Total Pancreatectomy

Total pancreatectomy may be indicated in the treatment of neoplasms of the pancreas as well as for incapacitating, chronic, recurrent pancreatitis. Excision of the entire gland ensures more complete removal of neoplasms but adds little to the average long-term survival. Multicentric tumor locations are excised and cellular implantations are obliterated within the remaining ductal system, and intimately attached lymph nodes are excised. Removal of the pancreas simplifies the reconstruction of the upper gastrointestinal tract and minimizes the complications from pancreatic duct implantation, postoperative pancreatitis, hemorrhage, and sepsis.

The diabetes associated with total pancreatectomy is difficult to manage because of hypoglycemia and requires careful and frequent evaluation of insulin requirements. The indications for this procedure are related not only to the clinical history but also to the findings at the time of the surgical exploration.

These patients are frequently poor surgical risks who have lost considerable weight and may be diabetic. The blood volume should be restored and blood sugar levels monitored. Total parenteral nutrition may be indicated for several days before exploration. In the presence of deep jaundice, the biliary tree is decompressed by percutaneous transhepatic intubation or stenting using at the time of endoscopic retrograde cholangiopancreatography. The bile is cultured and the appropriate antibiotics are given, depending upon sensitivity studies. Vitamins are given along with pancreatic replacement if floating stools are present. Several units of blood should be available. Systemic antibiotics are given. Constant gastric suction is instituted.

General anesthesia combined with endotracheal intubation is satisfactory.

The patient is placed in a comfortable supine position.

The skin of the lower thorax as well as of the entire abdomen is prepared in a routine manner.

A liberal midline incision extending from over the xiphoid process down to or below the left of the umbilicus is made (Figure 1). Some prefer an inverted U incision that parallels the costal margins and crosses the midline near the top of the xiphoid process. All bleeding points are carefully controlled. The first decision involves establishing the diagnosis, ascertaining the presence or absence of metastases, and finally, establishing the mobility of the pancreas with special reference to the portal vein. Any evidence of distant metastasis to the omentum, the base of the mesentery of the transverse colon, or to the liver or adjacent lymph nodes makes any procedure palliative. In the absence of metastasis, and in the presence of a freely movable pancreas, further exploration is warranted. The removal of the entire pancreas does simplify the reconstruction of the gastrointestinal tract by a variety of methods (Figures 2 and 3). Only the common duct and the remaining hemigastrectomy remain to be anastomosed to the jejunum.

The omentum is detached from the transverse colon and the lesser sac inspected after the right gastroepiploic vessels are divided. A Kocher maneuver is carried out to mobilize the duodenum and head of the pancreas (Figure 4). Needle or knife biopsies of any suspicious tumor mass are taken, and suspicious regional lymph nodes are sent for frozen-section examination.

The duodenum and head of the pancreas can be mobilized as for the Whipple procedure (Plates 131, 132, and 133). When it has been decided to remove the body and tail of the pancreas as well as the head, the peritoneum along the inferior border of the pancreas is incised in preparation for mobilization by blunt finger dissection (Figure 5). The splenic artery is ligated near its point of origin. After the peritoneum over the portal vein has been incised, it is possible to insert the finger between the pancreas and the portal vein (Figure 6). There should be no communicating veins anteriorly. The pancreas can be divided with electrocautery in this area, and the two segments of the pancreas resected separately if preferred.

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Although antrectomy with gastrojejunostomy is the usual technique for reconstruction, some preserve the entire stomach and pylorus plus several centimeters of duodenal bulb for end-to-side anastomosis to the jejunal limb according to the method of Longmire. In the usual reconstruction, however, better exposure is obtained for the subsequent steps of the procedure if the stomach is divided at a level that ensures complete removal of the antrum (Figure 7). Truncal vagotomy also is performed to decrease the incidence of late postoperative gastrojejunal stomal ulceration, unless lifetime treatment with proton pump inhibitors or other acid suppressing medication is determined to be preferable.

The spleen is freed up and all gastrosplenic vessels are divided and ligated. The spleen and left half of the pancreas are reflected to the right, providing good exposure for maximal ligation and division of the splenic artery and vein at their origins (Figure 8). Any arterial branches to the superior mesenteric artery are carefully isolated and ligated (Figure 9). The most difficult part of the procedure may be the isolation and ligation of the several short veins entering between the portal vein and the pancreas (Figure 10). The ligated right gastric artery and the pancreaticoduodenal artery are shown in Figure 10.

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The gallbladder is removed in a routine manner and the liver bed may be closed with interrupted sutures. A noncrushing clamp is applied across the common duct and the duct is divided (Figure 11). The next step is to excise the rest of the duodenum down to and slightly beyond the ligament of Treitz (Plate 134, Figures 27 and 28).

A long arm of jejunum is prepared by dividing several vascular arcades (Figure 12). The mobilized jejunum is brought through an opening made in the mesocolon of the transverse colon (Figure 12). This opening is made at either side of the middle colic vessels, depending upon how easily the jejunal loop can be brought up to the region of the common duct. The jejunum is closed with a running 00 absorbable suture or a stapler, and this layer is inverted with a layer of 00 silk mattress or interrupted sutures. Following a gastrojejunal anastomosis, the jejunal loop is anastomosed without tension to the common duct (Figure 2). Alternatively, some prefer to anastomose the biliary duct to the jejunum, followed by an anastomosis with the gastric pouch (Figure 3). It is not necessary to make the stoma the full width of the stomach. A stoma of 3 to 5 cm can be made at the greater curvature end (Figure 13). The jejunum should be anchored to the entire gastric outlet, regardless of how much has been closed off by sutures. The jejunum between the stomach and the common duct should be quite loose and free of tension (Figure 14). All openings in the mesocolon about the arm of the jejunum should be closed with interrupted sutures to avoid angulation of the arm of jejunum or the possibility of an internal hernia. Closed-system suction catheters made of Silastic are used.

The incision is closed in the routine manner. A subcuticular close of the skin may be used, or the skin may be approximated with interrupted sutures or clips.

Constant gastric suction is maintained until bowel function returns within a few days. Blood sugar levels are determined every 4 to 6 hours until stable control is attained. The amount of insulin may not exceed 25 to 30 units daily in some patients. An insulin drip may be necessary in the initial days after surgery. Blood losses must be replaced. Oral pancreatic replacement therapy is started as soon as tolerated. Frequent nutritional evaluation is essential in postoperative care.