Pancreas Surgery & Complications

Milestones in Pancreatic Surgery

• First Successful Resection:
  • Performed by Whipple and Parsons.
• First One-Stage Whipple Procedure:
  • Performed by Trimble.

Arterial Resection in Pancreatic Cancer

• High Morbidity and Mortality: Arterial resection is associated with significant risks.
• Neoadjuvant Chemotherapy (NACT): Recommended before considering arterial resection.
• Regional Pancreatectomy: Involves both venous and arterial resection.
• Appleby Procedure:
  • Indicated for celiac axis involvement with a patent gastroduodenal artery (GDA).
  • The celiac origin must be free from the aorta.

Henle’s Trunk (Gastrocolic Trunk of Henle)

• Location: Henle’s trunk, also known as the Gastrocolic Trunk of Henle, is a venous structure located in the right upper quadrant of the abdomen. It is situated near the head of the pancreas, typically behind the first part of the duodenum.
• Formation: The trunk is formed by the convergence of several veins:
  • Right Gastroepiploic Vein: Drains the greater curvature of the stomach.
  • Anterior Superior Pancreaticoduodenal Vein: Drains part of the pancreas and duodenum.
  • Right Colic Vein (sometimes): Most Commonly Superior RCV Drains the ascending colon.
• Drainage: Henle’s trunk typically drains into the superior mesenteric vein (SMV), which is a significant vessel in the portal venous system. The SMV then continues to join the splenic vein to form the portal vein.

Most Common variant is TYPE 1 = has SRCV 2nd Most Common = Type 2 =no SRCV

Step 1 of Whipple’s Surgery: Key Points

• Entering the Lesser Sac:
  • The lesser sac is entered, and the hepatic flexure of the colon is mobilized.
• Identifying the Inferior Body of the Pancreas:
  • The inferior body of the pancreas is identified at the level of the proximal body of the gland.
• Incising the Visceral Peritoneum and Mesentery:
  • The visceral peritoneum and root of the mesentery are incised in a lateral direction toward the junction of the second and third portions of the duodenum.
• Exposing the SMV:
  • The goal is to expose the anterior wall of the superior mesenteric vein (SMV).
  • The SMV is exposed at the inferior border of the pancreas near the neck of the pancreas and uncinate process.

Step 2 of Whipple’s Surgery: Key Points

• Kocher Maneuver:
  • The Kocher maneuver is performed by first identifying the inferior vena cava (IVC) at the level of the promixal portion of the duodenum (D3).
• Mobilization of the Duodenum and Pancreatic Head:
  • The duodenum and pancreatic head are mobilized off of the IVC in a cephalad direction, while carefully removing all soft tissue attachments.
• Preservation of the Right Gonadal Vein:
  • The right gonadal vein is preserved if possible, serving as a guide for preventing injury to the underlying ureter or other structures.
• Left Renal Vein and Adjacent Anatomy:
  • The Kocher maneuver extends to the left lateral border of the aorta (AO).
  • Attention is given to preserving any accessory renal arteries that may travel anterior to the IVC.

Step 4 of Whipple’s Surgery: Key Points

• Resection of the Stomach:
  • The antrum of the stomach is resected as part of the main specimen.
• Division at Lesser Curvature:
  • The stomach is divided at the level of the third or fourth transverse vein on the lesser curvature.

Step 5 of Whipple’s Surgery: Key Points

• Transection of the Jejunum:
  • The jejunum is transected and followed by ligation and division of its mesentery.
• Mobilization of the Duodenum:
  • The loose attachments of the ligament of Treitz are released.
  • The fourth and third portions of the duodenum are mobilized by dividing their short mesenteric vessels.
• Reflection of the Duodenum and Jejunum:
  • Both the duodenum and jejunum are reflected underneath the mesenteric vessels in preparation for the final steps of the pancreaticoduodenectomy.

Step 6 of Whipple’s Surgery: Key Points

• Separation of the Pancreatic Head and Uncinate Process:
  • The pancreatic head and uncinate process are separated from the superior mesenteric-portal vein confluence.
• Transection at the Portal Vein:
  • The pancreas is transected at the level of the portal vein, and the pancreatic head is reflected laterally.
• Ligation of Small Venous Tributaries:
  • Small venous tributaries from the portal vein and superior mesenteric vein (SMV) are identified, ligated, and divided.
• Important Tributary:
  • A constant venous tributary from the portal vein to the cephalad pancreatic head is often referred to as the superior pancreaticoduodenal vein.
• Venous Hypertension Management:
  • To minimize venous hypertension, some surgeons prefer leaving this venous branch intact until at least one caudal inferior pancreatoduodenal artery (off the SMA) is divided, reducing blood loss during dissection.

Step 6 (Continued) and Final Resection in Whipple’s Surgery: Key Points

Image 1: Attempted Removal of Pancreaticoduodenectomy Specimen

• Avoid Mobilization Without SMA and SMV Identification:
  • Failure to properly identify and control the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) can lead to SMA injury and postoperative hemorrhage.
  • Directly identifying and ligating the inferior pancreaticoduodenal arteries is critical to avoid complications.
• Technique:
  • Proper SMA identification ensures safe retroperitoneal and mesenteric dissection, minimizing the potential for a margin-positive resection.

Image 2: Final Resection Step

• Medial Retraction of the Superior Mesenteric-Portal Vein Confluence:
  • Medial retraction of the superior mesenteric-portal vein confluence facilitates dissection of the soft tissues adjacent to the lateral wall of the proximal SMA.
  • This step defines the SMA margin.
• Ligation and Division of Inferior Pancreaticoduodenal Arteries:
  • The inferior pancreaticoduodenal artery (or arteries) is identified at its origin from the SMA, ligated, and divided.
  • 2nd Most Common source of bleeding

Key Points for Revision: Important Aspects of Pancreaticoduodenectomy

• Test Clamp GDA: Performed to rule out celiac artery stenosis.
• Important Lymph Node: CHA lymph node (Common Hepatic Artery node).
• "Tunnel of Love": Refers to the SMV-Portal vein tunnel.
• Pylorus Preservation vs Classical Whipple:
  • No difference in outcome regarding delayed gastric emptying (DGE).
• Vascular Resection:
  • Overall survival (OS) is similar to resectable cancer when vascular resection is performed.
• SMA Resection:
  • Does not improve long-term survival.
  • Associated with high morbidity and mortality.

Lymphadenectomy During Pancreaticoduodenectomy [Guidelines by ISGPS] :

• Lymph Node Stations:
  • No. 5: Suprapyloric lymph nodes
  • No. 6: Infrapyloric lymph nodes
  • No. 8a: Anterosuperior group along the common hepatic artery [node of importance]
  • No. 12b and 12c: Along the bile duct and around the cystic duct
  • No. 13a: Posterior aspect of the superior portion of the head of the pancreas
  • No. 13b: Posterior aspect of the inferior portion of the head of the pancreas
  • No. 14: Along the right lateral superior mesenteric artery (SMA)
  • No. 17a: Anterior surface of the superior portion of the head of the pancreas
  • No. 17b: Anterior surface of the inferior portion of the head of the pancreas

Extended Lymphadenectomy in Pancreaticoduodenectomy

• Additional Lymph Node Stations in Extended Lymphadenectomy:
  • Station 9: Celiac lymph nodes
  • Station 7: Left gastric artery (LGA) lymph nodes
  • Station 10: Splenic lymph nodes
  • Station 16: Para-aortic lymph nodes
• Extended Lymphadenectomy Includes:
  • Lymph nodes in the para-aortic region, celiac trunk, and inferior mesenteric artery (IMA) (as practiced in Japan).
• Indication:
  • Not routinely indicated as it does not improve survival and is associated with increased morbidity, particularly diarrhea.

Reconstruction Techniques in Pancreaticoduodenectomy

• Pancreaticojejunostomy:
  • Types of Anastomosis: there are many types but the most important are discussed below.
    • Duct-to-mucosa (Katita technique)
    • Invagination (Dunking procedure)
    • Blumgart's anastomosis: Duct-to-mucosa anastomosis with transpancreatic horizontal mattress sutures.
  • Outcome: Technique does not influence leak rate.
• Pancreaticogastrostomy:
  • Associated with higher bleeding complications.

Gastrointestinal Reconstruction in Pancreaticoduodenectomy

• Pylorus-Preserving PD (Pancreaticoduodenectomy):
  • Preserves the pylorus ring, avoiding antrectomy.
• Classical PD:
  • Involves antrectomy.
• Pylorus Ring-Preserving PD:
  • Similar to pylorus-preserving PD but focuses specifically on preserving the pyloric ring.
• Outcomes:
  • Pylorus preservation does not increase delayed gastric emptying (DGE).
• Reconstruction Route:
  • Antecolic reconstruction is preferred over retrocolic for better outcomes of DGE rates.

Use of Drains in Pancreaticoduodenectomy

• Drain Placement:
  • Did not decrease morbidity associated with the procedure.
• Fistula Formation:
  • No significant difference in fistula occurrence or fistula-related complications with drain placement.
• Early Drain Removal:
  • Associated with decreased rates of pancreatic fistula.

Artery-First Approach in Pancreaticoduodenectomy

• First step:
  • Dissect the uncinate from SMA to assess SMA for resectability
• Purpose:
  • Facilitates early identification of resectability in borderline cases.
• First Artery to be Divided:
  • Inferior Pancreaticoduodenal Artery (IPDA). [ In conventional approach = GDA ?]
• Outcomes:
  • Does not increase survival but may decrease blood loss and affect lymph node yield.
• Benefits:
  • Useful in venous resection.
  • Clears the right lateral border of the SMA first.
  • Aids in the identification of aberrant anatomy.
  • Helpful in extended pancreatectomy.

Six different surgical approaches to the superior mesenteric artery (SMA), commonly used in pancreatic surgery or other abdominal procedures. Here's a breakdown of the labeled approaches in the diagram:

• S (Superior Approach): Access to the SMA from above.
• A (Anterior Approach): Coming in from the front (ventral side).
• P (Posterior Approach): Approaching from behind the artery.
• L (Left Posterior Approach): Coming from behind but to the left side.
• R (Right/Medial Uncinate Approach): This approach refers to accessing the artery medially near the uncinate process of the pancreas.
• M (Mesenteric Approach): This refers to approaching the artery through the mesentery.

Posterior Approach in Pancreaticoduodenectomy = Most Commonly done

• Kocherization:
  • The duodenum is kocherized (mobilized) to expose the SMA above the left renal vein (LRV).
• Arteries Divided:
  • The Superior Pancreaticoduodenal Artery (SPDA) and Inferior Pancreaticoduodenal Artery (IPDA) are divided during this approach.
• Key Anatomical Structures:
  • SMA is exposed in front of the left renal vein (LRV).
  • Other structures include the Inferior Vena Cava (IVC).

Medial Uncinate Approach in Pancreaticoduodenectomy = also Most Commonly done

• Medial Uncinate Approach:
  • Focuses on the dissection and exposure of the uncinate process (UP).
• Key Structures Exposed:
  • Inferior Pancreaticoduodenal Artery (IPDA) and Inferior Pancreaticoduodenal Vein (IPDV).
  • Superior Mesenteric Artery (SMA) and Superior Mesenteric Vein (SMV).
• Kocherization:
  • The duodenum is mobilized with Kocherization and mobilization of the duodenojejunal flexure to provide access for further dissection.

Inferior Infracolic (Mesenteric) Approach in Pancreaticoduodenectomy

• Inferior Infracolic (Mesenteric) Approach:
  • Exposes the Superior Mesenteric Artery (SMA) and Superior Mesenteric Vein (SMV) after dividing the peritoneum.
• Key Dissection Area:
  • The peritoneum is divided to the right of the duodenojejunal flexure (DJF) within the transverse mesocolon.

• Key Structures Exposed:
  • Pancreas (P)
  • Splenic Vein (SV)
  • Middle Colic Vein (MCV)
  • Inferior Pancreaticoduodenal Artery (IPDA)
  • Middle Colic Artery (MCA)

Left Posterior Approach in Pancreaticoduodenectomy

• Division of Jejunal Arteries (JA):
  • First and second jejunal arteries are divided at their origin.
• Assessment Advantage:
  • Allows for tumor assessment without mobilization of the colon and duodenum.
• Tumor Focus:
  • Primarily used for tumors arising from the uncinate process or the posterior aspect of the head of the pancreas.

Inferior Supracolic (Anterior) Approach in Pancreaticoduodenectomy

• Neck Division:
  • The neck of the pancreas may need to be divided in this approach.
• En Bloc Removal:
  • Ensures en bloc removal of the tumor and surrounding structures.
• Tumor Focus:
  • Primarily used for tumors of the lower head of the pancreas.

Superior Approach in Pancreaticoduodenectomy = Very difficult and Least favoured

• Superior Approach:
  • Focuses on exposing the celiac axis and its branches, as well as the superior mesenteric artery (SMA) in the lesser sac above the neck of the pancreas.
• Key Structures Exposed:
  • Left Gastric Artery (LGA)
  • Common Hepatic Artery (HA)
  • Splenic Artery (SA)
  • Portal Vein (PV)
  • Gastroduodenal Artery (GDA)

Approach	Indications	Advantages	Disadvantages
Posterior	Posteromedial tumors in the head/neck, especially involving PV-SMV.	Early identification of SMA involvement, identification of replaced RHA, enables retroperitoneal lymphadenectomy.
Early identification of SMV involvement and facilitates enbloc resection	Difficult in patients with pancreatitis or inflammation and adhesions around the head of the pancreas.
Medial Uncinate	Malignant tumors of the uncinate process.	Early identification of SMA involvement at the uncinate, early ligation of IPDA minimizes bleeding.	Late identification of replaced RHA.
Inferior Infracolic (Mesenteric)	Locally advanced tumors with questionable SMA involvement, malignant uncinate or ventral pancreas tumors.	Early identification of replaced RHA, better exposure to dissect SMA from aorta, early ligation of IPDA minimizes bleeding.	Difficult in morbidly obese patients, difficult exposure with high SMA origin.
Left Posterior	Tumors along the uncinate and ventral pancreas.	Facilitates isolation of the SMA in the retroperitoneum without kocherization of duodenum.	Extensive dissection of SMA, requiring antimesenteric dissection.
Inferior Supracolic (Anterior)	Tumors along the inferior border of the pancreas.	Early ligation of IPDA, retroperitoneal dissection in patients with advanced tumors, "no-touch" technique.	Early division of the stomach and neck of the pancreas.
Superior	Malignant tumors of the superior pancreas.	Early identification of CHA, celiac axis, and SMA involvement.	Difficult exposure in patients with low origin SMA.

Laparoscopic Distal Pancreatectomy (LDP) and Minimally Invasive Pancreaticoduodenectomy

• Laparoscopic Distal Pancreatectomy (LDP):
  • Growing interest in minimally invasive surgery for distal pancreas tumors.
  • Advantages:
    • Smaller incisions.
    • Shorter hospital stay.
  • Morbidity rate: 38%.
  • Hospital length of stay: 5 days.
  • Increasingly used for benign conditions, but its role in PDAC (Pancreatic Ductal Adenocarcinoma) is still under evaluation.
• Spleen-Preserving LDP:
  • Can be done by:
    • Preserving the splenic vessels or
    • Sacrificing the splenic vessels and relying on the short gastric vessels for perfusion.
• DIPLOMA Trial:
  • Compared open vs minimally invasive (laparoscopic/robotic) approaches in over 1200 patients.
  • No inferiority found with minimally invasive techniques.
  • No randomized trials have yet assessed minimally invasive versus open surgery approaches.
• Minimally Invasive Pancreaticoduodenectomy:
  • Increasing in popularity, though there is lack of evidence for its benefits.
  • LEOPARD-2 Trial:
    • Multicenter randomized controlled trial comparing minimally invasive vs open pancreaticoduodenectomy.
    • Trial closed early due to increased mortality in the minimally invasive group.
    • Mortality rate: 10% for minimally invasive group vs 2% for open surgery group.
    • Debate continues on the appropriateness of minimally invasive pancreaticoduodenectomy.

Morbidity after Pancreaticoduodenectomy

1. Delayed Gastric Emptying (DGE):

• Occurs in 5-15% of cases.
• Characterized by the need for prolonged nasogastric decompression or inability to tolerate oral intake.
• DGE is likely multifactorial but may be related to the decrease in plasma motilin that occurs following duodenal resection, vagal innervation to the pylorus and antrum with gastric atony, and/or relative devascularization of the pylorus.
• Pylorus preservation may be associated with DGE, but findings are inconsistent.

• Cross-sectional imaging is necessary to rule out secondary causes such as pancreatic leak or intraabdominal abscess.

• Most important in the prevention of DGE is the avoidance of other complications, namely POPF, as discussed earlier, because such complications are clearly associated with a secondary DGE.

• Nutritional management: Enteral feeding through a feeding tube is used until stomach function returns.

2. Pancreatic Leak or Post-Operative Pancreatic Fistula (POPF)

• Defined as output from an intraoperatively placed drain on or after postoperative day 3 with amylase >3 times normal serum value.
• Occurs in 5-22% of surgeries.
• The texture of the gland is a predictive factor, with soft, fatty glands at higher risk.
• Most fistulas are managed with drainage catheters placed during surgery.

• Rarely, uncontrolled fistulas require additional interventions such as operative exploration or completion pancreatectomy.

• Incidence:

  • 30-40% (including biochemical leak).
  • 12-15% (excluding biochemical leaks).
• Definition:
  • Any amount of drain fluid with amylase > 3 times serum amylase on postoperative day 3.
• Classification:
  • Biochemical leak (previously Grade A).
  • Grade B and Grade C fistulas.
• Risk Factors:
  • Gland texture (softer glands at higher risk).
  • Duct diameter (narrow ducts increase risk).
  • Blood loss (higher blood loss during surgery correlates with increased risk).
  • Obesity.
  • Distal Pancreatectomy: Higher incidence (25-30%), though with a milder course.
  • Neoadjuvant Chemotherapy: Considered protective.

ISGPS Classification and Grading of Post-Operative Pancreatic Fistula (POPF)

Biochemical Leak (BL):

• NO POPF.
• Increased amylase level > 3 times upper limit.
• Drain placed ≥ 3 days.
• No clinical impact (no interventions or complications).
• NO organ failure.
• NO death.

Grade B POPF:

• Clinically relevant POPF with:
  • Yes for increased amylase level > 3 times upper limit.
  • Drain kept ≥ 3 weeks
  • Interventions or prolonged stay required (somatostatin analogues, TPN, etc.).
  • YES, without organ failure.
  • NO death.

Grade C POPF:

• Clinically severe POPF with:
  • Yes for increased amylase level > 3 times upper limit.
  • Interventions required.
  • YES, with organ failure.
  • YES for death related to POPF.

Clinically Relevant POPF:

• Defined as drain output of any measurable volume with amylase level > 3 times the upper normal limit.
• Associated with a clinically relevant condition directly related to POPF (e.g., prolonged hospital stay, specific therapeutic management).

Grade B:

• Prolonged hospital or ICU stay.
• Use of therapeutic agents such as somatostatin analogues, TPN/TEN, or blood product transfusions.

Grade C:

• Involves postoperative organ failure, defined by the need for:
  • Re-intubation.
  • Hemodialysis.
  • Inotropic agents for more than 24 hours (for respiratory, renal, or cardiac insufficiency).

Key Points for Revision: Flowchart for Biochemical Leak and POPF Grade Definition

1. Biochemical Leak (BL):
   • Amylase > 3 times upper institutional normal serum amylase value.
   • Persistent drainage >3 weeks but without clinically significant complications.
2. Grade B Pancreatic Fistula:
   • Involves clinically relevant change in the management of the POPF.
   • May require interventional or endoscopic drainage, angiographic procedures for bleeding, or management for signs of infection without organ failure.
3. Grade C Pancreatic Fistula:
   • Requires reoperation.
   • Associated with organ failure.
   • May result in death.

3. Anastomosis and Fistula Risk in Pancreaticoduodenectomy

• Leaks from hepaticojejunostomy and duodenojejunostomy are rare (<5%).

• Anastomosis Technique:

  • The technique of anastomosis (whether pancreaticogastrostomy (PG) or pancreaticojejunostomy (PJ)) does not significantly influence the anastomotic leak rate.
  • Leak rates for PG and PJ are similar at 11-12%.

  Objective Fistula Risk Score (o-FRS):

  • Developed by Kallery, the o-FRS calculates fistula risk based on key factors:
    • Gland texture.
    • Pathology (tumor type)
      • Periampullary / NET / Cystic Neoplasms = soft pancreas = has high leak rates
      • PDAC = firm pancreas = low leak rates
    • Duct diameter.
    • Blood loss during surgery.
  • Total score ranges up to 10, with higher scores indicating greater risk of postoperative fistula.

  Modified Fistula Risk Score:

  • a-FRS (Alternative Fistula Risk Score): Developed by the Dutch Pancreatitis Group, includes:
    • Gland texture.
    • Duct diameter.
    • BMI (Body Mass Index).
  • Ua-FRS (Updated Alternative FRS):
    • Includes additional factors such as:
      • BMI.
      • Gland texture.
      • Duct size.
      • Male sex.
      • Minimally invasive pancreaticoduodenectomy (PD).

  Fistula Prevention Strategies

  • Octreotide:
    • Conflicting evidence regarding its effectiveness.
    • May decrease fistula rate in high-risk pancreas cases.
  • Pasireotide has been shown to reduce the rate of clinically relevant POPF.
  • Stents:
    • External stent may be useful in certain cases involving a high-risk pancreas.

This image illustrates the bridge-stent technique used to address dehiscence of the pancreaticojejunal anastomosis:

• Figure A: Shows the dehiscence between the pancreatic remnant and the jejunum, creating a gap at the anastomotic site.
• Figure B: Demonstrates the bridge-stent technique with an externalized stent plus an external drain adjacent to the gap.
• Figure C: Illustrates the bridge-stent technique with an internal stent and an external drain positioned adjacent to the gap. This method allows for better drainage and helps in salvaging the anastomosis.

4. Infectious Complications:

• Intraabdominal abscess or wound infection may occur and require percutaneous drainage or wound dressing changes.

5. Pancreatic Endocrine and Exocrine Insufficiency:

• Endocrine (insulin) and exocrine (enzyme) insufficiency can occur but are rare in patients with a normal gland.
• Patients with chronic pancreatitis, gland fibrosis, or insulin resistance are at higher risk and may require enzyme and insulin replacement.

6. Postpancreatectomy Hemorrhage (PPH):

• Incidence: Occurs in 8-10% of cases.
• Classification:
  • Intraoperative: Occurs during surgery.
  • Early hemorrhage:
    • Within 24 hours postoperatively.
    • Common causes: Technical failure or coagulopathy.
    • Management: Prompt re-exploration if the patient is unstable.
  • Late hemorrhage:
    • Occurs after 24 hours.
    • Typically due to a pseudoaneurysm or related to a postoperative fistula.
    • Most common arteries involved in delayed hemorrhage:
      • Most Common = Gastroduodenal artery (GDA)
      • Hepatic artery
      • Splenic artery
      • SMA branches = 2nd Most Common is IPDA
      • Splenic vein stump

Management of Postpancreatectomy Hemorrhage (PPH):

Grade A:

• Early intraluminal/extraluminal, mild bleeding.
• Clinical condition: Well.
• Management: Observation, blood count, ultrasonography, and if necessary, CT scan.
• Therapeutic consequence: No intervention needed.

Grade B:

• Early intraluminal/extraluminal, severe or late intraluminal, mild bleeding.
• Clinical condition: Intermediate, rarely life-threatening.
• Management:
  • Observation, ultrasonography, CT, angiography.
  • Therapeutic consequence: Transfusion, intermediate care or ICU, therapeutic endoscopy, embolization, re-laparotomy for early PPH.
• Additional Note:
  • Late intraluminal or extraluminal, mild bleeding may not be immediately life-threatening, but it can be a warning sign for later severe hemorrhage ("sentinel bleed") and is therefore classified as Grade B.
  • Endoscopy should be performed when there are signs of intraluminal bleeding (e.g., melena, hematemesis, or blood loss via nasogastric tube).

Grade C:

• Late intraluminal/extraluminal, severe bleeding.
• Clinical condition: Severely impaired, life-threatening.
• Management:
  • Angiography, CT, endoscopy.
  • Therapeutic consequence: Localization of bleeding, angiography, embolization, re-laparotomy, ICU care.

Key Points:

• Early hemorrhage requires immediate intervention due to the risk of instability.
• Delayed hemorrhage, often caused by a pseudoaneurysm, may present later and is usually associated with a postoperative pancreatic fistula.

Key points on Management:

• Early extraluminal bleeding: Requires re-exploration.
• Gastrojejunostomy (GJ) / Duodenojejunostomy (DJ) bleeding: Managed with endoscopy.
• Late PPH:
  • CT angiography or Digital Subtraction Angiography (DSA) is used for diagnosis and management.
  • Presents as sentinel bleed or associated with septic complications.

Distal Pancreatectomy

• Conventional approach: The surgery is typically performed left to right.
• Pancreatic stump management:
  • Stapler division is used to divide the pancreatic tissue.
  • Duct ligation is performed to securely close the pancreatic duct and prevent postoperative complications such as pancreatic fistula.
• Postoperative pancreatic fistula (POPF):
  • Occurs in 10-35% of cases.
  • There is no superior technique identified for preventing POPF.
  • Using a well-vascularized omental flap may help decrease the rate of POPF.

Splenic Preservation Techniques

• Indications: Used for low-grade malignancy or benign conditions during distal pancreatectomy.

Techniques:

1. Division of Splenic Vessels (Warshaw Technique):
   • Splenic vessels are divided.
   • The spleen is perfused by short gastric vessels.
2. Preservation of Splenic Vessels (Kimura Technique):
   • Splenic vessels are preserved, allowing for better blood flow to the spleen.

Note: Both techniques aim to preserve the spleen, with the Warshaw technique relying on short gastric vessels for perfusion, while the Kimura technique maintains the splenic vessels intact.

Central Pancreatectomy

• Procedure:
  • Proximal stump: Oversewn to prevent leakage.
  • Distal stump: Anastomosed to the jejunum or stomach.
• Indications:
  • Used for benign, indolent, or premalignant lesions.
  • No lymphadenectomy is performed as it's typically unnecessary for benign or low-grade lesions.
• Postoperative Complications:
  • Higher risk of postoperative pancreatic fistula (POPF) compared to other procedures.

• Inclusion Criteria:

  • Tumor size < 5 cm.
  • Benign or low-grade malignant lesions.
  • Lesion located in the neck of the pancreas.
  • A distal stump of at least 5 cm is required for anastomosis.

  

This summary highlights the key surgical steps, indications, and criteria for central pancreatectomy, emphasizing its role in managing specific benign or low-grade malignant lesions.

RAMPS (Radical Antegrade Modular Pancreatectomy)

• Definition: Radical antegrade modular pancreatectomy.

• Procedure:

  • Performed from right to left, unlike conventional distal pancreatectomy, which is left to right.

    

• Advantages:

  • Provides better lymph node clearance, especially in cancers of the body of the pancreas.
  • Dissection is carried out at or below Gerota's fascia.
• Types:
  • Anterior RAMPS: Typically performed for less aggressive tumors.
  • Posterior RAMPS:
    • Involves removal of the adrenal gland.
    • Left renal vein forms the posterior plane of dissection.