Pancreatic Surgery

Airway: ETT
Access: 14G and CVC
Pain: Substantial, use ITM or thoracic epidural
Position: Supine
Time: 4-8 hours
Blood loss: 0.5-1.5L
Special: NG tube, neuraxial analgesia
The Bottom Line:

Major surgery typically occurring in an older cohort with malignant cachexia
Typically late presentation limiting opportunity for prehabilitation
Potential for endocrinologically active tumours requiring close intraoperative BSL monitoring
Significant analgesia requirements

Pancreatic surgery can include resection of the:

The pancreas has complex anatomy necessitating complex resection:

Two embryological buds (head and tail) with dual blood supply
- Head and uncinate process share perfusion with duodenum (via SMA)
- Body and tail supplied by splenic artery (via coeliac trunk)
May be incompletely fused, leading to separate ducts into the duodenum
Extensive anatomical variability with variable arterial dominance

Pancreatic head
Two broad approaches:
- The “Classic Whipple”
  - Resection of head of pancreas, gallbladder, duodenum, distal stomach, lower common hepatic duct
  - Three anastomoses:
    - Pancreaticojejunostomy
    - Hepaticojejunostomy
    - Gastrojejunostomy
- Pylorus-preserving
  Improve nutrition, ↓ gastric dumping, and ↓ jejunal ulceration:
  - Pylorus-preserving pancreaticoduodenectomy
    - Pylorus and distal stomach preserved
    - Gastrojejunostomy becomes duodenojejunostomy
  - Pylorus-resecting pancreaticoduodenectomy
    Less distal stomach resection than a a Whipple.
Distal pancreas
- Significantly reduces operative complexity
  No anastomoses required, as duodenum, stomach, and biliary tree are unaffected.
- Splenic preservation may be possible depending on the anatomy
Total pancreatectomy
- Requires anastomoses of pancreatic head resection, and en bloc splenectomy
- Complex post-operative diabetes

Pancreatic malignancy can be split into:

>95% ductal adenocarcinoma
<5% Endocrine tumours
Islet cell and pluripotent epithelial tumours. May be:
- Non-functioning
- Functioning
  Hormone producing (~10-30%). Include:
  - Insulinomas
    - ↓ BSL
    - Palpitations
    - Tremor
  - Glucagonoma
    - ↑ BSL
    - Weight loss
    - Polyuria
  - Gastrinoma
    - Zollinger-Ellison syndrome
  - Somatostatinoma
    - Diabetes
    - Cholelithiasis
    - Diarrhoea
  - VIPoma
    - Diarrhoea
    - Dehydration
    - Hypokalaemia

Surgical Stages

Exposure
- Typically performed by laparotomy
- Laparoscopic and robotic approaches described
Short gastric vessels ligated
Preserved if spleen-preserving.
Splenic mobilisation
Splenic artery and splenic vein (at location of pancreatic division) ligated
Pancreas divided and drained

Preoperative

Assessment:

Non-specific impact of malignancy
- Cardiorespiratory reserve
  - Consider CPET
- Ascites and intravascular volume depletion
- Anaemia correction
Specific effect of malignancy
- Gastric outlet obstruction
- Obstructive jaundice
- Functional tumours

Consultation:

Optimisation:

Premedication:

Control functional tumours
- Gastrinoma
  - High-dose PPI
- Insulinoma
  - Consider diazoxide
    Cease 24 hours prior to surgery if taking.
  - Close monitoring of BSL
- Glucagonoma
  - Consider ↑ dose enoxaparin due to risk of VTE

Explain/Consent:

Intraoperative

Preparation:

Calf compressors

Induction:

Maintenance:

↓ Intraoperative fluid administration is suspected to improve pancreatic healing

Echocardiography:

Use of oesophageal doppler and TOE is described to improve fluid management

Emergence:

Postoperative

Disposition:

Referrals/Review:

Analgesia:

Fluids:

Thromboprophylaxis:

Specific:

Pancreatic fistula formation
Drain output with amylase >3x ULN of serum amylase concentration.
Diabetes
Delayed gastric emptying

References

Jarvis MS, Laing RW, James A. Anaesthesia for pancreatic resection surgery: part 1. BJA Education. 2025 Feb 1;25(2):57–64.
Jarvis MS, Laing RW, James A. Anaesthesia for pancreatic resection surgery: part 2. BJA Education. 2025 July;25(7):257–64.