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Pancreatectomy is a term for surgical removal of all or part of the pancreas. There is a multitude of surgical techniques for both benign and malignant processes of the pancreas including different types of surgical excision. This activity reviews the current medical literature on pancreatectomy (excluding pancreaticoduodenectomy) and highlights the role of the healthcare team in evaluating and treating patients who undergo total, central, and distal pancreatectomy. Objectives: Identify the etiology of distal pancreatectomy. Outline the evaluation of patients for total, central, or distal pancreatectomy. Review the management options available for a total, central, or distal pancreatectomy. Access free multiple choice questions on this topic.

Pancreatectomy is a term for surgical removal of all or part of the pancreas. There is a multitude of surgical techniques for both benign and malignant processes of the pancreas, including different types of surgical excision. A surgeon must not only understand precise surgical techniques but also have a good comprehension of pancreatic anatomy, preoperative diagnostic modalities, and postoperative management. Pancreatic surgery has advanced tremendously over the course of history. However, it continues to be technically challenging while also requiring significant experience and excellent clinical judgment from the surgeon. Anatomy, physiology, indications, contraindications, evaluation, and surgical techniques for multiple different types of pancreatic resections will be discussed here. Pancreaticoduodenectomy (Whipple) will have a dedicated discussion regarding unique surgical techniques, challenges, and management elsewhere.

The following are the potential complications: Postoperative pancreatic complications can be some of the most feared complications in surgery. The complications can gravely affect the patient if not diagnosed and managed in a quick manner. Postoperative fistulas are one of the most common complications occurring after pancreatectomy. Each surgical procedure described above has a risk for the possible development of a fistula. Some reports have a fistula rate occurring as high as 20-60%. The majority of the reported fistulas are grade A and management consists of continued drainage as most of these types of fistulas will heal without other intervention. Occasionally a patient may need a percutaneous drain placed into a small fluid collection (grade B). Rare patients requiring ICU care for sepsis and multisystem organ failure of their pancreatic leak (grade C complications), but when recognized, need swift surgical intervention, which may end in completion pancreatectomy save the patient.  Pancreatic fistula is a serious complication and can greatly impact patient recovery and overall health.[24][25][26] Postoperative diabetes development s is another serious complication after pancreatic surgery if a large portion of parenchyma is removed. It usually occurs less than 10% of the time. Diabetes that occurs after total pancreatectomy is referred to as pancreatogenic diabetes. Total pancreatectomy may also lead to liver steatosis, exocrine insufficiency with steatorrhea, retinopathy, increased neuropathy, and increased cardiovascular disease.[27] Splenic infarction can occur after ligation of the splenic vessels during the Warshaw procedure. This at times leads to the development of an abscess. Ligation of the splenic vessels can also result in gastric varices formation. Delayed gastric emptying is a variable post-op complication that can occur in up to 50% of patients. It is diagnosed when there is significant nasogastric tube output. Delayed emptying can prolong the hospital stay and make the patient have a poor life quality until resolution. Prokinetics offer mixed results for potential relief of the motility issue.

Delayed gastric emptying is a variable post-op complication that can occur in up to 50% of patients. It is diagnosed when there is significant nasogastric tube output. Delayed emptying can prolong the hospital stay and make the patient have a poor life quality until resolution. Prokinetics offer mixed results for potential relief of the motility issue. An anastomotic leak from the newly created anastomotic sites is a major cause of postoperative complications. Multiple studies have been performed which show that regardless of the technique for the creation of the anastomosis there is still a large risk for a leak.[28] Intra Abdominal hemorrhage after pancreatic surgery can occur from multiple different etiologies. Early in the post-op course, it is likely due to the operative failure of hemostasis. The latter portion of the postoperative course is seen with pancreatic leaks causing erosion into a vascular structure or causing a breakdown to an anastomotic site.[29] Wound complications are also another complication that can occur following surgery. This is a broad topic as many patients have different pathologies but undergo pancreatic surgery. Patients with poor nutrition or those undergoing preoperative biliary stenting or other endoscopic biliary procedures have higher rates of wound complications and well as patients with diabetes and obesity.

Pancreatectomy may be performed laparoscopically or with an open technique and is most often indicated in the presence of benign or malignant tumors, chronic pancreatitis, and pancreatic trauma. Due to the unique anatomy and complex vasculature of the pancreas, surgical excision of the pancreas is extremely difficult. To improve the decision-making process, having interprofessional team meetings, including surgeons, anesthesiologists, nurses, and other OR personnel, is always advised. Preoperative preparation is key in order to have successful pancreatic surgery. Intraoperatively, all team members must be in constant communication and adhere to the preoperative plan as well as monitor the patient’s vital signs to assess the need for blood, fluid, or vasopressor administration. Assessment of the patient continues in the postoperative period in intensive care units as this is when many surgical patients experience hemodynamic issues and also experience increasing amounts of pain as they awaken from anesthesia. As always, interprofessional communication enhances healthcare team outcomes and decreases morbidity and mortality.

As mentioned above, an interprofessional team is needed in the partaking of a pancreatectomy. This team must always consist of the surgeon, an anesthesiologist or nurse anesthetist, surgical assistants or surgical scrub technicians, OR nurses, and other personnel, including the ICU nurses and doctors that will manage the patient postoperatively. While the surgeon will be the one to perform the actual pancreatectomy, the anesthesia specialist is responsible for keeping the patient asleep and minimizing the pain and discomfort that may be caused by the procedure. OR nurses and surgical scrub techs are strictly in charge of assisting the surgeon with whatever he or she needs, such as handing them instruments or repositioning the patient to better their view and access to the pancreas. ICU nurses will manage the patient vital signs by administering blood, fluids, and potentially vasopressors as in OR, but also manage the patient’s pain as they will be awake and especially in the case of total pancreatectomy close blood glucose monitoring is critical.

Each and every team member is responsible for monitoring the patient and being prepared for possible complications of the pancreatectomy. Whether laparoscopic or open, many of the complications are the same. Patients are at risk for the development of pancreatic fistula, postoperative diabetes, and splenic infarction. All of these complications, if not recognized and treated early, can severely affect the recovery of the patient. As the development of a pancreatic fistula can lead to malnutrition, skin excoriation, and infection, it is important to monitor the drain output, blood pressure, heart rate, respiratory rate, and white blood cell count, especially in the case of infection. While postoperative diabetes can also occur from pancreatectomy, it is essential to monitor blood glucose levels and assess the need for insulin as the patient may become insulin-dependent for life. In this case, diabetic education is extremely important both in the preoperative and postoperative settings. When blood flow to the spleen is compromised, the spleen can cause infarct and die, leading to infection. Signs and symptoms of infection are the key elements that all team members should be aware of.