Pancreatic Surgery

OPERATIVE DRAINAGE FOR PANCREATITIS

SURGICAL CONSIDERATIONS

Description: Surgical treatment for pancreatitis is indicated for drainage or debridement of infected peripancreatic tissue or pancreatic necrosis. Pancreatic necrosis is defined by areas of poor perfusion in the pancreas on CT-angiogram. Infected pancreatic necrosis occurs with the presence of gas and/or bacterial invasion. Pancreatic abscesses usually develop in the lesser sac, but may spread to the subphrenic spaces or into the pericolic gutters. Fistulization into adjacent organs, particularly the transverse colon and duodenum may occur. Severe intraabdominal hemorrhage from erosion into major arteries lying adjacent to the pancreas is uncommon, but may occur prior to, during, or after operative drainage. Intraop, exploration of the peritoneal cavity is performed before opening the lesser sac. Areas lateral to the left and right sides of the colon, as well as the base of the transverse mesocolon and the subhepatic areas, should be palpated to identify fluid or abscess collections. The gastrocolic ligament is then incised to approach the pancreas through the lesser sac. There are different operative approaches, depending on location of involved tissue and surgeon’s preference. Upper midline or transverse abdominal incisions are used most often. Posterior drainage through the bed of the 12th rib, or retroperitoneal lateral approaches, may be used (Fig. 7.8-1). Recently, laparoscopic opening between the stomach and retroperitoneum has also been used in select cases.

Usual preop diagnosis: Severe pancreatitis 2° to gallstones, alcohol, or post ERCP.

▪ SUMMARY OF PROCEDURE

Position	Supine or rotated slightly (Fig. 7.8-1) for posterior approach
Incision	Midline, transverse, flank, or synchronous anterior and posterior
Unique considerations	Must perform adequate debridement of necrotic tissue and provide adequate drainage of abdomen; NG tube; jejunal feeding tube
Antibiotics	Cefoxitin 1-2 g 30 min preop, or antibiotic directed at cultured organisms
VTE prophylaxis	Heparin 5000 units sq
Surgical time	1-2 h
Closing considerations	Adequate drainage of pancreatic bed and fluid resuscitation of patient
EBL	300-750 mL
Postop care	Routine wound and drain care; usually ICU and intubated; often, subsequent operative procedures are required.
Mortality	8-30%
Morbidity	Fistulae formation: 18-55% Delayed gastric emptying: 50% Unremitting sepsis: 10-30% Atelectasis: 5-10% Respiratory deterioration: 5% Hemorrhage Bowel perforations
Pain score	7-9

Figure 7.8-1. Incision for anterior and posterior drainage in pancreatitis. Note that bed or table is rotated until patient is almost supine. (Reproduced with permission from Berne TV, Donovan AJ: Synchronous anterior and posterior drainage of pancreatic abscess. Arch Surg 1981; 116:527-33. Copyright 1981, American Medical Association.)

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations for Pancreatic Surgery, p. 634.

Suggested Readings

1. Berne TV: Pancreatic abscesses. Probl Gen Surg 1984; 1:569-82.

2. Bradley EL: Fifteen-year experience with open drainage for infected pancreatic necrosis. Surg Gynecol Obstet 1993; 177(3): 215-22.

3. Feranandez-del Castillo C, Rattner DW, Makary MA, et al: Debridement and closed packing for the treatment of necrotizing pancreatitis. Ann Surg 1998; 228:676-84.

4. Freeman ML, Werner J, van Santovoort MC, et al: Interventions for necrotizing pancreatitis. Pancreas 2012; 41:1176.

5. Gotzinger P, Sautner T, Kriwanek S, et al: Surgical treatment for severe acute pancreatitis: extent and surgical control of necrosis determine outcome. World J Surg 2002; 474-8.

6. Shinzeki M, Ueda T, Takeyama Y, et al: Prediction of early death in severe acute pancreatitis. J Gastroenteral 2008; 43:152-8.

7. Villazon A, Villazon O, Terrazas F, et al: Retroperitoneal drainage in the management of the septic phase of severe acute pancreatitis. World J Surg 1991; 15:103-8.

DRAINAGE OF PANCREATIC PSEUDOCYST

SURGICAL CONSIDERATIONS

Description: Internal drainage of a pancreatic pseudocyst may be accomplished by anastomosing the cyst to the stomach, duodenum, or other small bowel via a Roux-en-Y loop of jejunum. The procedure of choice for internal decompression depends on the location of the pseudocyst in relation to the portion of the GI tract that will provide maximal dependent drainage of the cyst. Both open and laparoscopic procedures have been used with success. The two approaches should be equivalent. Operation is reserved for patients with refractory symptoms. At operation, the abdomen is entered via a midline incision or laparoscopically. The pseudocyst is localized by palpation with or without intraoperative ultrasound. If the pseudocyst lies behind the stomach (or duodenum), it is approached anteriorly, through the posterior wall of the stomach (or duodenum). A portion of the posterior wall is excised, allowing entry into the cyst cavity, which is then drained. An anastomosis is created between the cyst and stomach (or duodenum). The anterior wall of the stomach (or duodenum) is then closed. If the cyst presents inferior to the stomach, it is anastomosed
in a similar fashion to a Roux-en-Y loop of jejunum (Fig. 7.8-2). Drains are placed; external drainage is sometimes necessary, especially in the setting of infection. Spontaneous resolution of pancreatic pseudocyst may be expected in most patients with cysts < 6 cm. If infection of the pseudocyst occurs with clinical signs of sepsis, percutaneous drainage under CT guidance can be performed, although subsequent operative drainage is often necessary.

Figure 7.8-2. Roux-en-Y drainage of a pseudocyst. (Reproduced with permission from Scott-Conner CEH, Dawson DL: Operative Anatomy, 2nd edition. Lippincott Williams & Wilkins, Philadelphia: 2003.)

Usual preop diagnosis: Pancreatic pseudocyst 2° to acute pancreatitis refractory to medical management

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations for Pancreatic Surgery, p. 634.

Suggested Readings

1. Barthlet M, Lamblin G, Gasmi M, et al: Clinical usefulness of a treatment algorithm for pancreatic pseudocysts. Gastrointest Endosc 2008; 67:245-52.

2. Mori T, Abe N, Sugiyama M, et al: Laparoscopic pancreatic cystogastrostomy. J Hepatobiliary Pancreat Surg 2002; 9:548.

3. Neff R: Pancreatic pseudocysts and fluid collections. Surg Clin North Am 2001; 81(2):399-403.

LONGITUDINAL PANCREATICOJEJUNOSTOMY

SURGICAL CONSIDERATIONS

Description: Pancreaticojejunostomy, as described by Puestow, is typically done for chronic pancreatitis with pancreatic ductal obstruction. It consists of a longitudinal opening of the pancreatic duct, which is then anastomosed to a Roux-en-Y loop of jejunum (Fig. 7.8-3). This approach is necessary to ensure adequate drainage of a duct with multiple strictures and dilations. Through a midline or transverse abdominal incision, the pancreas is exposed by mobilizing the duodenum (Kocher maneuver), exposing the head of the pancreas, and opening the lesser sac to visualize the body and tail. The pancreatic duct may be aspirated to identify its location, and intraoperative ultrasound is commonly used, then it is incised longitudinally. A Roux-en-Y loop of jejunum is then brought up to the pancreas and anastomosed to the opened duct. A drain is left along the anastomosis, and the wound is closed in the usual fashion.

Variant procedure or approaches: A Whipple resection (pancreaticoduodenectomy; see p. 632) is an alternative surgical treatment for chronic pancreatitis confined to the head of the gland. Rarely, subtotal or near-total pancreatectomy is indicated. Fry procedure is near-total pancreatectomy with Roux-en-y drainage of the pancreatic head, and Beger procedure is doudenal presenting pancreatic head resection.

Usual preop diagnosis: Abdominal pain with chronic pancreatitis and dilated pancreatic duct (chain of lakes)