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PANCREATIC RESECTION

A pancreatic resection is an operation to remove part of the pancreas.  It is mostly performed to treat pancreatic neoplasms or in selected  patients with chronic pancreatitis. Removal of the entire pancreatic  gland is uncommon, but may be necessary in some cases. Here are outlined  the key steps of pancreatic resections. Click on the following links to  obtain more information.

PANCTREATICODUODENECTOMY

Panctreaticoduodenectomy (PD) is most commonly performed for  pancreatic head and periampullary malignancy, but may also be indicated  in select cases of chronic pancreatitis or benign periampullary tumors.  It is a major operation that involves the removal of the head of the  pancreas, the duodenum, the gallbladder and the common bile duct (Figure  1). A short length of small intestine beyond the duodenum is also  removed. In the classic Kausch-Whipple operation, the pylorus (outlet of the stomach) and the distal (lower) part of the stomach are removed, while in the Longmire-Traverso operation (pylorus-preserving pancreaticoduodenectomy), the stomach and the pylorus are not removed.
After resection, the end of the remaining bile duct; the remaining  pancreas and the stomach are then connected to the small bowel to ensure  flow of bile, digestive juices and food into the intestines (Figure 2).  Three anastomoses are constructed:
  • Pancreatic anastomosis. The pancreatic remnant is  anastomosed to the jejunum (pancreatico-jejunostomy) or to the posterior  wall of the stomach (pancreatico-gastrostomy).
  • Biliary anastomosis. Hepatico-jejunostomy is  performed between common hepatic duct remnant and a site on the jejunum  distal to the pancreaticojejunal anastomosis.
  • Enteric anastomosis. In Whipple PD, an antecolic  anastomosis is constructed between the stomach and the jejunum; in  Longmire-Traverso PD, an antecolic duodeno-jejunal anastomosis is  created.
Different technical modifications of reconstruction techniques have  been proposed, but none resulted superior in meta-analyses. The choice  of the reconstruction technique to adopt depends on the surgeon’s  preference and institutional practices.


Figure 1. Whipple pancreaticoduodenectomy


Figure 2. Reconstruction after Whipple pancreaticoduodenectomy (pancreatico-jejunostomy)

LEFT PANCREATECTOMY

Left (or distal) pancreatectomy is performed to treat pancreatic  diseases of the tail and body. This operation involves surgical  resection of the body and tail of the pancreas to the left of the  superior mesenteric-portal vein confluence. Left pancreatectomy can be  carried out with or without associated splenectomy. The choice of  procedure depends upon the disease process, and the characteristics of  the lesion.
  • Left pancreatectomy with splenectomy:  The spleen,  which is located near this part of the pancreas and shares some of the  same blood vessels, needs to be removed as part of the procedure when  the underlying pancreatic neoplasm is aggressive. Left pancreatectomy  with splenectomy enables ligation of splenic vessels at their origin and  an adequate lymph node clearance (Figure).
  • Spleen-preserving left pancreatectomy: This  procedure is reserved for benign/borderline pancreatic lesions and  cysts, and for localized neuroendocrine tumors. There are two distinct  approaches to preserve the spleen during the dissection of the distal  pancreas. The classic design is to identify, isolate, and preserve the  splenic artery and vein (Kimura procedure).  Alternatively, the splenic artery and vein are ligated with the  pancreas, and perfusion of the spleen is assured by the short gastric  vessels (Warshaw procedure). Both are accepted as appropriate techniques to address a mass in the tail of the pancreas.
The pancreatic stump can be either hand-sutured, closed with a  stapler, or sealed with harmonic scalpel. These stump closure techniques  seem to be equivalent.
Minimally invasive surgery is becoming the paradigm in left  pancreatic resections (laparoscopic and robot-assisted left  pancreatectomy). In the next future, the number of left pancreatic  resection performed with minimally invasive techniques is likely to  increase due to a variety of factors including increased operator  experience across centres and acceptance of the technique on the basis  of demonstrated outcomes in premalignant and malignant lesions. For more information on the minimally invasive pancreatic surgery click here.  


Figure. Left pancreatectomy with splenectomy. Image taken from WebMD.

TOTAL PANCREATECTOMY

Total pancreatectomy involves the resection of the whole pancreas,  the common bile duct, the gallbladder, the duodenum, a short segment of  small intestine beyond the duodenum, the pylorus (outlet of the  stomach), the distal (lower) part of the stomach, the spleen, and  regional lymph nodes (Figure 1A).

After resection, the end of the remaining bile duct and the stomach  are connected to the small bowel to ensure flow of bile and food into  the intestines (Figure 2). Two anastomoses are constructed (Figure 1B):

  • Biliary anastomosis. Hepatico-jejunostomy is performed between common hepatic duct remnant and a site on the jejunum.
  • Enteric anastomosis. An antecolic anastomosis is constructed between the stomach and the jejunum; distal to the hepatico-jejunostomy.

Indications to single-stage elective total pancreatectomy include the  presence of a multifocal neoplasm (intraductal papillary mucinous  neoplasia, pancreatic metastases from clear cell renal carcinoma,  neuroendocrine tumor in the setting of MEN1), or the presence of an  intraductal papillary mucinous neoplasm involving the entire main  pancreatic duct. Single-stage unplanned total pancreatectomy may be  necessary after an initial partial pancreatectomy because of positive  resection margins on intraoperative frozen section. Two-stage total  pancreatectomy (completion pancreatectomy) is performed because of  severe postoperative complications or neoplastic recurrence in the  pancreatic remnant after previous pancreatic resection.

Total pancreatectomy is invariably associated with the development of exocrine insufficiency (inability to properly digest food) and endocrine insufficiency (diabetes  mellitus). Management of pancreatic insufficiency include pancreatic  enzyme replacement therapy and insulin therapy. Exocrine insufficiency  and diabetes may be particularly hard to control in the first months  after the operation, but studies have indicated that quality of life in  the long term is satisfactory.

Figure 1. A: resection phase; B: reconstruction.

MIDDLE SEGMENT PANCREATECTOMY

Middle segment pancreatectomy consists of a limited resection of the midportion of the pancreas.  This procedure allows a surgeon to preserve pancreatic parenchyma and  consequently long-term endocrine and exocrine pancreatic function.  Indications to middle segment pancreatectomy include benign and  borderline neoplasms of the pancreatic body.
After identification and isolation of major vascular structures  around the pancreatic body and neck, the segment of the pancreas with  the tumor is transected to the left and to the right of the lesion  (Figure 1A). The cephalic stump is sutured with interrupted stitches  after elective ligation of the Wirsung’s duct or by means of a stapler.

The reconstruction phase involves one or two anastomoses:
  • Pancreatic anastomosis. The pancreatic distal  remnant is anastomosed to a jejunal Roux-en-Y loop  (pancreatico-jejunostomy, Figure 1B) or to the posterior wall of the  stomach (pancreatico-gastrostomy).
  • Enteric anastomosis. After pancreatic-jejunostomy, the Roux loop is connected to the distal jejunum.


Figure 1. A: Middle pancreatectomy; B: reconstruction by pancreatic-jejunostomy on the distal stump

ENUCLEATION OF PANCREATIC NEOPLASMS

A pancreatic enucleation procedure is an operation designed to remove  small (<2 cm), benign tumors of the pancreas. This procedure  involves shelling out the tumor from the surrounding pancreas. For  enucleation to be performed safely, the lesion should be at least 2-3  mm distant from the main pancreatic duct and not too deep in the  parenchyma. If the lesion is too close to a duct, the risk of  inadvertent ductal damage is substantial, and may result in a  particularly hard to treat pancreatic fistula. Therefore, the distance  between the tumor and the main pancreatic duct should be assessed  preoperatively by means of magnetic resonance imaging with  cholangio-pancreatography. Intra-operative ultrasound should be also  performed to confirm the relationship between the neoplasm and the main  pancreatic. Moreover, it allows clear identification of the lesion, and  evaluation of its morphology and site.
The incidence of postoperative complications, particularly pancreatic  fistula, is high, despite the majority of fistulas have an indolent  course. The main advantage of enucleation is the preservation of almost all the pancreatic parenchyma, thereby minimizing the risk of long-term exocrine and endocrine insufficiency.

Enucleation can be performed using a minimally invasive approach.  For more information click here.
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