whipple complication
TRANSCRIPT
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