Pancreatic surgery

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

Key physiology and pharmacology links (useful in viva)

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

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&E/creatinine, LFTs/bilirubin, coagulation (INR), glucose/HbA1c, group & 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 'sentinel bleed' 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