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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_901_Библиотеки_им_академика_М_И_Перельмана
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128
Key steps for pancreaticoduodenectomy
Steps Description
M. Krell et al.
Inspection for
metastasis
Exposure Hepatic exure of the right colon is mobilized and reected inferiorly
Dissection of
inferior border
of pancreas
Porta hepatis
dissection
Diagnostic laparoscopy before performing a laparotomy incision to inspect abdomen for
metastasis
Duodenum is kocherized by releasing duodenum from its retroperitoneal attachments➔this
allows palpating involvement of the retroperitoneum and SMA
Lesser sac entered by incision of omentum
Identify superior mesenteric vein at the conuence of middle colic and right gastroepiploic vein
(right gastroepiploic can be used as a guide to locate the SMV)
Dissect inferior border of the pancreas
Identify SMV
Ligate gastroepiploic
Tunnel anterior to the SMV and posterior to the neck of the pancreas
Cholecystectomy is performed using the “dome-down” technique
Hepatoduodenal ligament dissection
The gastroduodenal artery is identied within the hepatoduodenal ligament. Prior to transection,
the vessel is test-clamped to ensure that proper hepatic artery ow is not diminished
Dissect posterior to the gastroduodenal artery, identify PV, tunnel underneath the neck of the
pancreas
Common bile duct is then encircled and transected after conrming no aberrant right hepatic
artery
Right gastric artery is ligated
Duodenum is divided
Mobilization
and division of
jejunum
Mobilization
and division of
pancreas
Reconstruction Involves creating a pancreaticojejunostomy, a hepaticojejunostomy, and a gastro/
Divide jejunum ~10cm distal to Treitz
Pass jejunum under the root of the small bowel mesentery to the right upper quadrant
Pancreas is resected
Dissect uncinate process off the SMV
For adequate margins, dissecting 270° along the walls of the SMV and SMA above the rst
jejunal vein is necessary
duodenojejunostomy
4 Pancreas andSpleen
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Intraoperative decision making
Case Management
Tumor densely adherent to the vein SMV-portal vein resection+reconstruction
Tumor far away from pylorus Pylorus-preserving approach
129
Tumor involves proximal duodenum, pylorus, or gastric
antrum
Classic pancreaticoduodenectomy
Research
Reference Findings
Rodarte-Shade M, Kahaleh M, Stent placement as a
bridge to surgery in malignant biliary obstruction
(pancreatic cancer, distal bile duct cancer, hilar
tumor), Gastrointestinal Intervention (2015)
van der Gaag NA, Rauws EA, van Eijck CH, Bruno
MJ, van der Harst E, Kubben FJ, Gerritsen JJ,
Greve JW, Gerhards MF, de Hingh IH, Klinkenbijl
JH, Nio CY, de Castro SM, Busch OR, van Gulik
TM, Bossuyt PM, Gouma DJ.Preoperative biliary
drainage for cancer of the head of the pancreas. N
Engl J Med. 2010;362(2):129–37. https://doi.
org/10.1056/NEJMoa0903230. PMID: 20071702
Klaiber U, Probst P, Hüttner FJ, etal. Randomized
trial of pylorus-preserving vs. pylorus-resecting
pancreatoduodenectomy: long-term morbidity and
quality of life. J Gastrointest Surg 2020; 24:341
Preoperative biliary drainage (PBD) has been a matter of
controversy for years. The goal is to relieve patients with
malignant biliary obstruction. However, its efcacy and
safety have not been proven by randomized controlled
trials. Most drawbacks of PBD are related to the increase
in procedure-related adverse events and inappropriate
biliary decompression. Current trends in PBD show that
using self-expanding metallic stents (SEMSs) may reduce
the high incidence of stent-related complications with
improved outcomes
Routine preoperative biliary drainage in patients
undergoing surgery for cancer of the pancreatic head
increases the rate of complications
No signicant difference in outcomes between pylorus
resection compared to pylorus preservation
Late cholangitis occurred signicantly more often in
patients following pylorus resection
Kilambi R, Singh AN.Duct-to-mucosa versus
dunking techniques of pancreaticojejunostomy after
pancreaticoduodenectomy: do we need more trials?
A systematic review and meta-analysis with trial
sequential analysis. J Surg Oncol 2018; 117:928
Javed AA, Teinor J, Wright M, etal. Negative
pressure wound therapy for surgical-site infections:
a randomized trial. Ann Surg 2019; 269:1034
Systematic review and meta-analysis of eight trials
comparing the two anastomotic techniques for
pancreatojejunostomy: Duct-to-mucosa versus
invagination
No signicant difference between the two anastomotic
techniques in terms of overall and clinically relevant
postoperative pancreatic stula rates
Applying negative pressure wound therapy to the surgical
incision at the time of closure reduces surgical-site
infection by 69 percent after open
pancreaticoduodenectomy
130
Complications of pancreaticoduodenectomy and their management
Complications Characteristics Management
M. Krell et al.
Pancreatic stula Risk factors: High (BMI), preoperative
comorbidities, soft pancreas, and a narrow
pancreatic duct
Level of amylase in drain >3× serum amylase
on or after postop day 3
Bile leak Bile leaks from the choledochal-jejunal
anastomosis occur in 1–3% percent of cases
Heralded by the appearance of bile in the
drainage uid
Delayed gastric emptying Risk factors: Pancreatic leak; also prior
abdominal surgeries, history of cholangitis,
and diabetes mellitus
Rule out other causes of gastric dysmotility
(abscess, biloma, outlet obstruction) with
cross-sectional imaging
Pancreatic exocrine
insufciency
Diarrhea, steatorrhea, bloating, or cramping Pancreaolipase supplementation
Most pancreatic stulas close
spontaneously within 4–6weeks
Low volume stulas <200ml/d close
spontaneously
High-volume stulas➔NPO/TPN
Somatostatin does not hasten the rate
of stula closure, but is used
occasionally to assist in management
Drain should be left in place until the
leak stops
Concern for poor blood supply to the
biliary ducts (hepatic artery)
Prokinetics
±TPN supplementation as needed
Gastrostomy tube decompression a
last resort for intractable symptoms
Dose should be titrated up as needed
to achieve resolution of symptoms
New-onset diabetes or
exacerbation of previous
existing diabetes
Pancreaticojejunal
anastomotic stricture
Gastroduodenal artery
stump pseudoaneurysm
Incidence 16–40% (distal>whipple>central
pancreatectomy)
Rare late complication that occurs at a median
of 34months after pancreaticoduodenectomy
Present with postprandial abdominal pain,
recurrent acute pancreatitis, and impaired
pancreatic function
Rare complication that occurs 1week postop
Presents with bright blood coming out of
drain, hypotension, and tachycardia
CT angio for diagnosis
Medical management of diabetes
Endoscopic dilation
Surgical repair
Embolization of GDA
4 Pancreas andSpleen
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Research
Reference Findings
131
Bassi C, Marchegiani G,
Dervenis C, etal. The 2016
update of the International
Study Group (ISGPS)
denition and grading of
postoperative pancreatic
stula: 11years after.
Surgery. 2017;161(3):584–91
Updated international study Group in Pancreatic Surgery (ISGPS) pancreatic stula
grading scale:
Grade A postoperative pancreatic stula” is now redened and called a
“biochemical leak” because it has no clinical importance
Grade B: Requires a change in the postoperative management; drains are either left
in place >3weeks or repositioned through endoscopic or percutaneous procedures
Grade C: Postoperative pancreatic stula that requires reoperation or leads to single
or multiple organ failure and/or mortality attributable to the pancreatic stula
Hematological Disease oftheSpleen
Hematologic disease of the spleen
Causes of
enlarged spleen
Indications for
splenectomy
Hereditary spherocytosis, sickle cell disease, thalassemia, Hodgkin’s lymphoma and nonHodgkin’s lymphoma, acute myeloid leukemia, chronic myeloid leukemia, and chronic
lymphocytic leukemia, glucose-6- phosphate dehydrogenase (G6PD) deciency, immune
(idiopathic) thrombocytopenic purpura (ITP)
Splenectomy is indicated for symptomatic splenomegaly or hypersplenism refractory to
medical management
Splenectomy is indicated in patients with ITP refractory to steroids/incomplete response to
steroids, with a platelet count less than 10,000/μL for 6weeks, or in pregnant women who
have failed steroids/intravenous immune globulin and have platelet counts less than 10,000/μL
or less than 30,000/μL with bleeding
Hematologic diseases of spleen and indications of splenectomy
Hematologic
disease Characteristic Indications for splenectomy
Spherocytosis Spectrin decit
Autosomal dominant
Most common congenital
hemolytic anemia requiring
splenectomy
Preop workup: U/S gallbladder
Elliptocytosis Spectrin decit and protein 4.1
decit
Sideroblastic anemia Ring sideroblasts are present on the
bone marrow aspirate smear stained
for iron with Prussian blue
Splenectomy is the mainstay of treatment for
hereditary spherocytosis (should be performed after
age 5 to preserve immune function)
Splenectomy+possible cholecystectomy
Splenectomy
Splenectomy not indicated
132
Hematologic diseases of spleen and indications of splenectomy
Hematologic
disease Characteristic Indications for splenectomy
M. Krell et al.
Pyruvate kinase
deciency
G6PD deciency X-linked Generally be managed conservatively with
Warm antibody type
acquired immune
hemolytic anemia
Sickle cell anemia Autosomal recessive Spleen auto-infarcts
Beta-thalassemia Autosomal dominant Splenectomy if excessive transfusions are required
Autosomal recessive RBC survival is enhanced by splenectomy
avoidance of triggers
Most common autoimmune
hemolytic disease
Splenectomy if refractory to medical management
Idiopathic thrombocytopenic purpura (ITP)
Denition Acquired immune-mediated condition
Etiology Thrombocytopenia in the absence of underlying etiology
Pathophysiology
Diagnosis
Platelet destruction was initially believed to be the only etiology➔many patients are found to
have a decreased level of thrombopoietin
ITP is a diagnosis of exclusion
Workup requires excluding other causes of low platelets: Drug-induced thrombocytopenia,
viral infection, cirrhosis, pre-eclampsia, hypersplenism, autoimmune disease, and thrombotic
thrombocytopenic purpura
First-line therapy: Intravenous steroids, immunoglobulin, or both➔80 to 90% of patients will
respond➔only 1in 5 will achieve a durable result.
Management
Second-line therapies include rituximab, thrombopoietin receptor agonists (romiplostim,
eltrombopag), and splenectomy
Plasmapheresis is typically used in patients with antiphospholipid syndrome at risk for
thrombosis
Therapy Characteristic Side effects
Splenectomy Most effective response: Overall
88%, partial 22%, and complete 66%
Gold standard
Rituximab Monoclonal antibody that targets
CD20 on B-cells
Eltrombopag Oral agents administered once a week
and at home
80% response rate
Surgical procedure- associated risks
Risk of overwhelming postsplenectomy infection
Increased risk of thrombotic events
Long-term treatment
Long-term risks not known
Potential for toxicity
4 Pancreas andSpleen
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Research
Reference Findings
133
Taylor A, Westwood JP, Laskou F, McGuckin S,
Scully M.Thrombopoietin receptor agonist therapy
in thrombocytopenia: ITP and beyond. Br J
Haematol. 2017;177(3):475–80
Eltrombopag is an orally available, nonpeptide
thrombopoietin receptor agonist studied in patients with
ITP who have relapsed after rst-line therapies. It is
currently recommended in these patients in an attempt to
bring platelet counts back to normal
Splenic Abscesses, Cysts, andNeoplasms
Splenic cysts
Simple cysts Deroong, fenestration, partial splenectomy
Congenital epidermoid and dermoid cyst
Primary cysts
(25%)
Secondary cyst
(pseudocysts) (75%)
Parasitic (hydatid cyst)
Echinococcus multilocularis
Echinococcus granulosus
Neoplastic: Most commonly hemangiomas
or lymphangiomas
Caused by trauma, infarct, or nonspecic
bacterial infections
Splenectomy must be undertaken without
rupturing the cyst (cyst rupture➔anaphylaxis
and spread of disease)
E multilocularis➔resect with 1cm margin
due to invasive nature
Splenic abscess
Risk factors A history of trauma, recent abdominal surgery, or other recent infections (endocarditis, appendicitis,
diverticulitis)
Presentation Left upper quadrant pain and tenderness
Splenomegaly, fever, a left-sided pleural effusion, or pleuritic chest pain
Imaging Abscesses appear as hypodense lesions on CT.They may be heterogeneous and may have
peripheral enhancement and septations if the abscess has been present for longer periods of time
Management
Prognosis Mortality from splenic abscess is approximately 47%
Infection is often polymicrobial➔empiric broad-spectrum antibiotic
Immunocompromised patients➔cover for Candida, aspergillus, and mycobacterium
Splenectomy➔gold standard for management of splenic abscess
Patients with comorbidities that preclude operative intervention➔CT-guided aspiration
Unilocular collections, well-dened cavities, no septations, and no necrotic debris➔CT-guided
aspiration
134
Splenic ar
Splenic neoplasms
M. Krell et al.
Primary splenic
Angiosarcoma, lymphangiomas, and lymphangiosarcomas
neoplasms
Splenic metastasis Occur as tumors of breast, melanoma, and lung
Lymphoproliferative
lesions
Myeloproliferative
Non-Hodgkin and Hodgkin lymphoma, hairy cell leukemia, and chronic lymphocytic
leukemia
Chronic myeloid leukemia
lesions
Research
Reference Findings
Omar A, Freeman S.Contrast-enhanced
ultrasound of the spleen. Ultrasound.
2016;24(1):41–9
Renzulli P, Hostettler A, Schoepfer AM,
Gloor B, Candinas D.Systematic review of
atraumatic splenic rupture. Br J Surg.
2009;96(10):1114–21
Sulfur hexauoride lipid-type A microspheres, approved in 2016 to
characterize focal liver lesions in children and adults. Use has now
extended to the spleen. With ultrasound contrast, areas of infarction
do not enhance, are well dened, and can be used to better appreciate
the wedge-shaped nature of the lesion
Spontaneous atraumatic splenic rupture is an infrequent but
potentially life-threatening condition that occurs mainly in
histologically abnormal spleens. A systematic review described 6
major etiologic groups: Neoplastic (30.3%), infectious (27.3%),
inammatory or noninfectious (20%), drug- and treatment-related
(9.2%), mechanical disorders (6.8%), and normal spleen (6.4%).
Most patients were treated with splenectomy (84.1%) but a minority
were managed with successful splenic salvage (1.2%) or
nonoperative treatment (14.7%). Splenomegaly, age over 40years,
and neoplastic disorders were associated with increased mortality on
multivariable analysis
Splenectomy
Anatomy
Ligaments that attach spleen
Gastrosplenic ligament➔contains short gastrics and
left gastrosplenic artery
Splenorenal➔contain splenic artery and vein
Splenocolic, splenophrenic ligament
The spleen spans ribs 9–11 along the left mid to
posterior axillary line and abuts the curvature of the
stomach and tail of the spleen
Splenic vein
Gastrosplenic
ligament
Stomach
Pancreas
tery
Kidney
Spleen
Short
gastric
arteries
Splenorenal
ligament
4 Pancreas andSpleen
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Vaccinations regimens for splenectomy
Vaccination against Haemophilus inuenzae (type B conjugate), Streptococcus pneumoniae
Splenectomy
Revaccination as per
CDC
(23-valent polysaccharide vaccine not the 14-valent one), and Neisseria meningitides
(polysaccharide vaccine) within 14days from splenectomy
Booster dose of the 23-valent pneumococcal vaccine 4–6years after the initial dose and
repeat at age 65 or older, provided 5years have passed since the last dose
H inuenzae vaccine does not need to be repeated
Booster of the meningococcal vaccine every 5years
Splenectomy
Laparoscopic: Now the gold standard for elective splenectomy in patients with normal-sized
spleens; decreased intraoperative blood loss, shorter hospital length of stay, and lower
Laparoscopic
versus open
morbidity
Open: Favored in several clinical scenarios: Massive splenomegaly, ascites, portal
hypertension, multiple prior operations, extensive splenic irradiation, and possible splenic
abscess
Ruptured or enlarged spleen➔midline incision
135
Key steps
Elective procedure➔left costal margin incision
Mobilize the spleen by dividing ligamentous attachments, beginning with the splenocolic
ligament.
Enter the lesser sac
If signicant splenomegaly➔early ligation of the splenic artery along the superior border of
the pancreas (for safer manipulation of the spleen and dissection of the hilum, shrinkage of the
spleen, and provides an autotransfusion of red blood cells and platelets)
Incise the lateral peritoneal attachments
Develop a plane deep to the spleen and tail of the pancreas (identify tail of pancreas and
protect)
Divide the short gastric vessels
Ligate the splenic artery (if not divided yet) and vein before dividing them
Look for accessory spleens (most common locations: Splenic hilum, splenic pedicle, greater
omentum, the tail of the pancreas)
136
Complications of splenectomy and their management
Complications Characteristics Management
M. Krell et al.
Bleeding
Splenosis
Thrombosis of SMV
vessels
Portal vein
thrombosis
Post-splenectomy
sepsis
Risk factors: Postoperative antiplatelet agents or
anticoagulation
Most commonly bleeding from splenic bed, short
gastric artery, pancreatic tail, and splenic artery
Iatrogenic rupture of the spleen during
splenectomy➔implantation of splenic tissue
within the peritoneal cavity
Present with abdominal pain, partial return of
splenic function
Associated with post-splenectomy thrombocytosis
Occurs with associated myeloproliferative
disorders
Presents with vague abdominal pain, anorexia,
abdominal pain, leukocytosis, and thrombocytosis
Contrast-enhanced computed tomography is
diagnostic
0.1% risk
Patients at risk: Children, elderly,
immunocompromised
Most common pathogen: Encapsulated bacteria
(streptococcus pneumoniae, Hemophilus inuenza,
and Neisseria meningitidis)
Re-exploration
Does not require intervention
It is most often treated when the
platelet level exceeds 1,000,000/μL
and is generally treated with aspirin.
Anticoagulation
Broad-spectrum antibiotics
Occur within 2years after splenectomy
Mortality 50–70%
Pancreatic duct leak
after splenectomy
If concern for injury to pancreatic parenchyma or
ductal system, drain should be left in place
Research
Reference Findings
Khasawneh MA, Contreras- Peraza N,
Hernandez MC, Lohse C, Jenkins DH,
Zielinski MD.Outcomes after splenectomy
in children: a 48-year population-based
study. Pediatr Surg Int. 2019;35(5):575–82
Convert leak to controlled stula with
drain removal when healed tract
forms.
Recalcitrant leaks may require ERCP
with stent or surgical distal
pancreatectomy
For splenectomy: The best prognosis is associated with removal
after trauma. Patients with underlying malignancy had a more than a
fourfold increased risk of post-splenectomy sepsis compared with
trauma patients
Esophagus
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TirajehZohourian, CostasBizekis, JunLevine,
andMichaelZervos
5
T. Zohourian (*)
General Surgery Residency, NYU Long Island
School of Medicine, NYU Langone—Long Island
Hospital, Mineola, NY, USA
e-mail: tirajeh.zohourian@nyulangone.org
C. Bizekis
Department of Cardiothoracic Surgery, NYU
Grossman School of Medicine, NYU Langone
Health, New York, NY, USA
General Thoracic Surgery, Bellevue Hospital Center,
NYU Langone Health, New York, NY, USA
e-mail: costas.bizekis@nyulangone.org
J. Levine
Department of Surgery, NYU Long Island School of
Medicine, NYU Langone—Long Island Hospital,
Mineola, NY, USA
Division of Minimally Invasive and Bariatric Surgery,
NYU Langone Hospital Long Island,
Mineola, NY, USA
e-mail: jun.levine@nyulangone.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
H. Ajouz et al. (eds.), The ABSITE Blueprints, https://doi.org/10.1007/978-3-031-32643-1_5
M. Zervos
Department of CT Surgery, NYU Grossman School
of Medicine, New York, NY, USA
Clinical Thoracic Surgery, Tisch Hospital/Kimmel
Pavilion, NYU Langone Hospital,
New York, NY, USA
Robotic Thoracic Surgery, Tisch Hospital/Kimmel
Pavilion, NYU Langone Hospital,
New York, NY, USA
e-mail: michael.zervos@nyulangone.org
137
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