With regards to open surgery for carcinoma of the head of the pancreas, list the anastomoses formed during a Whipples procedure. (30% marks)

List the complications of this procedure that are of relevance to its ICU management. (70% marks)

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College answer

(A list of anastomoses was acceptable; the diagram is provided for clarity).

whipples.jpg

b)
List complications specific to this procedure of relevance to the Intensive Care management of patients who have had this procedure. (7 marks)

Specific early surgical complications (4 marks) Primary haemorrhage
Pancreatic fistula Pancreatitis
Bile leak
GI anastomotic failure Portal or SMA thrombosis Diabetes Mellitus
Gastric outlet obstruction Late complications
Anastomotic stricture Delayed gastric emptying Pancreatic fistula
Gastric fistula
Malabsorption and electrolyte abnormalities secondary to the above

Examiners Comments:

There was poor knowledge of the anatomy of a procedure that is commonly encountered in intensive care.
 

Discussion

The sites of anastomosis:

  • Bile duct anastomosed to jejunum
  • Stomach stump anastomosed to jejunim
  • Pancreatic duct anastomosed to jejunum

    Like so:

    Whipple procedure

This image is from thefreedictionary.com.

As one might imagine of a 6-8 hour procedure which ends with three anastomoses in the abdomen, "the complications of this procedure that are of relevance to its ICU management" are numerous, and making a coherent answer to this sort of question really relies on the candidate's abilities to categorise them quickly. 

Surgical complications

  • Specific to the Whipple procedure:
    • Anastomotic leak
    • Pancreatic fistula:  defined as drain output of amylase-rich fluid;  in 20%.
    • Hepaticojejunal fistula
  • Common to all major abdominal surgery
    • Abdominal wound infection (in 23.5%)
    • Wound dehiscence

Airway-related concerns

  • These patients may return from theatre intubated
  • The decision to extubate them is more delicate than usual, given their predisposition to pain-associated atelectasis
  • This is complicated further by the relative contraindication for any positive airway pressure (eg. high flow nasal prongs and NIV)

Respiratory complications

  • Atelectasis
  • Hospital-acquired pneumonia

Vascular complications

  • Intra-abdominal haemorrhage occurs in <2%, but accounts for 38% of the deaths following Whipples- mainly from the gastroduodenal artery.
  • Hepatic ischaemia (due to compression or inadvertant damage to the hepatic artery)

Pain

  • The transverse subcostal incision which is usually required is a significant source of pain
  • The operation takes place high enough that even a high thoracic epidural may not cover all of the involved structures

Electrolyte derangement

  • Normal anion gap metabolic acidosis can be produced by a high-volume pancreaticojejunal fistula

Fluid balance

  • High output pancreatic fistula can produce a lot of fluid loss
  • High volume NG drainage due to delayed gastric emptying can also cause you to become rapidly very volume-depleted

Nutritional problems

  • Delayed gastric emptying (20%)
  • Prolonged period of fasting post operatively
  • These people have pancreatic cancer, so they are not coming off a particularly high nutritional baseline

Intra-abdominal collections (12.2%)

  • Bilious collection ("biloma") in <2%
  • Hepatic abscess (due to the reflux of enteric contents up the bile duct)

Thromboembolic disease

  • Apart from the major surgery they've just had, these people are also prone to clots because of their underlying malignancy

References

Schnelldorfer, Thomas, and Michael G. Sarr. "Alessandro Codivilla and the first pancreatoduodenectomy." Archives of Surgery 144.12 (2009): 1179-1184.

Kausch, W. "Das Carcinom der Papilla duodeni und seine radikale Entfernung." Beitr Klin Chir. 78 (1912): 439-486.

Are, Chandrakanth, Mashaal Dhir, and Lavanya Ravipati. "History of pancreaticoduodenectomy: early misconceptions, initial milestones and the pioneers." Hpb 13.6 (2011): 377-384.

Whipple, A. O. "Observations on radical surgery for lesions of the pancreas." Surg Gynecol Obstet 82 (1946): 623-631.

Whipple, Allen O., William Barclay Parsons, and Clinton R. Mullins. "Treatment of carcinoma of the ampulla of Vater." Annals of surgery 102.4 (1935): 763.

Butturini, Giovanni, et al. "Complications after pancreaticoduodenectomy: the problem of current definitions." Journal of hepato-biliary-pancreatic surgery 13.3 (2006): 207-211.

Karim, Sherko Abdullah Molah, et al. "The outcomes and complications of pancreaticoduodenectomy (Whipple procedure): Cross sectional study." International Journal of Surgery 52 (2018): 383-387.

McEvoy, S. H., et al. "Pancreaticoduodenectomy: expected post-operative anatomy and complications." The British journal of radiology 87.1041 (2014): 20140050.

Keim, Volker, et al. "Postoperative care following pancreatic surgery: surveillance and treatment." Deutsches Ärzteblatt International 106.48 (2009): 789.