- Malignant lesions involving the head of pancreas, ampulla of Vater, distal end of the common bile duct, or duodenum.
- Absence of metastasis.
- Absence of arterial involvement.
- Refractory severe pain from chronic pancreatitis.
- Refractory to medical therapy.
- Repeat hospital admissions.
- Majority of disease limited to the head of the pancreas.
- Evidence of metastatic disease.
- Evidence of para-aortic nodes outside the field of dissection.
- Involvement of the aorta or vena cava.
- Involvement of the superior mesenteric artery, hepatic artery, or celiac axis.
- Cardiopulmonary comorbidities.
- Survival following resection of periampullary and pancreatic lesions depends on the site of the primary tumor and stage.
- The overall 5-year survival rate is 20–30% but may be significantly better in patients with limited disease burden.
- Using prognostic modeling, a patient with a well- differentiated small tumor (1 cm) and no nodal involvement would have a 50% 5-year survival.
- A patient with a poorly differentiated lesion > 4 cm and 10 positive lymph nodes would have an estimated 10% 3-year survival rate.
- To remove malignancies involving the head of the pancreas, ampulla, distal common bile duct, or duodenum while restoring continuity of the biliary-pancreatic system.
- Surgical site infections (superficial or deep, abscess).
- Cardiovascular events.
- Venous thromboembolism.
- Delayed gastric emptying (15–40% of patients).
- Anastomotic leak (most commonly from the pancreaticojejunal anastomosis).
- Pancreatic fistulas.
- Incomplete resection and positive margins.
- General surgery instrument tray.
- Self-retaining abdominal retractor to aid exposure.
- A surgical energy device (eg, harmonic scalpel or LigaSure) is useful for dividing the jejunal mesentery.
- Gastrointestinal anastomosis (GIA) stapler.
- Thoracoabdominal (TA) stapler.
- Assessment of tumor resectability.
- Fine-cut (3-mm) pancreatic protocol CT.
- MRI and magnetic resonance cholangiopancreatography (MRCP) can be useful to clarify the relationship of the tumor to the blood vessels and biliary system.
- Endoscopic retrograde cholangiopancreatography (ERCP) should be reserved for patients with obstructive jaundice and no mass noted on CT.
- ERCP with stent placement may be used for deeply jaundiced patients.
- Endoscopic ultrasound (EUS) is helpful in assessing lymph node involvement and relationship to the major vasculature.
- Assessment of cardiovascular risk.
- The patient should be supine.
- The entire abdomen is shaved and prepped.
- The abdomen is entered through a midline incision or bilateral subcostal "Chevron" incision, depending on surgeon preference.
- The procedure can be divided into three stages: assessment of resectability, resection, and reestablishment of continuity.
- Figure 15–1: The round ligament and falciform ligaments are divided to provide adequate exposure.
- A Kocher maneuver is performed initially to expose the proximal duodenum and pancreas and ensure that no direct extension of the tumor involves the aorta or inferior vena cava.
- The duodenum is retracted medially under tension, and the peritoneum is incised along the lateral edge of the duodenum.
- The retroperitoneum is entered ...
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