperitoneal fashion via the path of the resected duodenum can aid in reducing tension.
520
https://t.me/med1917
Fig. 6 Pancreaticojejunostomy. The pancreatic duct
is anastomosed to the
jejunal mucosa and
supported by transpancreatic mattress sutures
(Blumgart technique)
Fig. 7 Hepaticojejunostomy. The distal common
hepatic duct is sewn to the
jejunum in an end-to-side
fashion
K. McElroy and J. B. Rose
3.10 Hepaticojejunostomy
Next, biliary drainage to the enteric system is restored through a hepaticojejunostomy (HJ). This is done using interrupted absorbable suture. The anterior row is rst
placed through the bile duct only and used to display the duct lumen (Fig.7). Next
an enterotomy is made and the posterior row is placed through both the bowel and
the bile duct, and then tied with the knots on the inside of the anastomosis. Lastly
the anterior row is placed through the bowel and tied to complete the anastomosis.
Care should be taken when selecting the site of your HJ enterotomy to insure no
undue tension is placed on your pancreatic anastomosis.
Pancreatoduodenectomy (Whipple Procedure)
https://t.me/med1917
521
3.11 Enteric Reconstruction
For the nal anastomosis, enteric integrity is restored either through a gastrojejunostomy (GJ) or a duodenojejunostomy (DJ) depending on whether the surgeon
employed a pylorus-preservation or classic technique. The GJ anastomosis can be
performed using a hand sewn or stapled approach depending on surgeon preference
[15]. This author generally employs a classic Whipple approach and reconstructs
utilizing a retrocolic, handsewn GJ with a “ange technique” (Fig.8). [16]
3.12 Closure
The abdomen is then irrigated and inspected for hemostasis. Our institution places
one peripancreatic drain unless pre-operative stula risk score is high, then a second
drain is considered along with utilizing an external pancreatic duct stent as discussed below. A nasogastric tube may be placed according to surgeon preference.
We prefer to close fascia using 0 PDS suture and skin can be closed with staples
or suture.
Fig. 8 Gastrojejunostomy.
The “ange technique” of
a hand-sewn
gastrojejunostomy is a two
layer anastomosis that
approximates the stomach
to a loop of jejunum in a
retrocolic and antiperistalic
orientation
522
https://t.me/med1917
K. McElroy and J. B. Rose
4 High Risk Stenting
Despite modern technical advances, the Whipple procedure is still associated with a
high pancreatic stula rate. The Fistula Risk Score (FRS) is a prognostic tool utilized to predict the risk of clinically relevant-post-operative pancreatic stula
(CR-POPF) [16, 17]. In general, soft glands with small pancreatic ducts are at highest risk for leak. Surgeons often employ various mitigation strategies for high-risk
glands to better control expected stulae. Common strategies include peri-operative
somatostatin analog administration, drain placement, external or internal transanastomotic stent placement, tissue patches, and biologic sealants. There is randomized clinical trial data suggesting perioperative pasireotide decreased CR-POPF, but
subsequent prospective studies have not shown benet. A meta-analysis of commonly employed mitigation strategies found that omission of octreotide, external
stenting, and drain placement was associated with CR-POPF risk reduction from
33.5% to 13.2% [16–19]. Our institution utilizes both drain placement and external
trans-anastomotic stenting in high-risk glands as determined by FRS (Fig.9).
Fig. 9 Trans-anastomotic
stent. Pancreatic stula
mitigation strategies like
external trans-anastomotic
stenting and drain
placement should be
considered for high-risk
pancreatic anastomoses
Pancreatoduodenectomy (Whipple Procedure)
https://t.me/med1917
523
5 Minimally Invasive Pancreatoduodenectomy
High volume institutions have shown that a minimally invasive pancreatoduodenectomy can be done safely and has similar outcomes to open surgery with shorter inhospital stays [20]. However, the learning curve for this approach is steep and
should be relegated to high volume surgeons with appropriate training [21].
6 Vascular Reconstruction
Experienced surgeons may opt to perform vascular reconstruction to extend resection criteria for borderline and locally advanced disease. Concomitant portal vein
and superior mesenteric vein reconstruction has been reported since the 1950s;
however, some high-volume institutions have begun to implement arterial resections in patients with limited arterial involvement [22]. Vascular reconstruction during a Whipple increases complexity and post-operative risk, these operations should
be performed at centers with high-volumes, experience with complex reconstructions, and after multi-disciplinary review.
7 Special Post-operative Considerations
In effort to decrease length of stay and patient morbidity, enhanced recovery after
surgery (ERAS) pathways have developed for the Whipple procedure. Previous
recovery paradigms were associated with long in-hospital stays and slow initiation
of diet. However, recent studies describing modern ERAS pathways have suggested
that decreased opioid use, early diet advancement, and early mobilization are safe
and decrease hospital length of stay [20, 23]. Early enteral nutrition is safe to begin
post-operatively and should be initiated in clinically stable patients. Clinically irrelevant biochemical leaks are not a contradiction to enteral feeding [5].
References
1. Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA Cancer J Clin.
2023;73(1):17–48. https://doi.org/10.3322/caac.21763.
2. Are C, etal. History of pancreatoduodenectomy: early misconceptions, initial milestones and
the pioneers. HPB (Oxford). 2011;13(6):377–84.
3. Feng M, Cao Z, Sun Z, Zhang T, Zhao Y.Pancreatic head cancer: open or minimally invasive
pancreatoduodenectomy? Chin J Cancer Res. 2019;31(6):862–77. https://doi.org/10.21147/j.
issn.1000- 9604.2019.06.03.
4. Park W, Chawla A, O’Reilly EM.Pancreatic cancer: a review. JAMA. 2021;326(9):851–62.
https://doi.org/10.1001/jama.2021.13027. Erratum in: JAMA. 2021 Nov 23;326(20):2081.
524
https://t.me/med1917
5. Gianotti L, Besselink MG, Sandini M, Hackert T, Conlon K, Gerritsen A, Grifn O, Fingerhut
A, Probst P, Abu Hilal M, Marchegiani G, Nappo G, Zerbi A, Amodio A, Perinel J, Adham
M, Raimondo M, Asbun HJ, Sato A, Takaori K, Shrikhande SV, Del Chiaro M, Bockhorn M,
Izbicki JR, Dervenis C, Charnley RM, Martignoni ME, Friess H, de Pretis N, Radenkovic D,
Montorsi M, Sarr MG, Vollmer CM, Frulloni L, Büchler MW, Bassi C.Nutritional support and
therapy in pancreatic surgery: a position paper of the International Study Group on Pancreatic
Surgery (ISGPS). Surgery. 2018;164(5):1035–48. https://doi.org/10.1016/j.surg.2018.05.040.
Epub 2018 Jul 17.
6. Bundred JR, Kamarajah SK, Hammond JS, Wilson CH, Prentis J, Pandanaboyana
S.Prehabilitation prior to surgery for pancreatic cancer: a systematic review. Pancreatology.
2020;20(6):1243–50. https://doi.org/10.1016/j.pan.2020.07.411. Epub 2020 Aug 3.
7. Truty MJ, Kendrick ML, Nagorney DM, Smoot RL, Cleary SP, Graham RP, Goenka AH,
Hallemeier CL, Haddock MG, Harmsen WS, Mahipal A, McWilliams RR, Halfdanarson
TR, Grothey AF. Factors predicting response, perioperative outcomes, and survival following total neoadjuvant therapy for borderline/locally advanced pancreatic cancer. Ann Surg.
2021;273(2):341–9. https://doi.org/10.1097/SLA.0000000000003284.
8. D’Angelica MI, Ellis RJ, Liu JB, Brajcich BC, Gönen M, Thompson VM, Cohen ME, Seo
SK, Zabor EC, Babicky ML, Bentrem DJ, Behrman SW, Bertens KA, Celinski SA, Chan
CHF, Dillhoff M, Dixon MEB, Fernandez-Del Castillo C, Gholami S, House MG, Karanicolas
PJ, Lavu H, Maithel SK, McAuliffe JC, Ott MJ, Reames BN, Sanford DE, Sarpel U, Scaife
CL, Serrano PE, Smith T, Snyder RA, Talamonti MS, Weber SM, Yopp AC, Pitt HA, Ko
CY. Piperacillin-tazobactam compared with cefoxitin as antimicrobial prophylaxis for pancreatoduodenectomy: a randomized clinical trial. JAMA. 2023;329(18):1579–88. https://doi.
org/10.1001/jama.2023.5728.
9. Clancy TE, Baker EH, Maegawa FA, Raoof M, Winslow E, House MG, Members of the
AHPBA Professional Standards Committee. AHPBA guidelines for managing VTE prophylaxis and anticoagulation for pancreatic surgery. HPB (Oxford). 2022;24(5):575–85. https://
doi.org/10.1016/j.hpb.2021.12.010. Epub 2021 Dec 20.
10. Li L, Wang Y, Wang S. Efcacy comparison of chlorhexidine and iodine preparation in
reduction of surgical site infection: a systemic review and meta-analysis. Int J Nurs Stud.
2022;127:104059. https://doi.org/10.1016/j.ijnurstu.2021.104059. Epub 2021 Aug 6.
11. Allen VB, Gurusamy KS, Takwoingi Y, Kalia A, Davidson BR. Diagnostic accuracy of
laparoscopy following computed tomography (CT) scanning for assessing the resectability
with curative intent in pancreatic and periampullary cancer. Cochrane Database Syst Rev.
2016;7:CD009323. https://doi.org/10.1002/14651858.CD009323.pub3.
12. Kelly KN, Macedo FI, Seaton M, Wilson G, Hammill C, Martin RC, Maduekwe UN, Kim HJ,
Maithel SK, Abbott DE, Ahmad SA, Kooby DA, Merchant NB, Datta J.Intraoperative pancreatic neck margin assessment during pancreaticoduodenectomy for pancreatic adenocarcinoma
in the era of neoadjuvant therapy: a multi-institutional analysis from the central pancreatic consortium. Ann Surg Oncol. 2022;29(9):6004–12. https://doi.org/10.1245/s10434- 022- 11804- w.
Epub 2022 May 5.
13. Wang SE, Chen SC, Shyr BU, Shyr YM. Comparison of modied Blumgart pancreaticojejunostomy and pancreaticogastrostomy after pancreaticoduodenectomy. HPB (Oxford).
2016;18(3):229–35. https://doi.org/10.1016/j.hpb.2015.09.007. Epub 2015 Nov 17.
14. Olakowski M, Grudzińska E, Mrowiec S. Pancreaticojejunostomy-a review of modern techniques. Langenbeck’s Arch Surg. 2020;405(1):13–22. https://doi.org/10.1007/
s00423- 020- 01855- 6. Epub 2020 Jan 23.
15. Sigmon DF, Lopez PP.Gastrojejunostomy. 2022 Jul 25. In: StatPearls [Internet]. Treasure
Island: StatPearls Publishing; 2023 Jan.
16. Ecker BL, McMillan MT, Asbun HJ, Ball CG, Bassi C, Beane JD, Behrman SW, Berger
AC, Dickson EJ, Bloomston M, Callery MP, Christein JD, Dixon E, Drebin JA, Castillo
CF, Fisher WE, Fong ZV, Haverick E, Hollis RH, House MG, Hughes SJ, Jamieson NB,
Javed AA, Kent TS, Kowalsky SJ, Kunstman JW, Malleo G, Poruk KE, Salem RR, Schmidt
K. McElroy and J. B. Rose
Соседние файлы в папке Библиотека им академика М.И. Перельмана