HIDI Whipple's resection-proximal pancreaticoduodenectomy

Pancreatic resection offers the potential for long-term cure in 15% of patients with pancreatic cancer. This article describes the author’s technique of pancreaticoduodenectomy (PD), together with guidelines for disease staging, preoperative work-up and patient selection. The role of neo-adjuvant and adjuvant chemotherapy is currently under evaluation and all patients who have a curative resection should be considered for entry into the ESPAC 3 trial that aims to establish the definitive role of adjuvant chemotherapy in pancreatic cancer.

Keywords: Pancreatic cancer, staging, Whipple's resection, pancreaticoduodenectomy, technique, complications

Pancreatic cancer is a common cause of cancer-related death in the United Kingdom, and is regularly encountered in general surgery. (1) Most patients present with advanced disease and require palliative treatment only. (2) First line palliation primarily includes a biliary endoprosthesis to alleviate symptoms associated with jaundice, whereas operative biliary-enteric or gastric bypass are generally reserved for stent dysfunction and/or gastric outlet obstruction, respectively.(3-18) Chemoradiotherapy achieves a modest survival benefit for those with locally advanced disease but cannot presently be recommended out-with clinical trials in the UK. (19-23) Similarly, systemic chemotherapy for disseminated disease appears to have a limited survival benefit, but requires further randomised studies that include quality-of-life endpoints if routine therapy is to be advocated. (24-29)

Surgical resection remains the only modality to offer the possibility of long-term survival. (30-39) It is important, therefore, that all patients deemed suitable for surgery are staged accurately and referred for appropriate specialist assessment. Contemporary staging protocols remain varied and contentious, but include a combination of contrast-enhanced helical computerised tomography (CT), dynamic magnetic resonance imaging (MRI) and magnetic resonance cholangio pancreatography, endosonography, limited and extended laparoscopy, including laparoscopic ultrasonography. (40-63) Ultimately, 15-20% of patients referred to a specialist hepatobiliary (HPB) centre for further assessment are suitable for curative pancreatic resection.

Outcomes after major pancreatic resections (e.g. Whipple's resection) have improved significantly in recent years, and specialist units aim to achieve a procedure-related mortality of less than 5 per cent. (34,38,39,64) Pancreatico-duodenectomy (PD) was first performed by Kausch in 1908, and popularised by Whipple in the 1930s (who performed 37 procedures). The classical 'Whipple’s operation' 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. (36,39,65-67)A more limited duodenectomy with preservation of the stomach and antropyloric region is preferred by some experts but the pylorus preserving pancreatico-duodenectomy (PPPD) is associated with increased morbidity and involves a lesser lymphadenectomy. (34,35, 68-74) Personal preferences aside, the principle indications for classical PD are:

ASSESSMENT PRIOR TO DEFINITE SURGERY

With rapid developments in imaging technology, there is the likelihood of developing complex staging protocols. However, the wholesale incorporation of all new modalities into standard staging protocols should be resisted, as this leads to inappropriate resource utilisation and delays in referral to appropriate specialist centres. Even within centres of excellence there are widely varying opinions as to appropriate staging protocols, a pragmatic approach should be advocated and individualised according to clinical circumstances. (17,56,63,75-84)

When evaluating a jaundiced patient with suspected ductal carcinoma of the pancreas, trans-abdominal ultrasound is the initial imaging modality to exclude cholelithiasis and confirm obstruction to the extra-hepatic biliary tree. In addition, the presence of a large pancreatic mass lesion, portal vein thrombosis, extra-pancreatic lymphadenopthy and hepatic metastases are usually indicative of incurable disease. Cystic neoplasms of the pancreas, non-functional islet cell tumours, and pancreatic lymphomas should always be considered for aggressive therapy regardless of the initial tumour size.

The optimal widely available radiological staging investigation for pancreatic cancer is a contrast-enhanced triple phase helical abdominal CT scan. (85) This should be carried out with thin cuts to provide arterial (3mm cuts) and venous phase (3 or 5mm cuts) cross sectional imaging. A CT scan using an appropriate pancreatic protocol has an accuracy of 75%-98%, when combined with 3-dimensional vascular reconstruction. (86,87) Computerised tomographic based criteria to predict resectability are: (1) absence of extra-pancreatic disease, (2) patent superior mesenteric vein - portal vein confluence, and (3) no tumour extension to, or encasement of the coeliac axis or superior mesenteric artery. (85, 88-92)

Using these criteria, CT protocols are able to predict resectability with an accuracy of around 80-90%. (93) In addition to evaluation of local resectability, the CT scan will identify many patients with metastatic disease, who are then referred for appropriate palliative care.

Patients with resectable disease on CT or MRI should finally undergo a laparoscopy to confirm resectability. Laparoscopy is essential if unnecessary laparotomies are to be avoided, as it is well recognised that occult peritoneal and hepatic deposits will be identified in 5 to 42%. (43,55,80,90,94-99) All patients diagnosed as having incurable disease should have cytological or histological confirmation of the diagnosis (Figure 1).

Major pancreatic resections are performed with acceptable morbidity and mortality rates; but this operation should not be considered lightly. In addition to staging and assessment of resectability, attention should be focussed on patient comorbidity prior to surgical intervention. Most important in an elderly population is associated cardiovascular disease and diabetes mellitus, which increase significantly the risk of peri-operative and postoperative myocardial infarction. (100)

Several scoring systems stratify risk of a cardiac event prior to embarking on major non-cardiac surgery and are to be recommended. The Eagle Index and Revised Cardiac Risk Index are simple to use, and stratify patients according to potential risk for which further cardiovascular work-up may be necessary. The Eagle Index allocates 1 point to each of the following (101)

Using the Eagle Index, those patients with no points are at low risk, those with 1 or 2 points are at intermediate risk, and patients with >2 points are at high risk of significant cardiac events without further optimisation. (102) Patients at low risk are able to proceed directly to surgery following a normal ECG at rest. Intermediate risk patients require an ECG stress test to exclude significant myocardial ischaemia; with thallium perfusion scans required for those unable to complete the exercise stress test. High risk patients require coronary angiography and an appropriate revascularisation procedure before embarking on a major pancreatic resection.

An alternative preoperative scoring system is the Revised Cardiac Risk Index which allocates 1 point to each of the following: (103)

With this clinical scoring system patients with 0, 1, 2, or >2 risk factors are graded into Classes I, II, III and IV, respectively. The approximate risk of a major cardiac event using this system is approximately 0.5%, 1.3%, 4% and 9% for Class I to IV, respectively. Patients in Class III and IV should undergo a similar preoperative work-up to that described above. (100, 104-106)

Having clarified that the patient will tolerate a major pancreatic resection with acceptable risk relative to their CO-morbidity, one should then proceed with invasive staging protocols. In my opinion, these should include at least a limited staging laparoscopy either as a separate anaesthetic procedure or as an immediate precursor to the definitive pancreatic resection. (107)

Prediction of local resectability is primarily based on high-quality CT scanning. (43,108) Some centres advocate surgery on the basis of the CT findings without staging laparoscopy, but are then committed to perform a surgical by-pass procedure for palliation in a significant proportion of patients. (17,84,90)

Most specialist HPB centres within the UK now recommend staging laparoscopy as an essential part of the staging algorithm. (58,60,61,76,77,95,99,109-114) Staging laparoscopy avoids an unnecessary laparotomy in patients with limited life expectancy, and facilitates the decision-making for palliative by-pass procedures and chemoradiotherapy. (80,98,115)

The main impact of laparoscopy in contemporary practice is the detection of occult liver and peritoneal metastases that preclude a curative resection. Several recent studies have demonstrated occult disease in 5-15% of patients thought to have resectable disease on preoperative CT scanning. (43,90,91,94,95,116) The author’s preference, after initial assessment with thin slice triple-phase contrast-enhanced helical CT, is to carry out a limited laparoscopy immediately preceding definitive laparotomy, as approximately 90% will proceed to laparotomy and a definitive resection. (117) Most patients discovered at laparoscopy to harbour CT-occult M1 disease have a biliary stent in-situ (80%) and no further procedure carried out. (61,118)

Twenty percent of patients proceed directly to surgery without prior endoscopic retrograde cholangiopancreatiography (ERCP) and biliary stent placement. If CT-occult M1 disease is identified a palliative by-pass procedure is performed. (98) It is debatable, however, whether a gastric bypass procedure is necessary in these patients as Brennan's group in New York recently reported that only 3 of 155 patients with irresectable pancreatic cancer at the time of staging laparoscopy later presented with biliary or gastric obstruction. (118) This is not the experience of others, who still advocate prophylactic bypass in all patient. (83,84,119) In the author’s practice only two percent of patients with peri-ampullary or pancreatic cancer undergo surgical bypass as the initial palliative procedure. (8,120)

Patients with inoperable disease who present late with biliary stent failure or radiologically proven gastric outlet obstruction are considered for a laparoscopic bypass, provided their general condition is reasonable and their estimated survival is greater than 6 weeks. (121-124) However, endoscopically placed self-expandable metal stents in the duodenum may prove a suitable alternative to laparoscopic gastric bypass, but data for palliation in this condition are still limited. (6, 125) Laparoscopy is essential prior to laparotomy in all patients with carcinoma of the body and tail of the pancreas, as >90% will have M1 disease. (126,127)

There is debate as to the timing of definitive surgery in jaundiced patients with peri-ampullary and pancreatic carcinoma. Some advocate urgent resection without preoperative biliary tree decompression to avoid colonisation of the biliary tree, as this may be associated with an increase in sepsis-related complications and 30-day mortality. (128-130) Other groups, however, have shown no differences in surgical outcomes, irrespective of preoperative biliary tree decompression or not. (131-133)

Whilst early definitive resection, without preoperative biliary stenting, is probably optimal practice, a pragmatic approach should be adopted, as it is not always possible to schedule an urgent pancreaticoduodenectomy. The author’s preference is to proceed directly with a definitive resection without preoperative biliary stenting provided this can be scheduled within 7 days, and the patient is not otherwise nutritionally compromised. However, 80% of referred patients cannot be accommodated within this time scale and, therefore, proceed to ERCP and biliary endoprosthesis insertion prior to definitive surgery. This allows resolution of jaundice and the associated symptoms, and provides a window in which to optimise the patient’s medical and nutritional status. (131-133)

A limited laparoscopy is undertaken to detect the 10% of patients with occult M1 disease, and they are then palliated according to the protocol above. A limited laparoscopy without IOUs is completed within 15 minutes and does not add significantly to the overall operation time. (117,134)

SURGICAL RESECTION

Resection of the tumour and adjoining structures is carried in a systematic manner. This is described below, with each step in a sequential manner.

My preference is a bilateral sub-costal or transverse abdominal incision and a fixed costal margin retraction system (i.e. Bariatric UA200 OmnitractTM System, Meddis Ltd, Wallingford, UK). The lower abdominal flap is retracted by suturing it to the abdominal wall below the umbilicus. However, in thin emaciated patients with a narrow sub-costal angle, an upper mid-line incision extended to just below the umbilicus provides adequate access and exposure.

After placement of the sub-costal (sternal) blades, a flexible third blade in the midline elevates the liver to expose the hilum and hepatoduodenal ligament. A full laparotomy is undertaken to confirm that CT and laparoscopy findings are correct, and that a resection is feasible with curative intent. Suspicious liver and peritoneal deposits, or distant (coeliac, para-aortic) suspicious nodes are biopsied for frozen section analysis, and the root of the transverse meso-colon inspected and palpated for small extra-pancreatic deposits that might preclude curative resection. Preliminary duodenal and pancreatic exposure

The key to this resection is exposure of the superior mesenteric vein (SMV) and the anterior surface of the head and neck of the pancreas. This is achieved by extensive mobilisation of the hepatic flexure and right half of the transverse colon, which is reflected downwards towards the midline, to give a wide unimpeded exposure of the infra-hepatic inferior vena cava (IVC), right kidney, and second and third parts of the duodenum. The right half of the greater omentum is dissected off the transverse colon in the avascular plane, and is included in the resection specimen attached to the greater curvature of the stomach.

The duodenum is kocherised from the patient’s right side using diathermy or scissor dissection to widely expose the infra-hepatic IVC, left renal vein and infra-renal aorta.

This is aided by the assistant retracting the duodenum and pancreatic head upwards, whilst the surgeon pushes the retro-peritoneal structures backwards with a swab. The lymphatics encountered anterior to the IVC and aorta are reflected up with the duodenum and head of pancreas to be included with the specimen. This process is continued until the left border of the aorta is exposed, and the pulsation of the superior mesenteric artery (SMA) clearly felt anterior to the plane of dissection. Resectability relative to the SMA is confirmed by lifting the head of the pancreas in the left hand between the fingers posteriorly and thumb anteriorly, to ensure the tumour is clear of the SMA (it is not possible at this stage to evaluate SMV or portal vein involvement). As a precursor to exposing the SMV at the pancreatic neck it is useful to first expose the anterior and inferior borders of the pancreas by dividing the flimsy adhesions between the stomach and the gland, and also by division of the avascular peritoneum along the inferior border of the pancreas lateral to the superior mesenteric vessels. This dissection should be continued towards the right side behind the gastric antrum and duodenum to the point where the gastroepiploic and/or gastroduodenal vessels are encountered. These vessels are divided and ligated at this stage using Lahey forceps (Downs Surgical, Sheffield) and 2/0 ties (Ethicon LTD, Edinburgh UK).

The plane between the third part of the duodenum and transverse mesocolon is now developed by scissor (or diathermy) dissection along the inner aspect of the duodenal loop towards the root of the small bowel mesentery. This exposes the right lateral aspect of the SMV, which is then followed up towards the neck of the pancreas. Small venous tributaries from the uncinate process to the SMV, identified at this stage, should be carefully ligated and divided using fine Lahey (Downs Surgical, Sheffield, UK) or Mixter right angle forceps (Aesculap, Braintree, UK).

Several small venous branches from the uncinate process and head of the pancreas are sequentially exposed using scissor and pledget dissection, then divided and ligated. As the dissection proceeds towards the inferior margin of the pancreas, it is essential to divide all peri-venous areolar and fibrous tissue so that the plane of dissection beneath the pancreas is directly along the anterior vessel wall. The retro-pancreatic tunnel anterior to the SMV is then developed using scissor or ultrafine artery clamp dissection and a fine tipped suction. Helpful manouvres in developing the tunnel are (i) downward traction on the transverse mesocolon to straighten and flatten the SMV, and (ii) insertion of 3/0 stay sutures either side of the SMV to control the marginal arteries. These are then lifted to elevate the neck of the pancreas away from the SMV.

Having established that there is no major venous encroachment by the tumour, the tunnel is not completed at this stage. It is far simpler to first expose the supra-duodenal portal vein and place a sling around the neck of the pancreas, thereafter.

The gastrohepatic ligament is divided close to its insertion into the liver, with care being taken to preserve an aberrant left hepatic artery if present. This dissection is continued from left to right across the anterior peritoneum of the hepatoduodenal ligament to expose the main portal inflow structures. The main hepatic artery is controlled with a sling and traced inferiorly to identify the gastroduodenal and right gastric arteries. These are divided and the gastroduodenal artery suture-ligated. This exposes the anterior surface of the portal vein and allows safe placement of the sling under direct vision through the retro-pancreatic tunnel. This manouevre confirms resectability relative to the anterior aspect of the portal vein and one proceeds with the resection.

Now committed to the resection, the gall bladder is mobilised fundus first from the hepatic fossa using diathermy dissection. The cystic artery is ligated and divided, leaving the gall bladder in-continuity with the main bile duct to provide retraction during mobilisation of the bile duct and lymphatics off the portal vein. The main bile duct is divided above the insertion of the cystic duct. The distal duct is ligated with a 2/0 tie and the proximal common hepatic duct is left unclamped to drain into a small swab. The soft tissues behind the bile duct are palpated for an aberrant right hepatic artery, which, if present (20-25%), is skeletonised of lymphatics and preserved. The distal duct and associated soft tissue lymphatics are mobilised off the portal vein, and dissection continued between the common hepatic artery and superior border of the pancreas to free the neck of the pancreas.

Having placed a sling around the pancreatic neck, the lesser curve of the stomach is prepared for transection. The descending branches of the left gastric artery are divided to create a window above the incisura. The greater omentum is divided and an area cleared on the greater curvature by division of several gastro-epiploic vessels. The stomach is transacted using the GIA 4.8mm linear stapler device,( US Surgical, Tyco Healthcare, Gosport, UK) after ensuring the nasogastric (NG) tube is retracted into the proximal gastric remnant. After division of the stomach, the antrum is rotated to the right to expose the head and neck of the pancreas. The proximal stomach is packed away into the left upper quadrant.

The sling elevates the pancreatic neck and four stay sutures of 3/0 Nurolon (braided nylon, Ethicon LTD, Edinburgh, UK) are inserted into the superior and inferior borders of the pancreas, either side of the planned line of transection.

These sutures are primarily placed for haemostasis by suture ligation of the marginal pancreatic arteries, but may also be inserted earlier in the dissection to facilitate exposure of the SMV. A fine haemostat is placed behind the neck of the pancreas to protect the SMV and portal vein and the pancreas divided using diathermy. The duct is identified and small bleeding vessels within the pancreatic parenchyma controlled with interrupted 5/0 Monocryl (US-DG, Tyco Healthcare, Gosport, UK) absorbable suture.

The proximal jejunum and ligament of Treitz are mobilised by division of the lateral peritoneal attachments. The inferior mesenteric vein runs parallel to the DJ flexure and should be preserved. The mesenteric vessels to the proximal 15cm of jejunum are individually divided and ligated, and the jejunum is divided 15cm beyond the ligament of Treitz using a GIA 3.8mm linear stapler device (US-DG, Tyco Healthcare, Gosport, UK). The proximal jejunum is passed behind the mesenteric vessels and retracted to the right.

With the stomach and proximal jejunum retracted to the right side the mesenteric vessels are put on gentle tension. The SMV and portal vein are teased away from the groove in the pancreas and as the venous tributaries are exposed they are carefully ligated and divided. The main superior and inferior pancreaticoduodenal veins are suture-ligated with 4/0 polypropylene (Prolene, Ethicon LTD, Edinburgh, UK). A vascular suture 5/0 polypropylene (Prolene, Ethicon LTD, Edinburgh, UK) should be readily available to deal with any troublesome bleeding encountered. During division and ligation of these vessels it is helpful for the surgeon to position his left hand behind the uncinate process, to then control venous bleeding by gentle forward pressure. Small side holes in the SMV or portal vein are then readily oversewn.

Once the SMV and portal vein are freed from the pancreatic groove, the portal vein is retracted to the left to expose the anterior surface of the SMA, which still remains firmly adherent to the uncinate process via a thick band of fibrous tissue, the portal plate. This tough fibrous tissue and the branch arteries are serially divided, and suture-ligated to skeletonise the anterolateral aspect of the SMA. The specimen is passed off and the operative site irrigated with warm saline, and packed with a warm saline soaked swab for 5 minutes.

There are many variations described for the reconstruction. The classical reconstruction is a simple C-loop configuration where the proximal jejunum is sequentially anastamosed to the pancreatic remnant, bile duct and stomach. The proximal jejunal loop is delivered to the supra-colic compartment through a mesenteric window to the right of the middle colic vessels.

An end-to-end or end-to-side pancreatico-jejunostomy is the most proximal anastomosis and is performed first with a single layer of interrupted 3/0 braided nylon ( Nurolon, Ethicon LTD, Edinburgh, UK). The body of the pancreas is mobilised off the splenic vein for 2-3cm by careful ligation and division of 2-4 small venous branches emanating from the pancreas to the splenic vein. This allows the residual pancreas to be rotated to the left so that deep bites can be taken when inserting sutures into the posterior aspect of the gland. The entire posterior row of sutures are inserted then tied and cut, with the two end sutures clipped as stay sutures. A small free-floating silicone stent is inserted into the pancreatic duct and secured with a single 5/0 monocryl suture (US-DG, Tyco Healthcare, Gosport, UK). When the duct is dilated 2 or 3 sutures are inserted to include the duct lumen in the posterior suture line.

The anterior row of sutures is started by burying the two stay sutures at each end of the suture line, then the anterior row of interrupted sutures are all inserted, tied and cut. The anastamotic leak rate using this technique is 9%, as determined by high amylase levels in the drain fluid at day 5, or later in the postoperative period. This single layer anastomosis is ideally suited to the fibrotic atrophic gland, most often encountered with chronic obstruction of the pancreatic duct by tumour and in chronic pancreatitis.

An alternative popular technique for the pancreatic anastomosis is an end-to-side two layer duct-to-mucosa anastomosis, which achieves similar satisfactory results with reported leak rates of 8-12%. This technique is used by the author when faced with a 'high-risk' pancreatic anastomosis (small pancreatic ducts in a normal pancreas), e.g. peri-ampullary carcinoma, cystic neoplasm, ampullary carcinoid and resection for trauma.

An end-to-side hepatico-jejunostomy is fashioned 10-15cm distal to the pancreatic anastomosis using a single layer of interrupted 4/0 resorbable sutures (Polydiaxanone (PDS) or vicryl; Ethicon LTD, Edinburgh, UK) .

The technique is similar to that of the Hepp-Couinaud hepaticojejunostomy used for a high biliary-enteric anastomosis. The entire anterior row of sutures are placed from left to right into the hepatic duct, and from outside to inside and clipped with the needles attached. Gentle retraction on the sutures lifts the anterior wall of the bile duct to give a good view for placement and completion of the posterior wall anastomosis.

An enterotomy slightly smaller than the diameter of the bile duct is made with diathermy in the anti-mesenteric border of the jejunum. Stay sutures between the bile duct and jejunum are placed at each corner and at the mid-point of the posterior wall. The posterior wall is then completed by placement of interrupted sutures placed from left to right taking seromuscular bites of jejunum and full thickness bites of bile duct. The sutures are clipped and placed on a kilt pin to avoid tangling.

Once all sutures are in place the jejunum is parachuted down onto the bile duct, and the knots tied from right to left so that they lie inside on the luminal aspect. The anterior anastomosis is now completed by taking generous seromuscular bites of jejunum from right to left. Once all the sutures have been placed to complete this layer the sutures are tied sequentially with the knots placed outside on the jejunum.

If the bile duct is narrow (following preoperative biliary stenting) or the pancreatic anastomosis is considered 'high-risk,' a T-tube is placed across this anastomosis and exteriorised 15-20cm downstream.(135) The venting T-tube is clamped prior to patient discharge and is removed 2 weeks later. A venting drain is not required routinely but should be considered for the high-risk pancreatic anastomosis.

The end-to-side gastroenterostomy is fashioned 50cm downstream from the biliary anastomosis in 2 layers using 3/0 polydiaxanone PDS (Ethicon LTD, Edinburgh, UK). The outer continuous seromuscular layer incorporates the gastric staple line in the posterior wall to ensure adequate haemostasis of the staple line. A generous gastrotomy (4-5cm) is made in the midpoint of the gastric remnant, adjacent to a correspondingly sized jejunostomy. The inner layer of the anastomosis is completed using a continuous suture of 3/0 PDS (Ethicon LTD, Edinburgh, UK), taking full thickness bites of both stomach and jejunum to ensure a haemostatic anastomosis. The anterior second layer is completed with a continuous seromuscular suture of 3/0 PDS (Ethicon LTD, Edinburgh, UK), tied at both ends to the first suture used for the posterior outer layer.

The abdominal cavity and operative site is irrigated with warm saline and aspirated dry. Two size 5mm closed silicone drains are placed into the abdomen via separate stab incisions. One from the left is placed below the left lobe of the liver anterior to the pancreatic anastomosis, and the second is placed from the right side to the hepatorenal space below the biliary (and pancreatic) anastamoses.

The incision is closed en-masse using 2 or 3 looped 0 PDS (Ethicon LTD, Edinburgh, UK) sutures mounted on blunt (dolphin nose) needles. The skin edges are approximated with skin staples (USSC, Tyco Healthcare, Gosport, UK).

Patients receive peri-operative antibiotic prophylaxis with amoxycillin and clavulanic acid (Augmentin• 1.2g; Smithkline Beecham, Uxbridge, UK), and a second dose is given after 2-3 hours. Fragmin• (Pharmacia, Milton Keynes, UK) 2500u is commenced at 1800h on the evening before surgery, and this is continued daily until hospital discharge. Patients are commenced on a proton pump inhibitor the evening before surgery, and this is continued for 3 months. All patients receive octreotide (Sandstatin•, Norvatis, Horsham, UK) 100mcg three times daily for 7 days, and this is started at 10pm the evening before surgery. Much debate surrounds the use of octreotide in prevention of complications in elective pancreatic surgery, but there does appear to be some benefit provided the drug is commenced in the appropriate preoperative period. Definitive answers are still awaited.(136-138)

All patients are extubated in theatre and transferred to the High Dependency Unit for 72 hours continuous monitoring and nursing care. Epidural anaesthesia is used routinely for postoperative pain control and is continued for 72 hs. Following removal of the epidural catheter patients are transferred back to the general surgical ward, with patient controlled analgesia for a further 24-48 Hs if required.

The NG tube is removed at 48hs provided the NG aspirates are <400ml/24hs. The abdominal drains are monitored for amylase levels and removed at day 5-7, provided there is no suggestion of a pancreatic leak. A jejunal venting drain (when present) is clamped prior to patient discharge and removed 14-21 days thereafter.

Preoperative chemoradiotherapy is not employed in the United Kingdom, but there are reports that suggest a survival benefit. (156) Some studies have demonstrated efficacy in downstaging otherwise inoperable disease and a survival advantage in patients receiving preoperative chemoradiotherapy. (157, 160)

However, adjuvant chemotherapy or chemoradiotherapy are not recommended as standard practice within the UK. (162) Currently all patients who undergo a curative resection of peri-ampullary or pancreatic cancers should be entered into the ESPAC 3 study that will compare chemotherapy with no adjuvant treatment. (23, 161-163)

ACKNOWLEDGEMENTS

The author is indebted to Mr Mohammed Thaha, clinical research fellow, for his photographic skills and expert editing assistance in the production of the operative photographs included in this manuscript.

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Whipple's resection-proximal pancreaticoduodenectomy

I S Tait
Department of Surgery & Molecular Oncology, Ninewells Hospital & Medical School, Dundee DD1 9SY, UK J.R.Coll.Surg.Edinb., 47 June 2002, 528-540

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ASSESSMENT PRIOR TO DEFINITE SURGERY

SURGICAL RESECTION

ACKNOWLEDGEMENTS

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REFERENCES

Whipple's resection-proximal pancreaticoduodenectomy

I S Tait Department of Surgery & Molecular Oncology, Ninewells Hospital & Medical School, Dundee DD1 9SY, UK J.R.Coll.Surg.Edinb., 47 June 2002, 528-540

Return to specialty index

ASSESSMENT PRIOR TO DEFINITE SURGERY

SURGICAL RESECTION

ACKNOWLEDGEMENTS

Return to specialty index

REFERENCES

I S Tait
Department of Surgery & Molecular Oncology, Ninewells Hospital & Medical School, Dundee DD1 9SY, UK J.R.Coll.Surg.Edinb., 47 June 2002, 528-540