Chapter 16. Distal Pancreatectomy

• Distal pancreatic solid mass.
  • Neuroendocrine tumor.
  • Pancreatic adenocarcinoma.
  • Solid neoplasm of indeterminate diagnosis.
• Distal pancreatic mucinous cystic neoplasms.
  • Asymptomatic, ≥ 3 cm in size.
  • Symptomatic, any size.
  • Presence of a solid component.
  • Dilated main pancreatic duct.
• Distal pancreatic symptomatic serous cystadenoma.
• Chronic calcific pancreatitis or small symptomatic pseudocyst limited to pancreatic tail (less common).

Absolute

• Proximal mass requiring pancreatoduodenectomy.
• Known metastatic disease.
• Local invasion of structures that cannot be resected en bloc with the pancreas.
• Mass encasing mesenteric vessels, with loss of usual fat planes noted on preoperative imaging (CT, MRI, or endoscopic ultrasound [EUS]).
• Portal hypertension.

Relative

• Cardiopulmonary comorbidities.
• Splenic vein thrombosis.

Expected Benefits

• Surgical cure of a neoplasm in the distal pancreas.
• Prevention of malignant transformation of mucinous cystic neoplasms.
• Treatment of symptomatic benign disease.

Potential Risks

• Surgical site infection, bleeding, and damage to adjacent structures.
• Removal of the spleen.
  • Should this be necessary, patients are at risk for the rare complication of post-splenectomy sepsis.
• Complications unique to operations on the pancreas include:
  • Postoperative pancreatitis.
  • Pancreatic leaks.
  • Pancreatic fistula formation.

• No special equipment is needed.
• A self-retaining retractor helps facilitate exposure of the operative field.
• A surgical energy device (eg, harmonic scalpel, LigaSure) is extremely useful.
• Depending on surgeon preference, a surgical stapler may be used to transect the pancreatic tail. In that case, a thoracoabdominal (TA) or gastrointestinal anastomosis (GIA) stapler is used.

• Thorough preoperative evaluation is essential before undertaking this procedure.
• For symptomatic patients, delineation of the presenting symptoms and correlation of these symptoms with the mass in the pancreatic tail or body is critical.
• Potentially useful tests include:
  • Abdominal CT, ultrasonography.
  • Endoscopic retrograde cholangiopancreatography (ERCP) or EUS.
  • Magnetic resonance cholangiopancreatography (MRCP).
• For cystic neoplasms, cyst fluid is often obtained during EUS and analysis is performed to differentiate mucinous from serous cystic lesions and to determine cyst fluid CEA levels.
• Side branch versus main duct intraductal papillary mucinous neoplasms should be differentiated preoperatively using ERCP, MRCP, or EUS, if at all possible.
• Patients with persistent hypoglycemia and suspected insulinoma should receive glucose supplementation.
• Patients with refractory ulcers, elevated gastrin levels, and the suspicion of a gastrinoma should receive preoperative treatment for acid secretion and appropriate fluid and electrolyte supplementation.
• If splenectomy is planned, patients should undergo immunization for encapsulated organisms at least 2 weeks before surgery.

• The patient should be supine.
• The skin is prepared from the level of the nipples to the pubis, extending along the flank.
• The abdomen is entered through a midline incision.
• Alternatively, a bilateral subcostal incision may be used.

• Figure 16–1: Ligation of the short gastric vessels.
  • For resection of the distal pancreas, the standard approach is through an upper midline incision.
  • The pancreas is approached as in other pancreatic procedures through the lesser ...