This document provides an overview of pancreatic surgery and management of pancreatic conditions. It discusses the anatomy of the pancreas, classification and management of acute pancreatitis including necrotizing pancreatitis. It covers the indications, timing and approaches for intervention in infected pancreatic necrosis, including radiologic drainage, minimally invasive techniques like VARD and nephroscopic debridement, and open necrosectomy. It also summarizes the principles and techniques of surgical management of pancreatic cancer.

1. Dr Harsh Shah
MS, FMAS, DNB, MCh (MAMC, New Delhi)
Surgical Gastroenterologist & HPB Surgeon
Pancreatic Surgery - An
Update

2.  Anatomy
 Management of Necrotizing pancreatitis
 Management of Pancreatic cancer

3. Anatomy
 Pan Kreas (Greek)– all flesh

5. Pancreatic ducts

6. Celiac Trunk

7. Arterial supply

9. Venous Drainage

12. Learning points
 Duodenum will always be excised due to a
common blood supply with HOP
 Spleen with distal pancreas
 GDA acts as a communicating vessel between
celiac & SMA
 Positive resection margin near SMA in
uncinate tumours

13. Pancreatitis

14. Etiologies of Acute Pancreatitis
Common Causes
• Gallstones (most common)
• Alcohol Intake
• ERCP
• Blunt trauma abdomen
• Drugs (sulfonamides, 6-MP)
• Hypertriglyceridemia
Uncommon Causes
• Hypercalcemia
• Periampullary diverticulum
• Pancreas divisum
• Hereditary pancreatitis
• Cystic Fibrosis
• Ca head of pancreas

15. Diagnosis
Two out of three:
(1) abdominal pain consistent with acute
pancreatitis (acute onset of a persistent, severe,
epigastric pain often radiating to the back)
(2) serum lipase activity (or amylase activity) at
least three times greater than the upper limit of
normal; and
(3) characteristic findings of acute pancreatitis on
contrast-enhanced computed tomography (CECT)
and less commonly magnetic resonance imaging
(MRI) or transabdominal ultrasonography.

16. Revised Atlanta Classification-
2012
 Interstitial edematous pancreatitis
 Acute peripancreatic fluid collection
 Pancreatic pseudocyst
 Necrotizing pancreatitis
 Acute necrotic collection
 Walled off necrosis

17. Interstitial Edematous
Pancreatitis
 Acute inflammation of
pancreatic parenchyma &
peripancreatic tissue
without recognizable tissue
necrosis
 CECT criteria:
 Parenchymal
enhancement by
intravenous contrast
agent
 No e/o necrosis

18. Acute Peripancreatic Fluid
collection
 Peripancreatic fluid associated
with IEP
 Within first 4 weeks of onset of
IEP
 CECT criteria
 IEP
 Homogenous collection with
fluid density
 Confined by normal
peripancreatic fascial
planes
 Adjacent to pancreas

19. Pancreatic Pseudocyst
 Encapsulated collection of
fluid with a well defined
inflammatory wall outside the
pancreas with minimal or no
necrosis
 >4 weeks after IEP
 CECT criteria:
 Well circumscribed(round or
oval)
 Homogenous fluid density
 No non-liquid component
 Well defined wall

20. Necrotising Pancreatitis
 Inflammation associated with pancreatic
parenchymal or peripancreatic necrosis
 CECT criteria:
 Lack of parenchymal enhancement by IV contrast
&/or
 Presence of peripancreatic necrosis

21. Acute Necrotic collection
 Collection containing variable amounts of both
fluid & necrosis associated with NP
 Can involve pancreatic parenchyma &/or
peripancreatic tissue
 CECT criteria:
 Only with NP
 Heterogenous & non-liquid density of varying
degrees
 No definable wall
 Intrapancreatic &/or extrapancreatic

22. Acute Necrotic collection

23. Walled-off Necrosis
 A mature, encapsulated collection of
pancreatic &/or peripancreatic necrosis
 >4weeks after onset of necrotising pancreatitis
 CECT criteria:
 Heterogenous with liquid & non-liquid density
(may be homogenous)
 Completely encapsulated
 Intrapancreatic &/or extrapancreatic

24. Walled-off Necrosis

25. Infected Pancreatic Necrosis
 Pancreatic and peripancreatic necrosis can
remain sterile or become infected;
 Failure of intestinal barrier
 Incidence of Infection of necrosis- 25-70 %
 Mortality of infected PN- 20-25 %
 No absolute correlation between the extent of
necrosis and the risk of infection
 Infected necrosis is rare during the first week
Rau BM. Outcome determinants in acute pancreatitis. Am J Surg
2007; 194:S39-S44.

26. Infected Pancreatic Necrosis

27. Infected Pancreatic Necrosis
 The diagnosis of infected pancreatic necrosis is
important
 Need for antibiotic treatment
 Need for active intervention
 The presence of infection can be presumed
 extraluminal gas in the pancreatic and/or
peripancreatic tissues on CECT or when
percutaneous, image-guided, fine-needle
aspiration (FNA) is positive for bacteria and/or
fungi on Gram stain and culture

28. Natural course of Acute
Pancreatitis
 Early Phase
 1st week
 Mild pancreatitis- resolve
 Organ failure related to SIRS: transient vs persistent
 Infection usually does not occur
 Late phase
 From 2nd week onwards
 Disease severity: Necrosis, Organ failure
Buchler et al. Acute necrotizing pancreatitis: Treatment strategy according
to status of infection. Ann Surg 2000;232:619-26

29. Medical management of AP
 Adequate pain relief
 Fluid resuscitation- Target HCT: 35-45%
 No role of prophylactic antibiotics
 Enteral nutrition preferred (NG/NJ)

30. MANAGEMENT OF
INFECTED PANCREATIC
NECROSIS

31. DIAGNOSIS

32. CECT Scan
 Pancreatic protocol – 25 sec (Delayed arterial
phase)
 slice thickness (i.e. 5mm or less),
 During follow up only a portal venous phase
(monophasic) is generally sufficient

33. CECT scan
 Necrosis: Absence of enhancement of
pancreatic parenchyma
 Infected pancreatic necrosis: presence of
multiloculated gas within the gland and
surrounding tissues
 Multisystem impairment:
 Evidence of pulmonary edema, pleural effusions
 Diminished renal enhancement
 Anasarca

35. Silvermann et al, 2004: A modified CT severity index for evaluating acute
pancreatitis: improved correlation with patient outcome. Am J Roentgenol
183:1261-1265

36. FNAc
 Routine percutaneous FNAc of peripancreatic
collections to detect bacteria is not indicated.
Indications
 To rule infection in sterile necrosis- persistent
SIRS, organ failure
 False negative rate: 12-15 %

37. Microbiology
 Gram-negative
(Escherichia coli, Klebsiella) 35%–55%.
 Gram-positive isolates
(Staphylococcus, Streptococcus) 20%–
35%.
 Anaerobic isolates
(Bacteroides sp.) 8%–15%.
 Fungal isolates
(candida) 20%–25%.

38. MANAGEMENT

39. INDICATIONS FOR
INTERVENTION IN
NECROTIZING PANCREATITIS
IAP/APA guidelines for the management of acute
Pancreatitis-2012

40. Changing concepts in the Management of
Necrotizing Pancreatitis
Era Indication for Time of
intervention
Type of
intervention
Pre 1990s1 Pancreatic
necrosis
Week 1 Pancreatic
resection
1990s2 Pancreatic
necrosis
> Week 2 Open
necrosectomy
2000s Infected
pancreatic
necrosis3
> Week 4 PCDMIN ON
if required4
1. Kivilaakso E. et al. Ann Surg 1984
2. Mier J et al. Am J Surg 1988
3. Rau B et al. J Am Coll Surg 1995
4. Dutch pancreatitis study group. N Engl J Med 2010.

41. Indications for Intervention
 Infected pancreatic Necrosis
 Symptomatic sterile necrosis
 gastric outlet, intestinal, or biliary obstruction due
to mass effect(>4 week)
 Persistent symptoms (e.g. pain, ‘persistent
unwellness’) (i.e. >8 weeks)

42. Timing of intervention
 At least >4weeks after the onset of disease
 When necrotic process has stopped extending
 Clear demarcation between viable & non-viable
tissues
 Infected necrotic tissue has become walled-off
 This approach
 Decreases the risk of bleeding
 Avoiding removal of normal pancreatic tissue-
endocrine & exocrine insufficiency

43. Classification of type of
intervention
Depending on how the target lesion is visualized
on
 Radiological method
 CT, USG, Fluoroscope
 Endoscopic methods
 Gastroscope
 Laparoscope
 Nephroscope
 Open surgical

44. Minimally Invasive Techniques
Potential benefits claimed
 Minimizing operative trauma
 to postpone or obviate the need for surgical
intervention
 Minimize damage to healthy pancreatic tissue

45. Radiologic Drainage
Techniques
 Most effective if target lesion is liquified
 Most common location lesser sac, anterior & left
pararenal spaces
 USG or CT guidance
 Retroperitoneal approach is preferred to reduce
the risk of contamination and possible peritonitis
 Needle guidewire is passed down the needle
the tract is dilated to accommodate a catheter
 Catheter upgradation is essential

46. Radiologic Drainage
Techniques
 Repeated flushing of catheter to prevent
blockage
 Multiple catheters are required, especially for
large or complex lesions
 The efficacy is reduced with more solid lesions

47. Videoscopic-assisted retroperitoneal
debridement (VARD) Hovrath- 2001
 Radiologic drainage of the lesion is first instituted
 The patient is placed in supine position with the
left side 30-40 degree elevated
 A subcostal incision of 5 cm is placed over drain
site.
 A finger is used to probe and confirm entry into
the necrotic cavity
 Fluid and loose necrotic debris are removed by
suction

48. Videoscopic-assisted retroperitoneal
debridement (VARD) Hovrath- 2001
 Two ports (10 to 12 mm) are inserted through
the incision
 The incision is sealed with wet sponges and
towel clips to allow insufflation with CO2
 Debridement of necrotic tissue is performed
with hydrodissection and 10 mm forceps
 Drains are placed for postoperative continuous
lavage
 An ostomy bag is then positioned over the flank
continuous lavage is performed

50. Nephroscopic techniques
-Carter 2000
 The first step is to insert a drainage catheter into
the pancreatic lesion under CT guidance
 the drain tract is dilated to allow insertion of a 34-
Fr Amplatz sheath
 A nephroscope is inserted through the sheath into
the cavity, and jet lavage with warm saline is used
to clear away debris and suppurative fluid
 Drains placed for post-op lavage

51. Nephroscopic techniques
-Carter 2000
Pre-op Post-op

52. Indications for Open
Necrosectomy
 Failure of minimally invasive techniques to drain
the infected necrosis & persistent sepsis
 Massive haemorrhage
 Bowel perforation (Duodenum or transverse
colon)

53. Principle of surgical
techniques
 Eliminate necrotic & infected tissue/fluid
 Preservation of vital tissue
 Avoidance of haemorrhage
 All fluid collection identified on CT scan should
be identified, opened & evacuated

54. Open Surgical Necrosectomy
 midline or bilateral subcostal incision
 The body and tail of the pancreas exposed by
entering the lesser sac
 Either by division of gastrocolic omentum or
gastrohepatic omentum
 Via transverse mesocolon
 Great care is required- as Inflammatory
adhesions may exist between the pancreas and
stomach or transverse mesocolon

55. Technical pearls
 Debridement is performed bluntly, usually with
digital dissection, careful use of instruments &
lavage
 Only loosely adherent tissue should be removed
 Avoid sharp dissection- to prevent haemorrhage
 Strands of tissue forming bridges across cavity
may be vessels & should not be avulsed
 Extensive irrigation of necrotic cavity

56. Technical pearls
 Hydrogen peroxide may be used
 Systematic approach- examining in turn in
retroperitoneum behind transverse, ascending &
descending
 Do not leave any collection undrained
 If massive bleeding is encountered packing
 If colon viability is doubtful- perform ileostomy
 Feeding Jejunostomy is routine

57. What is a step-up approach ?
 The first step is percutaneous or endoscopic
drainage of the collection of infected fluid to
mitigate sepsis
 If drainage does not lead to clinical improvement,
the next step is minimally invasive retroperitoneal
necrosectomy
 Open Necrosectomy

58. Step up approach- PANTER study
Besselink MG. Dutch study group. A Step-up Approach or Open
Necrosectomy for Necrotizing Pancreatitis. N Engl J Med 2010
 Multicenter RCT, 88 patients
 45-primary open necrosectomy, 43- MI step up
approach
 The primary end point was occurence
 major complications (new-onset multiple-organ failure or
multiple systemic complications, perforation of a
visceral organ or enterocutaneous fistula, or bleeding)
 death

59. Step up approach- PANTER study
Results:
 The primary end point occurred in 31 of 45 patients
(69%) assigned to open necrosectomy and in 17 of
43 patients (40%) assigned to the step-up approach
(P = 0.006).
In patients assigned to the step-up approach
 35% were treated with percutaneous drainage only
 New-onset multiple-organ failure occurred less often
(12% vs. 40%, P = 0.002).
 Lower rate of incisional hernias (7% vs. 24%, P =
0.03) and new-onset diabetes (16% vs. 38%, P =

61. Summary
 Mild acute pancreatitis- 80% case- no role of
surgery
 Severe necrotizing pancreatitis- 20%
 Interventions should preferably be delayed:
>4weeks
 Indications for interventions : infected necrosis,
Clinical deterioration, persistent organ failure- in
sterile necrosis
 Step up approach is preferred

62. Pancreatic & Periampullary
Tumours

63. Lower end of CBD
Periampullary pancreas
Duodenum
Ampulla

65. Clinical features

66. CT protocols for pancreas
 Noncontrast phase:
 Evaluation of pancreatic calcifications
 Arterial phases (early and delayed)
 Early arterial phase evaluates pancreatic vasculature without
interference from venous opacification.
 Late arterial phase is to distinguish pancreatic tumor from adjacent
normal pancreatic tissue
 Evaluate hypervascular liver metastases in patients with NET of
the pancreas.
 Portal venous phase
 Evaluation of relationship with the veins and hypovascular liver
metastases in patients with adenocarcinoma

67. Staging – investigations
Tumour
CBD
Pancreatic duct
GB
stent

68. Cystic neoplasm in body-tail

69. MRCP
 Magnetic resonance
cholangiopancreatography
shows a clearer delineation
of the pancreatic duct.
 Normal pancreatic duct in
the pancreatic head
(arrowheads)
 Filling defect in the
pancreatic body, and distal
dilation of the pancreatic
duct in the tail 69

70. EUS (Endoscopic Ultrasound)
• Small lesions
• Vascular involvement
• FNAc

71. Pancreatic Ca
 Most common site is pancreatic head (78%)
 body and tail (20-25%)
 Surgery is the cornerstone of treatment
 In the late 1960s postoperative morbidity rate was up to 60%
and mortality rate approaching 25%
 Mortality rate is less than 2% and morbidity rate 30-40% in
high volume centre
Büchler et al, 2003; Cameron et al, 2006; Wagner et al, 2004

72. Preoperative Preparation
• Nutrition
• Assess for vascular involvement & liver mets
• CBD stent placement
• An absolute indication for biliary drainage is
 Bil >15mg%
 Cholangitis
 Malnutrition

73. Types of Resections
 Whipple’s Pancreaticoduodenectomy
 Distal pancreatectomy
 Segmental pancreatectomy
 Total pancreatectomy

74. Resectable lesion
SMV
SMA
Head mass

75. Borderline resectable tumour
Tumour
SMV
SMA

76. Unresectable tumour
Tumour
SMA

77.  Nonresectable lesions:
 Encase (i.e., >180° invasion) SMA, CA or CHA
 Occlude the SMV- PV such that no reconstruction is
possible
• Borderline resectable lesions:
 Abut the visceral arteries (<180° invasion)
 Distort the visceral veins, or even occlude the SMV-PV but venous
reconstruction still technically feasible
Callery MP et al. Ann Surg Oncol 2009

78. Role of staging laparoscopy
 Approximately 50% of patients with pancreatic
cancer can have liver or peritoneal mets on
operation
 SL can avoid unnecessary exploration
 Prospective study at MSKCC: of 115 pts 36% saved
from exploration Conlon KC et al. Ann Surg 1996

79. Staging – investigations

80. Staging Lap - Indications
 HOP tumor size >4cm
 Boarder line resectable tumors
 CA 19-9 >150 IU/ml
 Body and tail carcinoma

83. WPD specimen
Contact with SMV & SM

84. SMA first approach

85. Uncinate tumour with SMA
involvement

86. Replace
d right
hepatic
artery

87. Vein resection

88. PJ Vs PG
 PG was developed as an alternative to PJ
 Chance of leakage may be less due to rich gastric
vascularity
 Pancreatic enzymes may be inactivated by the gastric acid
 Meta analysis including 3RCTs, concluded no added
advantage of PG over PJ Menahem B, Ann Surg 2014

89. Extended Lymphadenectomy
 Standard PD involves removal of peripancreatic and
subpyloric nodes
 Extended lymphadenectomy involves removal of nodes from
liver hilum, paraaortic nodes from diaphragm to IMA
 Riall et al showed no difference in survival with significant
higher morbidity
Riall TS J Gastrointest surg, 2005
 Jin Young et al showed increased operative time with similar
morbidity and mortality without any survival benefit
Jin Young Ann Surg, 2014
 Exteneded lymphadenectomy is not recommended for
pancraetic cancers

90. Venous Resection
 Peritumoral inflammation can mimic tumor
invasion
 Traditionally involvement of SMV or PV were
considered unresectable

91. Venous Resection
 Perioperative morbidity and mortality rates for pancreatic
resections with PV or SMV resection are similar to those
without it
 Bachellier et al, 2001; Carrere et al, 2006; Leach et al, 1998; Nakao
et al, 2006; Riediger et al, 2006; Wagner et al, 2004
 Tumor infiltration into the tunica media of the PV has a
worse prognosis and a long-term survival of less than 2
years

92. Arterial reconstruction
 Arterial reconstruction is associated with high
morbidity and poor short and long term survival
 Stitzenberg KB, Ann Surg Oncol 2008
 Nakao A, World J Surg, 2006
 Mollberg N, Ann Surg 2011
 Sufficient data is not available to change the
practice so arterial involvement is still a
contraindication

93. Distal Pancreatectomy
 For tumors arising in the body or tail of the
pancreas
 Types
1. Classical Left to right distal pancreatectomy
2. Radical antegrade modular pancreaticosplenectomy
(RAMPS)
3. Distal pancraetectomy with celiac artery resection

94. Left to right distal pancreatectomy
 Performed by early ligation of the splenic artery followed
by mobilization of the spleen and pancreas, from a left-
to-right
 Drawbacks
 Inadequate nodal dissection
 Higher rate of margin positivity

95. RAMPS
 Complete regional LN dissection and less incidence of
margin positivity mainly the posterior tangential margin
 Plane of the posterior dissection is modular depending on
the position of the tumor in relation to the adrenal gland on
preoperative CT scans
 Not an extended pancreatic resection

96. Anatomic Basis for the RAMPS
Procedure
 Pancreatic body and tail lies within the pararenal fascial
space behind the peritoneum and infront of a distinct layer of
fascia called the anterior renal fascia
 The kidney and the adrenal lie behind the anterior renal
fascia in the perirenal space and bounded posteriorly by the
posterior renal fascia.
 The two leaves of transverse mesocolon is attached on the
inferior border of the pancreas

97. Plane of resection
 When the tumor has not penetrated the posterior capsule of
the pancreas on preoperative CT scans, resection plane is
behind the anterior renal fascia (anterior RAMPS)
 When the posterior capsule is invaded the plane of resection
is behind the adrenal gland and Gerota fascia (posterior
RAMPS)
 In each case, the adrenal vein is the intraoperative guide to
the position of the margin.

98.  In anterior RAMPS, the posterior margin is formed by
identifying the adrenal vein at its junction with the left renal
vein and following its anterior surface retrograde in a right
to-left direction to the left OF adrenal gland.
 In the posterior RAMPS, the adrenal vein is divided at its
termination with the renal vein and elevated along with the
adrenal to give the posterior margin.

99. Anterior RAMPS
 The tumor has not
penetrated the posterior
capsule of the pancreas
 Green line shows planned
plane of posterior dissection
in anterior RAMPS
 Red line shows possible
plane when standard distal
pancreatectomy is
performed without regard to
the position of the anterior
renal fascia.

100. Posterior RAMPS
 Green line shows
planned plane of
posterior dissection
in posterior RAMPS
 The tumor has
penetrated the
posterior capsule of
pancreas.

101.  Red : standard distal
pancraetectomy
 Green: anterior
RAMPS
 Blue posterior
RAMPS
A
P

102. Results
 long-term results of 47 patients
 Negative tangential margin rate of 89%
 An actuarial overall 5-year survival rate of 35.5%.
 The actual 5-year survival was 30.4%
 Steven M. Strasberg, The Cancer Journal 2012

103. Distal pancreatectomy with celiac axis
resection
 Procedure for cancers with celiac axis involvement
 It is based on the fact that resection of the celiac axis may
be performed without devascularizing the liver, which then
receives its blood supply by the pancreaticoduodenal
arcade.

104. Total
Pancreatectomy
 Indications
1. IPMN – for clear margins
2. To achieve negative margin
3. Atrophic, soft, friable remnant
 c/c
1. Brittle diabetes
2. steatorrhea

105. Summary
 EUS has added advantage in staging
 SMA first approach for pancreatic head
tumours
 RAMPS gives negative posterior margin in
distal pancreatic tumours

106. THANK YOU