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Complications after-pancreaticoduodenectomy-1228906772887050-1



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  • 1. Complications after Pancreaticoduodenectomy Surgical Gastroenterology Clinics T. Hema
  • 2. • 64 yrs female diagnosed with Ca head pancreas, underwent PPPD with PJ, HJ, antecolic DJ & FJT • NGT was removed on POD 1, Oral sips were allowed on POD 2; Abdominal drain output was ~ 10 -15 ml, serous, till POD 4 • POD 5 drain out put ~ 40 ml/day, clear, increased to ~ 70 ml/day, slightly turbid by day 10 • What is the next step?
  • 3. • Fluid amylase • CECT Abdomen • Total count • Diagnosis? • What next?
  • 4. POPF Management Algorithm Diagnosis by accepted definition CT – no collection CT small collection/ no air local sepsis No sepsis not tolerating orals systemic sepsis Tolerating orals CT- AF level no pain no fever/ TC normal s/o sepsis Re - operation Allow /ct orals NPO IV Antibiotics options? TPN/EN CT guided pigtail Delay drain removal Octreotide Usually stops<3 wks Grade A PF Grade B PF Grade C PF
  • 5. Risk factors for POPF • Surgeon factors - high volume specialized - standardised meticulous technique • Patient factors - Pancreas Anastomosis Score - Cardiovascular disease - Site of malignancy - Type of Anastomosis?? (PJ vs PG) - Preop chemoradiotherapy - Reoperative PD • Role of prophylactic Octreotide ??
  • 6. Suggested reading • Lowy AM et al, 1997: Prospective randomised trial of octreotide to prevent pancreatic fistula after pancreaticoduodenectomy for malignant disease. Ann Surg 226:632-641. • Yeo CJ etal, 2000: Does prophylactic octreotide decrease the rate of pancreatic fistula and other complications after pancreaticoduodenectomy; results of a prospective, randomised placebo- controlled trial. Ann Surg 232:419-429. • Yeo CJ etal, 1995b: A prospective randomsed trial of pancreaticojejnosomy and pancreaticogastrostomy after pancreaticoduodenectomy. Ann Surg 222:580-588. • Claudio Bassi et al, 2005 : Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy. Ann Surg 242(6):767-771. • Bassi et al, 2005. Post operative fistula: An international study group (ISGPF) definition. Surgery July138(1): 8-13.
  • 7. • This patient had intolerance to fluids orally, vomited, and required reinsertion of NGT for 2 days; Managed with NPO, erythromycin and jejunostomy feeds • On POD 14, drain was blood tinged, which cleared by evening; no hematemesis/ malena; pt was hemodynamically stable What is the next step?
  • 8. Selective Angiography Pseudoaneurysm of GDA Embolisation done
  • 9. Management of Post Pancreatic Hemorrhage Early(< 24hrs) Delayed (usu.1-3wks) Sentinel overt Only drain drain+intraluminal pt stable= endoscpy Selective stable Unst angio +ve -ve embol/ DJA stentg P. stump rebleed REOPERATE STRATEGIES?
  • 10. Suggested Reading • Wente MN et al; Postpancreatic hemorrhage: an International study Group of Pancreatic Surgeons Definition. Surgery 2007 July; 142(1):20-5 • Management of delayed pancreatic hemorrhage after pancreaticoduodenectomy: a meta-analysis. Arch Surg 2008 Oct;143(10):1001-7. • Jagad RB et al. Postoperative hemorrhage after major pancreatobiliary surgery: an update. Hepatogastroenterology 2008 Mar-Apr; 55(82-83):729-37. • Blan T et al. Hemorrhage After Pancreaticoduodenectomy; when is Surgery still Indicated? Am J Surg 2007 July; 194(1):10-2. • Yekebas EF et al. Post Pancreatectomy Hemorrhage: diagnosis and Treatment: an analysis of 1669 consecutive pancreatic resections. Ann Surg 2007 Aug; 246(2):269-80.
  • 11. Delayed Gastric Emptying • Definition • Risk factors - age, DM ??? - PPPD vs Classic ??? - pancreatic fistula, biliary fistula, abcess - Extended radical surgery - retrocolic DJ/ GJ - venous congestion of jejunal limb - kinking of normally dilated postop stomach - proximity to PJ (leak / pancreatitis)
  • 12. Suggested Reading • Horstmann O et al, 2004: Pylorus Preservation has no impact on Delayed Gastric Emptying after Pancreatic head Resection. Pancreas 28:69-74 • Alternative reconstruction after Pancreaticoduodenectomy. WJS Oncol 2008 Jan; 28: 6-9 • Delayed Gastric Emptying after Pancreatic Surgery: a suggested definition by ISGPS. Surgery 2007 • Lytras D et al. Therapeutic Strategies for management of delayed gastric emptying after pancreatic resection. Arch Surg 2007 Jan:392(1) • Halloran CM et al, 2002: Complications of pancreatic cancer resection. Dig Surg 19:138-46.