COMPLICATIONSOFWHIPPLE OPERATION

Mohamad Dughayli M.D, FACS

General Surgery

Henry Ford Wyandotte Hospital

ALLEN OLDFATHER WHIPPLE (1881-1963)

Pancreatico-duodenectomy (PD) was first performed by Kausch in 1908, and popularized by Whipple in the 1930s (who performed 37 procedures).

—Whipple AO, Parsons WB, Mullins CR. Treatment of Carcinoma of the Ampulla

of Vater. Ann Surg 1935; 102: 763-769.

CLASSIC WHIPPLE RESECTION—PANCREATICO-DUODENECTOMY

The operation' classical 'Whipple involves an 'en-bloc' resection of the pancreatic head, together with the distal stomach and omentum, the duodenum and upper jejunum, and the distal biliary tree including the gall bladder

Reconstruction after Classic Whipple Resection

MODIFIED WHIPPLE OPERATION—PPPD

A more limited duodenectomy with preservation of the stomach and antropyloric region is preferred by some experts and the pylorus preserving pancreatico-duodenectomy (PPPD) involves a lesser lymphadenectomy

PPPDPylorus-preserving

pancreatico- duodenectomy

(a) pancreaticogastrostomy (b) end-to-end pancreaticojejunostomy (c) end-to-side pancreaticojejunostomy

CLASSIC WHIPPLE V.S. PPPD

PPPD—protects against gastric dumping, marginal ulceration, and bile reflux gastritis. Significant reduction of the operation time, the intraoperative blood loss and the consequent need for blood substitution.

But sufficiently radical to treat pancreatic cancer? Similar or even better postoperative morbidity and mortality result was debated.

PRINCIPLE INDICATIONS FOR PD

(1) Ductal adenocarcinoma of the pancreatic head

(2) Cholangiocarcinoma of the distal biliary tree

(3) Periampullary adenocarcinoma and ampullary carcinoid

(4) Primary duodenal adenocarcinoma, duodenal GIST and duodenal lymphoma

(5) Chronic pancreatitis with associated mass lesion of uncertain aetiology

RESULTS FOLLOWING PANCREATICODUODENECTOMY

Due to improved surgical skill and peri-operative care

Mortality rate 20%-40% in earlier days During the past decades, dramatically

decreased and currently is between 0-4% in experience centers with experience.

Complication rate is still 30%-40%

COMPLICATIONS OF PANCREATICODUODENECTOMY

Common Uncommon Delayed gastric emptying Fistula Pancreatic fistula   Biliary Intra-abdominal abscess   Duodenal Hemorrhage   Gastric Wound infection Organ failure Metabolic   Cardiac   Diabetes   Hepatic   Pancreatic exocrine Pulmonary insufficiency Renal   Pancreatitis Marginal

ulceration

PANCREATIC FISTULAS AND LEAKAGE OF THE PANCREATICOINTESTINAL ANASTOMOSIS

Definition: persistent drainage of 50 ml or more of amylase-rich fluid per day after postoperative day 7

4-24% —the second leading cause of morbidity, is often undiscovered harmless

If progress to a real anastomosis leakage with consequent sepsis and hemorrhage— the major cause of the mortality

If a pancreatic leakage occurs, 20-40% die

RISK FACTORS OF PANCREATIC FISTULAS AND LEAKAGE OF THE PANCREATICOINTESTINAL ANASTOMOSIS

1.soft texture of the pancreatic remnant in pancreatic cancer patients

2.the side of the pancreatic remnant 3.continuous exocrine pancreatic

secretion that may cause tension on the pancreatico-intestinal anastomosis

4.the technical difficulty of performing a proper and safe anastomosis between the stomach or small bowel and the pancrease

BEST SURGICAL PREVENTION OF POSTOPERATIVE COMPLICATION

Safe surgical technique 1. End-to-side pancreaticojejunostomy 2. End-to-end pancreaticojejunostomy 3. Pancreaticogastrostomy

4.PANCREATIC DUCTAL OCCLUSION OR DRAINAGE

Pancreatic duct closure by ligation, stapling, or suturing

1. Inevitable fistula rate—50-100% 2. Exocrine insufficiency— steatorrhea and diarrhea

=>unfavorable

DETECTION OF PANCREATIC FISTULAS

AND ANASTOMOSIS LEAKAGE

Day after surgery(days) 5(1-20)

Clinical sign temp>38.5 62% abd. Pain 41% dyspnea 34% peritoneal tenderness 66%

Laboratory findings leukocytosis >15000 69% amylase drain >3* serum amylase 72%Diagnostic procedure ultrasound 90% pancreatography 100% CT-scan 89& CXR pleural of fusion 74%

Adapted from

Complications after resection of biliopancreatic cancer.

Annals of Oncology 10 suppl. 4:S257-260

MANAGEMENT OF PANCREATIC FISTULAS AND LEAKAGE

No sign of local peritonitis or ongoing hemorrhage in clinically stable patient

—TPN and close observation Administration of a somatostatin analogue

(Octreotide)—reduce pancreatic secretion —shortens the spontaneous closure time

MANAGEMENT OF PANCREATIC FISTULAS AND LEAKAGE

Unstable clinical situation & ongoing or recurrent hemorrhage

=>Completion Pancreatectomy =>operative lavage or placement of additional drains—outcome is

dissatisfying =>not advisable to construct a new anastomosis

INTRAABDOMINAL ABSCESS

Incidence—10% Pancreatic Fistulas and Leakage Intraabdominal Abscess SepsisD/D—postoperative intraabdominal fluid collectionresolve spontaneously by drainage fluid character

MANAGEMENT OF INTRAABDOMINAL ABSCESS

Controlling the underlying causes —fistula & anastomosis leakage Completion Pancreatectomy if neccessary

Ultrasonographic or CT guide percutaneous catheter drainage

Operative lavage or placement of additional drains

HEMORRHAGE

Incidence—5-16% Mortality rate—15-58% Classification (a) Bleeding within 24 hr (b) Bleeding occurs in the 2th and 3th

weeks (1) Intraabdominal bleeding(mostly

from the retroperitoneal operation field) (2) Gastrointestinal

bleeding(intraluminal)

BLEEDING WITHIN 24 HR

Mostly caused by— Insufficient Intraoperative Hemostasis

Detection—(1)output of the drain (2)Hb level (3)vital sign of the patient

BLEEDING WITHIN 24 HR

Bloody output of NG tube or melena suture line bleeding gastroscopy no stablization after blood & FFP reoperation

BLEEDING IN THE LATER COURSE

Anastomostic suture line bleeding or marginal ulcer

often masking “Sentinel Bleed” (the erosive bleeding from the retroperitoneal vessels) leakage of the pancreatic anastomosis carefully D/D by gastroscopy

D/D STRESS ULCER

Rarely seen after pancreaticoduodenectomyPrevention by administration of H+ pump

inhibitor, H2-antagonist Detected and resolved by interventional

endoscopy

PREVENTION OF HEMORRHAGE

Perform a proper operation with a careful hemostasis

Pre-operation bile drainage into the duodenum by ERCP or PTCD in jaundice patients(because coagulation disturbance usually seen in jaundice patients)

DELAYED GASTRIC EMPTYING

(1) Persistent secretion via the gastric tube of

more than 500 ml/day over more than 5

days after surgery(2) Recurrent vomitting (3) Swelling of the gastrojejunostomy/ duodenojejunostomy(4) Dilation of the stomach in the

contrast medium passage

DELAY GASTRIC EMPTYING

Incidence 25-70%Resolves spontaneously within 2-4 week Risk factor a. Presence of intraabdominal

complication b. Radicality of the resection (Lymph node dissection) D/D obstruction at the

duodenojejunostomy or gastrojejunostomy

MECHANISM OF DELAY GASTRIC EMPTYING

(1)Gastric atony caused by disruption of the gastroduodenal neural network after extended retroperitoneal lymphadenectomy

(2)Decreased Motilin level(produced from the enterochromaffin cells of duodenum and proximal jejunum) reduce the gastric motility

(3)Ischemic injury to the antropyloric muscle mechanism

(4)Gastric arrythmias secondary to intra-abdominal complication such as anastomostic leakage or abscess

MANAGEMENT OF DELAY GASTRIC EMPTYING

Incorpotrating prolonged nasogastric or gastrostomy tube decompression combined with TPN or Enteral nutrition

Administration of (1) motilin agonist—erythromycin (2) prokinetic agents—metoclopramide and/or cisapride

PANCREATOGENIC DIABETES Pancreaticoduodenectomy remove 30-40% of

the pancreatic parenchymal mass Majority of patients—no important clinically

important effect on glucose homeostasis Minority—hyperglycemia and glucosuria —dietary adjustment, OHA or parenteral insulin

PANCREATIC EXOCRINE INSUFFICIENCY

Fecal fat measurement or N-benzoyl-L-tyrosil-P-aminobenzoic acid test

Presumably related to obstruction of the pancreatic duct

Management—exogenous pancreatic enzyme supplementation(Creon, Pancrease, Viokase) in the early post-op period and weaning in patients who survival more than 1 year and have no malabsorption

WOUND INFECTION

Incidence:5-20% Management: (1)Antibiotics: Prophylasis and post-op (2)suture or staple removal, drainage, and packing