Preoperative Evaluation and Questions: 5-year survival rate is 15% – 25% (versus 1% – 5% with no cancer-directed treatment) [Marandola M et al. Transplantation Proceedings 40: 1195, 2008]. Electrolyte abnormalities are common in patients with abdominal pain or vomiting, thus consider a preoperative chem-7. Blood products available + Ranger / rapid infuser.
Risk: operative mortality is less than 5% in centers that perform > five cases per year. Systemic (non-operative) complications cause the majority of perioperative deaths [Marandola M et al. Transplantation Proceedings 40: 1195, 2008] – the most common causes of death are sepsis, hemorrhage, and cardiovascular events [Schwartz’s Principles of Surgery, 8th ed. Chapter 32: Pancreas. McGraw-Hill, 2004]
Induction/Airway: if the tumor is obstructive, consider RSI.
Lines and Monitors: two large-bore IVs, arterial line (frequent labs, esp. glucose), +/- central line.
Preoperative Meds: cefoxitin (do not give SQ heparin (5000 U) until AFTER the epidural, if placed).
Mode of anesthesia: general +/- epidural (T6-8, inferior angle of scapula is approximately T7), although exclusively epidural anesthesia has been performed on at least 15 patients [Nakashima H et al. Int Surg 80: 125, 1995]. If an opiate-enhanced epidural is used, consider a lipophilic drug (ex. fentanyl), as morphine will potentially spread rostrally, potentially causing mental status changes and respiratory depression. Consider 0.5% bupivacaine intraoperatively, followed by 0.125% – 0.25% post-operatively. If blood loss is a major concern, consider holding local anesthetics until towards the end of surgery. In patients for whom an epidural is not possible, consider ketamine at 0.2 mg/kg/hr after a 0.5 mg/kg bolus, as well as gabapentin 600-1200 mg PO.
Surgical Course: laparotomy to gain access to the peritoneum, followed by a determination of resectability (an over-involved or highly metastatic tumor will not be resected). If the tumor is resectable, the head of the pancreas is mobilized (“Kocher maneuver” is performed, dissecting behind the head of the pancreas), the common bile duct is transected and the gall bladder removed, vascular structures (ex. SMV) are freed, and then the pancreas, proximal duodenum / distal stomach, and jejunum (distal to the ligament of Treitz) are incised, and the entire specimen subsequently removed. Drains are almost always placed in organ bed. According to Schwartz, “Traditionally, most surgeons place drains around the pancreatic and biliary anastomoses because the most dreaded complication of pancreaticoduodenectomy, disruption of the pancreaticojejunostomy, cannot be avoided in 1 out of 10 patients. This complication can lead to the development of an upper abdominal abscess or can present as an external pancreatic fistula. Usually a pure pancreatic leak is controlled by the drains and will eventually seal spontaneously… some recent studies have questioned the practice of routine drain placement after pancreaticoduodenectomy. These studies [Heslin MJ et al. J Gastrointest Surg 2: 373, 1998] indicated that most pancreatic leaks can be managed with percutaneous drainage” [Schwartz’s Principles of Surgery, 8th ed. Chapter 32: Pancreas. McGraw-Hill, 2004]
Intraoperative Goals and Events: placement of nasogastric tube (will be used post-operatively). WARM maintenance fluids at 6-10 cc/kg/hr.
EBL: 500-750 cc
Duration: 4-5 hours
Emergence: depends on fluid shifts and cardiopulmonary status. May remain intubated.
Post-Operative Concerns, Transport, Disposition: ICU or epidural-trained ward if epidural in place.
Octreotride (3 x 100 ucg/day, SC) may reduce post-operative complications [Fiess H et al. Digestion 55 S1: 35, 1994]. There does not appear to be a difference between octreotide and somatostatin [Closset J et al. Hepatogastroenterology 55: 1818, 2008]
An exhaustive review of intraoperative radiotherapy (IORT) stated that IORT “may have an important palliative role in patients with unresectable pancreatic cancers, ameliorating visceral pain and promoting local control of the primary tumor; however, IORT appears to have no significant effect on overall survival” [Sindelar WF and Kinsella TJ. Ann Oncol 10S: S226, 1999]