clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

832 SECTION 6 Pancreas

Postoperative Tests

Hold all glucose for 24h (insulinoma)

Plasma glucose every 6–8h for 48h then twice daily until oral intake resumes (insulinoma)

Every other day CBC, electrolytes, amylase Drain fluid amylase if fluid becomes cloudy

Local Postoperative Complications

■Short term:

–Pancreatic leak

–Acute pancreatitis

–Bleeding

–Intra-abdominal abscess

–Wound infection

–Persistent hypoglycemia, hypergastrinemia

■Long term:

–Chronic pancreaticocutaneous fistula

–Pancreatic ascites (internal fistula)

–Pancreatic pseudocyst

–Diabetes mellitus

–Recurrent peptic ulcer disease (gastrinoma)

–Recurrent hypoglycemia secondary to missed insulinoma, unrecognized factitious hypoglycemia, nesidioblastosis, multiple endocrine neoplasia syndrome

Tricks of the Senior Surgeon

Open Enucleation

■Minimize mobilization of the pancreas if the tumor is readily apparent (use IOUS to look for multiple tumors).

■IOUS guides tumor removal (enucleation versus resection); use IOUS to check the continuity of the main pancreatic duct after enucleation.

■Avoid sutures and unipolar electrocautery; utilize a traction suture, bipolar cautery, fine clips, and an endarterectomy spatula during enucleation to avoid major ductal injury.

■Leave the enucleation sites open.

■Fibrin glue and octreotide do not prevent pancreatic fistulas.

■Always leave drain(s).

Laparoscopic Enucleation

■A 5-mm hook cautery can be very useful to dissect the deep plane between the pancreas and insulinoma.

■Reuse the laparoscopic ultrasound probe to monitor enucleation.

■If the enucleation plane is difficult, perform a laparoscopic or open distal pancreatectomy.

■Clip the last deeper posterior centimeter of the pancreatic parenchyma to control posterior vessels feeding the tumor and possible pancreatic ductules.

Transduodenal Resection

of Periampullary Villous Neoplasms

Michael L. Kendrick, Michael B. Farnell

Introduction

Halsted reported the first ampullary resection of a periampullary carcinoma in 1899. This approach offers a decreased operative risk and potential complications

compared to more radical procedures; however, the disadvantages include a high incidence of recurrence and the need for ongoing endoscopic surveillance.

Indications and Contraindications

Preoperative Investigations and Preparation for Procedure

Endoscopy with Biopsy

■Mandatory in all patients

■With high suspicion or biopsy-proven malignancy, especially with tissue invasion, strong consideration should be given for radical resection

■Findings suggesting malignancy include: bile and/or pancreatic ductal dilation, hard or ulcerated tumor, or high-grade dysplasia

■Cautionary notes:

–Endoscopic biopsy misses diagnosis of malignancy in 40%

–Most accurate diagnostic method for invasion is complete excision with pathologic analysis

Endoscopic Retrograde Cholangiopancreatography

■The gold standard

■Determines ductal extension

Computed Tomography

■Excludes evidence of local complications (ductal dilation, pancreatitis, etc.) or metastatic disease

Endoscopic Ultrasonography

■Can (in experienced hands) delineate transmural invasion, ductal extension, or nodal involvement

■Very operator-dependent

Cholecystectomy is performed in routine fashion. A flexible catheter (e.g., biliary Fogarty® catheter) is placed antegrade from the cystic duct distally through the papilla into the duodenum, which assists localization of the ampulla.

A 5- to 10-mm margin is scored circumferentially in the mucosa around the adenoma with electrocautery. Sutures placed at the margins assist with retraction. A mixture of saline and epinephrine (1:100,000) is injected submucosally to elevate the mucosa and the tumor to facilitate resection.

Local Postoperative Complications

■Short term:

–Transient increases in of serum liver function studies and pancreatic enzymes (infrequently clinically significant)

–Duodenal, pancreatic, or biliary leak

–Intraduodenal hemorrhage

–Pancreatitis

■Long term:

–Common bile duct or pancreatic duct stricture

–Duodenal stricture

–Recurrent villous adenoma (est. ~40% at 10years of follow-up)

–Development of ampullary carcinoma (malignant recurrence) is possible and thus requires regular surveillance

Postoperative Surveillance

■Endoscopic gastroduodenoscopy with a side-viewing instrument should be performed 6months postoperatively, biannually for 2years, and then annually.

■Strictures are interrogated for recurrent neoplasm and ideally treated with pancreatoduodenectomy.

Tricks of the Senior Surgeon

■A subcostal incision provides excellent lateral exposure, greatly facilitating access for the dissection.

■An anterolateral oblique duodenotomy gives ideal exposure, allows further extension if needed, and a two-layer closure does not compromise duodenal lumen.

■An extended Kocher maneuver is imperative.

■A folded laparotomy pad placed behind the duodenum displaces the operative field anteriorly.

■A catheter placed antegrade via the cystic duct provides assurance in locating and protecting the retroduodenal common bile duct, especially when a full thickness excision is performed.

■Placement of sutures at the margin of the specimen assists exposure and dissection.

■Optical magnification is very helpful for resection and reconstruction.

Pancreas Transplantation

Nicolas Demartines, Hans Sollinger

Introduction

The aim of pancreas transplantation is to restore normal glycemia in diabetics and to attempt to stop the vascular pathophysiology of diabetes, i.e., microangiopathy and, whenever possible, to reverse established renal, ophthalmologic, and neurologic complications of microangiopathy. Pancreas transplantation can be performed either simultaneously with or sometimes after a previous kidney transplant, or less commonly as a primary procedure alone.

The operative technique of the pancreas transplantation has evolved from a

Indications for Simultaneous Pancreas and Kidney Transplantation

■Diabetic nephropathy

■End-stage renal disease

Indication for Pancreas Transplantation After Kidney Transplantation

■ Functioning kidney graft

Indication for Pancreas Transplantation Alone (Severe Complications of Diabetes)

■Instability of glycemia – unstable,“brittle”, insulin-dependent diabetes

■Progressive retinopathy

■Progressive neuropathy

Preoperative Investigations and Preparation for the Procedure

■Routine evaluation for transplantation with appropriate serum cross-match

■Evaluation of renal function unless on preoperative hemodialysis

■Clinical cardiovascular evaluation, further cardiac workup if clinically indicated

■Clinical exclusion of concurrent infection

ligated with 0 silk. The superior mesenteric artery and vein distal to the pancreatic vessels are divided in one of two ways: either with a vascular stapler close to the pancreas or by ligating the vessels with 0 silk and oversewing them with polypropylene running sutures. A 12-cm segment of the second portion of the duodenum containing the entrance of the pancreatic duct is isolated using a gastrointestinal stapler. The staple lines are oversewn for hemostasis with a running suture of resorbable suture. The portal vein is usually left short at the procurement; this permits a very short portal anastomosis, which decreases the risk of venous thrombosis. The mesenteric and splenic arteries are connected with use of a Y-graft from the donor iliac bifurcation with running sutures of 6-0 polypropylene. The graft is now ready for implantation.