Total pancreatectomy may be indicated in the treatment of neoplasms of the pancreas, including main duct intraductal papillary mucinous neoplasms and incapacitating, chronic, recurrent pancreatitis. Total pancreatectomy also may be indicated in a small subset of patients with multifocal adenocarincoma or neuroendocrine tumors.
The indications for total pancreatectomy relate not only to the clinical history but also to findings at the time of surgical exploration. Removal of the pancreas simplifies the reconstruction of the upper gastrointestinal tract and minimizes some types of complications, such as pancreatic duct anastomotic leak or postoperative pancreatitis, whereas other types of complications, such as hemorrhage and sepsis, persist. Diabetes and exocrine insufficiency following total pancreatectomy also can be difficult to manage. With removal of the entire pancreas, the normally occurring glucagon response to hypoglycemia is abolished. Hence hypoglycemia frequently occurs and requires careful and frequent evaluation of insulin requirements. The exocrine insufficiency requires treatment with oral pancreatic enzymes.
Islet cell autotransplantation is an option in some patients with chronic pancreatitis undergoing total pancreatectomy. If this option is considered, these patients should be referred to a high-volume specialized center.
Often patients being considered for total pancreatectomy are poor surgical risks who have lost considerable weight and may be diabetic. The blood volume should be restored, and blood sugar levels should be monitored. In the presence of deep jaundice, the biliary tree is decompressed by percutaneous transhepatic intubation or stenting at the time of endoscopic retrograde cholangiopancreatography. Vitamins are given along with pancreatic replacement if floating stools are present. Several units of blood should be available. Preoperative antibiotics are administered prior to incision. A nasogastric or orogastric tube is placed. Epidural anesthesia may be considered in select patients for postoperative pain control.
General anesthesia combined with endotracheal intubation is satisfactory.
Patients are placed in the supine position.
The skin of the lower thorax as well as of the entire abdomen is prepared in routine manner. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.
A liberal midline incision extending from over the xiphoid process down to or below and left of the umbilicus is made (FIGURE 1A). Some surgeons prefer an inverted-U incision that parallels the costal margins and crosses the midline near the top of the xiphoid process (FIGURE 1B). All bleeding points are carefully controlled. The surgeon should first explore the abdomen, confirm the diagnosis, and ascertain the presence or absence of metastases. Any evidence of distant metastasis to the omentum, the base of the mesentery of the transverse colon, or the liver or adjacent lymph nodes makes any procedure palliative. In ...