Preprocedural Evaluation
History and physical examination
Key elements of the patient's history and physical examination include the following information:
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Unintended weight loss
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Pancreatitis
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Biliary obstruction
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Painless jaundice
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Social (smoking, tobacco)
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Family history of pancreatic cancer
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Familial syndromes ( Peutz-Jeghers syndrome, familial atypical multiple mole melanoma [FAMMM], hereditary nonpolyposis colorectal cancer [HNPCC])
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Body habitus (temporal wasting, cachexia)
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Icterus, jaundice
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Lymphadenopathy
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Ascites, hypoalbuminemia
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Elevated tumor markers (elevated CA 19-9 in the absence of biliary obstruction)
Workup
The following laboratory and imaging studies should be obtained to help determine the patient's fitness for surgery:
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Complete blood count (CBC), basic metabolic panel (BMP), liver function tests (LFTs), and a coagulation panel
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Tumor markers, such as CA 19-9 and carcinoembryonic antigen (CEA)
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Abdominal ultrasonography (US) - Primary imaging modality for evaluation of biliary obstruction and/or ascites
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Pancreatic-protocol contrast-enhanced computed tomography (CT) - Thin cuts are needed to assess criteria for tumor resectability (see Determination of resectability in Technical Considerations)
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Chest x-ray (CXR) or chest CT - Metastatic workup
Endoscopic US (EUS), fine-needle aspiration (FNA), or both are occasionally performed in a patient who is being considered for PPPD. EUS, though not routinely employed, is helpful when pancreatic head masses are poorly detected on CT. Tumor aspiration is not routinely employed for preoperative tissue diagnosis, because FNA results do not affect surgical decision-making; however, confirmation of malignancy can be useful in the setting of neoadjuvant therapy. Also, there is a finite risk of seeding the peritoneum with malignant disease from percutaneous needle biopsy.
Endoscopic retrograde cholangiopancreatography (ERCP) may be performed for preoperative endobiliary stent placement in the setting of cholangitis or biliary obstruction with anticipated delay to surgery or need for neoadjuvant therapy.
Patients will be restaged after neoadjuvant therapy before the surgical procedure.
Equipment
Equipment needed for pylorus-preserving pancreaticoduodenectomy (PPPD) includes the following:
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Arterial and central venous lines for hemodynamic monitoring
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Nasogastric tube
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Foley catheter
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Closed-suction transcutaneous drains
The patient and surgical team should also be prepared for total pancreatectomy if intraoperative pathologic analysis reveals evidence of malignancy at the pancreatic margin.
Patient Preparation
The procedure is performed with the patient under general anesthesia. Preoperative anesthesia evaluation includes the following:
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Nutritional status
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Functional status
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Cardiac risk factors
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American Society of Anesthesiologists (ASA) class
For this procedure, the patient is placed in the supine position.
Monitoring & Follow-up
After the operation, obtain the following laboratory and radiologic studies as needed:
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CBC, BMP, serum amylase, drain amylase, LFTs to monitor total bilirubin, and albumin; other laboratory tests may be indicated in the specific clinical setting
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CT for persistent fever, leukocytosis, or sepsis with concern for pancreatic anastomotic leak
Close follow-up of the patient by the surgeon is mandated for at least 6 months postoperatively. However, patient follow-up also takes place in a multidisciplinary manner that involves surgical, medical, and hematologic/oncologic specialists.
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Pylorus-preserving pancreaticoduodenectomy (Whipple procedure). Procedure performed by John Chabot, MD, Columbia University Medical Center, New York, NY. Video courtesy of ColumbiaDoctors (https://www.columbiadoctors.org).
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Duodenum and pancreas.
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Pancreas and duodenum, posterior view.
