clavien_atlas_of_upper_gastrointestinal_and_hepato-pancreato-biliary_surgery2007-10-01_3540200045_springer

A Satinsky vascular clamp is placed on the vena cava for the venous anastomosis.

The type of clamp used on the common iliac artery depends on the site for anastomosis and the presence/absence of arteriosclerosis, either a Satinsky clamp or two right angle vascular clamps.

For the posterior aspect of the venous anastomosis, the cava is opened longitudinally for 20–30mm, corresponding to the size of the portal vein of the graft. A stay suture on the left side of the opened vena cava maximizes exposure. After irrigating the lumen with a heparin/saline solution, a 6-0 polypropylene running suture starts on the right side of the cava and is carried around the posterior circumference. The technique for the vascular anastomosis is also used for a portomesenteric venous anastomosis.

The anterior part of the anastomosis is performed next with the same running suture, taking care not to include the posterior wall with the anterior suture layer. Before completing the anastomosis by tying the two ends of the suture, a bulldog clamp is placed on the portal vein and the anastomosis is tested by filling and distending the cava and portal vein with a heparin/saline solution through a cannula. The bulldog clamp should remain in place while the vascular clamp on the cava is removed.

Whenever possible, the venous anastomosis should be performed without an additional venous graft to decrease the risk of venous thrombosis. For this procedure, the colon is not mobilized. The small intestine is retracted to the left, and the superior mesenteric vein is located caudal to the transverse mesocolon. An incision is made about 20mm lateral of the vein to allow a better control of this vein while positioning the pancreas graft. The venous anastomosis is performed with the same technique described above. For the arterial anastomosis, the common iliac artery is palpated medial to the ileocolic artery through the mesocolon, and the mesentery opened for 4–5cm to expose the common iliac artery. The anastomosis is performed through the mesentery using the same technique as above.

This approach speeds the procedure and avoids complete mobilization of the right colon. The retroperitoneum is not opened, decreasing the risk of postoperative hemorrhage. Whether benefit is achieved through a portomesenteric versus systemic venous drainage is still debated.

A-1

An 18-Fr. closed suction drain is placed alongside the pancreas graft. The cecum is usually pexed or reperitonealized with either running or interrupted polypropylene sutures to avoid later cecal volvulus. Such lateral refixation is not necessary for portomesenteric venous drainage.

If a simultaneous kidney transplant is to be done, the same intra-abdominal access can be used to expose the iliac vessels transperitoneally or a separate contralateral retroperitoneal approach is an alternative.

Postoperative Tests

The intraoperative glycemia monitoring shows usually normalization without additional insulin within 1–2h after the graft reperfusion.

■Close postoperative management in an intensive or immediate care unit

■Daily hemoglobin and kidney function

■Blood sugar determination every 4h

Local Postoperative Complications

■Short term:

–Postoperative bleeding

–Duodenal anastomotic leak

–Ascites (R/O pancreatic ascites/anastomotic leak)

–Portal vein graft thrombosis

–Hypoglycemia

–Acute rejection

–Mild pancreatitis

■Long term:

–Chronic pancreas rejection

–Adhesive small bowel obstruction

Tricks of the Senior Surgeon

■Whenever possible, avoid the use of a venous graft on the donor portal vein.

■Meticulous hemostasis at the end of the procedure is imperative to prevent delayed hemorrhage up to 2h after reperfusion.

■The exocrine drainage must be tension-free, and the drainage catheter kept away from the anastomosis to avoid catheter erosion.

Chronic Pancreatitis

L. William Traverso (Proximal Pancreatectomy),

Charles F. Frey, Kathrin Mayer, Hans G. Beger, Bettina Rau, Wolfgang Schlosser (Non-Anatomic Resections: The Frey and Beger Procedures)

Introduction

As our knowledge of the pathogenesis of pancreatitis-associated pain has matured and as experience with formal operative pancreatectomies has grown, the emphasis on operative treatment of patients with symptomatic chronic pancreatitis has switched from distal-based resections (60%Æ80%Æ95% pancreatectomies) to proximal based resections (pancreatoduodenectomy) and more recently to non-anatomic, duodenumpreserving subtotal resections. The following sections will address proximal and distal resections, respectively.

Proximal Pancreatectomy

L.William Traverso

The goals of a pylorus preserving Whipple procedure for chronic pancreatitis are twofold. The first goal is to remove the head of the pancreas, what Longmire referred to as the “pacemaker of pancreatitis”, which serves as the source of chronic pain.

In properly selected patients, relief of pain will occur in almost every patient, 75% of whom will remain pain-free. In the remaining patients, pain relief will have been achieved that yields substantial improvement that allows the patient to reenter daily life patterns.

The other goal is to minimize gastrointestinal dysfunction. To achieve the latter, the author has followed patients for over a decade to determine that these goals have been achieved using techniques described in this chapter. The anatomic approach is to preserve a functioning pylorus, the entire stomach, and the first 3–5cm of the duodenum. Therefore, the neurovascular supply to the pylorus is protected and

preserved by wide dissection; maintaining intact vagal innervation to the distal stomach appears to be mandatory for a functioning pylorus.

Preoperative Investigations and Preparation for the Procedure

■The goal of imaging studies is to picture the anatomy, i.e., a “composite pancreas” from images of pancreas-protocol CT, endoscopic retrograde cholangiography (ERCP), and, if necessary, intraoperative pancreatography; if jaundiced, biliary decompression is usually indicated until bilirubin is almost normal.

■Allow acute inflammation or infection to subside with minimally invasive drainage as necessary.

■If CT shows an intrapancreatic pseudocyst in the head of the gland, arteriography is often indicated to investigate the presence of a pseudoaneurysm. If present, then preoperative embolization is needed.

■Preoperative mechanical bowel preparation is used as are intravenous perioperative antibiotics.