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Complications after Pancreaticoduodenectomy  Surgical Gastroenterology Clinics T. Hema
<ul><li>64 yrs female diagnosed with Ca head pancreas, underwent PPPD with PJ, HJ, antecolic DJ & FJT  </li></ul><ul><li>N...
<ul><li>Fluid amylase </li></ul><ul><li>CECT Abdomen </li></ul><ul><li>Total count </li></ul><ul><li>Diagnosis? </li></ul>...
<ul><li>POPF Management Algorithm </li></ul><ul><li>Diagnosis by accepted definition </li></ul><ul><li>CT – no collection ...
<ul><li>Risk factors for POPF </li></ul><ul><li>Surgeon factors </li></ul><ul><li>-   high volume specialized </li></ul><u...
<ul><li>Suggested reading </li></ul><ul><li>Lowy AM et al, 1997: Prospective randomised trial of octreotide to prevent pan...
<ul><li>This patient had intolerance to fluids orally, vomited, and required reinsertion of NGT for 2 days; Managed with N...
<ul><li>Selective Angiography </li></ul><ul><li>Pseudoaneurysm of GDA </li></ul><ul><li>Embolisation done  </li></ul>
<ul><li>Management of Post Pancreatic Hemorrhage </li></ul><ul><li>Early(< 24hrs)  Delayed (usu.1-3wks) </li></ul><ul><li>...
<ul><li>Suggested Reading </li></ul><ul><li>Wente MN et al; Postpancreatic hemorrhage: an International study Group of Pan...
<ul><li>Delayed Gastric Emptying </li></ul><ul><li>Definition  </li></ul><ul><li>Risk factors </li></ul><ul><li>- age, DM ...
<ul><li>Suggested Reading </li></ul><ul><li>Horstmann O et al, 2004: Pylorus Preservation has no impact on Delayed Gastric...
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Pancreaticoduodenectomy

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Pancreaticoduodenectomy

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

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