Plate 129
###### Figure 6

The head of the pancreas is usually removed for malignancy involving the ampulla of Vater, the lower end of the common duct, the head of the pancreas, or the duodenum. Far less frequently, the procedure is carried out to manage intractable pain associated with a chronic calcific pancreatitis or for massive trauma when there is irreparable “burst” damage to the head of the pancreas, the ductal structures, and the duodenum. In the presence of malignancy, the resection is indicated in the absence of proven metastases and if the tumor is of such a limited size that the portal vein is not involved beyond the ability of the surgeon to accomplish a safe vascular resection and repair. Total pancreatectomy may be considered in some cases because of the tendency for multicentric foci of malignancy to develop as well as seeding within the pancreatic duct. This procedure also decreases the incidence of postoperative complications from the leakage of pancreatic juice from the anastomosis. The patient should be made aware of the problem of diabetes mellitus after operation as well as the need for daily pancreatic enzyme replacement.

Patients will have had imaging including CT, MRI, and possibly endoscopic ultrasound prior to the procedure. Some patients may have had biliary stents placed by an endoscopic or transhepatic route. Transfusions of blood products may be required preoperatively to restore the blood volume and decrease the tendency to hypotension and renal shutdown that may occur after operation. The electrolyte levels should be returned to normal and particular care should be taken that the INR is normal and that renal function is not impaired, as shown by creatinine and blood urea nitrogen levels. Blood should be available. The measured amount of blood lost should be replaced during the operative procedure, preferably via a central venous catheter. It is advisable to have a catheter in the bladder in order to follow the postoperative hourly output of urine. Antibiotic therapy should be started prior to operation. This is particularly important for patients with stents, as they are prone to wound infections.

A nasogastric tube is inserted. General anesthesia with endotracheal intubation is recommended.

The patient is placed supine on the table with the feet slightly lower than the head. Facilities should be available for performing a cholangiogram or ...

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