Prevention and management of complications of pancreatic surgery

Dr. Zeeshan Rahman

Introduction Mortality of pancreatic surgery has decreased:- 33% in Whipple’s reports to 5 % in high

volume centres. Morbidity – 35 – 50 %

The three most common complications:- Delayed gastric emptying (14%)- Wound infection (7%)- Pancreatic fistula (5%)

Importance of hospital volume on outcome There was a 3-4 fold increase in mortality in

low volume centres compared to high volume ones.

A recent single institution study reports that higher surgeon volume is associated with shorter operating time, less intraoperative blood loss and higher lymph node harvest.

Post-pancreatectomy hemorrhage Incidence : 8% Mortality : 11% - 38% Definition developed by International Study

Group of Pancreatic Surgery (ISGPS)- Intraoperatively- Early postoperative period (<24 hours)- Late postoperative period (>24 hours)

Intra-operative hemorrhage Usually occurs in the event of aberrant

vasculature

Common variations:- Replaced right hepatic artery (11 – 21 %)- Replaced left hepatic artery (4 – 10 %)- Accessory right or left hepatic artery (<1% -

8%)- Coeliac artery stenosis (2% - 8%)

To avoid intraoperative hemorrhage

Measures to be taken Direct pressure over bleeding site

Aberrant vessels may need to be reconstructed or reanastomosed to an alternate vessel

Doppler ultrasonography may identify aberrant vessels

Venous injuries may require a venoplasty or a patch venorrhapy

In exsanguating uncontrollable hemorrhage – portal vein ligation has been described with a potential to survive when accompanied with a second look laparotomy

GOAL- Allow ICU resucsitation to reverse

accompanying hypothermia, coagulopathy and acidosis

Other techniques:- External drainage, packing, stapled bowel

closure and rapid abdominal closure

Management of Early and Late PPH Early PPH : Usually a technical factor If severe – prompt re-laparotomy required Late PPH : result of postoperative

complications- Fistula- Anastomotic ulceration- Pseudoaneurysm formation

PPH once apparent – what to do?? Evaluation depending upon hemodynamic

status of patient and site of bleed ( intraluminal versus extraluminal)

Endoscopy, angiography, CT scan and reoperation.

Pancreatic fistula Incidence : 30 %

Difference from a leakFistula : Abnormal communication between two

epithelial surfacesLeak: An abnormal escape of fluid through an

orifice or opening

POPF : Occurs with leakage of amylase rich fluid from the transection margin of the gland or pancreatico-enteric anastomoses

Classified by ISGPF into grade A, B and C.

Grade A fistulas : Biochemical only (not clinically relevant)

Grade B fistulas: Requiring further evaluation and management with antibiotics, nutritional support, octreotide or percutaneous drainage

Grade C fistulas: Requiring surgery

Risk stratification Prevention of POPF relates to risk stratification

according to disease related, patient related and operative risk factors.

DISEASE RELATED

A soft gland or diagnosis of ampullary, duodenal, cystic or islet cell pathology increases risk by 10 fold.

Small MPD (<3mm) increases risk of POPF

PATIENT RELATED- Older age, male gender, IHD, jaundice and low

creatinine clearance – predictors of POPF- Neoadjuvant therapy reduce risk of POPF

OPERATIVE RISK FACTORS- Blood loss > 1000 ml- Duration of operating time- Incidence of POPF same after distal and

central pancreatectomy ( Clinical course in distal resection is milder)

Preventive measures Technique of suturing :- Duct to mucosa versus invagination

technique:

Type of anastomoses:

- Pancreatico-gastrostomy is advantageous compared to pancreatico- jejunostomy

(a) Thickness and blood supply of gastric wall.(b) Proximity to pancreas(c) Incomplete activation of pancreatic enzymes

in presence of gastric secretions

Why do pancreatico jejunosotomy ? Yeo et al demostrated no difference in fistula rate

in a prospective randomised controlled trial comparing pancreaticogastrostomy to pancreaticojejunosotomy.

Fistula rate was 12 % each.

In summary a successful pancreatico-enteric anastomoses required:

- Tension free anastomoses- Preserved bloos supply of pancreatic remnant- Unobstructed flow from pancreas to GI tract

Stapled versus sutured pancreatic remnant No clear advantage of one technique over another Either approach is acceptable

ROLE OF OCTREOTIDE- Studies of octreotide are conflicting

- Some authors have found its effectiveness in distal or local resection but not for pancreaticoduodenectomies

- Benefit is clearly for high risk glands- No benefit for low risk patients

Management Diagnosis requires :- Drain amylase- Clinical and imaging data NPO Supplementation nutrition (TPN/ NJ feeds) Antibiotics Procedure (Imaging guided) +/- Octreotide

Re-exploration indicated in :- Clinical decline- Undrainable fistulas or abscesses- Suspicion of pancreatico-jejunal anastomotic

dehiscence

Management of pancreatico-jejunal dehiscence using bridge technique

Delayed gastric emptying Incidence : 6 – 50 % Defined by ISGPS

Preventive measures DGE is multifactorial

Etiology:- Decrease in plasma motilin following duodenal

resection

- Loss of vagal innervation to pylorus and antrum

- Relative devascularisation of antrum

Surgery advised : Pylorus preserving pancreaticoduodenectomy

shown to be advantageous in some studies but others found the opposite.

Currently NO clear better technique

Other surgeons advise pylorus preserving pancreaticoduodenectomy with pyloromyotomy

RETROCOLIC versus ANTEROCOLIC gastro/duodeno – jejunostomy

Retrocolic approach – 50 %

Anterocolic – 5 %

Use of promotility agents Erythromycin - 37% reduction in incidence of

DGE

Metoclopramide : commonly used

Management of DGE NPO NG tube Nutritional rehabilitation ( TPN/ FJ feeds) Rule out intra-abdominal collections / POPF

Thank- you