Perioperative management - Left pancreatic resection, spleen-preserving, robotically assisted

Indications for Spleen-Preserving Distal Pancreatectomy

• Pathological changes limited to the pancreatic body or tail, excluding primary pancreatic carcinomas:
  • Benign solid and cystic lesions of the pancreatic tail and body
  • Pancreatic pseudocysts
  • Adenomas
  • Cystic tumors without suspicion of malignancy (suspected IPMN + MCN)
  • Neuroendocrine tumors
  • Metastases in the pancreatic tail
  • Focal chronic pancreatitis
  • Trauma
• Alternative procedures:
  • Distal pancreatectomy with splenectomy, especially in primary pancreatic carcinomas
  • Open distal pancreatectomy
  • Local excision (only for benign lesions)
• An oncological distal pancreatectomy with splenectomy is indicated for
  • All cystic and solid tumors with proven malignancy or suspicion of malignancy

Note: During the implementation phase of a robotics program, distal pancreatectomy is ideally considered as an "entry" into robotic surgery at pancreatic centers with prior laparoscopic experience due to its specific characteristics. After all, an isolated resection occurs without reconstruction. Initially, "uncomplicated" resections are recommended, for example, in benign findings. With initial experience, the spectrum can quickly expand to malignant tumors and resections in pancreatitis.

• Primary malignancies of the exocrine pancreas
• Also inflammatory changes extending to the splenic hilum
• Involvement of the pancreatic head then pancreatectomy
• Locally unresectable tumor with central vascular invasion
• Non-resectable distant metastases
• Portal vein thrombosis or other conditions with pronounced venous collateral circulation (liver cirrhosis).
• Splenic vein occlusion with pronounced collaterals and presence of gastric varices
• Acute pancreatitis
• Liver cirrhosis Child B and C
• Patients with severe cardiovascular comorbidities for whom anesthesia alone poses a risk (e.g., NYHA III constellation with high-grade carotid stenoses)

Medical history/Clinical Findings:

• No characteristic leading symptom, nonspecific with loss of appetite, feeling of fullness, digestive disorders, weight loss.
• Upper abdominal and back pain with localization in the body/tail area
• Newly onset diabetes mellitus due to destruction of the islets of Langerhans
• Obstructive pancreatitis, palpable tumor
• Previous surgeries

Laboratory Diagnostics

• Complete blood count, CRP, albumin, lipase/amylase, blood sugar, oral glucose tolerance test or HbA1c, blood group and possibly erythrocyte concentrates as per surgeon's discretion
• Tumor marker CA 19-9 (independent predictor of poorer overall survival)
• CEA (also and especially from endosonographically obtained cyst punctate)
• Genetics: PRSS1, SPINK1, PSTI, CFTR (in young patients to exclude hereditary genesis – strict indication due to high cost!)
• Hormone analysis if endocrine active neoplasms are suspected

Note: Pancreatic function diagnostics can employ the following tests (in processes in the body and tail, exocrine dysfunction is not assumed):

• Oral glucose tolerance test in previously unknown diabetes mellitus to assess endocrine pancreatic function
• HbA1c to assess endocrine pancreatic function
• Stool elastase for diagnosing exocrine pancreatic function

Imaging Diagnostics

• Transcutaneous Sonography: Basic diagnostics with good and non-invasive visualization of the pancreatic parenchyma, also allowing detection of pancreatic duct dilation. Additional assessment of the portal vein system through color Doppler sonography. Ultrasound contrast agents can contribute to differential diagnosis between inflammatory and tumorous, cystic tumor - pseudocyst. Furthermore, detection of cholestasis, cholecystolithiasis, liver metastases, ascites.
• CT Abdomen: For solid changes, a 4-phase CT of the abdomen is most suitable. CT can fundamentally assess pancreatic masses, lymph node enlargements, perfusion of the superior mesenteric vein, portal vein, superior mesenteric artery, and celiac trunk, distant metastases, pancreatic calcifications, pancreaticolithiasis, distant metastasis.
• MRI with MRCP (Magnetic Resonance Cholangiopancreatography): For cystic tumors, an MRI of the upper abdomen with MRCP is recommended, which is superior to CT in terms of diagnostic power. Additionally, MRI with MRCP better visualizes the spatial relationships between the tumor and pancreatic duct system. Furthermore, duct irregularities, stenoses, dilations, double-duct sign = simultaneous stenosis of the pancreatic duct and common bile duct, common bile duct stenosis, dilation, and pancreaticolithiasis can be detected.
• Possibly CT Thorax: to exclude pulmonary metastasis
• Possibly CEUS ultrasound (contrast-enhanced ultrasound) to assess liver lesions
• Possibly FDG-PET-CT: in suspected metastatic situation

Endoscopic/Invasive Diagnostics

• Possibly EGD with Endosono: Clarification of gastric collateral pathologies and further depiction of the pancreas through endosonography to assess mural changes in cystic neoplasms for type diagnosis of these changes as well as for cyst puncture or biopsy confirmation, examiner-dependent
• Possibly Laparoscopy in suspected peritoneal carcinomatosis and/or proven ascites -> puncture with cytology
• Possibly ERCP: Due to possible complications (pancreatitis, bleeding, perforation), preferably only for therapeutic intervention, otherwise MRCP or EUS.

Preoperative Functional Diagnostics

• ECG
• Lung function
• Chest X-ray
• Others depending on pre-existing conditions

Special Preparation

• Blood group determination
• Possibly provision of 2 cross-matched erythrocyte concentrates as per surgeon's discretion
• Possibly stabilization of coagulation (e.g., Konakion®)
• Possibly improvement of liver function (e.g., DHC stenting in jaundice)

Preoperative Preparation:

• Body care: shower the evening before
• Shaving: from jugulum to symphysis; legs in case of vein removal for vascular construction
• Preoperative nutrition: eat lunch the day before, then small intestine absorbable diet (SAD), in case of reduced general condition and nutritional status (albumin < 30mg/dL) additionally high-calorie nutrition (3 days preoperatively), human albumin, iron (Ferrinject), vitamin B12, folic acid
• Thrombosis prophylaxis: See guideline Prophylaxis of venous thromboembolism (VTE)
• Premedication: Epidural catheter. Intensive care unit registration. Central venous catheter
• Antibiotics: according to house standard, e.g., Cefuroxime 1.5g and Clont 500 mg or Rocephin 2g + Clont 500mg (repeat after 3 hours of surgery time)

General Risks

• Wound healing disorder
• Thromboembolism
• Lymphatic fistula
• Injury to internal organs (intestine, liver, stomach, spleen)
• Subsequent interventions
• Bleeding/Rebleeding: PPH = postpancreatectomy hemorrhage

Specific Risks

• Splenectomy.
• Pancreatic fistula: POPF = postoperative pancreatic fistula
• Acute pancreatitis
• Endocrine pancreatic insufficiency with diabetes mellitus (lifelong)
• Stomach wall injury
• Gastric emptying disorder: DGE = delayed gastric emptying

Definition and classification of PPH, POPF, and DGE by the International Study Group of Pancreatic Surgery (ISGPS), see literature references for this

• Intubation anesthesia
• Urinary catheter
• Perioperative antibiotic prophylaxis
• Intra- and postoperative analgesia with epidural catheter
• Nasogastric tube
• 2 large-bore IV cannulas
• If necessary, central venous catheter
• If necessary, arterial pressure monitoring

Follow this link to PROSPECT (Procedure specific postoperative pain management) or to the current guideline Management of acute perioperative and post-traumatic pain.