Plate 138
###### Figure 6

Total pancreatectomy may be indicated in the treatment of neoplasms of the pancreas as well as for incapacitating, chronic, recurrent pancreatitis. Excision of the entire gland ensures more complete removal of neoplasms but adds little to the average long-term survival. Multicentric tumor locations are excised and cellular implantations are obliterated within the remaining ductal system, and intimately attached lymph nodes are excised. Removal of the pancreas simplifies the reconstruction of the upper gastrointestinal tract and minimizes the complications from pancreatic duct implantation, postoperative pancreatitis, hemorrhage, and sepsis.

The diabetes associated with total pancreatectomy is difficult to manage because of hypoglycemia and requires careful and frequent evaluation of insulin requirements. The indications for this procedure are related not only to the clinical history but also to the findings at the time of the surgical exploration.

These patients are frequently poor surgical risks who have lost considerable weight and may be diabetic. The blood volume should be restored and blood sugar levels monitored. Total parenteral nutrition may be indicated for several days before exploration. In the presence of deep jaundice, the biliary tree is decompressed by percutaneous transhepatic intubation or stenting using at the time of endoscopic retrograde cholangiopancreatography. The bile is cultured and the appropriate antibiotics are given, depending upon sensitivity studies. Vitamins are given along with pancreatic replacement if floating stools are present. Several units of blood should be available. Systemic antibiotics are given. Constant gastric suction is instituted.

General anesthesia combined with endotracheal intubation is satisfactory.

The patient is placed in a comfortable supine position.

The skin of the lower thorax as well as of the entire abdomen is prepared in a routine manner.

A liberal midline incision extending from over the xiphoid process down to or below the left of the umbilicus is made (Figure 1). Some prefer an inverted U incision that parallels the costal margins and crosses the midline near the top of the xiphoid process. All bleeding points are carefully controlled. The first decision involves establishing the diagnosis, ascertaining the presence or absence of metastases, and finally, establishing the mobility of the pancreas with special reference to the portal vein. Any evidence of distant metastasis to the omentum, the base of the mesentery of ...

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