Anaesthesia for Pancreaticoduodenectomy (Whipple)

This is not intended to restrict clinical freedom but to give guidance from educational reviews to produce the best possible outcome for the patient.

An overview of the process

Resection of the pancreatic head, duodenum, gallbladder and distal bile duct, followed by three anastomoses — pancreatic, biliary and gastric or duodenal. It is among the longest operations on a general surgical list.

The pancreatic anastomosis is the one that determines the postoperative course. Excess perioperative fluid causes bowel wall oedema and is associated with an increased rate of pancreatic fistula.

Physiological demand is not evenly distributed through the operation. It concentrates at two bleeding steps: dissection of the retropancreatic tunnel over the superior mesenteric and portal veins, and the uncinate dissection off the superior mesenteric artery.

Pre-op assessment

Most patients present with obstructive jaundice. Preoperative biliary drainage if decompression is needed — bilirubin above 250 µmol/L, previous cholangitis, pruritus, or planned neoadjuvant treatment.
Where an endobiliary stent is in place, intraoperative bile cultures should be sent.
Establish whether gastric outlet obstruction is present. If so, treat as a full stomach and omit carbohydrate loading.
Nutritional assessment. Preoperative nutritional intervention is indicated for weight loss above 15% or BMI below 18.5 kg/m². Immunonutrition is not recommended.
Establish diabetic status. Pancreatic head disease causes new or worsening diabetes and the resection worsens endocrine function further.
Thromboprophylaxis with low molecular weight heparin or unfractionated heparin is continued to discharge. Extended prophylaxis for 4 weeks is advised after resection for malignancy. Mechanical measures should be used in addition to chemical thromboprophylaxis. Timing must be planned against the epidural.
Confirm a valid crossmatch and that blood is physically available before the list starts.
Consent covers general anaesthesia, thoracic epidural, arterial line, central line, nasogastric and nasojejunal tubes, blood loss and transfusion, and HDU.

Induction and intra-operative management

Volatile or TIVA. Treat as a full stomach where there is gastric outlet obstruction.
An arterial line is required.
Central venous access is required.
Large-bore peripheral cannulae.
Cardiac output monitoring to guide fluid therapy can be helpful.
Core temperature monitoring, neuromuscular monitoring, urinary catheter. All patients should leave theatre with a urinary catheter.
Active warming before induction if temperature is below 36 °C, continued intraoperatively to maintain temperature above 36 °C. Patients should not leave recovery below 36 °C.
Single-dose antibiotic prophylaxis within 60 minutes of incision, redosed according to half-life and duration.
Nasogastric and nasojejunal tubes are sited after intubation at the surgeon's request.
Maintain full neuromuscular blockade with train-of-four monitoring.

Stages of particular risk

Exploration and staging. The operation may be abandoned at this point.
Kocher manoeuvre and mobilisation. Retraction causes caval compression and sudden falls in arterial pressure. This is mechanical and resolves when the retractor moves.
Dissection of the retropancreatic tunnel over the superior mesenteric and portal veins. Blood must be immediately available before this step begins.
Division of the pancreatic neck and uncinate dissection off the superior mesenteric artery. Venous resection and reconstruction, where required, occurs at this point.
Reconstruction. Long and comparatively stable. Maintain arterial pressure to perfuse the anastomoses without giving excess fluid.

Fluid management

Goal-directed fluid therapy using cardiac output monitoring. Avoid fluid overload.
Hypotension from epidural sympathetic block occurs at normal intravascular volume and should be treated with a low-dose vasopressor rather than repeated fluid boluses.
Maintain mean arterial pressure while avoiding fluid excess.

Perioperative analgesia

Mid-thoracic epidural for open resection, using a low-concentration local anaesthetic with a low-dose opioid, run for 48–72 hours postoperatively.
Continuous wound infiltration through a preperitoneal catheter is an alternative to epidural.
Where neither is used, a multimodal opioid-sparing regimen with patient-controlled analgesia is appropriate.
Regular paracetamol every 4–6 hours to a maximum of 4 g in 24 hours, reduced in documented liver dysfunction.
NSAIDs. The default is cautious use rather than avoidance. They may be used where renal function is adequate, the patient is euvolaemic and there is no specific contraindication. A selective COX-2 inhibitor is an alternative. Where they are withheld, record the reason.
PONV prophylaxis for all patients. Two antiemetics where two or more risk factors are present, two to three where three or four are present.
For prophylactic low molecular weight heparin, allow 12 hours from the last dose before siting or removing an epidural catheter and 4 hours afterwards; for treatment dose, 24 hours and 4 hours. Extend the interval if insertion was traumatic.

Post-operative care

Patients are anticipated to go to HDU.
Handover should include the anastomoses formed, whether bile cultures were sent, the drains and where they run, the blood loss, total fluid and vasopressor, the epidural settings, the last dose of low molecular weight heparin and when the next is due, the glycaemic plan, and the last gas.
Maintain glucose as close to normal as is safe.
Normal diet without restriction according to tolerance. Enteral route preferred where artificial nutrition is required.
Early and active mobilisation from the day of surgery.
A sentinel bleed from a drain or nasogastric tube may precede major post-pancreatectomy haemorrhage from an arterial pseudoaneurysm. Escalate any unexplained blood in the drain immediately.

References

Melloul E, Lassen K, Roulin D, et al. Guidelines for Perioperative Care for Pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) Recommendations 2019. World Journal of Surgery, 2020.
Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula. Surgery, 2017.
Wente MN, Bassi C, Dervenis C, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery, 2007.
Association of Anaesthetists of Great Britain & Ireland, Obstetric Anaesthetists' Association, Regional Anaesthesia UK. Regional anaesthesia and patients with abnormalities of coagulation.
Kietaibl S, Ferrandis R, Godier A, et al. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. European Journal of Anaesthesiology, 2022;39:100–132.
Centre for Perioperative Care. Guideline for Perioperative Care for People with Diabetes Mellitus Undergoing Elective and Emergency Surgery, 2021, updated 2023.