Whipple (Pancreaticoduodenectomy)

Anesthesia Implications

Position: Supine, arms tucked
Time: 4+ hours (very long)
Blood Loss: High (200 – 500 ml)
Post-op Pain: High (7-10)
Blocks: TAP

Combined General Anesthesia and Thoracic Epidural Anesthesia (TEA) – Preferred for managing intraoperative and postoperative pain.

Epidural Placement – Typically inserted at T6-T11 to provide adequate analgesia. It’s essential to place the epidural before VTE prophylaxis to minimize bleeding risks.

TAP Block – This can be an alternative when an epidural is contraindicated.

A-line (Arterial Line) – Mandatory for continuous blood pressure monitoring and blood sampling due to expected fluid shifts.

Large-Bore IVs and Central Line – While two large-bore IVs are recommended, a central line with CVP measurement is less commonly used.

Avoid Hypervolemia and Hypovolemia – Fluid shifts are typical in open abdominal surgeries; careful management is critical to prevent organ dysfunction.

Intraoperative Considerations 

Positioning – Supine with arms tucked to the side.

NG tube – placed to decompress the stomach;

Avoid nitrous oxide – due to potential bowel expansion.

Pulmonary Recruitment Maneuvers – Upper abdominal surgery increases pulmonary risk, so recruitment maneuvers before emergence are beneficial.

Emergence and Extubation – Awake extubation may be ideal for elderly patients, those with extended surgical duration, or those who received significant intraoperative volume.

Careful Fluid Management – Pancreatic surgery patients often experience intraoperative fluid shifts.

Careful BG Monitoring – Patients with pancreatic resection can develop “brittle” diabetes, with rapid fluctuations in blood glucose levels. This results from upregulated insulin receptors and necessitates close monitoring to prevent hypo- or hyperglycemia.

Postoperative Care and Complications

Pulmonary complications – can be common post-op, especially in patients with a history of pulmonary disease.

Optimized Blood Glucose Control – Essential during the perioperative period to avoid both hypo- and hyperglycemia.

Pain Control – Epidural analgesia is effective for pain relief post-surgery. An alternative is a TAP block if an epidural is contraindicated.

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

High Blood Loss (general considerations): Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.

Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.

High post-operative pain (general considerations): Plan ahead to treat pain in the postoperative period. If not contraindicated, consider hydromorphone or other long-acting analgesics along with adjuncts such as Ofirmev and/or toradol. Where possible, give during the operative period to limit pain in the postoperative period. Where applicable, consider peripheral nerve blocks and/or epidural interventions.

Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.

Airway Fire Risk (general considerations): Keep the inspired oxygen concentration (FIO2) below 30% in the breathing circuit to prevent airway fires. It is crucial to note that even after adjusting to the “safe” FIO2 range, the expiratory oxygen concentration can remain above 30% for a considerable amount of time, presenting an ongoing risk of airway fire. The inspired and expired oxygen concentrations in the circuit are influenced by various factors including the circuit’s length, the fresh gas flow rate, and the starting oxygen concentration, potentially taking several minutes to decrease to below 30%.

High blood loss RISK (general considerations): Though most of these cases don’t result in a high blood loss, there is a high blood loss RISK. Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra IV push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.

Pancreatic cancer (PC) is often aggressive, with only 15-20% of patients being eligible for surgical intervention.

The Whipple procedure is most often indicated for tumors located in the head of the pancreas or near adjacent structures.

With surgery, the five-year survival rate improves to 15-20%, but without intervention, it remains at a low 5%.

Pathophysiological Considerations

• Age and Comorbidities – Most patients with pancreatic cancer are over 65 years old and may have underlying conditions, such as cardiovascular disease or diabetes, increasing surgical risk.
• Diabetes and Hyperglycemia – Nearly 80% of PC patients present with either diabetes or impaired glucose tolerance, which can elevate risks of perioperative complications, including myocardial ischemia, cerebrovascular events, and renal ischemia.
• Venous Thromboembolism (VTE) – High incidence due to cancer-related hypercoagulability. A careful evaluation of anticoagulation status is crucial, particularly when considering epidural analgesia.

The Whipple procedure involves the resection of multiple structures and requires precise reconstruction to restore digestive function. Variants include:

Standard Whipple – Removes the head of the pancreas, gallbladder, part of the duodenum, the pylorus, and lymph nodes near the pancreas. Surgeons re-establish connections among the pancreas, bile duct, and stomach to allow the passage of digestive enzymes and food into the small intestine.

Pylorus-Preserving Whipple – Similar to the standard approach but preserves the pylorus, potentially reducing post-op delayed gastric emptying.

Due to the complex vascular anatomy of the area, the surgery typically lasts 4-7 hours with an estimated blood loss (EBL) of 200-800 mL, depending on the surgeon and patient anatomy.

Complications may include hemorrhage, pancreatic fistula, bowel leakage, abscess, pneumonia, and post-op respiratory failure.