Full CH 1 _Lillemoe-9781496385574

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PART I Pancreas and Biliary Tract

gland. In a recent RCT of pancreatic duct stenting during PD, for example, patients were stratified into soft versus hard gland texture and the rate of POPF was severalfold higher in the soft-gland group: 9% for patient with hard glands versus 41% for those with soft glands. Similarly, certain biochemical markers obtained on routine blood tests have been found to predict complication rates and severity. For example, patients with peak postoperative serum amylase that is low (<100 U/L), medium (100 to 299 U/L), or high (>400 U/L) have a corresponding risk of devel- oping a POPF: 4%, 14%, and 20%, respectively. Elevated postoperative transaminases also predict outcome. Patients with transaminases ≥ 2000 U/L have a nearly logarithmic increase (56% vs. 7%) in the risk of a CT-detected cavitating hepatic infarct as opposed to mere hepatic ischemia. Risk of postoperative mortality also correlated with transaminase levels: Patients who have low (<500 U/L), medium (500 to 1999 U/L), or high ( ≥ 2000) elevations in transaminases bear a 0.9%, 5%, and 25% risk of mortality, respectively. Other factors, such as obesity and age, that have traditionally been thought to predict morbidity, have, in isolation, been shown recently to play a relatively minor role in large-volume centers. Detection of Complications Most of the postoperative complications in pancreaticobiliary patients are detected as a result of routine clinical and laboratory evaluation: Vital signs and laboratory-detected anemia indicate the possibility of hemorrhage; visual and laboratory examinations of drain effluent detects POPF or bile leaks; inspection of surgical sites detects superficial surgical site infections; and, of course, nausea and vomiting in the appropriate clinical setting readily aids the diagnosis of DGE, which may be confirmed with an upper gastrointestinal contrast evaluation under fluoroscopy. Management of Complications One of the most important aspects of complication management is patient education. Although there is a relatively wide range of acceptable management of many complications, any path of complica- tion and management is more easily traveled by the patient and the surgeon if there exists a strong foundation of communication and trust. Specific management of selected complications is discussed in the following section. Delayed Gastric Emptying DGE virtually always resolves with time, although upper endoscopy may be performed with balloon dilation of the gastric outlet if indicated and percutaneously placed gastrojejunal feeding access can be considered in more protracted cases. Medical therapy, which is often concurrent with interven- tional therapy, consists of motility agents such as the prokinetics erythromycin and metoclopramide. Erythromycin or azithromycin, although found to accelerate gastric emptying, is already being taken prophylactically by patients on pathway, and metoclopramide seems to have relatively little effect on gastric emptying. Given that small-bowel function often returns prior to gastric function, we (SCC) have a low threshold for leaving in place a nasojejunal feeding tube and starting trickle tube feeds the night of surgery, increasing to goal as small bowel function returns. Once a liquid diet is well tolerated postoperatively, the nasojejunal feeding tube is removed. Pancreatic Fistula POPF, like most complications, may be mild and self-limited, or severe and life-threatening. Similar to DGE, the medical management typically starts prophylactically, as most high-risk patients are given octreotide to prevent POPF. Mild cases are treated with prolonged drainage and allowing enteral feeding if tolerated. More severe cases, however, may require the cessation of enteral feeding with the initiation of parenteral nutrition. Drains are typically left in place until effluent is low-out- put or low-amylase. If not previously initiated, octreotide therapy should be employed in these cases. Undrained fluid collections are detected by CT scan, usually prompted by fevers or elevated white blood cell counts, and are drained percutaneously by interventional radiology. Hemorrhage Hemorrhage following pancreaticobiliary surgery may be divided into early and late hemorrhage. Early hemorrhage (within 24 to 72 hours) is usually surgical bleeding resulting from a technical problem, whereas late hemorrhage (after 5 days) is often associated with a pancreatic leak and

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