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PANCREATITIS
83
and then free congenital adhesions to the stomach to gain full access to the
body of the pancreas ( Fig. 1.58 ).
After confirming histology of the tumour from the frozen sections (and
negative results from any other biopsies), the duodenum is fully Kocherized and
a further examination of the tumour made to assess its mobility ( Fig. 1.59 ).
We prefer to determine that there is no vascular involvement at this stage.
The middle colic vein is followed down to the inferior border of the pancreas
and the SMV and portal vein junction identified ( Fig. 1.60 ).
The space anterior to the portal vein is then identified and opened either
with a finger or a large blunt curved clip such as a Moynihan or Semm. A sling
is placed around the neck of the pancreas at this point and when it is clear that
there is no vascular invasion we would continue to mobilize the head of the
gland.
A cholecystectomy is performed and the bile duct identified, mobilized, and
slung above the entry of the cystic duct ( Fig. 1.61 ).
Care must be taken before dividing the bile duct to identify the right hepatic
artery and ensure that any anatomical variants are identified. The only com-
mon one to pose problems is an aberrant right hepatic artery which arises from
the SMA and can be damaged or divided as it runs alongside the bile duct. The
bile duct is examined carefully to ensure that it does not have any adherent
vessels and then divided and ligated distally. The distal portion is followed
down to the head of the pancreas and if the Kocherisation has been adequate
there remains very little tissue between the bile duct and the gastroduodenal
artery. The artery is identified and clamped (ensuring that the hepatic artery is
still palpable) prior to division.
With mobilization of the head and division of the CBD and gastroduodenal
artery, it is possible to divide the duodenum. We always try to preserve the
pylorus to prevent bile reflux with our reconstruction and do not divide the
right gastric artery unless essential. Occasionally, however, it is required and
we will examine the proximal duodenum at the end of this procedure prior to
anastomosis to satisfy ourselves that the blood supply is adequate. The duode-
num is now further mobilized by clearing the antimesenteric border of the
duodenojejunal (DJF) flexure until we encounter the dissection done to
Kocherize the duodenum. We continue the dissection until the fourth part of
the duodenum and proximal jejunum will prolapse through behind the SMA
and good mobility is demonstrated.
The mobility is, however, somewhat variable and the proximal jejunum is
used for the neo-duodenum to anastomose to the cut pancreas. If the mobility
will not allow the jejunum to prolapse without tension or kinking, it may be
necessary to resect a further 10–15cm of jejunum as the vessels beyond this
PANCREAS
84
point are longer and more mobility is obtained. The gland is transected usually
just to the left of the portal vein as long as this provides sufficient tumour
clearance macroscopically (at least 2cm). After placing a soft clamp on either
side we divide the pancreas with a scalpel to make identification of the pancre-
atic duct easier ( Fig. 1.65 ).
The head of the gland is then oversewn with 3/0 PDS and the clamp removed
(or the clamp can be left in place if it does not interfere with the resection). The
distal pancreatic clamp is then removed and a 2–3-mm slice of pancreas is
taken and sent for frozen section examination. The pancreatic vessels are then
oversewn with 4/0 prolene to ensure haemostasis and a small infant feeding
tube inserted into the pancreatic duct to aid later identification. When this
has been achieved, a window is created in the jejunal mesentery adjacent to
the wall in the antemesenteric border, sufficiently large to accept a straight
stapler.
After dividing the proximal jejunum beyond the DJ flexure, it is then
returned to its usual position and this leaves the head of the gland only attached
to the SMA and portal vein ( Figs. 1.66 and 1.67 ).
The remainder of the mobilization requires care as venous tributaries from
the head of the gland to the portal vein are quite delicate and the SMA branches,
including the pancreaticoduodenal, need to be secured and oversewn to pre-
vent them retracting and being difficult to control ( Fig. 1.68 ).
The portal vein branches are identified first and they are separately ligated
and oversewn. There are always one or two large tributaries inferiorly and
special care must be taken to avoid difficult bleeding from these. When the
portal vein has been cleared, attention is turned to the SMA branches which
are enveloped in dense fibrous tissue. This dense fibrous tissue obscures the
smaller branches and makes them difficult to locate and the safest approach is
to identify the SMA and dissect directly on to it. Care must be taken during the
initial dissection to avoid rolling the SMA laterally and damaging it. It is easily
located by palpation and generally lies sufficiently to the left and posterior to
the vein to prevent this, but occasionally can lie more laterally.
After all the SMA branches have been ligated and transfixed, the specimen is
removed and any residual bleeding is controlled.
Our reconstruction places the pancreatic remnant on a separate loop (the
proximal jejunum) and the stomach and bile duct on a Roux loop. The ration-
ale for this is as follows:
♦
The pancreas is anastomosed to the most proximal loop of jejunum, which
has the best blood supply
♦
The pancreas is on a separate loop, which will reduce activation of pancreatic
enzymes by biliary secretions
PANCREATITIS
85
♦
The majority of serious postoperative problems after Whipple’s procedures
relate to pancreatic leaks. Placing the pancreas on a separate loop would
hopefully allow the best chance of these settling spontaneously with conser-
vative management and would simplify surgery if this did not occur. In ex-
treme circumstances, resection of the residual pancreas would not require
disrupting the other anastomoses
♦
Apart from the anastomosis of the pancreatic duct, the rest of the recon-
struction uses standard components of our other operations. The bilioen-
teric anastomosis is our standard approach and means that we are familiar
with its performance. In addition, the use of these components effectively
increases the number of these reconstructions done and aids teaching and
profi ciency.
Prior to beginning the reconstruction the results of the frozen section of the
distal pancreas must be checked and, if positive, a further 2cm of the body of
the pancreas is resected and a further frozen section taken (Table 1.12). When
clearance is confirmed, the reconstruction starts with the pancreatic anasto-
mosis. The proximal jejunum is delivered behind the SMA as a neo-duodenum
after oversewing the staple line, and then the pancreaticojejunal anastomosis is
performed. Initially the outer layer is completed with a continuous 4/0 prolene
from the serosa to the posterior wall of the transected pancreas ( Fig. 1.71 ).
4/0 prolene is also used for the duct and the anterior sutures are placed ini-
tially (as for a biliary anastomosis). A small enterotomy is then created with a
diathermy point and the posterior wall of the enterotomy is sutured to the
posterior wall of the duct with interrupted full thickness 4/0 prolene sutures. A
small piece of T-tube or infant feeding tube for very small ducts (3–4mm) is
then fashioned (cut to 3–4cm and several holes made in the side) and placed
across the anastomosis to allow drainage despite any oedema of the small
bowel mucosa and also prevent the posterior wall of the duct being picked up
with the anterior row of sutures ( Fig. 1.72 ).
The anterior row is completed using the sutures already in the pancreatic
duct (compare with biliary bypass). The anterior outer row is then completed
by running the rest of the posterior continuous 4/0 Prolene suture along the
anterior wall and tying it to itself at the end ( Fig. 1.72 ).
The defect produced by mobilizing the DJ flexure is then closed, 70cm meas-
ured downstream, and the jejunum divided with a straight stapler. The Roux
loop is oversewn and anastomosed end-to-side to the proximal duodenum (if
this still looks healthy) using interrupted sero-submucosal 4/0 PDS sutures.
This can be done as an end-to-end or end-to-side anastomosis and this is decided
by the position in which the Roux loop lies most comfortably. If the proximal
duodenum beyond the pylorus looks ischaemic then a small antrectomy is
PANCREAS
86
performed and the anastomoses completed similarly (end-to-side). The biliary
anastomosis and jejunojejunostomy are exactly as discussed for biliary bypass
earlier in this section.
After a thorough washout, two tube drains are inserted, one to the biliary
and one to the pancreatic anastomosis and the wound closed. Octreotide is
given intraoperatively (100mcg) and 100mcg three times a day for 5 days post-
operatively (Lowy et al ., 1997 ). Drains are removed on day 4–5 after the patient
has started eating and the drain fluid has been checked to ensure that the
amylase level is less than 3000IU/L. If levels are above this then the drains
should be left for a further 5 days and rechecked. Postoperative care is other-
wise standard with heparin (preferably low molecular weight), acid reduction,
and intravenous antibiotics for 48 hours (or 72 hours if the patient has had an
endoscopic stent). The nasogastric tube is removed on the third or fourth day
and oral intake started. The small piece of T-tube used as a stent across the
bilioenteric anastomosis passes eventually down the intestinal tract.
Laparoscopic pancreatic surgery
Despite a few enthusiastic reports of series of laparoscopic pancreatic resec-
tions, it has no place for the vast majority of pancreatic neoplasms. While
technically possible for all procedures and straightforward for lesions in the
tail of the pancreas (Dulucq et al ., 2006 ; Fernandez-Cruz et al ., 2007 ; Palanivelu
et al ., 2007 ), there still appears to be little or no benefit over open resection and
a significant incidence of pancreatic leaks (Mabrut et al ., 2005 ). In the majority
Table 1.12 Main stages in the management of carcinoma of the head of the
pancreas
Diagnosis, management, and surgery should be done in specialized units with
mutidisiplinary teams and acceptable volumes
EUS/laparoscopy and intraoperative ultrasound are important in the evaluation of these
patients and alter the management in a significant proportion
At surgery, a diligent search for extrahepatic disease must be made to include
intraoperative ultrasound of the liver and frozen sections
Positive histology should be obtained prior to all resections for carcinoma of the head of
the pancreas (HOP) and lower CBD cholangiocarcinomas. Choledocoscopy may be
required for small CBD cholangiocarcinomas with no preoperative histology
After removal of the HOP specimen, a frozen section of the cut resection margin of the
pancreatic remnant should always be taken and the resection extended by 1–2cm if
the biopsy is positive. If the second specimen is also positive then total pancreatectomy
is indicated (probable multifocal tumour). The finding of ductal abnormalities such as
Pan1N is difficult and will depend on the pathologist’s report but is best treated by
postoperative surveillance
PANCREATITIS
87
of studies with left laparoscopic resections the hospital stay is also either the
same as for open surgery or prolonged (Kooby et al ., 2008 ). The old adage
appears to apply, that ‘if the insult of the surgery is greater than the insult from
the wound then there is nothing to be gained by a laparoscopic approach’.
For carefully selected patients with a strong wish to have a laparoscopic
approach it can be offered, providing the increased risks associated with it are
clearly discussed.
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Section 2
Duodenum
The duodenum is often forgotten due to the enthusiasm to manage the more
acclaimed surrounding organs of the gallbladder, pancreas, liver, and stomach.
The improvements in pharmacological management of peptic ulcer disease
and endoscopy have seen the surgeon operating far less often on the duode-
num. Nonetheless, duodenal pathology and trauma are difficult to manage
and while constituting only a small proportion of the hepatobiliary and pan-
creatic surgeons’ workload, the possibility of a poor outcome, even if expertly
managed, is high.
Trauma
Trauma to the first and second part of the
duodenum ( Fig. 2.1 )
Trauma to the duodenum is often difficult to diagnose. In the case of a blunt
abdominal injury, it is usually in the context of other intra-abdominal injuries
with free intraperitoneal fluid and distortion of the normal anatomy. It is not
generally found as an isolated injury and may not have even been anticipated
at the time of laparotomy (Levison et al ., 1984 ; Subramanian et al ., 2007 ;
Stawicki and Schwab, 2008 ). The surgical principle is to establish the extent of
the injury and mobilize the duodenum with a Kocher’s manoeuvre (see
Figs. 1.42 and 1.43). Devitalized tissue will need to be removed to allow the full
extent of the defect to be determined. Primary closure with adequate drainage
may be possible, particularly with penetrating injuries.
Blunt abdominal trauma may produce a more swollen and ragged edge that
cannot be brought together safely with sutures. In this situation, the use of a
Roux-en-Y loop represents the safest repair. Some have advocated serosal
patches from the adjacent small bowel and while undoubtedly this can work,
the added advantage of a Roux-en-Y anastomosis around the edge of the duo-
denal injury is the provision of a tension-free repair with a luminal option for
drainage of any leak ( Fig. 2.2 ).
A duodenal injury is often associated with extensive duodenal swelling and
in such circumstances the option of decompressing the biliary tree should
be considered. A cholecystectomy with insertion of a T-tube into the CBD
DUODENUM
90
Fig. 2.1 Management of duodenal trauma.
Well
Iatrogenic
Unrecognized
operative injury
Controlled by
conservative
management/
drainage
Management as
for pancreatic
trauma
Traumatic assault
road traffic
accident etc.
Duodenal
trauma
ERCP
Conservative
management
Deteriorates
Unwell and no
response to
conservative
management
Resolves
Resolves
Surgical
exploration
Deteriorated or
large volume
fistula which
doesn’t settle
TRAUMA
91
Fig. 2.2 A large defect in the second part of the duodenum, too extensive for
a safe primary closure. A 70 cm Roux-en-Y limb is mobilized to close the defect.
A T-tube is used to decompress the biliary system. A feeding jejunostomy is inserted.
DUODENUM
92
provides a useful bypass for the bile while the oedema and swelling settles in
the duodenal ampullary region. A feeding jejunostomy should be routinely
considered.
Delayed presentation
Unfortunately, duodenal injuries are not always recognized at the time of the
initial trauma and present later with sepsis, increasing peritonism, and organ
failure. Such situations require immediate resuscitation and prompt surgery.
The intra-abdominal situation may render definitive surgical repair impos-
sible and the initial treatment should be directed at the washing out of the
abdominal cavity and supplying adequate drainage to the duodenal injury.
With control of the injury obtained, subsequent surgery can be planned once
the patient’s sepsis and nutritional condition improves. If further intervention
is required then adequate imaging and the use of a Roux-en-Y may well produce
a definitive solution to the problem.
Trauma to the third and fourth part of the duodenum
Trauma to this segment of the duodenum requires a different approach. Simple
penetrating injuries can be sutured closed and a drain placed. Blunt traumatic
injuries are best managed by closing off the proximal duodenum ( Fig. 2.3 )
using viable tissue and creating a blind limb ( Fig. 2.4 ).
Fig. 2.3 Ragged trauma to the third and fourth parts of the duodenum.