Pancreatosplenectomy and Spleen-Preserving Distal Pancreatectomy Periprocedural Care

Updated: Sep 06, 2016
  • Author: Camille Blackledge, MD; Chief Editor: Kurt E Roberts, MD  more...
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Periprocedural Care

Equipment

Preoperative placement of invasive monitors, such as an arterial line and a central venous line, should be considered and used in accordance with the patient’s clinical picture.

A standard general surgery open tray can be used. A gastrointestinal anastomosis stapler, surgical clips, an ultrasonic scalpel, and vascular clamps should also be available in the event of vascular injury.

Various techniques for transecting the pancreas are described (see Technique). The appropriate instruments for a giving approach should be available, according to the surgeon's preference and experience.

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Patient Preparation

This procedure is completed with the patient under general endotracheal anesthesia.

After anesthesia is induced, the patient is placed on the table in a supine position with the arms extended or in a modified right lateral decubitus position with the arms tucked. For the open approach, a midline, left subcostal, or bilateral subcostal incision allows adequate exposure. Trocar placement for laparoscopic distal pancreatectomy is discussed elsewhere (see Technique).

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Monitoring & Follow-up

If stable, patients can be sent to a surgical floor in the immediate postoperative period. Unstable patients should be admitted to the intensive care unit for further resuscitation and monitoring. A diet can be started as early as postoperative day 1 and advanced as tolerated to a diabetic diet.

Drain output should be recorded daily and monitored for increases in output and changes in color as the diet is advanced. A drain amylase level should be checked prior to discharge with a cutoff value of greater than 5000 U/L of amylase for removal or continuation. If a fistula is suspected and adequately drained, the drain should remain until the fistula resolves.

Pancreatic fistulas can form along the track of the previous drain, and should be managed conservatively. Fistula were defined by the International Study Group of Pancreatic Fistula as “output via an operatively placed drain of any measurable volume of drain fluid on or after postoperative day 3 with amylase content greater than three times the upper normal serum value.” [12]

The drain is removed once the output has decreased. Fistulas typically heal spontaneously, but output can be controlled with a low-fat diet, somatostatin analogues, and octreotide. Persistent fistulas may require a pancreatic duct stent, total parenteral nutrition, and bowel rest.

In the immediate postoperative period, patients should be monitored with sliding scale insulin and tight glucose control. Patients are at risk for developing diabetes, and blood glucose should be monitored with subsequent follow-up. Malabsorption from deficiency of the exocrine pancreas can occur and should be treated with pancreatic replacement enzymes and diet modification. Patients with malignant tumors should have interval follow-up in 3-6 months with serial imaging to evaluate for disease recurrence.

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