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  • 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.

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Absolute

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  • 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.

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Relative

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  • Cardiopulmonary comorbidities.

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  • 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.

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Expected Benefits

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  • To remove malignancies involving the head of the pancreas, ampulla, distal common bile duct, or duodenum while restoring continuity of the biliary-pancreatic system.

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Potential Risks

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  • Surgical site infections (superficial or deep, abscess).
  • Bleeding.
  • Pneumonia.
  • Cardiovascular events.
  • Venous thromboembolism.
  • Delayed gastric emptying (15–40% of patients).
  • Anastomotic leak (most commonly from the pancreaticojejunal anastomosis).
  • Abscess.
  • Biloma.
  • Pseudocyst.
  • Pancreatic fistulas.
  • Incomplete resection and positive margins.

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  • 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.

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  • 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.

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  • 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.

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  • 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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