Perioperative management - Duodenohemipancreatectomy with Blumgart anastomosis and biliopancreatic separation

The pylorus-preserving pancreaticoduodenectomy according to Traverso-Longmire is considered the current standard for malignant tumors of the pancreatic head.

Despite the generally poor prognosis of these tumors, the surgery represents the only potentially curative procedure.

In principle, the indication for pancreaticoduodenectomy exists in malignancies or sufficient suspicion of malignancy whenever there is at least the prospect of resecting the tumor in toto pre- and intraoperatively, and when the patient is in a general condition adequate for this procedure.

The most common malignant tumor of the pancreas is ductal adenocarcinoma (85%), with the pancreatic head being affected in 65% of cases.

Other indications:

• distal bile duct carcinoma/papillary carcinoma
• duodenal carcinoma
• large adenomas of the papilla or near the papilla in the duodenum
• benign/cystic tumors of the pancreatic head
  • mucinous-cystic neoplasm (> 3 cm)
  • solid-pseudopapillary neoplasm
  • intraductal papillary-mucinous neoplasm (except branch duct IPMN < 2 cm)
• chronic pancreatitis with complications, especially with distal bile duct stenosis
• so-called "dilemma" cases (when imaging and clinical presentation cannot reliably differentiate between inflammatory and malignant pancreatic head tumors)
• hereditary gastrinomas in MEN-1 syndrome (multiple duodenal gastrinomas)
• metastases in the pancreatic head

The main difference from the classic Kausch-Whipple operation is the preservation of the stomach with its neurovascular supply. There is no difference between the two procedures in terms of mortality, morbidity, and oncological radicality. The limiting factor for an R0 resection is not the gastric margin but the dorsal, retroperitoneal pancreas margin.

The advantage of the pylorus-preserving method is a shorter operation time and less blood loss. Furthermore, patients with preserved physiological gastric emptying show better function regarding absorption, food utilization, and postoperative weight gain.

In the case of infiltration of large veins (superior mesenteric vein, splenic vein, or portal vein), resection should be pursued, if necessary with vascular reconstruction, as preoperative diagnostics often cannot differentiate between inflammatory adhesion and tumor infiltration. Patients seem to benefit from vascular resection if an R0 resection is achieved.

The resection of visceral arteries is a case-by-case decision to achieve an R0 resection given the current insufficient study situation.

The indication for resection is made by the surgeon promptly after diagnosis, especially if it is a potentially resectable finding in jaundiced patients. Only in patients with manifest secondary complications of jaundice (deranged plasma coagulation, liver synthesis disorder, reduced cellular defense, purulent cholangitis) should preoperative endoscopic bile duct drainage be considered to gain time and create a better starting situation for the operation. In all other cases, preoperative bile duct drainage, whether TPCD (transpapillary) or PTCD (percutaneous-transhepatic), is avoided due to increased postoperative morbidity.

Comorbidity is another essential factor in the indication process. Patients with severe cardiovascular comorbidities carry a significantly increased surgical risk. High age per se is no longer a contraindication for pancreaticoduodenectomy today.

In locally advanced tumors with questionable resectability, an attempt at neoadjuvant radio-chemotherapy can be made (preferably in studies) to still enable a resection with a curative approach.

Lymphadenectomy includes the regional lymph nodes at the duodenum and pancreatic head. An extension beyond this does not lead to improved survival. Therefore, extended lymph node dissection is controversial due to an increased complication rate. Vascular skeletonization along the aorta and superior mesenteric artery with removal of nerve tissue can result in persistent gastric emptying disorders and severe diarrhea with malnutrition.

In the demonstrated case, it is the oncological resection of a papillary carcinoma.

• Pancreatic head malignancies with proximal infiltration of the superior mesenteric artery or the celiac trunk
• Locally unresectable tumor with mesenteric root infiltration
• In the presence of unresectable distant metastases
• Portal vein thrombosis or other conditions with pronounced venous collateral circulation (liver cirrhosis).
• Patients with severe cardiovascular comorbidities for whom anesthesia alone poses a risk (e.g., NYHA III constellation with high-grade carotid stenoses)

History/Clinical Findings:

• No characteristic leading symptom, nonspecific with loss of appetite, feeling of fullness, digestive disorders, weight loss.
• Painless jaundice in tumors of the pancreatic head
• Upper abdominal and back pain with localization in the body/tail area
• Newly onset diabetes mellitus
• Cholestasis, cholangitis, obstructive pancreatitis, Courvoisier sign (palpable enlarged tense elastic gallbladder), palpable tumor, previous surgeries

Laboratory Diagnostics:

• CBC, CRP, blood sugar, oGTT (oral glucose tolerance test), lipase/amylase in serum
• Tumor marker CA 19-9 (independent predictor of poorer overall survival)
• CEA (especially from endosonographically obtained cyst punctate)
• Genetics: PRSS1, SPINK1, PSTI, CFTR (in young patients to exclude hereditary genesis – strict indication due to high cost!)

Imaging Diagnostics

The diagnosis of a pancreatic head tumor is based on the detection of morphological changes using imaging techniques. Laboratory, endoscopy, and biopsy play a subordinate role. CT is most commonly used, increasingly also MRI with MRCP. Preoperative differentiation can be difficult and often can only be made intraoperatively or even through the definitive histology of the specimen.

• Transcutaneous Sonography: Basic diagnostics with good and non-invasive visualization of the pancreatic parenchyma, also allowing detection of pancreatic duct enlargement. Additional assessment of the portal venous system through color Doppler sonography. Ultrasound contrast agents can contribute to the differential diagnosis of inflammatory vs. tumorous, cystic tumor vs. pseudocyst. Furthermore, detection of cholestasis, cholecystolithiasis, liver metastases, ascites.

• CT or MRI: Confirmation of tumor suspicion, assessment of local resectability (vascular infiltration), distant metastasis (liver), vascular supply of the liver/upper abdomen (e.g., anomalies such as atypical right hepatic artery), calcifications in the pancreas, pancreaticolithiasis, ascites.

A depiction of the biliary or pancreatic duct system is only required in unclear cases. ERCP and MRCP are suitable for this purpose. The "double-duct sign" (simultaneous stenosis/interruption of the pancreatic duct and common bile duct) is considered pathognomonic for carcinoma.

• MRCP (MR cholangiopancreatography): Non-invasive visualization of the biliary and pancreatic duct system. More sensitive than ERCP in detecting solid wall changes (so-called "mural nodules").
• ERCP: Due to possible complications (pancreatitis, bleeding, perforation), preferably only for therapeutic intervention, otherwise MRCP or EUS.
• Interventional relief of the bile duct system only in case of irresectability or delay of surgery, otherwise immediate surgical intervention.
• Endoscopic Ultrasound (EUS): Mass in the pancreatic head, determination of local tumor extent and assessment of local lymph nodes (lymph nodes > 1 cm are suspicious for malignancy), possibly with puncture (fine needle aspiration of cyst fluid) and biopsy.
• Exclusion of lung metastases by thoracic CT.

Gastroduodenoscopy:

• Histological confirmation possible in papillary carcinoma
• Exclusion or extent of duodenal polyps with stomach preservation
• Transpapillary secretion of viscous mucus highly suspicious for IPMN

A histological confirmation of the tumor is not required preoperatively if there is sufficient tumor suspicion, but it is necessary before initiating neoadjuvant radiochemotherapy or palliative chemotherapy in the metastatic stage.

• Blood group determination
• Provision of 4 cross-matched erythrocyte concentrates
• Icteric patients: parenteral administration of Vitamin K for 2-3 days preoperatively regardless of coagulation values.
• Only for patients with manifest secondary complications of jaundice (deranged plasma coagulation, liver synthesis disorder, reduced cellular defense) preoperative endoscopic bile duct drainage
• Gastric outlet stenosis: preoperative gastric tube

Significant procedure, therefore pay special attention to the informed consent period (> 24h; better to inform during the initial consultation).
Always use surgical drawings to clarify postoperative anatomy! 

Consequences of the procedure:

General

• Wound healing disorder
• Thromboembolism
• Pneumonia
• Lymphatic fistula
• Injury to adjacent structures (intestine, vessels, nerves, other organs)
• Extension of the surgery at the discretion of the surgeon
• Subsequent interventions
• Long-term intensive medical treatment in case of complications
• Bleeding/rebleeding: Allogeneic blood transfusions necessary in about 50%

Specific

• Pancreatic fistula
• Gastric emptying disorder
• Bile leakage/biloma
• Anastomotic insufficiency/stenosis
• Necrosis of the pancreatic remnant
• Endocrine and exocrine pancreatic insufficiency, possibly associated dietary changes
• Insulin-dependent diabetes mellitus (lifelong)
• Peptic ulcers of the jejunum
• Episodes of cholangitis with biliodigestive anastomosis