Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++ Malignant lesions involving the head of pancreas, ampulla of Vater, distal end of the common bile duct, or duodenum. Absence of metastasis.Absence of arterial involvement.Refractory severe pain from chronic pancreatitis. Refractory to medical therapy.Repeat hospital admissions.Majority of disease limited to the head of the pancreas. +++ Absolute ++ Evidence of metastatic disease.Evidence of para-aortic nodes outside the field of dissection.Involvement of the aorta or vena cava.Involvement of the superior mesenteric artery, hepatic artery, or celiac axis. +++ Relative ++ Cardiopulmonary comorbidities. ++ Survival following resection of periampullary and pancreatic lesions depends on the site of the primary tumor and stage. The overall 5-year survival rate is 20–30% but may be significantly better in patients with limited disease burden.Using prognostic modeling, a patient with a well- differentiated small tumor (1 cm) and no nodal involvement would have a 50% 5-year survival.A patient with a poorly differentiated lesion > 4 cm and 10 positive lymph nodes would have an estimated 10% 3-year survival rate. +++ Expected Benefits ++ To remove malignancies involving the head of the pancreas, ampulla, distal common bile duct, or duodenum while restoring continuity of the biliary-pancreatic system. +++ Potential Risks ++ Surgical site infections (superficial or deep, abscess).Bleeding.Pneumonia.Cardiovascular events.Venous thromboembolism.Delayed gastric emptying (15–40% of patients).Anastomotic leak (most commonly from the pancreaticojejunal anastomosis).Abscess.Biloma.Pseudocyst.Pancreatic fistulas.Incomplete resection and positive margins. ++ General surgery instrument tray.Self-retaining abdominal retractor to aid exposure.A surgical energy device (eg, harmonic scalpel or LigaSure) is useful for dividing the jejunal mesentery.Gastrointestinal anastomosis (GIA) stapler.Thoracoabdominal (TA) stapler. ++ Assessment of tumor resectability. Fine-cut (3-mm) pancreatic protocol CT.MRI and magnetic resonance cholangiopancreatography (MRCP) can be useful to clarify the relationship of the tumor to the blood vessels and biliary system.Endoscopic retrograde cholangiopancreatography (ERCP) should be reserved for patients with obstructive jaundice and no mass noted on CT.ERCP with stent placement may be used for deeply jaundiced patients.Endoscopic ultrasound (EUS) is helpful in assessing lymph node involvement and relationship to the major vasculature.Assessment of cardiovascular risk. ++ The patient should be supine.The entire abdomen is shaved and prepped.The abdomen is entered through a midline incision or bilateral subcostal "Chevron" incision, depending on surgeon preference. ++ The procedure can be divided into three stages: assessment of resectability, resection, and reestablishment of continuity.Figure 15–1: The round ligament and falciform ligaments are divided to provide adequate exposure. A Kocher maneuver is performed initially to expose the proximal duodenum and pancreas and ensure that no direct extension of the tumor involves the aorta or inferior vena cava.The duodenum is retracted medially under tension, and the peritoneum is incised along the lateral edge of the duodenum.... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Download the Access App: iOS | Android Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.