Whipple (Pancreaticoduodenectomy)
Patient phenotype
Typically 60s–70s, painless jaundice, weight loss, often poor nutrition. Most common indication is pancreatic head adenocarcinoma; also ampullary, distal CBD, or duodenal tumors. Often diabetic, frequently with biliary stents already in place.
Procedure
Long open (or robotic) operation: resection of pancreatic head, duodenum, distal bile duct, gallbladder ± distal stomach, then reconstruction (pancreaticojejunostomy + hepaticojejunostomy + gastrojejunostomy). 4–8 hours, large fluid shifts, frequent transfusion.
Anesthetic plan
GETA + thoracic epidural (T6–T9) for postop analgesia is the classic plan; ERAS protocols increasingly favor TAP/rectus blocks + multimodal if epidural contraindicated. A-line, CVC if pressors expected, goal-directed fluid (SVV/PPV-guided). Avoid N₂O.
Setup
- ·2× large-bore PIVs + A-line pre-induction or post
- ·CVC for pressors, especially with portal vein involvement
- ·Thoracic epidural placed pre-induction (test dose verified)
- ·Type & cross 2–4 units PRBC
- ·Forced air warmer (upper body) + fluid warmer
- ·Foley with hourly UOP
- ·Goal-directed monitor (FloTrac, Vigileo, or pulse contour)
Biggest concerns by phase
Malnutrition + obstructive jaundice physiology
Albumin often < 3, INR may be elevated from vitamin K malabsorption. Bili > 10 carries higher AKI risk — adequate preop hydration matters. Confirm vitamin K given if INR elevated. Type and screen, hold metformin, continue beta-blockers + statins.
Coagulation + epidural risk-benefit
Verify INR < 1.4 + platelets > 100k before epidural. Hold heparin SQ ≥ 12 h, LMWH ≥ 24 h. Document neuro exam pre + after epidural. Discuss risks (epidural hematoma) with patient given older population.
Major fluid shifts + third spacing
Open abdomen + duodenal/pancreatic resection = significant evaporative + third-space loss. Goal-directed fluid (SVV target < 13%, dynamic) outperforms fixed liberal protocols. Excess crystalloid → bowel edema, anastomotic leak, prolonged ileus.
Hemodynamic management with epidural
Dosing thoracic epidural during long case drops SVR; vasopressor (phenylephrine or low-dose norepinephrine) often required. Run epidural lightly (bupivacaine 0.0625–0.125% + fentanyl 2 mcg/mL) intraop, escalate post-extubation.
Hyperglycemia + glycemic control
Pancreatic resection + steroids + stress = hyperglycemia. Insulin infusion if BG > 180. Tight control associated with lower SSI rates but avoid hypoglycemia. Recheck hourly intraop.
Extubation criteria + ICU disposition
Most extubate in OR if hemodynamics + temp + acid-base stable. ICU admission common for first 24 h given fluid shifts + epidural management. Watch for delayed gastric emptying postop (common Whipple complication).
Pancreatic leak + delayed bleeding
Pancreatic anastomotic leak in 5–20% — presents POD 3–7 with elevated drain amylase, sepsis. Postpancreatectomy hemorrhage is bimodal: early (POD 1) surgical, late (POD 5–14) often pseudoaneurysm requiring IR.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
70-year-old with painless jaundice, bili 14, INR 1.6, albumin 2.7, scheduled for Whipple. The surgeon wants to start at 0700. Walk me through your preop optimization and anesthetic plan.
What an examiner probes for
- ▹Recognizes need for vitamin K + INR correction before epidural
- ▹Discusses nutritional state + transfusion preparation
- ▹Justifies thoracic epidural choice + risk-benefit
- ▹Plans goal-directed fluid management
- ▹Names ICU disposition + postop concerns
Four hours into a Whipple, the surgeon mobilizes the SMV and you suddenly drop pressure to 70/40, HR 130. EBL noted as 800 mL but increasing rapidly. What's your move?
What an examiner probes for
- ▹Recognizes likely portal/SMV venous injury
- ▹Activates massive transfusion if appropriate
- ▹Calls for surgical pause + tamponade while resuscitating
- ▹Verifies adequate access (large-bore + rapid infuser)
- ▹Considers TXA, calcium replacement, temperature management
Sources
- Miller's Ch 71
- Stoelting/Hines Ch 19
- ERAS Society Pancreaticoduodenectomy Guidelines 2019
Anatomy reference
Sourced reference images. 4 matches for "pancreas duodenum biliary liver".
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