Chapter 89: Resection of the Tail of the Pancreas

INDICATIONS

The more common indications for resecting the body and tail of the pancreas include localized adenocarcinoma, pancreatic neuroendocrine tumors, premalignant cysts, and chronic calcific pancreatitis.

PREOPERATIVE PREPARATION

Preparation is related to the preoperative diagnosis. If splenectomy is contemplated, then vaccine administration for encapsulated organisms preoperatively is recommended. Vaccinations against pneumococcus, Haemophilus influenzae, and meningococcus should be administered approximately 2 weeks prior to surgery. Patients with suspected insulinoma, suggested by repeated fasting blood sugar determinations of less than 50 mg/dL, may require admission for supplementary glucose prior to surgery due to their nothing-by-mouth status, which may cause the patient to become severely hypoglycemic.

When an ulcerogenic tumor or gastrinoma is suspected, the fluid and electrolyte balance should be corrected, particularly if there have been large losses of gastric secretions or losses from enteritis. Serum gastrin levels may establish the diagnosis. Every effort should be made to localize one or more endocrine tumors by computed tomography, magnetic resonance imaging, octreotide scan, or gallium positron emission tomography/computed tomography. In select patients, selective arteriography and selective arterial stimulation with either secretin (for gastrinoma) or calcium (for insulinoma) may be required.

ANESTHESIA

General anesthesia with endotracheal intubation is used.

POSITION

The supine position with the left side on a bump is used based on surgeon preference.

OPERATIVE PREPARATION

The hair is clipped across the abdomen, and the skin is prepared and draped in routine manner. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.

INCISION AND EXPOSURE

Either a long vertical midline or a left upper quadrant incision parallel to the costal margin is used.

DETAILS OF THE PROCEDURE

When the procedure is carried out for an inflammatory lesion of the body and tail of the pancreas, direct exploration of this region is performed. When the procedure is carried out for a tumor, thorough exploration of the abdomen with particular reference to the liver and gastrohepatic ligament in the region of the celiac plexus should be done looking for evidence of metastasis. Evidence of gastric hypersecretion, as indicated by increased vascularity and thickening of the gastric wall, along with a hyperemic and hypertrophic duodenum and an ulcer in the duodenum or beyond the ligament of Treitz, adds support to the potential diagnosis of gastrinoma tumor of the pancreas. Likewise, the inner wall of the duodenum should be carefully palpated in the search for small tumors extending into the lumen of the duodenum from the pancreatic side. If a gastrinoma is not identified in the pancreas, the best way to assess the duodenum is by performing a duodenotomy in the descending duodenum. In sporadic cases, most duodenal gastrinomas will be ...