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INDICATIONS

Pancreaticoduodenectomy, commonly known as a Whipple procedure, is most commonly indicated for neoplasms of the head of the pancreas, ampulla of Vater, distal common bile duct, or duodenum. In addition, pancreaticoduodenectomy may be performed for cystic neoplasm of the pancreas at high risk for harboring malignancy or for malignant transformation. Far less frequently, the procedure is carried out to manage intractable pain associated with chronic calcific pancreatitis.

For patients with periampullary cancers, pancreaticoduodenectomy is indicated in thosets without evidence of metastases or advanced comorbidities of prohibitive risk for major surgery. All patients should undergo pancreas protocol cross-sectional imaging (multiphase contrast-enhanced imaging with thin cut slices through the region of the pancreas) to assess resectability, identify individual arterial anatomy, and inform preoperative planning. In general, tumors are resectable if they are separate from the superior mesenteric artery and branches of the celiac trunk (including the hepatic artery) and have less than 180-degree involvement of the superior mesenteric/portal vein. Borderline resectable and locally advanced cancers may be operable following downstaging neoadjuvant therapy in experienced centers but commonly require concomitant vascular resection and repair.

OVERVIEW OF THE PROCEDURE

Pancreaticoduodenectomy involves removal of the head of the pancreas, distal common bile duct, duodenum, and gallbladder. In a classic Whipple procedure, the distal stomach is also removed, whereas in a pylorus-preserving pancreaticoduodenectomy, it is not. In the adjacent anatomic plate, the gallbladder, antrum of the stomach, head of the pancreas, and duodenum have been separated to call attention to the various relationships, including the blood vessels that must be ligated in this procedure. These structures are numbered for convenient identification.

PREOPERATIVE PREPARATION

Patients will have had imaging including computed tomography and/or magnetic resonance imaging, and possibly endoscopic ultrasound, prior to the procedure. Some patients may have had biliary stents placed by an endoscopic or transhepatic route. The electrolyte levels should be returned to normal, and particular care should be taken to ensure that the international normalized ratio is normal and that renal function is not impaired, as demonstrated by creatinine and blood urea nitrogen levels. Patients with jaundice may have occult vitamin K deficiency that may not become apparent until blood loss occurs. A urinary catheter is placed, deep venous thrombosis prophylaxis is administered, and prophylactic antibiotics are given prior to incision.

ANESTHESIA

Either an orogastric or nasogastric tube is inserted. General anesthesia with endotracheal intubation is recommended. An epidural catheter for postoperative pain management may be used selectively.

POSITION

Patients are placed supine on the table.

OPERATIVE PREPARATION

The skin should be clipped from the level of the nipples well out over the chest wall and down over ...

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