CHAPTER 14 Pancreatic Resection
Case Study
A 65-year-old male is referred to a surgeon for evaluation of a pancreatic mass. He reports a 2-month history of progressive jaundice, anorexia, and loss of 15 pounds. Additionally, he notes intermittent dull upper abdominal pain, light-colored stools, and tea-colored urine. He was recently seen by a gastroenterologist and underwent endoscopic retrograde cholangiopancreatography (ERCP), which showed narrowing of the distal common bile duct and pancreatic duct; a biliary stent was placed during the procedure. A subsequent computed tomography (CT) scan of the abdomen and pelvis showed a mass in the head of the pancreas without evidence of metastases or vascular encasement or invasion (Fig. 14-1).

Figure 14-1 Computed tomography scan. There is a mass in the head of the pancreas (black arrowhead) adjacent to the duodenum (white arrowhead). A stent is seen in the intrapancreatic segment of the common bile duct (asterisk). The superior mesenteric artery (black arrow) and the superior mesenteric vein (white arrow) are not involved.
On physical examination, his sclerae are icteric. His abdomen is soft and nontender. No mass or lymphadenopathy is appreciated. Results of laboratory testing are remarkable for a conjugated hyperbilirubinemia and an elevated CA 19-9 level. Liver enzymes, amylase, and lipase levels are within normal limits.
BACKGROUND
The pancreas is a retroperitoneal structure located behind the stomach and lesser omentum; it is composed of four anatomic regions: head, neck, body, and tail. The head lies medial to the C-loop of the duodenum. The neck lies anterior to the mesenteric vessels and portal vein. The body and tail extend obliquely toward the hilum of the spleen. The uncinate process, an extension of the pancreatic head, wraps posteriorly around the superior mesenteric vessels.
The majority of pancreatic resections are performed for neoplasia. Generally, pancreaticoduodenectomy (Whipple procedure) is performed for lesions near the head of the pancreas and ampulla of Vater. Distal pancreatectomy is reserved for lesions of the body and tail. Total pancreatectomy, an infrequently performed procedure, is indicated for rare pancreatic malignancies that involve the entire gland. This chapter focuses on indications for and technical aspects of pancreaticoduodenectomy and distal pancreatectomy.
INDICATIONS FOR PANCREATIC RESECTION
Malignancies of the periampullary region are the most common indication for pancreaticoduodenectomy. These include primary pancreatic head and neck malignancies, distal common bile duct lesions, cancer of the ampulla of Vater, and periampullary duodenal cancers. Lesions localized to the body and tail of the pancreas (to the left of the mesenteric vessels) can be treated with distal pancreatectomy.
PREOPERATIVE EVALUATION

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