Full CH 1 _Lillemoe-9781496385574

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1 Pancreaticobiliary Surgery: General Considerations

pancreatic–enteric continuity, including pancreaticojejunostomy and pancreaticogastrostomy, nei- ther of which is conclusively better. Our preference is pancreaticojejunostomy, and even this may be done in a variety of ways, including the so-called Blumgart anastomosis, the Hopkins techniques described in Cameron’s Atlas of Gastrointestinal Surgery, and others. One new technique that one of the authors (SCC) has recently developed, thus far with zero cases of clinically relevant postop- erative pancreatic fistula (POPF), is the Colonial Wig anastomosis, which combines some of the best features of the abovementioned techniques, adding a novel wrapping of the jejunum around the leak-prone corners, as well as three adjunctive measures: an omental wrap, somatostatin analogs (viz., octreotide or pasireotide), and selective use of decompression of the pancreaticobiliary limb (e.g., via a Braun enteroenterostomy or a internal–external tube). Drains The presence, number, size, type, and duration of drains used before closing the abdomen vary widely from surgeon to surgeon. Given that one of the most common complications of pancreatic surgery is pancreatic fistula, most have traditionally advocated the use of intraperitoneal drainage following PD or distal pancreatectomy, especially after operation upon a soft gland or small-di- ameter pancreatic duct. However, the question of a selective approach has been proposed by some groups after pancreatectomy, given some data that omission of—or at least early removal of—drains is associated with favorable outcomes. Of note, there has been a RCT that had to be stopped early because of significant mortality in the no drain group. THE NORMAL POSTOPERATIVE PATHWAY Postoperative considerations begin preoperatively and are chiefly designed to prevent complica- tions, or at least to achieve their early detection and expeditious and successful treatment, with the goal of minimizing morbidity. At Johns Hopkins Hospital (JHH), a critical postoperative pathway of patients undergoing pancreatectomy has been employed since the early 1990s and has recently been successfully transplanted from Johns Hopkins to Thomas Jefferson Hospital, and to our current institutions. Table 1.1 summarizes one current critical pathway for enhanced recovery after PD. TABLE 1.1  Critical (Enhanced Recovery) Pathway for Pancreaticoduodenectomy Prior to Operation Dedicated, Patient-Centered Preopearative Counseling Avoidance of preoperative biliary drainage a Abstinence from alcohol and tobacco Postoperative day 0 Before operating room Heparin, 5000 units SC given Beta-blockade if indicated In operating room Thromboembolic deterrent (TED) stockings and sequential compression devices Arterial catheter Central venous catheter if indicated Perioperative antibiotics begun before incision Nasogastric tube placed after anesthesia induction, typically removed in OR or POD 1 Octreotide or pasireotide if high risk of postoperative pancreatic fistula, for 7 days Perianastomotic drains (0–3) placed Transversus abdominis plane block in consultation with anesthesiologist Strict maintenance of normothermia Noninvasive monitoring to optimize fluid balance After operating room Night of operation spent in ICU

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Intravenous patient-controlled analgesia Intravenous proton pump inhibitor (PPI) Insulin gtt to keep finger-stick levels 120 to 150 preferred Nasojejunal tube feeds (10 mL/h and advance as bowel function returns) (Continued)