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Acs0524 Procedures For Benign And Malignant Pancreatic Disease 2006
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Acs0524 Procedures For Benign And Malignant Pancreatic Disease 2006

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    Acs0524 Procedures For Benign And Malignant Pancreatic Disease 2006 Acs0524 Procedures For Benign And Malignant Pancreatic Disease 2006 Document Transcript

    • © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 24 PROCEDURES FOR PANCREATIC DISEASE — 1 24 PROCEDURES FOR BENIGN AND MALIGNANT PANCREATIC DISEASE Attila Nakeeb, M.D., F.A.C.S., Keith D. Lillemoe, M.D., F.A.C.S., and John L. Cameron, M.D., F.A.C.S. Over the past two decades, both the mortality and the morbidity asso- ERCP allows direct imaging of the pancreatic and bile ducts and is ciated with pancreatic surgery have been reduced substantially. In the gold standard for diagnosing chronic pancreatitis. It also allows many high-volume centers, the perioperative mortality for pancreatic therapeutic stenting of biliary and pancreatic duct strictures.The sen- resection is now less than 3%.1-3 This decline in mortality may be sitivity of ERCP for the diagnosis of pancreatic cancer approaches attributed to more careful patient selection, better understanding of 90%. The presence of a long, irregular stricture in an otherwise nor- surgical anatomy, advances in critical care medicine, and improve- mal pancreatic duct is highly suggestive of a pancreatic malignancy. ments in the management of perioperative complications. Often, the pancreatic duct is obstructed with no distal filling. In what follows, we describe the operative techniques we employ EUS, though newer than the aforementioned modalities, has begun in the management of both benign and malignant pancreatic dis- to play an important role in the evaluation of pancreatic diseases. It is ease, including pancreaticoduodenectomy (the Whipple procedure), a semi-invasive test that can be performed with a very low rate of com- distal pancreatectomy (open and laparoscopic), longitudinal pancre- plications (< 0.1%). EUS can diagnose the most common causes of aticojejunostomy (the Puestow procedure), enteric drainage of pan- extrahepatic biliary obstruction (e.g., choledocholithiasis and pancre- creatic pseudocysts (open and laparoscopic), and palliative bypass aticobiliary malignancies) with a degree of accuracy equaling or for unresectable periampullary cancer. exceeding that of direct cholangiography or ERCP, and it is the most sensitive modality for the diagnosis of pancreatic carcinoma.The par- ticular strengths of EUS in the diagnosis of pancreatic cancer are (1) Preoperative Evaluation that it can clarify small (< 2 cm) lesions when CT findings are ques- A number of different imaging options are available to help deter- tionable or negative, (2) that it can detect malignant lymphadenopa- mine the appropriate surgical approach to management of pancreatic thy, and (3) that it can guide fine-needle aspiration (FNA) for defini- disease [see 5:9 Tumors of the Pancreas, Biliary Tract, and Liver]. These tive diagnosis and staging. On average, EUS without FNA is 85% options include both noninvasive modalities (e.g., transabdominal ultra- accurate for T stage disease and 70% accurate for N stage disease.The sonography, computed tomography, and magnetic resonance imaging) combination of EUS and FNA is 93% sensitive and 100% specific for and invasive modalities (e.g., endoscopic retrograde cholangiopancre- T stage disease and 88% accurate for N stage disease.4 atography [ERCP] and endoscopic ultrasonography [EUS]). Transabdominal ultrasonography can identify changes associated with chronic pancreatitis, biliary and pancreatic duct dilation, and the Pylorus-Preserving Pancreaticoduodenectomy presence of pseudocysts. In the setting of malignant disease, it may (Whipple Procedure) demonstrate dilated intrahepatic and extrahepatic bile ducts, liver Surgical resection of a periampullary carcinoma can be accom- metastases, pancreatic masses, ascites, and enlarged peripancreatic plished by means of either a pylorus-preserving pancreaticoduodenec- lymph nodes. A malignancy of the pancreas typically appears as a tomy (PPPD) or the classic Whipple resection (including an antrecto- hypoechoic mass; ultrasonography reveals a pancreatic mass in 60% my). Multiple randomized trials have failed to show any significant to 70% of pancreatic cancer patients. differences between the two in terms of either relative ease of perfor- Currently, helical (spiral) CT is the preferred noninvasive imaging mance or short- or long-term outcome (including survival).The choice test for pancreatic disease, having largely supplanted ultrasonography between them is usually made on the basis of individual surgeons’ in this context. Helical CT can delineate the anatomy of the pancreas and preferences (unless there is obvious tumor encroachment on the first the surrounding organs in considerable detail, and it can easily define portion of the duodenum). In the ensuing technical description, we pancreatic calcifications, inflammation, necrosis, and masses. Pancrea- focus primarily on the pylorus-preserving modification but also refer tic cancer usually appears as an area of pancreatic enlargement with a to certain important components of the classic Whipple resection. localized hypodense lesion. A triple-phase intravenous contrast study is OPERATIVE PLANNING ideal for the assessment of pancreatic lesions. Thin cuts are obtained through the pancreas and the liver during both the arterial phase and Operative management of periampullary cancer is carried out in the venous phase after the injection of I.V. contrast material. Besides two phases. First, the resectability of the tumor is assessed; then, if the being used to determine the primary tumor size, CT is used to look for tumor is resectable, a pancreaticoduodenectomy is performed and and evaluate invasion into local structures or metastatic disease. gastrointestinal continuity restored. Selective use of staging laparos- In general, MRI has no significant advantages over CT: its signal- copy should be considered for patients at high risk for occult metasta- to-noise ratio is low, it is prone to motion artifacts, it does not opaci- tic disease, such as patients with large primary tumors; patients with fy the bowel, and it has low spatial resolution. Nevertheless, magnetic lesions in the neck, body, or tail of the pancreas; patients with equivo- resonance cholangiopancreatography (MRCP) can be quite useful for cal radiographic findings suggestive of occult distant metastatic dis- defining the anatomy and pathology of the bile ducts and the pancre- ease (e.g., low-volume ascites, CT findings indicating possible carci- atic duct noninvasively. It can be especially useful in cases where the nomatosis, and small hypodense regions in the hepatic parenchyma ampulla of Vater is not accessible (as in patients who have previously indicating possible hepatic metastases that are not amenable to percu- undergone Roux-en-Y or Billroth II reconstructions). taneous biopsy); and patients with clinical and laboratory findings
    • © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 24 PROCEDURES FOR PANCREATIC DISEASE — 2 Hepatic Artery Portal Vein Gallbladder Common Hepatic Duct Duodenum Pancreas Figure 1 Whipple procedure. The common hepatic duct is divided at an early stage to facilitate identification of the portal vein. This division also untethers the first portion of the duodenum and allows it to be retract- Kocherized Second ed anteriorly. Portion of Duodenum suggesting more advanced disease (e.g., marked hypoalbuminemia or The final operative step for determining resectability involves dis- weight loss, significant increases in the CA 19-9 level, and severe back section of the SMV and the portal vein to rule out tumor invasion. or abdominal pain). Identification of the portal vein is greatly simplified if the common hepatic duct is divided early in the dissection.5 Once the hepatic duct OPERATIVE TECHNIQUE has been divided, the anterior surface of the portal vein is easily and The peritoneal cavity is entered through an upper midline incision quickly identified [see Figure 1]. The lymph node tissue lateral to the or a bilateral subcostal incision.The liver, the omentum, and the peri- hepatic duct and the portal vein should be dissected off the structures toneal surfaces are inspected and palpated. Biopsy is performed on to be included in the surgical specimen. It must be remembered that suspicious lesions, and specimens are submitted for frozen-section important variations in the hepatic arterial anatomy, including a analysis. Regional lymph nodes are examined for evidence of tumor replaced right hepatic artery, may be encountered during this dissec- involvement.The presence of tumor in the periaortic lymph nodes of tion. If the appropriate plane is found along the anterior surface of the the celiac axis indicates that the tumor has extended beyond the lim- portal vein, it should be easy to pass the index finger of the left hand its of normal resection; however, the presence of tumor in lymph on top of the vessel posterior to the first portion of the duodenum and nodes that normally would be incorporated within the resection spec- the neck of the pancreas (because there usually are no veins joining imen does not constitute a contraindication to resection. the anterior surface of the portal vein). If this maneuver proves diffi- Once distant metastases have been excluded, the resectability of cult, the gastroduodenal artery should be identified where it comes off the primary tumor is assessed.Various local factors may preclude pan- the common hepatic artery. Once adequate dissection has been car- creaticoduodenal resection, including retroperitoneal extension of the ried out, the artery should first be clamped with a nonoccluding vas- tumor to involve the inferior vena cava or the aorta and direct involve- cular clamp, then, if the hepatic artery pulse is preserved, it should be ment or encasement of the superior mesenteric artery (SMA), the divided and ligated with 2-0 silk ties. (The initial clamping of the gas- superior mesenteric vein (SMV), or the portal vein. Often, the deter- troduodenal artery with a vascular clamp is done to confirm that the mination of resectability is made on the basis of a careful review of the arterial supply to the liver will not be interrupted should either varia- preoperative imaging (CT plus EUS) in conjunction with operative tions in hepatic arterial anatomy or important collateral circulation be exploration. present in the face of celiac artery stenosis.) After the artery has been Operative assessment of resectability begins with a Kocher maneu- divided and ligated, an additional ligature of 3-0 polypropylene ver and mobilization of the duodenum and the head of the pancreas should be placed on the proximal stump. Division of the gastroduo- from the underlying inferior vena cava and aorta. When the duode- denal artery unroofs part of the tunnel through which the index fin- num and head of the pancreas have been mobilized sufficiently, a ger is slipped, thereby greatly facilitating the separation of the portal hand is placed under the duodenum and the head of the pancreas to vein from the posterior aspect of the first portion of the duodenum palpate the tumor mass and determine its relation to the SMA. and the neck of the pancreas. Inability to identify a plane of normal tissue between the mass and the Once the anterior surface of the portal vein has been dissected pos- arterial pulsation indicates that the tumor directly involves the SMA, terior to the neck of the pancreas, the next step is to identify the SMV which means that complete tumor resection is not possible. and dissect its anterior surface. This is most easily accomplished by
    • © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 24 PROCEDURES FOR PANCREATIC DISEASE — 3 Head of Pancreas Stomach Gallbladder Duodenum Pancreas Figure 2 Whipple procedure. Kocherization of the duodenum is con- tinued along the third portion until the superior mesenteric vein is reached. This vein can then be easily cleaned up to its connection with the portal vein. Duodenum Superior Mesenteric Vein Uncinate Process of Pancreas extending the Kocher maneuver past the second portion of the duo- is continued until it connects to the portal vein dissection from above. denum to include the third and fourth portions. During this extensive If this maneuver can be completed without evidence of SMV or por- kocherization, the first structure encountered anterior to the third por- tal vein involvement, the tumor can generally be considered resectable. tion of the duodenum is the SMV [see Figure 2]. The anterior surface It is still possible, however, for an uncinate tumor to involve the right of the vein can then be cleaned rapidly and dissected under direct lateral surface and the undersurface of the SMV, and this possibility vision by retracting the neck of the pancreas anteriorly.This dissection should be carefully evaluated. If the neck of the pancreas can be successfully dissected off of the anterior and lateral surfaces of the portal vein and the SMV, most Right Gastric Artery experienced pancreatic surgeons will proceed with pancreaticoduo- denectomy without obtaining a tissue diagnosis. In defining the diag- Stomach nosis of malignancy, an intraoperative biopsy is less conclusive than the combination of the clinical presentation, the results of preopera- tive CT scanning and cholangiography, and the operative finding of a palpable mass in the head of the pancreas. In a PPPD,6 the duodenum is first mobilized and divided approxi- mately 2 cm distal to the pylorus with a gastrointestinal anastomosis Right Gastroepiploic (GIA) stapler.The posterior surface of the proximal first portion of the Artery duodenum is dissected until the lesser sac is entered. At this point, the soft tissue attachments from the inferior border of the duodenum to the inferior border of the pancreas are divided. The right gastroepi- ploic vessels, which can be sizable, are clamped, divided, and ligated. In a similar fashion, the soft tissue areolar attachments found superi- orly are divided with the electrocautery. Care must be taken to identi- fy and preserve the right gastric artery, which comes off the common hepatic artery and actually joins the foregut along the proximal part of the first portion of the duodenum. In a classic Whipple procedure, an antrectomy is performed. The right gastroepiploic arcade and the right gastric vessels are divided to permit mobilization of the antrum. The stomach is then divided with a GIA stapler, usually at the level of the incisura. At this point, if the gastroduodenal artery was not divided earlier, it is identified, divided, and ligated as described (see above). During this step, particular care must be taken to ensure that the lumen of the common hepatic artery is not encroached on by one of the proximal ties. Duodenum The neck of the pancreas is then divided with the electrocautery Superior Neck of Mesenteric Vein [see Figure 3], with care taken not to injure the underlying SMV and Pancreas portal vein.These veins are mobilized away from the uncinate process Figure 3 Whipple procedure. Transection of the neck of the pan- of the pancreas; the dissection should continue until the SMV, clear- creas with electrocautery. ly palpable with the index finger of the left hand, is visualized. If a
    • © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 24 PROCEDURES FOR PANCREATIC DISEASE — 4 Portal Vein Stomach Divided First Portion of Duodenum Uncinate Process Divided Neck of Pancreas Superior Mesenteric Figure 4 Whipple proce- Vein dure. The uncinate process is divided flush with the superi- Duodenum or mesenteric artery. Superior Mesenteric Artery replaced right hepatic artery is present, its origin from the SMA will Once the uncinate process has been completely divided, the speci- be encountered at this point and must be preserved. The uncinate men is attached only by the third portion of the duodenum. At this process is divided between clamps flush with the SMA [see Figure 4], point, the upper abdomen is copiously irrigated with an antibiotic then ligated with 2-0 silk ties; alternatively, either a vessel-sealing sys- solution and packed. The transverse colon, along with the greater tem (e.g., LigaSure; Valleylab, Boulder, Colorado) or an ultrasonic omentum, is reflected cephalad. The proximal jejunum and the liga- shears may be used.The SMA is completely exposed during this dis- ment of Treitz, along with the fourth portion of the duodenum, are section, which proceeds from cephalad to caudad. As a rule, there are dissected free, and the dissection is continued until it meets the right- two large veins joining the SMV inferiorly that must be dissected free, side upper abdominal dissection. At a convenient point where there is doubly ligated, and divided. a wide vascular arcade, the proximal jejunum is divided with a GIA Jejunum a Pancreatic Duct b Jejunal Limb Invaginated Pancreas Small Enterotomy Figure 5 Whipple procedure. (a) An end-to-side mucosa-to-mucosa pancreaticojejunostomy is done in two layers with an outer layer of interrupted 3-0 silk sutures and an inner layer of interrupted 5-0 absorbable synthetic sutures. (b) Alternatively, the end of the pancreas can be invaginated into the end of the jejunum for approximately 2 cm. The anastomosis is done with an outer interrupted layer of 3-0 silk and an inner continuous layer of 3-0 absorbable synthetic suture material.
    • © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 24 PROCEDURES FOR PANCREATIC DISEASE — 5 stapler approximately 10 to 12 cm from the ligament of Treitz. The proximal jejunum is then grasped with a Babcock clamp and retract- ed cephalad. The mesentery to the proximal jejunum is divided between clamps and ligated with 2-0 silk (or divided with a vessel-seal- ing device such as the LigaSure). When division of the mesentery is complete, the specimen is free and can be removed from the operative field. The bile duct, the pan- Common Hepatic Duct creatic neck, and the uncinate margins should be tagged with sutures and sent for frozen-section analysis. The bed of the tumor should be carefully inspected for hemostasis and its margins marked with ligat- ing clips (e.g., LigaClip; Ethicon Endo-Surgery, Inc., Cincinnati, Ohio) to facilitate postoperative radiation therapy. There are several technical options for restoring GI continuity after a pancreaticoduodenal resection. Our preferred technique is to bring the end of the divided jejunum through the transverse mesocolon to the right of the middle colic vessels in a retrocolic fashion and to per- form an end-to-side pancreaticojejunostomy. A row of interrupted 3- 0 silk Lembert sutures is placed between the side of the jejunum and Jejunum the posterior capsule of the end of the pancreas. A small enterotomy, matching the size of the pancreatic duct, is made in the jejunum, and an inner layer of interrupted 5-0 absorbable monofilament sutures is placed to create a duct-to-mucosa anastomosis [see Figure 5a]. Meti- Figure 6 Whipple procedure. The common hepatic duct is culous stitch placement is crucial, and many surgeons use some de- anastomosed to the jejunum in an end-to-side fashion with a gree of magnification to complete the anastomosis in small ducts. Often, single layer of 4-0 interrupted absorbable synthetic sutures. a short segment of a pediatric feeding tube is placed across the anas- tomosis to be used as a temporary indwelling stent. The anastomosis is completed with an outer layer of 3-0 silk Lembert sutures placed End-to-End between the anterior pancreatic capsule and the jejunum. A popular Pancreaticojejunostomy alternative to this duct-to-mucosa technique is to create an enteroto- my approximately the same size as the pancreatic neck and to place an End-to-Side inner continuous layer of 3-0 absorbable synthetic suture material cir- Hepaticojejunostomy cumferentially around the entire gland. The neck is then invaginated 1 to 2 cm into the lumen of the bowel, and an outer interrupted layer End-to-Side of 3-0 silk is placed to complete the anastomosis [see Figure 5b]. Duodenojejunostomy The biliary-enteric anastomosis is performed 6 to 10 cm distal to the pancreaticojejunostomy. An end-to-side hepaticojejunostomy is fash- ioned with a single interrupted layer of 4-0 absorbable synthetic suture material [see Figure 6]. Generally, there is no need for a T tube or a stent. Approximately 15 cm distal to the biliary-enteric anastomosis, an end-to-side duodenojejunostomy is performed with an inner continu- ous layer of 3-0 absorbable synthetic suture material and an outer interrupted layer of 3-0 silk [see Figure 7]. Some experienced pancreat- ic surgeons prefer to perform the duodenojejunostomy further distally in an antecolic position, in the belief that doing so reduces the inci- dence of early postoperative delayed gastric emptying. If an antrecto- my was performed, the medial half of the gastric staple line is rein- forced with interrupted 3-0 silk seromuscular Lembert sutures. The gastrojejunal anastomosis is completed to the lateral (greater curvature) aspect of the staple line as a two-layer Hofmeister-style anastomosis. The abdomen is copiously irrigated with an antibiotic solution.The jejunal loop is tacked to the rent in the transverse mesocolon with interrupted 3-0 silk sutures. The defect in the retroperitoneum previ- ously occupied by the fourth portion of the duodenum is closed with a continuous 2-0 silk suture. One or two closed suction Silastic drains are placed in the vicinity of the hepaticojejunostomy and the pancre- aticojejunostomy and brought out through a stab wound in the right upper quadrant. The abdomen is closed in a standard fashion. Figure 7 Whipple procedure. After the end-to-end pancreatico- jejunostomy and the end-to-side hepaticojejunostomy, the duode- Distal Pancreatectomy with Splenectomy num is anastomosed to the jejunum in an end-to-side fashion Distal pancreatic resection is performed for a variety of conditions, with an inner continuous layer of 3-0 absorbable suture material including inflammatory processes, benign tumors and cysts, and pan- and an outer interrupted layer of 3-0 silk.
    • © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 24 PROCEDURES FOR PANCREATIC DISEASE — 6 Spleen thrombosed splenic vein may have left-side portal hypertension and multiple collateral vessels leading from the spleen to the stomach via the short gastric vessels.With such a patient, it is usually preferable to Pancreatic Tumor ligate and divide the splenic artery early in the procedure. The spleen is retracted toward the midline with the left hand; it should be compressed medially toward the spine rather than retract- ed anteriorly. It is then mobilized out of the retroperitoneum with the Divided electrocautery. The retroperitoneum usually consists of loose areolar Duodenum Splenic Artery tissue that is easily mobilized. The omental attachments anterior to the hilum of the spleen are divided between Kelly clamps and ligated with 2-0 silk.The line of division is easily determined if the omentum Portal has previously been completely taken off the transverse colon. As the Vein division extends up toward and then along the greater curvature of the stomach, the vasa brevia are encountered and are doubly clamped, divided, and ligated. The splenic flexure of the colon is carefully dis- sected away from the inferior pole of the spleen, and the peritoneal attachments that make up the splenocolic ligament are divided. The tail and the body of the pancreas are further mobilized out of the retroperitoneum by retracting the spleen and the pancreatic tail medially. In the course of this mobilization, care must be taken not to injure the left adrenal gland, which often occupies a fairly superficial position in the retroperitoneum, anterior and medial to the superior pole of the left kidney; care must also be taken not to carry the dissec- tion too deep and thereby risk injuring the kidney or the renal vessels. The splenic vein is easily identified in the middle portion of the pos- Superior terior aspect of the pancreas. The inferior mesenteric vein (IMV), Mesenteric Vein which joins the splenic vein at the middle of the body of the pancreas, Divided Inferior is identified in the retroperitoneum just lateral to the ligament of Divided Mesenteric Treitz and can be divided at this point. Splenic Vein Vein Further mobilization of the pancreas to the midline exposes the Figure 8 Distal pancreatectomy. The splenic vein is divided just splenic artery where it takes off from the celiac axis. As noted (see distal to its junction with the inferior mesenteric vein, then dissect- ed away from the posterior surface of the pancreas from the point of division up to the point where it joins the superior mesenteric vein to form the portal vein. Portal Vein creatic malignancies. The following discussion focuses on distal pan- Splenic Vein createctomy for malignant disease, but the basic technical principles of distal pancreatectomy for benign disease are much the same. OPERATIVE TECHNIQUE The peritoneal cavity is usually entered through a left subcostal incision that extends to the right of midline. In thin patients, an upper midline incision may be used instead. Upon entry into the abdomen, a careful exploration is performed to confirm the absence of dissem- inated disease. The lesser sac is entered by dividing the gastrocolic omentum. Generally, this is best done by separating the greater omentum off Inferior Mesenteric the transverse colon and leaving it attached to the greater curvature Vein of the stomach. Once the lesser sac has been entered, the posterior wall of the stomach is separated from the pancreas with sharp and blunt dissection to expose the body and tail of the pancreas. The duodenum is kocherized, and the head and the uncinate process of the pancreas are palpated and visualized; the entire gland can then be inspected and palpated. Intraoperative ultrasonography may be Head of employed for further delineation of the tumor’s relation to the sur- Pancreas rounding vascular structures. Superior Superior Once the pancreas has been exposed, the celiac axis and the supe- Mesenteric Vein Mesenteric Artery rior mesenteric vessels are identified and assessed to determine Figure 9 Distal pancreatectomy. A row of overlapping horizontal whether the tumor is resectable.The splenic artery is identified where mattress sutures is placed in the neck of the pancreas just proximal it comes off the celiac axis, and a vessel loop is placed around it; in to where it is to be divided, the neck is divided with the electro- this way, the vessel is controlled at an early stage of the procedure and cautery, and a row of figure-eight sutures of 3-0 absorbable synthet- can be promptly ligated if bleeding should occur. A patient with a ic suture material is placed over the end of the pancreas.
    • © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 24 PROCEDURES FOR PANCREATIC DISEASE — 7 The portal vein and the SMV are carefully dissected away from the undersurface of the neck of the pancreas. Stay sutures of 2-0 silk are placed at the superior and inferior edges of the pancreas proximal to 5 mm the site of transection, and the neck of the pancreas is divided with the 5 mm electrocautery (or, alternatively, with a transverse anastomosis [TA] or 12 mm GIA stapler). The operative specimen should be sent for frozen-sec- tion evaluation to ensure a negative microscopic margin. A row of figure-eight sutures of 3-0 absorbable synthetic suture 5 mm 12 mm material is placed over the end of the pancreas [see Figure 9]. Using large needles that have been straightened makes this task simple even if the head-neck junction through which the needles are passed is thickened. If the pancreatic duct can be identified, it should be sepa- rately oversewn with a figure-eight or mattress suture of 5-0 absorbable synthetic suture material. The resection bed should be marked with titanium clips to guide postoperative radiation therapy if necessary. Figure 10 Laparoscopic distal pancreatectomy. Shown is the The abdomen is copiously irrigated with an antibiotic solution.The placement of ports for distal pancreatectomy. pancreatic remnant is drained with a closed suction Silastic drain brought out through a stab wound in the left upper quadrant. There is no need to drain the splenic bed. The abdomen is then closed in a above), this artery will already have been isolated with a vessel loop. standard fashion. The splenic artery is triply clamped, divided, and triply ligated with 2- 0 silk and a 4-0 polypropylene suture near its point of origin. Laparoscopic Distal Pancreatectomy with or without The SMV can then be identified. A plane is developed by dissect- Splenectomy ing between the anterior surface of the SMV and the neck of the pan- creas; a Penrose drain may be looped around the neck to facilitate Selected patients may benefit from a laparoscopic spleen-preserving exposure. With larger pancreatic cancers, tumor extension into the distal pancreatectomy (SPDP) or a laparoscopic distal pancreatectomy retroperitoneum may involve the splenic vein. Dividing the pancreat- with splenectomy. Conditions that are potentially amenable to treat- ic neck with the electrocautery at this point may facilitate dissection of ment with a laparoscopic distal pancreatectomy include benign or pre- the splenic vein–portal vein confluence under direct vision. The malignant cystic neoplasms, islet cell tumors of the pancreas, chronic splenic vein is clamped, divided (without compromising the portal pancreatitis with symptomatic ductal obstruction, and pancreatic vein–SMV complex), and ligated with 0 silk ties and a 4-0 polypropy- pseudocysts confined to the distal body and tail of the pancreas. lene suture on the proximal stump [see Figure 8]. If there is a pancre- OPERATIVE TECHNIQUE atic tumor arising from the proximal body of the gland, the splenic vein may be ligated flush with the SMV. At this location, it is best to The patient can be placed either supine in a low lithotomy position oversew the vein with a continuous 3-0 polypropylene suture so as not or in a semilateral position with the left side up. For lesions in the distal to compromise the portal vein–SMV complex. body or tail of the pancreas, we prefer the semilateral position; for lesions closer to the neck of the pancreas, we prefer the low lithotomyposition. Five ports are placed [see Figure 10], and a 10 mm 30° laparoscope is used. As in all pancreatic procedures, the peritoneal surfaces, the omen- Splenic Vein tum, the mesentery, and the viscera should all be carefully inspected to rule out metastatic disease. Intraoperative ultrasonography may be employed to evaluate the liver and locate the lesion in the pancreas. The body and tail of the pancreas are exposed by opening the less- er sac.The gastrocolic omentum is divided and widely mobilized with an ultrasonic scalpel (e.g., Harmonic Scalpel; Ethicon Endo-Surgery, Inc., Cincinnati, Ohio), with care taken to stay outside the gastroepi- ploic vessels. A retractor is advanced into the lesser sac through the subxiphoid port and used to elevate the stomach anteromedially.The splenocolic ligament is divided, and the splenic flexure of the colon is reflected inferiorly. After these maneuvers, the inferior pancreatic margin should be exposed.The peritoneum is then incised along the inferior pancreatic border, and the pancreatic body is separated from the retroperi- toneum by means of sharp and blunt dissection along its inferior bor- der. Laparoscopic ultrasonography and direct visual inspection, com- bined with the findings from preoperative imaging, may be employed to determine the extent of the dissection. Initially, the dissection should be directed so that it is medial to the pancreatic lesion. The pancreatic body is elevated by means of blunt and sharp dissection, after which the splenic vein should be easily identifiable [see Figure 11]. Figure 11 Laparoscopic distal pancreatectomy. Once the pancre- Care must be exercised to prevent inadvertent injury to this vessel. atic body has been mobilized from the retroperitoneum, the splenic Once the splenic vein has been identified, a careful circumferential vein can be identified. dissection around the splenic vein is performed with a right-angle
    • © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 24 PROCEDURES FOR PANCREATIC DISEASE — 8 Splenic the spleen.The spleen is then supplied solely by the short gastric ves- Pancreatic Artery sels and the left gastroepiploic vessels. Tail If an en bloc distal pancreatectomy with splenectomy is performed, the splenic artery and vein are divided after the pancreas is transect- Splenic ed. The distal pancreas is dissected free in a medial-to-lateral direc- Vein tion. The short gastric vessels are divided with the ultrasonic scalpel, with care taken not to injure the stomach wall. The retroperitoneal attachments of the spleen and the tail of the pancreas are divided with Spleen the ultrasonic scalpel. The specimen is then placed in a specimen retrieval bag and extracted from a port site that has been enlarged to a size of 3 to 6 cm.To facilitate extraction of the specimen, the spleen may be morcellated within the bag [see 5:25 Splenectomy]. Laparoscopic Pancreatic Enucleation Laparoscopic techniques have now been applied to the enucleation of benign neuroendocrine tumors of the pancreas. This approach is indicated for tumors in the body and tail of the pancreas that, on pre- operative imaging, appear not to involve the pancreatic duct. Patients are positioned and trocars placed in much the same way as for laparo- scopic distal pancreatectomy [see Laparoscopic Distal Pancreatectomy with and without Splenectomy, Operative Technique, above]. The body and the tail of the pancreas are widely exposed by enter- Figure 12 Laparoscopic distal pancreatectomy. After having been ing the lesser sac through the gastrocolic omentum. Intraoperative transected, the distal portion of the pancreas is dissected away ultrasonography is extremely useful for identifying the tumor and for from the splenic vessels in a medial-to-lateral direction. The pan- further delineating its relation to the splenic vessels and the pancreat- creatic branches of the splenic vessels are divided sequentially as ic duct. Once identified, the lesion is dissected out of the pancreatic they are encountered. parenchyma with the ultrasonic shears and the electrocautery. The specimen is placed in a specimen retrieval bag and removed. The enu- clamp, and a vessel loop is placed around the vein. This dissection cleation bed is then inspected for hemostasis, and a closed suction helps identify the splenic artery as well, which also is controlled with drain is placed to control any pancreatic leakage that may develop. a vessel loop. These precautionary measures allow quick control of bleeding should a vascular tear occur later in the procedure. Longitudinal Pancreaticojejunostomy Once the pancreatic body has been adequately mobilized from the (Puestow Procedure) splenic vessels, the pancreatic parenchyma is divided with the ultrason- ic scalpel. Alternatively, an endoscopic stapler can be placed across the OPERATIVE TECHNIQUE body of the pancreas, sparing the main splenic vessels. Once the prox- imal pancreatic tissue is divided, the specimen is grasped and gently The abdomen is entered through an upper midline incision. The retracted anteriorly to allow further dissection of the vessels. The dis- lesser sac is entered by removing the greater omentum from the trans- section proceeds toward the splenic hilum in a medial-to-lateral direc- verse colon along virtually its entire length, thereby exposing the entire tion.The pancreatic branches of the splenic vein are sequentially iden- tail, body, neck, and head of the pancreas.The pancreas often appears tified, dissected free with laparoscopic Metzenbaum scissors, and markedly fibrotic and scarred.The posterior wall of the stomach may divided with the ultrasonic scalpel [see Figure 12].The branches of the be adherent to a portion of the body of the pancreas as a result of mul- splenic artery, which runs just superior to the vein, are treated similar- tiple episodes of inflammation; if it is adherent, it is easily dissected ly. Special care must be taken as the dissection approaches the hilum free. The duodenum is kocherized, and the head and the uncinate of the spleen. process of the pancreas are palpated from both an anterior and a pos- At the completion of an SPDP, the specimen is placed and removed terior direction. In many cases, the pancreatic duct is markedly dilat- in a standard endoscopic retrieval device (e.g., Endo Catch; United ed and can actually be palpated through the anterior surface in the States Surgical, Norwalk, Connecticut). The pancreatic remnant is middle portion of the body of the pancreas. The rest of the abdomen then oversewn with a series of interrupted absorbable horizontal mat- is explored to check for the presence of other pathologic conditions. tress sutures. A single round Jackson Pratt drain is placed near the pan- To confirm the position of the dilated pancreatic duct, a 20-gauge creatic transection line and brought out through one of the 5 mm lat- needle on a 10 ml syringe is used to aspirate the duct. Intraoperative eral ports. ultrasonography can be quite helpful for identifying the dilated pan- An alternative approach to SPDP involves dividing the splenic ves- creatic duct. Once pancreatic juice is obtained, the syringe is removed sels proximally and distally while preserving the short gastric and left from the needle hub, with the needle left in place. gastroepiploic vessels to maintain splenic perfusion [see Figure 13]. The pancreatic duct is entered by dividing the pancreatic parenchy- The initial steps of this technique are essentially the same as those ma with the electrocautery on either side of the needle. A large right- already described (see above), up to the point where the pancreas is angle clamp is then inserted, and the duct is filleted open with the divided. In the alternative approach to SPDP, after pancreatic transec- electrocautery both proximally and distally [see Figure 14]. Small pan- tion, the splenic artery and vein are divided with an endovascular sta- creatic ductal concretions are carefully removed. At least 6 cm of the pler.The left portion of the pancreas is lifted up and mobilized poste- duct must be opened to yield a good chance of long-term success. riorly along with the splenic artery and vein, and the vessels are again Ideally, if the duct is dilated all the way out to the tail, it can be fillet- divided as they emerge from the pancreatic tail to enter the hilum of ed open virtually to the tip of the pancreas. In the proximal direction,
    • © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 24 PROCEDURES FOR PANCREATIC DISEASE — 9 the duct can easily be opened as far as the neck of the pancreas. Beyond this point, however, the duct passes posteriorly and inferiorly into the head of the pancreas; because the head can be very thick, opening up the duct any further can be difficult. A Bakes dilator is carefully passed proximally through the open pan- Stomach creatic duct, down through the pancreatic duct in the unopened head, through the ampulla of Vater, and into the duodenum. If a Bakes dila- tor cannot be passed into the duodenum, some surgeons elect to open Spleen the duodenum and perform a sphincteroplasty [see 5:22 Procedures for Benign and Malignant Biliary Tract Disease], so that by working both from within the duodenum and from within the open pancreatic duct, they can ensure the patency of the entire pancreatic duct. A Roux-en-Y jejunal loop approximately 60 cm long is construct- ed. The most proximal loop of jejunum in which there is a good vas- cular arcade is selected. A 2 cm segment of this loop is cleaned and divided with a GIA stapler. The small bowel mesentery is divided between clamps down through the arcade vessel and is ligated with 3-0 silk.The end of the distal jejunum is oversewn with a layer of 3-0 silk Lembert sutures. A 60 cm length is then measured. Alimentary Divided tract continuity is reestablished by means of an end-to-side jejunoje- Omentum junostomy, in which the most proximal portion of the divided jejunum is anastomosed to the side of the Roux-en-Y jejunal loop 60 cm dis- tally with an inner continuous layer of 3-0 absorbable synthetic suture Dilated material and an outer interrupted layer of 3-0 silk. The defect in the Pancreas Pancreatic Duct small bowel mesentery is closed with a continuous 4-0 silk suture. The Roux-en-Y jejunal loop is brought up into the lesser sac in a Figure 14 Puestow procedure. The dilated pancreatic duct is fillet- retrocolic position through a small rent in the transverse mesocolon. ed open with the electrocautery both proximally and distally. At least 6 cm of the duct should be opened. A side-to-side pancreaticojejunostomy is performed in two layers. Before the Roux loop is opened, an outer interrupted layer of 3-0 silk is placed between the jejunal loop and the pancreatotomy, passing able synthetic suture material is placed in an over-and-over locking through the capsule of the pancreas and out through the opened pan- fashion through the entire wall of the jejunum and the entire divided creatic parenchyma along the inferior border of the pancreas. When surface of the pancreas and into the duct [see Figure 15]. The inner this layer is complete, an enterotomy approximately 2 mm from the layer of the superior suture line is placed in an over-and-over fashion jejunal suture line is made along the entire length of this line. Starting without locking, again with a continuous 3-0 absorbable synthetic at the distal pancreatic tail, an inner continuous layer of 3-0 absorb- suture.The outer layer of the superior suture line consists of interrupt- ed 3-0 silk sutures placed in a Lembert fashion. When the pancreatic duct is dilated to a diameter of 1 cm or Divided Splenic Artery greater, a two-layer anastomosis is possible and is in fact preferred. When the diameter of the duct is between 5 mm and 1 cm, however, a two-layer anastomosis is generally difficult, and a one-layer anasto- Divided mosis is preferred. A single layer of interrupted 3-0 silk sutures is Splenic Vein placed so that the knots are tied on the outside. This is easily accom- plished with the superior suture line. With the inferior suture line, which is placed first, the suture passes from outside inward on the pancreas and then from inside outward on the jejunum. In a single- layer side-to-side pancreaticojejunostomy, the jejunotomy must be performed before any sutures are placed. The procedure is completed by tacking the Roux-en-Y jejunal loop to the rent in the transverse mesocolon with interrupted 3-0 silk sutures. The pancreaticojejunostomy is drained with closed suction Silastic drains that are placed on either side of the anastomosis and brought out through separate stab wounds in the left upper quadrant. The abdomen is copiously irrigated with an antibiotic solution and closed in a standard fashion. Spleen Drainage of Pancreatic Pseudocyst OPERATIVE TECHNIQUE Figure 13 Laparoscopic distal pancreatectomy. In an alternative approach to spleen-preserving distal pancreatectomy, the splenic Drainage into Roux-en-Y Jejunal Loop artery and the splenic vein are divided, and the viability of the spleen is maintained by preserving the short gastric and left gas- The peritoneal cavity is entered through a midline incision, and the troepiploic vessels. abdomen is explored. Typically, a substantial mass that is cystic and
    • © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 24 PROCEDURES FOR PANCREATIC DISEASE — 10 Inner Layer Figure 15 Puestow procedure. When the diameter of the dilated pancreatic duct is 1 cm or wider, a side-to-side pancreaticojejunostomy should be done in two layers. Once an outer layer of interrupted 3-0 silk sutures is placed between the jejunal loop and the pancreatotomy, an enterotomy is made along the entire length of the jeju- nal suture line, and an inner layer consisting of a contin- uous 3-0 absorbable synthetic suture is placed. easily ballotable is palpable posterior to the stomach. The duodenum drained into a Roux-en-Y jejunal loop through the transverse meso- and the head of the pancreas are kocherized so that the head may be colon, and the lesser sac need not be explored. Most pseudocysts are palpated both anteriorly and posteriorly. The physical characteristics formed by anterior disruptions of the main pancreatic duct.When pan- of chronic pancreatitis are usually present.The body and the tail of the creatic secretions leak out into the lesser sac, the body walls off the leak pancreas are palpated as well; the pancreas is usually fibrotic, firm, and through its inflammatory response.The transverse mesocolon becomes somewhat enlarged.The rest of the abdomen is explored to check for adherent to the posterior wall of the stomach, which in turn becomes the presence of other pathologic conditions. adherent to other adjacent structures in and around the retroperi- At this point, the size and configuration of the cyst are compared toneum, and the leak is sealed off. Thus, the transverse mesocolon is with the size and configuration on the preoperative CT scan. If the CT usually the inferior and most dependent portion of the pseudocyst, and scan shows a unilocular solitary cyst and if, at the time of laparotomy, this site is the ideal location for drainage [see Figure 16]. there appears to be a mass that coincides exactly with what is seen on The transverse colon is retracted cephalad, and the cyst is easily the CT scan, there is no need to enter the lesser sac.The lesion can be visualized and palpated through the transverse mesocolon. The loca- Transverse Colon Sagittal Section Liver Pseudocyst Transverse Mesocolon Pancreas Stomach Pancreatic Transverse Duct Mesocolon Pseudocyst Duodenum Transverse Colon Roux-en-Y Jejunal Loop Omentum Roux-en-Y Jejunal Loop Figure 16 Drainage of pancreatic pseudocyst into Roux-en-Y jeju- nal loop. The transverse mesocolon is usually the most inferior and Figure 17 Drainage of pancreatic pseudocyst into Roux-en-Y dependent part of a pancreatic pseudocyst; thus, drainage through jejunal loop. The outer posterior layer of the side-to-side cystoje- the transverse mesocolon into a Roux loop is usually the ideal junostomy comprises a series of 3-0 silk sutures placed through approach. and through the jejunal loop and the transverse mesocolon.
    • © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 24 PROCEDURES FOR PANCREATIC DISEASE — 11 A side-to-side cystojejunostomy is performed with an outer inter- rupted layer of 3-0 silk and an inner continuous layer of 3-0 absorb- Figure 18 Drainage of able synthetic suture material.The posterior outer layer of the anasto- pancreatic pseudocyst into mosis consists of a series of 3-0 silk sutures passed through and through stomach. Once an incision the jejunal loop and through and through the transverse mesocolon has been made through (which is the inferior wall of the pseudocyst) [see Figure 17]. The the posterior wall of the suture line should be approximately 2.5 to 5 cm long. After the poste- stomach, through the cyst rior layer has been secured, a cystotomy is performed with the electro- wall, and into the pseudo- cautery. An ellipse of cyst wall is removed and sent for frozen-section cyst, a continuous locking examination. No matter how clear it seems to be that the lesion is a 3-0 absorbable synthetic suture is placed through pseudocyst, a specimen from the cyst wall should always be sent for and through the posterior frozen-section examination. Some cystic lesions of the pancreas are wall of the stomach and cystic neoplasms, which must be resected rather than drained. If no the cyst wall. epithelial lining is found on frozen-section examination, it is safe to assume that the lesion is not a cystic neoplasm but a pancreatic pseudocyst and to proceed accordingly. A parallel enterotomy is made in the jejunum. An inner continuous layer of 3-0 absorbable synthetic suture material is placed inferiorly in a locking fashion, then brought around superiorly in a Connell stitch. An outer interrupted layer of 3-0 silk is placed superiorly.With the cyst decompressed, a sizable lumen should be easily palpable in the anas- tomosis between the cyst and the jejunal loop. A closed suction Silastic drain is left near the anastomosis and Pseudocyst Cavity brought out through a stab wound in the left upper quadrant. The Transverse Colon Transverse Mesocolon Tacked to Stomach Cyst Wall Posterior Wall of Stomach tion of the cyst is confirmed by aspirating pancreatic juice through the transverse mesocolon with a 10 ml syringe and a 20-gauge needle.The middle colic vessels must be carefully identified and avoided. A 60 cm long Roux-en-Y jejunal loop is constructed. The proximal jejunum is divided with a GIA stapler at the first convenient arcade. The small bowel mesentery is divided down through the arcade. The distal end Jejunal of the jejunum is inverted with an interrupted layer of 3-0 silk Loop Lembert sutures. Alimentary tract continuity is reestablished by means of an end- to-side jejunojejunostomy, in which the proximal jejunum is anas- tomosed to the side of the Roux-en-Y jejunal loop 60 cm from the inverted end. This anastomosis is performed with an inner contin- Figure 19 Palliative double bypass for unresectable pancreatic uous layer of 3-0 absorbable synthetic suture material and an outer cancer. Once the retrocolic gastrojejunostomy is complete, the interrupted layer of 3-0 silk.The rent in the small bowel mesentery anastomosis is tacked to the rent in the transverse mesocolon on is closed with a continuous 3-0 silk suture. the gastric side with interrupted 3-0 silk sutures.
    • © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 24 PROCEDURES FOR PANCREATIC DISEASE — 12 End-to-Side Hepaticojejunostomy Chemical Splanchnicectomy Gallbladder Retrocolic Fossa Jejunal Loop Figure 20 Palliative double bypass for unre- sectable pancreatic cancer. An end-to-side hepaticojejunostomy is performed, followed by a side-to-side jejunojejunostomy between the afferent loop leading to the biliary anastomosis and the efferent loop leading from it. An open- ing is made in the lesser omentum, and a chemical splanchnicectomy is performed by injecting alcohol into the celiac plexus. Duodenum Transverse Mesocolon Tacked to Stomach Side-to-Side Enteroenterostomy abdomen is copiously irrigated with an antibiotic solution and closed absorbable synthetic material is placed through and through the pos- in a standard fashion. terior wall of the stomach and the anterior wall of the cyst [see Figure 18]. This step may or may not actually be important for achieving Drainage into Stomach long-term patency of the opening between the cyst and the posterior The peritoneal cavity is entered through an upper midline incision, wall of the stomach, but it does ensure good hemostasis.The anterior and the abdomen is explored. Typically, a pseudocyst that is not gastrotomy is closed with an inner continuous layer of 3-0 absorbable amenable to drainage through the transverse mesocolon presents as a synthetic suture material in a Connell stitch and an outer interrupted mass that is cystic and is palpable through the anterior wall of the layer of 3-0 silk. The abdomen is closed in a standard fashion. stomach and the lesser omentum in the upper abdomen; such a mass generally is not palpable through the root of the transverse mesocolon with the transverse mesocolon reflected cephalad and thus is not eas- Laparoscopic Drainage of Pancreatic Pseudocysts ily drained into a Roux-en-Y jejunal loop. The duodenum and the Five distinct laparoscopic approaches have been employed for the head of the pancreas are kocherized, and the head of the pancreas is drainage of pancreatic pseudocysts: (1) transgastric cystogastrostomy, palpated. Signs of chronic pancreatitis are invariably present.The rest (2) intragastric cystogastrostomy, (3) minilaparoscopic intragastric of the abdomen is explored to check for the presence of other patho- cystogastrostomy, (4) cystogastrostomy via the lesser sac approach, logic conditions. and (5) Roux-en-Y cystojejunostomy. Stay sutures of 3-0 silk are placed in the anterior wall of the body of In a laparoscopic transgastric cystogastrostomy, an anterior gastro- the stomach. A transverse gastrotomy is made with the electrocautery. tomy is created, and the electrocautery is used to open the cyst wall The cyst wall is easily palpable through the posterior wall of the stom- through the posterior wall of the stomach. A cystogastrostomy is then ach.The location of the cyst is confirmed by aspirating pancreatic juice created; it may be either stapled (with an endoscopic stapler) or hand- through the back wall of the stomach with a 10 ml syringe and a 20- sewn (with intracorporeal sutures). gauge needle.The mass palpated at the time of operation is compared In an intragastric cystogastrostomy, trocars are inserted percuta- with the cyst as it appears on the preoperative CT scan. If the CT scan neously through the abdominal wall and directly into the gastric shows a solitary unilocular cyst that corresponds to the palpable mass lumen under simultaneous laparoscopic and gastroscopic guidance. A identified at the time of laparotomy, it is safe to conclude that the cyst cystogastrostomy is then created by means of electrocauterization and is solitary and can be drained effectively into the stomach. sharp dissection. The technique for a minilaparoscopic intragastric A transverse incision is made with the electrocautery through the cystogastrostomy is essentially the same, except that 2 mm intragas- posterior wall of the stomach, through the cyst wall, and into the tric ports are used to reduce the invasiveness of the procedure and pseudocyst. It is often desirable to leave the 20-gauge needle in place minimize the trauma to the anterior gastric wall. and to perform the posterior wall gastrotomy on either side of the nee- When the anatomy is favorable, laparoscopic cystogastrostomy via dle. An ellipse of cyst wall is sent for frozen-section examination. the lesser sac approach is the preferred technique for minimally inva- Again, this step is mandatory, no matter how obvious it seems that the sive pseudocyst drainage.The advantages of this technique are (1) that lesion is an inflammatory cyst. A continuous locking suture of 3-0 it does not require an anterior gastrotomy and (2) that it ensures a large
    • © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 5 GASTROINTESTINAL TRACT AND ABDOMEN 24 PROCEDURES FOR PANCREATIC DISEASE — 13 anastomosis that is not dependent on the adherence of the cyst to the In the past, palliative duodenal bypasses for pancreatic cancer were posterior gastric wall. Because the entire anastomosis is either stapled frequently performed by carrying out an anterior antecolic gastroje- or sutured, the risk of bleeding is minimized. In this procedure, a win- junostomy. Delayed gastric emptying proved to be a common occur- dow is created in the gastrocolic omentum, through which the lesser rence with this approach. Fortunately, this complication can be virtu- sac is entered.The stomach is elevated, and a cystotomy is made adja- ally eliminated by performing a posterior gastroenterostomy. Once the cent to a posterior gastric wall gastrotomy. A cystogastrostomy is then posterior gastroenterostomy is complete, the anastomosis is tacked to created with an endoscopic stapler, and the opening is sutured closed. the rent in the transverse mesocolon on the gastric side with interrupt- For cysts that are large or are not in direct contact with the posteri- ed 3-0 silk sutures to prevent the afferent and efferent jejunal limbs or wall of the stomach, a laparoscopic Roux-en-Y cystojejunostomy may from herniating up through the transverse mesocolon [see Figure 19]. be performed instead. The omentum and the transverse colon are re- The gallbladder is mobilized out of the liver bed in a retrograde tracted cephalad. Often, the pseudocyst is then visible through the trans- fashion and placed on traction to facilitate identification of the com- verse mesocolon. Laparoscopic ultrasonography may also be used to mon hepatic duct. Once identified, the common hepatic duct is divid- help identify the location of the cyst. The jejunum is divided approxi- ed just proximal to the cystic duct. The gallbladder is removed, and mately 30 cm distal to the ligament of Treitz to create a Roux limb. The the distal biliary segment is oversewn with a continuous 3-0 poly- pseudocyst is opened through the transverse mesocolon with the ultra- propylene suture. The jejunum is divided approximately 30 cm distal sonic scalpel. A small enterotomy is made in the Roux limb, and a sta- to the gastrojejunostomy, and a Roux-en-Y limb is brought up into the pled cystojejunostomy is created.The cystoenterostomy is then closed right upper quadrant through a second opening in the transverse with a continuous suture. The procedure is completed by performing mesocolon. An end-to-side hepaticojejunostomy is performed with a a jejunojejunostomy at least 30 cm distal to the cystojejunostomy. single layer of interrupted 4-0 absorbable synthetic sutures [see Figure 20]. An end-to-side jejunojejunostomy is then performed 60 cm downstream to restore enteric continuity and complete the Roux-en- Palliative Bypass for Unresectable Periampullary Cancer Y.This anastomosis is performed with an inner continuous layer of 3- The peritoneal cavity is entered through an upper midline incision, 0 absorbable synthetic suture material and an outer interrupted layer and the abdomen is examined for evidence of liver metastases, serosal of 3-0 silk. The Roux limb is tacked to the opening in the transverse spread, carcinomatosis, involvement of regional lymph nodes, and mesocolon to prevent herniation. invasion of major vascular structures. Once the tumor has been shown The lesser omentum is divided, and a chemical splanchnicectomy to be unresectable and histologic confirmation of malignancy has is performed by injecting 20 ml of 50% alcohol into the celiac plexus been received, a palliative double bypass procedure is begun, in which on each side of the aorta at the level of the celiac axis.The level of the the duodenum is bypassed with a retrocolic gastrojejunostomy and celiac axis is easily determined by palpating the thrill that is invariably the distally obstructed biliary tree is bypassed with a hepaticojejunos- present in the common hepatic artery as it comes off the celiac axis. tomy. A chemical splanchnicectomy is also performed to reduce pain. A closed suction Silastic drain may be left posterior to the area of Approximately 4 cm of the most dependent portion of the greater the hepaticojejunostomy and brought out through a stab wound in the curvature of the stomach is cleaned by doubly clamping, dividing, and right upper quadrant. If tissue confirmation of the presence of adeno- ligating attachments of the greater omentum. Once this is accomplished, carcinoma of the head of the pancreas was not obtained preoperative- a small rent is made in the transverse mesocolon, and a proximal loop ly, it should be obtained during the operation. As a rule, this is most of jejunum is brought up through this rent and anastomosed in an easily accomplished by performing a transduodenal needle biopsy isoperistaltic fashion to the dependent wall of the stomach.The anas- (e.g., with a Tru-Cut needle; Cardinal Health, Dublin, Ohio). The tomosis is performed with an outer interrupted layer of 3-0 silk and abdomen is irrigated with an antibiotic solution and closed in a stan- an inner continuous layer of 3-0 absorbable synthetic suture material. dard fashion. References 1. Yeo CJ, Cameron JL, Sohn TA, et al: Six hundred Recommended Reading Lillemoe KD,Yeo CJ, Cameron JL: Pancreatic cancer: fifty consecutive pancreaticoduodenectomies in state-of-the-art care. CA Cancer J Clin 50:241, 2000 the 1990s: pathology, complications, and out- Sohn TA, Lillemoe KD, Cameron JL, et al: Surgical comes. Ann Surg 226:248, 1997 Cameron JL, Pitt HA,Yeo CJ, et al: One hundred and palliation of unresectable periampullary adenocarci- forty-five consecutive pancreaticoduodenectomies noma in the 1990s. J Am Coll Surg 188:658, 1999 2. Trede M, Schwall G, Saeger HD: Survival after without mortality. Ann Surg 217:430, 1993 pancreatoduodenectomy: 118 consecutive resec- Yeo CJ, Cameron JL, Lillemoe KD, et al: Does pro- Fernandez-Cruz L, Martinez I, Gilabert R, et al. phylactic octreotide decrease the rates of pancreatic tions without an operative mortality. Ann Surg Laparoscopic distal pancreatectomy combined with 211:447, 1990 fistula and other complications after pancreaticoduo- preservation of the spleen for cystic neoplasms of the denectomy? results of a prospective randomized 3. Fernandez-del Castillo C, Rattner DW, Warshaw pancreas. J Gastrointest Surg 8:493, 2004 placebo-controlled trial. Ann Surg 232:419, 2000 AL: Standards for pancreatic resection in the Fernandez-del Castillo C, Rattner DW, Warshaw AL: Yeo CJ, Cameron JL, Lillemoe KD, et al: 1990s. Arch Surg 130:295, 1995 Standards for pancreatic resection in the 1990s. Arch Pancreaticoduodenectomy for cancer of the head of 4. Dye CE, Waxman I: Endoscopic ultrasound. Surg 130:295, 1995 the pancreas: 201 patients. Ann Surg 221:721, 1995 Gastroenterol Clin North Am 31:863, 2002 Lillemoe KD, Cameron JL, Kaufman HS, et al: Chemical splanchnicectomy in patients with unre- 5. Cameron JL: Rapid exposure of the portal and sectable pancreatic cancer: a prospective randomized Acknowledgments superior mesenteric veins. Surg Gynecol Obstet trial. Ann Surg 217:447, 1993 176:395, 1995 Figures 1, 2, and 5 Tom Moore. Lillemoe KD, Cameron JL, Hardacre JM, et al: Is 6. Traverso LW, Longmire WP Jr: Preservation of the prophylactic gastrojejunostomy indicated for unre- Figures 3, 8, and 10 through 13 Alice Y. Chen. pylorus in pancreaticoduodenectomy. Surg Gyne- sectable periampullary cancer? a prospective random- Figures 4, 6, 7, 9, and 14 through 20 Tom Moore. col Obstet 146:959, 1978 ized trial. Ann Surg 230:322, 1999 Adapted from originals by Corinne Sandone.