Pancreatic surgery

10 min read Last updated April 9, 2026

Surgical approach

  • Common operations: pancreaticoduodenectomy (Whipple), pylorus-preserving pancreaticoduodenectomy (PPPD), distal pancreatectomy ± splenectomy, total pancreatectomy, pancreatic necrosectomy (open/minimally invasive), cystgastrostomy/cystjejunostomy (for pseudocyst), bypass (hepaticojejunostomy/gastrojejunostomy) for palliation
  • Access: upper midline laparotomy or rooftop/chevron, increasingly laparoscopic/robotic for distal pancreatectomy and selected Whipples
  • Whipple/PPPD key steps
    • Kocherisation and assessment of resectability (SMA/SMV/portal vein involvement, liver/peritoneal metastases)
    • Resection: pancreatic head + duodenum ± distal stomach (classic Whipple), gallbladder and distal CBD, lymphadenectomy, sometimes venous resection/reconstruction
    • Reconstruction: pancreaticojejunostomy (or pancreaticogastrostomy), hepaticojejunostomy, gastrojejunostomy
  • Distal pancreatectomy key steps
    • Resection of body/tail, splenic preservation or splenectomy, control of splenic vessels
  • Drains often placed near pancreatic anastomosis/stump, NG tube sometimes, feeding jejunostomy may be inserted

Anaesthetic management

  • Type of anaesthesia: general anaesthesia with endotracheal tube, regional adjunct often used (thoracic epidural or alternative fascial plane blocks)
  • Airway/ventilation: RSI often appropriate (obstruction, delayed gastric emptying, sepsis), lung-protective ventilation, consider recruitment/PEEP (upper abdominal surgery)
  • Duration: typically 4–8 hours (Whipple often 6–10 hours depending on complexity/vascular reconstruction), distal pancreatectomy often 2–5 hours
  • Pain: severe (upper abdominal incision, visceral pain), multimodal analgesia essential, epidural provides best dynamic analgesia but needs haemodynamic planning
  • Monitoring/lines: arterial line, large-bore IV access, consider CVC for vasoactive infusions/poor access, temperature monitoring and active warming, urinary catheter, consider cardiac output monitoring in high-risk
  • Fluids/haemodynamics: goal-directed therapy, avoid both hypovolaemia (renal injury, anastomotic hypoperfusion) and fluid overload (bowel oedema, pulmonary complications), vasopressors commonly required especially with epidural
  • Blood loss: variable, crossmatch and cell salvage where appropriate (consider institutional policy in malignancy), correct coagulopathy, maintain normothermia and calcium
  • Glycaemic control: frequent glucose monitoring, anticipate hyperglycaemia (stress, diabetes) and hypoglycaemia risk if insulin used, total pancreatectomy → brittle diabetes post-op
  • PONV: high risk (upper abdominal, opioids), multimodal prophylaxis, consider TIVA where appropriate
  • Post-op destination: HDU/ICU common after Whipple/total pancreatectomy or high-risk physiology, enhanced recovery pathways increasingly used

Indications and patient population

  • Malignancy: pancreatic adenocarcinoma (head → Whipple), periampullary tumours, cholangiocarcinoma, neuroendocrine tumours
  • Benign/inflammatory: chronic pancreatitis (drainage/resection procedures), pseudocyst complications, pancreatic trauma, necrotising pancreatitis (necrosectomy)
  • Typical comorbidity: older, frail, malnourished, jaundiced, diabetes, smoking/COPD, cardiovascular disease, alcohol-related liver disease

Pre-operative assessment and optimisation

  • Functional status and cardiopulmonary risk: CPET where available, ECG, echocardiography if indicated, optimise COPD and smoking cessation
  • Nutrition and frailty: assess weight loss, sarcopenia, albumin, consider dietitian, prehabilitation, correct anaemia (iron/ESA as appropriate)
  • Obstructive jaundice considerations
    • Coagulopathy: vitamin K deficiency and cholestasis, check INR, give vitamin K if elevated, consider FFP only if bleeding/procedure and INR significantly raised
    • Renal dysfunction and haemodynamic instability risk, higher infection risk (biliary sepsis), pruritus, malabsorption (fat-soluble vitamins)
    • Biliary drainage/stents: may reduce bilirubin but increase cholangitis risk, anticipate antibiotic prophylaxis and potential sepsis
  • Diabetes: optimise HbA1c if time, plan peri-operative insulin strategy, check for autonomic neuropathy and gastroparesis (aspiration risk)
  • Chronic pancreatitis: opioid tolerance, malnutrition, diabetes, exocrine insufficiency, consider alcohol withdrawal risk and electrolyte abnormalities (Mg, PO4)
  • Medication review: anticoagulants/antiplatelets (neuraxial timing), ACEi/ARB plan, beta-blockers continue, consider stress-dose steroids if indicated

Intra-operative conduct

  • Induction: RSI if high aspiration risk (gastric outlet obstruction, ileus, sepsis, diabetic gastroparesis), consider haemodynamic lability (sepsis, epidural), prepare vasopressor infusion early
  • Maintenance: volatile or TIVA, neuromuscular blockade, lung-protective ventilation, avoid high FiO2 unnecessarily, maintain normothermia
  • Analgesia options
    • Thoracic epidural (T7–T9): excellent analgesia and reduced ileus/opioid, risks: hypotension, failure, epidural haematoma (anticoagulation), infection
    • Alternatives: intrathecal opioid (e.g. morphine) + PCA, bilateral subcostal TAP/rectus sheath blocks, erector spinae plane block, wound infiltration catheters
    • Multimodal: paracetamol, consider NSAID if renal function and bleeding risk acceptable (often avoided early after major pancreatic surgery), ketamine/lidocaine infusion in opioid-tolerant patients (institutional practice)
  • Fluids and transfusion: balanced crystalloids, albumin/colloid selectively, GDT using stroke volume variation/oesophageal Doppler where appropriate, transfuse based on physiology and bleeding, consider fibrinogen early if major haemorrhage
  • Coagulation: monitor with labs/viscoelastic testing if available, correct hypocalcaemia with transfusion, maintain temperature and pH
  • Antibiotics: broad-spectrum prophylaxis, re-dose for long cases/major blood loss, cover biliary flora if stented
  • Thromboprophylaxis: high VTE risk (cancer, major abdominal), mechanical prophylaxis intra-op, pharmacological prophylaxis post-op per protocol and neuraxial safety

Post-operative care and complications

  • Respiratory: atelectasis, pneumonia, encourage early mobilisation, physiotherapy, adequate analgesia, consider CPAP/HFNO in high-risk
  • Haemodynamic: ongoing third-space losses, epidural-related hypotension, sepsis/bleeding, monitor lactate/urine output, early vasopressor support may be preferable to excess fluids
  • Pancreatic-specific complications
    • Post-operative pancreatic fistula (POPF): drain amylase high, sepsis, collections, may require antibiotics, drainage, re-operation
    • Delayed gastric emptying: prolonged NG, vomiting, aspiration risk, poor oral intake
    • Post-pancreatectomy haemorrhage: early (technical) or late (erosion/pseudoaneurysm), can present with sentinel bleed, urgent imaging/intervention
    • Bile leak/anastomotic leak, intra-abdominal sepsis
  • Metabolic/endocrine: hyperglycaemia, new insulin requirement, total pancreatectomy → insulin + pancreatic enzyme replacement, monitor electrolytes (Mg, PO4) and nutrition
  • Analgesia continuation: epidural infusion with HDU monitoring, transition plan to oral opioids/PCA, manage nausea/ileus, consider epidural removal timing with LMWH
  • Obstructive jaundice: altered drug handling (reduced bile excretion), vasodilation and myocardial depression described in severe jaundice, increased endotoxaemia and renal susceptibility, fat-soluble vitamin deficiency (A, D, E, K)
  • Major upper abdominal surgery: high risk of atelectasis, epidural improves ventilation by reducing splinting, careful fluid balance reduces pulmonary oedema and bowel oedema
  • Diabetes/autonomic neuropathy: labile haemodynamics, silent ischaemia, gastroparesis, peri-operative glucose targets per local policy (often 6–10 mmol/L) avoiding hypoglycaemia

Test yourself…

You are anaesthetising a patient for a Whipple procedure. How do you assess and optimise them pre-operatively?

Structure: indication/extent → comorbidity and functional capacity → jaundice/diabetes/nutrition → investigations → optimisation and planning (analgesia, blood, destination).

  • History: weight loss, exercise tolerance, cardiorespiratory symptoms, symptoms of gastric outlet obstruction/vomiting (aspiration risk), pruritus, pale stools/dark urine, infection/cholangitis, alcohol intake and withdrawal risk, opioid use (tolerance)
  • Examination: jaundice, cachexia, dehydration, sepsis, cardiopulmonary exam, signs of chronic liver disease, volume status
  • Investigations: FBC (anaemia), U&amp,E/creatinine, LFTs/bilirubin, coagulation (INR), glucose/HbA1c, group &amp, save/crossmatch, ECG ± echo, consider CPET, CXR if indicated
  • Optimisation: treat cholangitis (antibiotics, source control), correct coagulopathy with vitamin K if needed, optimise diabetes plan, nutritional support/prehab, manage anaemia, plan post-op HDU/ICU
  • Planning: discuss analgesia (epidural vs alternatives) and anticoagulation timing, aspiration strategy (RSI), blood products and cell salvage, invasive monitoring
What are the anaesthetic implications of obstructive jaundice in pancreatic head cancer?

Think: coagulation, infection/sepsis, renal risk, haemodynamics, drug handling, nutrition/vitamins.

  • Coagulopathy: reduced vitamin K absorption → prolonged INR, check coagulation, give vitamin K, neuraxial decisions depend on INR/platelets and anticoagulants
  • Sepsis risk: biliary obstruction/stents predispose to cholangitis, ensure antibiotics and vigilance for peri-op hypotension
  • Renal dysfunction: increased susceptibility to AKI, avoid hypovolaemia, careful nephrotoxin use, maintain perfusion pressure
  • Haemodynamics: vasodilation and myocardial depression may be present in severe jaundice, anticipate vasopressor need especially with epidural
  • Drug handling: altered biliary excretion and protein binding in cholestasis, titrate sedatives/opioids, consider prolonged effects in frail/malnourished
  • Nutrition/vitamins: fat-soluble vitamin deficiency (A, D, E, K), malnutrition affects wound healing and recovery
Outline your intra-operative management for a Whipple procedure (monitoring, fluids, analgesia, temperature, transfusion).

Provide a systematic plan and justify choices based on long duration, major upper abdominal incision, potential blood loss, and high-risk patients.

  • Monitoring/lines: A-line before induction if unstable, 2 large-bore IVs, consider CVC for vasoactive infusions, urinary catheter, temperature probe, consider cardiac output monitoring for high-risk
  • Induction: RSI if aspiration risk, prepare vasopressor infusion (e.g. noradrenaline) early, careful induction agent dosing in frail/jaundiced/septic
  • Analgesia: thoracic epidural (T7–T9) if suitable and coagulation acceptable, otherwise intrathecal morphine + PCA and/or subcostal TAP/ESP blocks, regular paracetamol, NSAID only if appropriate
  • Fluids: goal-directed balanced crystalloid, avoid overload, replace losses, use vasopressors to maintain MAP rather than excessive fluid, especially with epidural
  • Transfusion/coagulation: crossmatch, cell salvage per policy, monitor Hb and coagulation, treat hypocalcaemia during transfusion, keep warm to reduce coagulopathy
  • Temperature: forced-air warming, fluid warmer, long cases carry high hypothermia risk
  • Glucose: monitor regularly, insulin infusion if required, avoid hypoglycaemia
Discuss the pros and cons of thoracic epidural analgesia for pancreatic surgery, and what you would do if it fails.

Examiners want balanced risk-benefit and a practical rescue plan.

  • Benefits: superior analgesia (rest and movement), improved respiratory mechanics, reduced opioid requirements and ileus, facilitates early mobilisation and physiotherapy
  • Risks/downsides: hypotension requiring vasopressors/fluids, failure rate, urinary retention, motor block, rare but serious epidural haematoma/abscess (anticoagulation, sepsis), may mask early signs of intra-abdominal complication
  • Patient selection: check platelets/INR and anticoagulants, caution in sepsis, consider spinal pathology, discuss with patient and surgical team
  • Failure management: assess catheter position and sensory level, give test bolus, adjust infusion/concentration, if inadequate—switch to PCA opioid + multimodal, add regional blocks (subcostal TAP/ESP), consider wound catheters, involve acute pain team early
A patient becomes hypotensive after starting an epidural infusion during a Whipple. How do you manage this?

Prioritise: confirm cause, treat immediately, avoid fluid overload, maintain organ perfusion.

  • Immediate actions: check BP trace/artefact, assess depth of anaesthesia, bleeding, anaphylaxis, sepsis, check surgical field and blood loss, review ECG and end-tidal CO2
  • Treat sympathectomy: reduce/stop epidural temporarily, give vasopressor bolus (metaraminol/phenylephrine) and start/adjust noradrenaline infusion to target MAP
  • Volume status: small fluid bolus if hypovolaemic, use dynamic indices/CO monitoring if available, avoid large empiric boluses that risk bowel oedema
  • If ongoing: send ABG (Hb, lactate), check ionised calcium, consider transfusion if bleeding, reassess epidural dose/concentration
What are the important post-operative complications after pancreaticoduodenectomy and how would you recognise them on HDU/ICU?

Group into: bleeding, leak/fistula, sepsis, GI dysfunction, respiratory, metabolic.

  • Post-pancreatectomy haemorrhage: tachycardia, hypotension, falling Hb, increasing drain blood, late haemorrhage may present with a &#039,sentinel bleed&#039, then collapse, urgent escalation for CT angiography/interventional radiology or theatre
  • Pancreatic fistula/leak: rising drain output with high amylase, abdominal pain, fever, rising CRP/WCC, ileus, may progress to collections and sepsis
  • Bile leak/anastomotic leak: bilious drain output, sepsis, deranged LFTs, imaging and drainage may be needed
  • Delayed gastric emptying: persistent vomiting/NG aspirates, inability to tolerate diet, aspiration risk, impacts analgesia and mobilisation
  • Respiratory complications: atelectasis/pneumonia due to pain and upper abdominal incision, monitor oxygenation, work of breathing, ensure effective analgesia and physiotherapy
  • Metabolic: hyperglycaemia/new insulin requirement, electrolyte disturbances, after total pancreatectomy—brittle diabetes and need for enzyme replacement
How would your anaesthetic plan differ for distal pancreatectomy compared with Whipple?

Distal pancreatectomy is often shorter with different bleeding/complication profile, but still major upper abdominal surgery.

  • Duration/complexity: typically shorter (2–5 h) and less reconstructive anastomosis than Whipple, may be laparoscopic/robotic (pneumoperitoneum considerations)
  • Blood loss: can still be significant (splenic vessels, splenectomy), ensure crossmatch and large-bore access but may not need CVC routinely
  • Analgesia: epidural may still be appropriate for open surgery, for laparoscopic cases consider intrathecal opioid + multimodal and TAP/ESP blocks
  • Post-op: VTE risk persists, consider post-splenectomy infection considerations if splenectomy performed (vaccination usually pre-op/elective pathway, ensure awareness for sepsis risk)
A patient with chronic pancreatitis is listed for pancreatic surgery. What specific issues do you anticipate peri-operatively?

Chronic pancreatitis patients can be challenging: pain, opioids, malnutrition, diabetes, alcohol-related disease.

  • Analgesia: opioid tolerance/hyperalgesia, consider epidural or intrathecal opioid, ketamine/lidocaine infusion may help, involve pain team early
  • Nutrition/metabolic: malnutrition, low albumin, electrolyte abnormalities (Mg, PO4), exocrine insufficiency, diabetes common
  • Alcohol-related issues: withdrawal risk, cardiomyopathy, liver disease, coagulopathy, plan CIWA-based management where appropriate
  • Respiratory/cardiovascular: smoking/COPD, assess functional status, optimise prehab
Describe a safe peri-operative anticoagulation plan when using a thoracic epidural for pancreatic surgery.

Answer should reference local policy/ASRA/RA-UK principles: avoid neuraxial puncture and catheter removal during therapeutic anticoagulation, document timing.

  • Before insertion: confirm platelet count and INR acceptable, stop anticoagulants/antiplatelets for appropriate intervals, avoid insertion in uncontrolled coagulopathy or sepsis
  • Intra/post-op prophylaxis: use mechanical prophylaxis immediately, start LMWH prophylaxis post-op as per protocol ensuring adequate interval after insertion
  • Catheter removal: remove at a safe interval from last LMWH dose and delay next dose after removal, monitor for neurological symptoms, document clearly
  • If therapeutic anticoagulation needed (e.g. VTE): discuss risk-benefit urgently, consider removing epidural before escalation, involve acute pain/haematology

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