Whipple complication

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1. ComplicationsComplications
ofof
Whipple OperationWhipple Operation
By Ri 林帛賢

2. Reference
1.Prevention and treatment of complications in pancreatic cancer
surgery. Review. Digestive Surgery 1999;16:327-336
2.Complications after resection of biliopancreatic cancer. Annals of
Oncology 10 suppl. 4:S257-260
3.Management of complication after pancreaticoduodenaectomy in
a high volume center:Results on 150 consecutive patients.
Digestive Surgery 2001;18:453-458
4. Management of complications following
pancreaticoduodenectomy. Surg Clin North Am 75:913-924,
5. Trends in indications and outcomes in the Whipple procedure
over a 40-year period.Am Surg. 1999 Sep;65(9):889-93.
6. Pancreatic Resection: Effects on Glucose Metabolism. World J
Surg. 2001 Apr;25(4):452-60. Epub 2001 Apr 11
Sabiston Textbook of Surgery, 16th ed
Oxford Textbook of Surgery 2000. 2th ed
http://www.rcsed.ac.uk/journal/vol47_3/4730003.html

3. Allen Oldfather Whipple
(1881-1963)
Pancreatico-duodenectomy
(PD) was first performed
by Kausch in 1908, and
popularized by Whipple in
the 1930s (who performed
37 procedures).
—Whipple AO, Parsons WB,
Mullins CR.
Treatment of Carcinoma of the
Ampulla of Vater. Ann Surg 1935;
102: 763-769.

4. The operation' classical 'Whipple involves an 'en-bloc'
resection of the pancreatic head, together with the distal
stomach and omentum, the duodenum and upper jejunum,
and the distal biliary tree including the gall bladder
Classic Whipple
Resection—
Pancreatico-
duodenectomy

5. Reconstruction after Classic Whipple Resection

6. Modified Whipple operation
—PPPD
A more limited duodenectomy with
preservation of the stomach and
antropyloric region is preferred by some
experts and the pylorus preserving
pancreatico-duodenectomy (PPPD)
involves a lesser lymphadenectomy

7. PPPD
Pylorus-
preserving
pancreatico-
duodenectomy

8. (a) pancreaticogastrostomy
(b) end-to-end pancreaticojejunostomy
(c) end-to-side pancreaticojejunostomy

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9. Classic Whipple V.S. PPPD
PPPD—protects against gastric dumping,
marginal ulceration, and bile reflux gastritis.
Significant reduction of the operation time, the
intraoperative blood loss and the consequent need
for blood substitution.
But sufficiently radical to treat pancreatic cancer?
Similar or even better postoperative morbidity
and mortality result was debated.

10. Principle Indications for PD
(1)Ductal adenocarcinoma of the pancreatic head
(2)Cholangiocarcinoma of the distal biliary tree
(3)Periampullary adenocarcinoma and ampullary
carcinoid
(4)Primary duodenal adenocarcinoma, duodenal
GIST and duodenal lymphoma
(5)Chronic pancreatitis with associated mass lesion
of uncertain aetiology

11. Results following
Pancreaticoduodenectomy
Due to improved surgical skill and peri-
operative care
Mortality rate 20%-40% in earlier days
During the past decades, dramatically
decreased and currently is between 0-4%
in experience centers with experience.
Complication rate is still 30%-40%

12. Complications of
Pancreaticoduodenectomy
Common Uncommon
Delayed gastric emptying Fistula
Pancreatic fistula Biliary
Intra-abdominal abscess Duodenal
Hemorrhage Gastric
Wound infection Organ failure
Metabolic Cardiac
Diabetes Hepatic
Pancreatic exocrine Pulmonary
insufficiency Renal
Pancreatitis
Marginal ulceration

13. Pancreatic Fistulas and Leakage
of the Pancreaticointestinal
Anastomosis
Definition: persistent drainage of 50 ml or more
of amylase-rich fluid per day after postoperative
day 7
4-24% —the second leading cause of morbidity,
is often undiscovered harmless
If progress to a real anastomosis leakage with
consequent sepsis and hemorrhage— the major
cause of the mortality
If a pancreatic leakage occurs, 20-40% die

14. Risk Factors of Pancreatic Fistulas
and Leakage of the
Pancreaticointestinal Anastomosis
1.soft texture of the pancreatic remnant in
pancreatic cancer patients
2.the side of the pancreatic remnant
3.continuous exocrine pancreatic secretion that
may cause tension on the pancreatico-intestinal
anastomosis
4.the technical difficulty of performing a proper
and safe anastomosis between the stomach or
small bowel and the pancrease

15. Supportive Evidence
 fistula mortality due to
fistula
Chronic pancreatitis 5% 9%
Pacreatic cancer 12% 31%
Ampullary cancer 15% 27%
Bile duct cancer 33% 70%

16. Supportive Evidence
Fibrotic pancreatic remnant , as commonly
found in chronic pancreatitis, facilitates the
anastomosis
Normal pre-operative exocrine function
test result—low degree of pancreatic
fibrosis and consequently a higher
incidence of postoperative pancreatic
fistula and leakage

17. Best surgical prevention of
postoperative complication
Safe surgical technique
 1. End-to-side pancreaticojejunostomy
 2. End-to-end pancreaticojejunostomy
 3. Pancreaticogastrostomy

18. 4.Pancreatic ductal occlusion or
drainage
Pancreatic duct closure by ligation,
stapling, or suturing
1. Inevitable fistula rate—50-100%
2. Exocrine insufficiency—
steatorrhea and diarrhea
=>unfavorable

19. 5. others
External stenting of the duct with separated
Roux loops
Sealing of the pancreaticojejunostomy with
fibrin glue
=> Minor Effective

20. Detection of Pancreatic Fistulas
and Anastomosis Leakage
Day after surgery(days) 5(1-20)

Clinical sign
temp>38.5 62%
abd. Pain 41%
dyspnea 34%
peritoneal tenderness 66%

21. Laboratory findings
leukocytosis >15000 69%
amylase drain >3* serum amylase 72%
Diagnostic procedure
ultrasound 90%
pancreatography 100%
CT-scan 89&
CXR pleural of fusion 74%

Adapted from
Complications after resection of biliopancreatic cancer.
Annals of Oncology 10 suppl. 4:S257-260

22. Management of Pancreatic
Fistulas and Leakage
No sign of local peritonitis or ongoing
hemorrhage in clinically stable patient
—TPN and close observation
Administration of a somatostatin analogue
(Octreotide)—reduce pancreatic secretion
—shortens the spontaneous closure time

23. Management of Pancreatic
Fistulas and Leakage
Unstable clinical situation & ongoing or
recurrent hemorrhage
=>Completion Pancreatectomy
=>operative lavage or placement of
additional drains—outcome is dissatisfying
=>not advisable to construct a new
anastomosis

24. Intraabdominal Abscess
Incidence—10%
Pancreatic Fistulas and Leakage
Intraabdominal Abscess
Sepsis
D/D—postoperative intraabdominal fluid
collectionresolve spontaneously
by drainage fluid character

25. Management of Intraabdominal
Abscess
Controlling the underlying causes
—fistula & anastomosis leakage
Completion Pancreatectomy if neccessary
Ultrasonographic or CT guide
percutaneous catheter drainage
Operative lavage or placement of
additional drains

26. Hemorrhage
Incidence—5-16%
Mortality rate—15-58%
Classification
(a) Bleeding within 24 hr
(b) Bleeding occurs in the 2th and 3th weeks
(1) Intraabdominal bleeding(mostly from the
retroperitoneal operation field)
(2) Gastrointestinal bleeding(intraluminal)

27. Bleeding within 24 hr
Mostly caused by—
Insufficient Intraoperative Hemostasis
Detection—(1)output of the drain
(2)Hb level
(3)vital sign of the patient

28. Bleeding within 24 hr
Bloody output of NG tube or melena
suture line bleeding
gastroscopy
no stablization after blood & FFP
reoperation

29. Bleeding in the later course
Anastomostic suture line bleeding or
marginal ulcer
often masking “Sentinel Bleed”
(the erosive bleeding from the
retroperitoneal vessels)
leakage of the pancreatic anastomosis
 carefully D/D by gastroscopy

30. D/D Stress Ulcer
Rarely seen after pancreaticoduodenectomy
Prevention by administration of H+ pump
inhibitor, H2-antagonist
Detected and resolved by interventional
endoscopy

31. Prevention of Hemorrhage
Perform a proper operation with a careful
hemostasis
Pre-operation bile drainage into the
duodenum by ERCP or PTCD in jaundice
patients(because coagulation disturbance
usually seen in jaundice patients)

32. Delayed Gastric Emptying
(1) Persistent secretion via the gastric tube of
more than 500 ml/day over more than 5
days after surgery
(2) Recurrent vomitting
(3) Swelling of the gastrojejunostomy/
duodenojejunostomy
(4) Dilation of the stomach in the contrast medium
passage

33. Delay Gastric Emptying
Incidence 25-70%
Resolves spontaneously within 2-4 week
Risk factor
a. Presence of intraabdominal complication
b. Radicality of the resection
(Lymph node dissection)
D/D obstruction at the duodenojejunostomy or
gastrojejunostomy

34. Mechanism of
Delay Gastric Emptying
(1)Gastric atony caused by disruption of the
gastroduodenal neural network after extended
retroperitoneal lymphadenectomy
(2)Decreased Motilin level(produced from the
enterochromaffin cells of duodenum and
proximal jejunum) reduce the gastric motility
(3)Ischemic injury to the antropyloric muscle
mechanism
(4)Gastric arrythmias secondary to intra-abdominal
complication such as anastomostic leakage or
abscess

35. Management of
Delay Gastric Emptying
Incorpotrating prolonged nasogastric or
gastrostomy tube decompression combined
with TPN or Enteral nutrition
Administration of
(1) motilin agonist—erythromycin
(2) prokinetic agents—metoclopramide
and/or cisapride

36. Pancreatogenic Diabetes
Pancreaticoduodenectomy remove 30-40%
of the pancreatic parenchymal mass
Majority of patients—no important
clinically important effect on glucose
homeostasis
Minority—hyperglycemia and glucosuria
—dietary adjustment, OHA or
parenteral insulin

37. AnyAdulthoodChildhood or
adolescence
Typical age of onset
LowHighHighPP levels
LowNormal or highNormal or highGlucagon levels
LowHighLowInsulin levels
DecreasedNormal or decreasedNormalHepatic insulin
sensitivity
IncreasedDecreasedNormal or
increased
Peripheral insulin
sensitivity
CommonRareCommonHypoglycemia
MildUsually mildSevereHyperglycemia
RareRareCommonKetoacidosis
Type III
pancreatogenic
Postoperative onset
Type II NIDDM
Adult onset
Type I IDDM
Juvenile onset
Parameter

38. Pancreatic exocrine
Insufficiency
Fecal fat measurement or N-benzoyl-L-tyrosil-P-
aminobenzoic acid test
Presumably related to obstruction of the
pancreatic duct
Management—exogenous pancreatic enzyme
supplementation(Creon, Pancrease, Viokase) in
the early post-op period and weaning in patients
who survival more than 1 year and have no
malabsorption

39. Wound Infection
Incidence:5-20%
Management:
(1)Antibiotics: Prophylasis and post-op
(2)suture or staple removal, drainage,
and packing

40. Thanks for your attention !