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Pancreaticoduodenectomy

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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.