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I perform performed the first, uh, anatomic pancreaticoduodenectomy for cancer of the pancreas. Uh, and it was a pylori is preserving pancreaticoduodenectomy. So he didn't respect any part of the stomach keeper from his transaction line at the level of the duodenum. Um, a few improved improvements had to be made. Um uh, and therefore the years of 1938 1941. Uh, people started observing that a lot of patients were dying from sepsis after these two stage operation, especially due to cholangitis. And therefore, they started figuring out that instead of draining the gall bladder to a loop of judge, no more the gall bladder to the stomach. Um, they were removing the gallbladder. So they're performing a cholecystectomy. And then they were draining the main, uh, drainage pipe of the liver into a loop of judging, um, And then eventually they figured I figured out that they had to drain the pancreatic juice as well. So they started performing the first pancreatic region ostomies. And it was only until 1940 when the first, um, complete stage resection of duodenum and pancreas was performed. So a few things about the surgical anatomy of the pancreas that we I'm sure you're all familiar with, uh, pancreas is a retroperitoneal organ. Uh, it consists of five parts. Uh, we have the head of the pancreas, which started the second number area, Um, followed by the neck of the pancreas, Um, under which we have the superior mesenteric vein and the superior mesenteric artery. We have the body of the pancreas extending towards the tail, which reaches the splenic hilum at the level of the 12th thoracic vertebra. And then we have the answer in it process, which is an embryologically different part of the pancreas. And, um, uh, you could see the accident process at the level of the 2nd and 3rd part of the duodenum. Just where the see loop is blood supply to the pancreas. Very, very important. Uh, is mainly, uh, via, uh, the celiac access and the superior mesenteric artery and many branches of those two arteries that are providing a lot of anastomosis making pancreas a very, very well vascularized organ. The body and the tail of the pancreas are mainly supplied by branches of the, uh, splenic artery, as you can see here, which is a branch of the celiac trunk um uh, and some vaginal branches. And the head of the pancreas is mainly supplied by an estimate. Uh, multiple anastomosis, um, from the pancreas Pancreaticoduodenal artery. Um, and these are branches from here, the common hepatic and gastroduodenal artery and branches from the SM A. The venous drainage of the pancreas is very, very, very important. And oncologically it's, um It gives you an idea that the pancreas drains into the portal vein and because it drains into the portal vein, the first side for distant metastases for pancreatic cancer is the liver. Yeah. So, um, either, uh, well, the head and the accident process, uh, they go into the pancreas pancreaticoduodenal veins first to the superior mesenteric vein here and then via the superior mesenteric vein to the portal vein, while the body and tail of the pancreas will first drain into the splenic vein and the splenic vein into the portal vein. So but it's very important to remember that that drains via the portal vein towards the liver and then through the IV, see into the heart and lungs. Okay, we can move on now. So the how close the pancreas is to all these vessels is very important in order to see which tumors are acceptable and non resectable. Obviously, you understand that if you have tumors that are invading important arterial structures that are bringing that supply to other vital organs, then these tumors cannot be surgically removed because it will compromise the viability of other important organs. So therefore, the NCCN guidelines for respectability of pancreatic cancer had to be formed. So and we have three cancers the receptible cancers, the borderline resectable and the locally advanced or unresectable cancers. The injectable is pretty easy. We all know that if the tumor is not in any contact with any of the major arteries, like the superior mesenteric artery or the aorta or the celiac trunk, then it is respectable. Now, if the tumor is in contact with a vein like the superior mesenteric vein or the portal vein and this venous contact is less than 100 and 80 degrees, then the tumor can also be in the category of resectable tumors. So these people who have resectable tumor is they can go straight to surgery. Yeah, and they do not need any further discussion for new adjuvant chemotherapy. Now then we have the borderline resectable tumors and the borderline resectable tumor is simply are tumors that they are invading, um, veins more than 100 and 80 degrees. And they can cause occlusion of the veins, like the superior mesenteric vein and the portal vein. But also, um, they can, um, invade arteries. They can actually not compress them, invade arteries less than 100 and 80 degrees in such a way that if we would like to resect this tumour would be able to reconstruct the artery without any detrimental effect to any vital organs. The Unresectable tumors, on the other hand, are tumors that either the invade veins and they include the veins more than 100 and 80 degrees. And, um, the the vein is not amenable to resection and reconstruction, and they invade arteries more than 100 and 80 degrees as well. So the borderline resectable tumors can, um, we can try neoadjuvant chemotherapy and see the response to neoadjuvant chemotherapy first, and then see whether we could downstage the tumor before we remove them. Uh, unresectable and locally advanced. We're talking about surgeries with very, very high morbidity and mortality. The majority of these patients cannot be resected and therefore are offered chemotherapy only. So we're going to talk about a little bit about imaging first. Uh and, um, human markets. We all know tumor marker for pancreatic cancer is see a 1 99. So and I'll talk to you about the, uh, pre operative biliary drainage, the optimization of nutrition, Um, and how we can optimize our patients prior to pancreatectomy, we can move slide. So, imaging, I put lots of imaging modalities on this scan. But it is very important for you to know that the imaging of choice is the CT scan CT scan, uh, dual face CT scan with a later cereal face and a portal venous face. Um, and it almost has 100% sensitivity in big tumors, slightly lower in smaller tumors. And it will give us information about the location of the tumor, its size. And it's really it's a relationship to the surrounding vessels and structures. Uh, now, if you have small liver metastases or if we have small deposits, it may give us false positive results. We may not be able to pick up these small deposit just with a CT scan. Um, the city is gonna should include the lungs as well for staging because up to 4% of patients with pancreatic cancer can have, um, uh, lung metastases at the time of presentation. A lot of people are discussing about the use of endoscopic ultrasound, and either we like it or not. Endoscopic ultrasound is an invasive procedure, and maybe it's not as readily available. Um, in all the centers that can, uh, that are diagnosing pancreatic cancer. Uh, realistically speaking, if we do have a nodule at the head of the pancreas, which looks cancerous, we're going to proceed to surgery. We do not need a tissue diagnosis. We do need tissue diagnosis if the tumor is not receptible and it's considered borderline receptible, um, or unresectable because these people will need to have neoadjuvant chemotherapy. And therefore you need to know what cancer they have, how aggressive the cancer is. Um, what is the metabolic metabolic index and information like this in these occasions? Yes, you do need tissue. Now, the MRI MRI in the form of MRI liver is very useful when we have an acceptable cancer, and we need to be sure that we don't have a small liver metastases because if we do have small liver metastases is better to know in advance rather than putting the patient to sleep, having a laparotomy and then finding out that you have liver metastasis at the time of surgery, which obviously will preclude the, uh from proceeding to resection. And there are some neoplasms that are arising from the pancreatic duct like the IPMN. And in those neoplasms MRI and MRI, C p is quite useful now the use of pets, uh, in royal. Sorry. We used to do a pet scan for almost every patient with pancreatic cancer. I know in Germany they don't use pet scan at all. If we do need to do a pet scan, we don't do it to see the actual tumor, but to assess for distant disease abnormal, distant influence. And be careful that if you do, uh, give new adjuvant chemotherapy to the patient, then there is no point of repeating the fdg pet because fdg pen will pick up metabolically active lesions lesions. And if you have just given neoadjuvant chemotherapy, obviously human metabolism has come down, so it may be falsely negative. You're f g pet so important as we said, um, standard. Um, imaging mortality is the dual face CT scan, chest, abdomen and pelvis. Here. Very nice lung metastases from pancreatic cancer. This patient will never get to surgery. Okay, Can move on. All right, So a lot of people say, When are we going to perform standing from, uh, for patients with pancreatic cancer? And this is a very, very important question to answer and to understand because we have someone who presents with John disease. Obstructive joint is painless jaundice, and they have a bilirubin of 80. And, um, immediately people say Yes, the obstructive joint. This is related to the head of the pancreas tumor. But we will put a drain for this patient before we consider him for resection. That's quite wrong to do, actually, because, um if you have someone who is ready to undergo theater, Yeah, to have a major resection who is not severely joined this and therefore his mind joined this will not impair his clotting, will not impair his renal function will not impair his healing capacity after a major surgery. Then why should you perform and other invasive procedure like the ercp which has risks on its own, like perforation and pancreatitis. Therefore, um, uh, there have been many, many studies in order to find What's the cutoff of Billy Reuben? That we are allowed to proceed to a hot Whipple's without standing the patients without compromising the aftercare and the healing process because of the joint is so most of the studies are talking about a cut off of Billy Rubin 250. So they say, if your bilirubin is above 250 you have to stand the patient. The lowest cut off rate is 130. Um, anything less than 100 and 30 you don't need to stand the patient. Yeah, you can refer him to a hepatobiliary sent it to consider a hot Whipple's procedure if the patient is fit and if the tumor is resectable because people who had post ercp pancreatitis and they initially had resectable tumors, they didn't make it to surgery because of the severe pancreatitis. Now, um, if we do, uh, stand the patient's, then we need to decide. Are we gonna stand them with an ercp, or are we gonna stand them percutaneously through their livers if we have to choose. Yes, we go for the ercp because PTC, uh, could increase the risk of peritoneal recurrence of the tumor due to, um, seeding of cancer cells. Uh, now, if we're going to choose an endoscopic approach with an ercp, yes, we go for a stent that will last for longer. So until the patient has the chemotherapy, until the patient gets two surgeries, it's going to be a metallic stent or a metal cover stent instead of a plastic stent. Now we're going to move to the next slide. All right, now very, very important. And you will see a lot of support in every HPV team from the dieticians. Because the patients undergoing Whipple's procedure are malnourished and therefore need to be fed, you need to be nutritionally optimized before the big surgery. The malnutrition, uh, for these patients is related to their age to the cancer, um, to the loss of appetite because of the pain. Yeah, they may have an undiagnosed diabetes due to the tumor, the tumor may contribute to exocrine insufficiency of the pancreas, and therefore they have malabsorption and steatorrhea. Um, so all these parameters need to be assessed and corrected if possible. prior to surgery. Now, um, people who have had weight loss more than 10% of their body weight of people whose albumin is less than 35 need to have pre operative nutritional support. And I'm sure you're all familiar with the different forms of support that we can provide. These patients, we have the food supplements. 46 the insurers. We have the nasal vaginal feet here. We have the parenteral nutrition up here, so it's very important. Optimize the patient before they go for such a big surgery. Next, please. All right. So I'm sure by now we will know that Yes. Who are we doing Whipple to? We're doing Whipple to, uh, fit patients who can undergo surgery. And they have periarticular religions. Majority of the malignant like Pepcid ac. Yeah. Cholangiocarcinoma, uh, cancer of the ampulla. Fatter duodenal adenocarcinoma. The second part of the duodenum. Neuroendocrine tumors. These tumors lymphomas. Very rarely. Pancreatic traumas, uh, or benign neoplasms of the pancreas. Do not perform a whipple procedure. If there is any evidence of metastatic disease outside your reception's own, if the tumor is involving important vessels that are not reconstruct a bubble, and if the patient is so frail that cannot undergo safe anesthesia and surgery next. All right, so I mean, I will. I will talk to you about the procedure steps, but, I mean, the the word says it all is pancreaticoduodenectomy. So it's the excision of the head of the pancreas and the duodenum. Yeah, and obviously because And at the Judean, um, we have drainage of bile from the stomach. We have to transect the distal part of the common bile duct and the gall bladder. So here is our transaction line here at the common hepatic duct just before the conference with the cystic duct. Then we have our transaction line at the neck of the pancreas. Yeah, just above the superior mesenteric vein and superior mesenteric artery. And then we have our transaction line distally at the margin of the duodenum to the jejunum down here. This is elevated or, uh, yeah, at the area of the, uh, proximal Jesuit, which is approximately 10 centimeters distal to the ligament of Tricuits. And then we have our proximal transaction, which, if we are dealing with the Whipple's procedure, it will be here in the stomach like an antrectomy distal stomach If we're dealing with a P ppd like the Pylorus preserving pancreaticoduodenectomy, it's going to be just after the level of the pylorus here at the first part of the duodenum. Obviously, you understand, if we resect all this and we throw it away as a specimen, we have to do three anastomosis. Yeah, the anastomosis of the gastric route to the jejunum of the, uh, drainage pipe of the liver to the jejunum and of the remnant of the pancreatic, uh, parenchyma to the gym. So here we have the pylorus preserving pancreaticoduodenectomy where you could see that the pylorus is a nasty most to look of jejunum and you could see the pancreatic jejunostomy and the hepatic or jejunostomy. And then you have here the formal whipple's procedure where the gastric Antrim is joined to a loop of jejunum. The pancreas here is joined to a loop of judgment and the common hepatic doctor loop of judging, um, in the pylorus preserving pancreaticoduodenectomy even though we have kept the pyloric sphincter intact. And this has a good, um, uh effect on the nutritional status of the patients, and it leads to, uh, less bile acid reflex. People who have undergone pee pee pee. This have a higher risk of delayed gastric emptying, and we'll see later on why, Okay, So very, very important when you're doing Whipple's procedure to be a very good plumber, and you could see how good good HPV surgeon is like they have every headlights on everything, and they fairly look like a good plumbers here. So because it is important, actually, uh, two things methodically identify your problem. Your problem. See whether you could resect that you're safely, then do your resection and then see how you're gonna put things together in a nice, meticulous way in order to avoid post operative complications. So the three steps that we need to all do when we're performing a Whipple is first to assess that the tumor is resectable. If the tumor is not receptible at the time of surgery, we stopped there, and we just bypass the patient. If the tumor is respectable, we proceed to resection, and then when we finish our resection, we will have to re establish the continuity. So, um, the assessment of respectability is mainly to see whether the tumor is invading vessels is invading the inferior vena cava the aorta. The portal vein. Yeah, uh, Syria trunk the hepatic artery. Uh, the very first step of every Whipple's procedure is the co authorization of the duodenum. The cauterization of the duodenum is the medial rotation of the duodenum. So we are basically lifting the duodenum off the inferior vena cava and the aorta, and we're mobilizing it, mobilizing it immediately until we see the left renal vein which meets the inferior vena cava. Yeah. So if we are able to lift the duodenum and the head of the pancreas up means that the tumor is not invading the IV C is not invading the aorta. Therefore, first stage of respectability ticked. Now, then we have to visualize the rest of the pancreas. So we have to uncover the pancreas where it's hidden in the lesser sac. So Well, actually, um, uh, divide the gastrocolic momentum and enter the less Uh, we see the anterior surface of the pancreas, and then we reflect the right side colon and the proximal transverse colon downwards in order to see the inferior part of the pancreas. Okay, up until now, we haven't done any irreversible steps yet. Anything we have, uh, that we can fix it. Yeah. Then we can perform. Are cholecystectomy straightforward. Next page, please. Okay. And then we need to see whether the hilar vessels are involved by the tumor. So we're going to go and find our hepatic a duodenal ligament. The hepatitis hepatitis cardinal ligament contains the, uh, Hyler structure. So we will find our common bile duct will find our hepatic artery and the portal vein. Yeah, Portal triad. So common bile, duct portal vein and hepatic artery. Yeah. Um, and then we find that the gastroduodenal artery, which is very important, and it arises from the common hepatic artery. Just, uh, here off the hepatic guard. We are not transacting anything. We're not cutting any vessels yet. Then if these vessels are not invaded by the tumor, then second stage of respectability ticked. Yeah, and then we we go to check whether R S m a N S m V are infiltrated by the tumor. So we're going to go and identify our pancreas. We're going to create a tunnel under the neck of the pancreas. And if this tunnel can be created freely without any, uh, invasion of the tumour, uh, of the superior mesenteric vein and superior mesenteric artery. Then third stage of respectability sticks and we can proceed to the resection. Okay, During that section, we can perform either the antrectomy distal gastrectomy or division at the first part of the pilots in case of the the first part of the duodenum in case of the P. Ppd. And the reason we can do this first is because if we detach the stomach part that we are keeping, we can send the stomach back into the left upper quadrant. So we give ourselves a bit more space, and then the next step is to divide the gastroduodenal artery before we divide. The gastroduodenal artery is very important to check that we have good flow after we clamp the gastrojejunal artery. It's very important to check that we have good flow at the hepatic artery because of anatomical. Vary patients, because there could be some collaterals from the gastroduodenal artery into the, uh, liver. And we don't want to, uh, to take the gastroduodenal artery. If by clamping it, we see no flow. Um, uh, you know, flow to the liver. Um, and when we're gonna, um, Kathy gastroduodenal artery is very important. to live a long stamp because, um, if the patient bleeds from there, we have to have a long enough stuff in order to go and embolize and stop the bleeding. Now, the next part of this procedure is, um, to divide the proximal genome. Uh, which is, um, what we call the go to the ligament of Tricuits on the left upper quadrant. Yeah, and we will go approximately 10 centimeters distal to the ligament of tries, and then we slowly transact, um, the small bowel mesentery of the original loops in order to, uh, transact basically and devascularize the whole duodenum. And then we will divide the common hepatic duct. Uh, so we have a little bit of spinach of pile everywhere. Last thing to be divided is the pancreas, because we don't want the pancreatic juice to leak everywhere and cause some quantification of, um of the fat, uh, and irritate tissues. Uh, the line of transaction, as we said, is that the neck is just at the level of the superior mesenteric vein. And then the final final step is get, uh, to remove the accident process and the head of the pancreas of the superior mesenteric vein and the portal vein Carefully. Uh, here is where we encounter a lot of bleeding from some small branches from the superior mesenteric vein and the portal vein. And eventually, this is how the whipple specimen looks. Time for reconstruction. The first anastomosis is the most difficult to be done first. And the pancreatic jejunostomy. Yeah, the second is the hypothetical jejunostomy. Yeah, and the last anastomosis is the gastrojejunostomy or the pylorus jejunostomy. Um, next. All right. The very I will talk about three post operative complications only. There are many, uh, is an operation with very high risk of morbidity and mortality. You understand? We're making at least three anastomosis in this operation. So if there is any leak, it could be a leak of gastric juice. If the gastrojejunostomy leaks, it could be a leak of bile if we have, um uh, look at the particle jejunostomy, but the most severe leak is obviously the pancreatic juice. Um, if we have, um, a problem with the pancreatic jejunostomy, then we may have pancreatic fistulas that are very difficult to manage. Um, then, um, this is the first complication that I'm going to talk about the pancreatic fistula. It can happen to up to 15% of people undergoing pancreaticoduodenectomy. And it is very important when you when you're doing a rotation, is a surgical Sholnn HPB department. To understand why your consultants are asking for a drain fluid amylase drain fluid. Amylase is important because it is more than three times above the upper normal limit of the serum amylase. Then this is diagnostic for pancreatic fistula. So if the upper normal limit of amylase is 100 in the certain serum and you have a drain fluid amylase of 300. Yes, this is pancreatic fistula. Okay, so after day three, more than three times above the upper normal limit of the ceremony malaise. That's the definition for a pancreatic fistula. Regardless, the volume, it could be 10 miles, 20 miles, one liter. It's still a pancreatic fistula. Now we have three grades of pancreatic fistula, grade A, B and C. So a is basically a biochemical like you have some fluid that the amylase is high. The patient is perfect, though without any symptoms, without any pain, you don't need to do much. Great. See is when the patient is very unstable and very unwell and therefore you really need to act quickly. Um, the patient may need to be transferred to intensive care. Of course, you have to nutritional support them. You get a scan. If there is any collection, you put another drain, you drain that collection and the warning signs for a pancreatic fistula in the world is any deviation from normal, um, postoperative course. So if the patient complains of severe abdominal pain that you don't expect if the patient is nauseous has tachycardia maybe low grade pyrexia and his inflammatory markers, especially the CRP, are trending up. These are signs that something is not right and it is important to escalate early and scan the patient early because a lot of people who do not do well after such a complication is not because the surgeons are not able to, um, treat and manage the problem when they know about it. But it's actually delay in the diagnosis. So the failure to rescue the patient to to delay diagnosis Next, please. Yes. So this is basically the I sgp classification for three grades of pancreatic, uh, fistula. But we've set all this already, um, so we can move to the next slide. Okay, So very, very important. Um uh, In order to decrease the rates and manage more efficiently, the patients with pancreatic fistula is first to identify, which are the patients who are at high risk of developing pancreatic fistula. So obese patients, patients. And that's why we have the high risk patients with the five piece so obese patients, patients who are malnourished patients who are psycho Penick. Uh, high risk pancreas is that are soft pancreas is or pancreas that have a very small pancreatic duct. These are high risk for, like, some certain pathologies. Um uh, like product, for example. Then the, uh, some procedure parameters. Obviously, if you are someone who is doing this every week, twice a week or you're a surgeon who is doing this once every month or once in a year, Yes, there is a surgeon's experience. Yeah, the type of the anastomosis There are many types of anastomosis is obviously not as part of our presentations and discussion tonight to explain the different anastomosis. Very important when we see the centralization. So these are very high risk operations. They cannot happen in the District General Hospital, where we perform like less than five. Whipple's a month Or, uh, they have to happen in big centers. Yeah, post operative parameters, of course. The drain fluid amylase. If the patient has received some other studies analog, the patient has received hydrocortisone how to prevent the pancreatic fistula from occurring. Yes, there are technical parameters, pharmacological parameters and parameters that have to do with the hospital and organization. Okay, I think it's common sense type of the anastomosis, Whether we're going to leave a drain or not, the mental flap is basically a technique where you wrap a piece of momentum around the anastomosis. So you say if it leaks, at least this fat is going to contain the leak. It doesn't the majority of the cases, but it may give some reassurance to the surgeons. Now, the pharmacological prevention, uh, it's been found that people who underwent new adjuvant chemotherapy with folfirinox they have less chances of developing, uh, pancreatic fistula. So matter, studying analog is basically the use of octreotide. And that's why if we have a patient who has a soft pancreas, we ask The initial is actually to give up a tree. A tight at the time of surgery, and sometimes the hydrocortisone is found to be beneficial in terms of the management is very important for you to know that the early recognition in the majority of cases can lead to, uh, conservative management up to 60 to 80% of cases and how is this done? First, we need to decrease the amount. Um, we'll decrease the stimulus, the pancreas. So we keep the patient eating and drinking because this will, um, lead to the production of more pancreatic juice, and therefore the fistula will not drive. So we stick the oral diet, and then we provide nutritional support either in the form of generational feeding. Because the majority of these patients already have, um, an N J tube instead of at the time of surgery or, um, in the form of parenteral nutrition with TPN, we put the patient on some other studies monologues to decrease the amount of pancreatic secretions like octreotide or lanreotide. Yeah, and then we start antibiotics because it's found that sometimes the a lot of bacteria can contribute to the formation of a pancreatic fiscal, especially equal I and with scan the patient and with drain any collection that need to be drained. This is again a summary that says that, yes, we do try conservatively. But if conservative management fails or percutaneously ranges not feasible or in case of bleeding embolization fails or it's not feasible, then we do have to take the patient back to theater. And obviously, completion. Pancreatectomy is a patient is a case with very, very high morbidity and mortality rates up to 30 to 50%. Um, and that's why we try to avoid this by by recognizing the complications early. Next, please. All right, so this is a question, Um, so you are the surgical S h O. And basically you have this patient wonder where the Whipple's procedure and on Day three, the drain fluid amylase was 1000. So you kept the draining. And then on the seventh post operative day, um, you see a little bit of it like a small tinge of fresh blood in the drain. Um, patient is relatively hemodynamically stable, I would say. I mean, his heart rate is only 100 and five. His BP is 100 over 75 his hemoglobin If not, it's a slight drop from 100. The day before yesterday to 85 today. So, um, in that occasion, I mean, do you think we should monitor the drain out, put prescribe some intravenous fluids group and save the patient, but actually say Look, the hemoglobin is not too low, so we don't need to transfuse. According to our hospital guidelines, we don't need to give transfusion if the hemoglobin is 85 and keep an eye on the drain and see, maybe next day the drain well, or even the same night the drain may fill up. Or do you think we should? As soon as we see this tinge of blood, we proceed with an urgent CT angiogram. We let the intensive care know and our seniors know, um, we inform interventional radiology. We cross match and transfuse the patient. So I don't know if you want to say or do you want me to tell you you can write in the chart? If you want, I would go for B. Okay? Yeah. I think this is the right answer. Really. I mean, you have to just the patient septic, right? Well, not accepting. I don't know his septic. Well, it's a red flag, right Yes. So basically, this type of bleeding is called sentinel. Bleeding is like a little tinge of blood before the catastrophe happens And because the drain fill up with blood afterwards. Okay, So and this is the CT scan, which is really, really impressive for this patient. So, um, this is a patient who, um you see, that's delivery here. And then you have what we call a subhepatic, uh, large hematoma. And you see, this is an arterial contrast CT scan, so you can see, uh, blood here like you can see the Contras story in the aorta. You see here, the celiac trunk emerging. Uh, and this blood here and here, um, is active bleeding from a gastroduodenal arteries to the aneurysm. Okay, So, um, yeah, we can move to the next page, so yes, that sentinel bleeding if you see something like this. Fresh blood, even a little tinge of blood in the drain. Urgent CT scan CT angiogram with arterial contrast. As we said, uh, in order to, um, see whether we have any active bleeding from a pseudo aneurysm. So the patient is hemodynamically stable? Yes. You do have time to do a CT angiogram. and identify the bleeding vessel. If the patient is hemodynamically unstable, on the other hand, then you may need to move the patient directly to the angio sweet in order to perform a catheter angiography instead and embolize straight away or the patient needs to go to the theater. Okay, so next, So potential point of bleeding during the Whipple's procedure. Obviously, uh, this can happen, Um, in about 10, UH, hopefully less than 10% of patients undergoing the Whipple's procedure. If it happens within the 1st 24 hours, we're talking about an early bleed, and this is usually due to a technical failure and in adequate hemostasis at the time of surgery. But if it happens more than 24 hours after the surgery, we were talking about a late bleed, and late bleed is usually a bigger bleed. It's unexpected, and it can be more deadly, really, uh, so usually is a result of an inflammatory process, especially if we have a pancreatic leak. If you have leakage of pancreatic juice from the pancreatic jejunostomy, you actually go and watch the Whipple's. You will see how close the pancreatic jejunostomy is at your gastroduodenal artery stamp And obviously, when we are performing the Whipple's and we want to perform a nice lymphadenectomy, we kind of make all these vessels kind of naked from, um the lymphatic tissue and the fatty tissue that they have around them. So a pancreatic leakage can erode through this big arterial structures that we have here and can cause either a pseudoaneurysm and bleeding from the pseudo aneurysm or disruption of the of the, uh, erosion of the vessels. Okay, so these are the potential point of bleeding. Yeah, the most important thing bleeding from the gastroduodenal artery. Here we see the bleeding. And here we have proceeded to embolization. So you can see here on the second picture. Actually, um, the celiac trunk is in the middle of the picture, uh, second picture. So if your celiac truck, I don't know if you see my arrow or you see only thing or a zero. Um, but the celiac trunk is on the second picture, uh, approximately the center of the picture. And then you can see an artery emerging towards the right, uh, top corner as we are looking, and that's the splenic artery. And then you can see another artery, uh, moving down into the right, um, lower corner. And this is the common hepatic artery. And then you could see, like, a little black circle there. Yeah, and on the second picture. And this is what we have the extra visitation of contrast from the pseudo aneurysm and the active bleeding of the gastroduodenal artery. And then you can see some contrast carrying on up, which is basically the hepatic artery proper and the bifurcation to the right and left hepatic artery. On the third picture, you could see how we decided to do what we call a coil embolization. And therefore you could see the contrast going from the celiac trunk into the common hepatic artery. Then you could see the coils in the common hepatic, and then you see no flow of contrast into the pseudoaneurysm. Because the in flow to the pseudo aneurysm has been, um, coiled. Therefore, you don't have any contrast. And then you could see more coils here into the proper hepatic artery. Uh, which is the outflow. And we always have to, um, coil the flow and the outflow. Because if you don't call the outflow, then you're gonna have back pressure. Or if you have collateral vessels into the outflow vessels into the outflow vessel, then the pseudo aneurysm will keep filling with blood. The problem with the coils is that sometimes, you know, sometimes but basically, uh, you you you disrupt the flow from the point where you insert the coils and distantly. So if you would like to keep your hepatic artery proper patent and to avoid disruption of the blood flow to the liver, then it's better to try to insert a covered stent in the Lumen of the hepatic artery, as we can see on the fourth picture. Uh, because, uh, yes, you do block the communication of this common hepatic artery into the gastroduodenal stamp and therefore you don't have any contrast and therefore no blood leaking out into the gastrojejunal artery. But you, uh, you have ongoing flow into the right and left hepatic artery can move to the next page. All right, so what kind of is in, in, in in this picture? The CT scan is the last complication that I would like to talk about, and it's called delayed gastric emptying. Okay, so this is a stomach here on the left upper quadrant filled with fluid and gas. Okay. Very, very common complication. Uh, it could be like from 10 to 20 to 30. Some, uh, literature is even talking about almost 40% in some occasions. Um, in patients who undergo, we put procedure and it's basically the functional gastroparesis without mechanical obstruction for people who have a Whipple's procedure or a pancreatic A p. Ppd. Um, now, if the definition says that it's functional gastroparesis without mechanical obstruction, we have to rule out mechanical obstruction first. Yeah, in order to say that this is delayed gastric emptying. And, yes, mechanical obstruction could be either, because our anastomosis is narrow, very, very narrow, and therefore the stomach is not emptying into the vaginal lube. Or it could be because, um, there is an early adhesion early scar tissue that is from the area of the anastomosis, and this prevents the stomach from emptying. And therefore it's very important to arrange what we call a fluoroscopy or like gastric emptying study in order to see the stomach emptying dynamically into the loop of gene. Um, because if it doesn't empty at all, yeah, it probably means it's obstruction. If it's very very slow and very distended. And the Paris dialysis very slow. It takes ages to empty is what we call delayed gastric emptying. A CT scan is also useful because there are some secondary causes that can cause delayed gastric emptying. So, for example, if you have a leak of bile or a leak of pancreatic juice and a collection that is from that, the area of your gastrojejunostomy can, um, uh, prevent the stomach from emptying properly. So CT scan is very, very useful. A lot of, uh, a lot of discussion has been made about what is causing the delayed gastric emptying. And why is it more severe when we do? Pylori is preserving pancreaticoduodenectomy. Uh So, um, there is a hormone called motel in which is produced by the duodenum and the proximal small power and understanding the procedure where you remove the duodenum. Yeah, you have decreased circulating modeling, and this operation on its own makes the patients more prone to develop a delayed gastric emptying due to the insufficiency of this prokinetic hormone. Uh, in the pilots preserving pancreaticoduodenectomy. If you if you ever see one, you will see that the pilots looks very dusty eventually it picks up, but you may have some ischemic changes, and this ischemic changes can, um, prevent the emptying of the stomach. Um, or they can cause the pilots to go into a spasm, or our section can cause the innovation of the pilots and insufficient, insufficient, empty. So many, many, many philosophies about what is causing it. Yeah, but it's very important to know how to manage it. So I put a table there for your own use later on. What do we call delayed gastric emptying? And it's great. A, B and C C is the very, very delayed. Gastric emptying is basically people who even three, three weeks after their operation, cannot tolerate any solid intake. They are vomiting. Their stomach is very distended. Of course, they need a nasogastric tube. Of course, they need nutritional support. Of course, they need pro kinetic medication. Yeah, and, um um grade A is when Basically it comes shortly after the surgery. So, um, it's basically, um the entity is required for 4 to 7 days after the surgery or if it has come out. It has to be reinserted after day three, and the patient is not able to eat for a week. Um, after his surgery, we can move to the next slide. So I put an example here of what we call delayed gastric emptying on the fluoroscopy study. So you could see that the contrast is remaining in the stomach. The stomach is not moving. Yeah, very, very slow transition of contrast into the bowel. Here, you can see very, very slow opposite fication of the small bowel loops. Gross distention of the stomach. Yeah, and the majority of the contrast is still sitting there. If this happens, stop the patient from eating. Put an M G tube. They compress the stomach, make sure the patient is well hydrated and all the electrolytes are replaced. Yeah, uh, start a prokinetic agent. Uh, start them initially on metoclopramide. Because if they have, um, a stomach full of fluid and you give them the color pride which comes as a tablet form, they will not be able to absorb them. So give them IV metoclopramide 10 mg TDs started for five days. See how it goes. If the output from the energy to decrease, you can then convert them to oral particular pride. Um, remember when rule out any other complications with the CT scan, and the patient needs to be nutritionally supported if they haven't had any oral feeding after a week to 10 days after the surgery. This can be done either with the n J feeding. Remember, the N J feeding goes to the genome so it goes beyond the point of the problem. Or it could be done via parenteral nutrition in the form of TPN. Next, please. Okay, so that's it. The presentation is coming to an end eventually. Uh, so very, very important for you, too familiar with yourself with the pancreatic anatomy. Always check the patient's imaging before, um, you go to theater because there are so many anatomical variations related to the blood supply to deliver the blood supply to the pancreas that you need to know before you perform a resection. Um, it's a surgery with very high morbidity, and it's better if we keep it with high morbidity rather than, um, leading into high mortality. That's why it's very important to know our patients very well and to be able to pick up complications early. We don't want to fail to rescue them because this will lead to high mortality and be very good friends with lots of people in the hospital because you will need their help. If you work in hepatobiliary surgery, you will need your interventional radiologist. You will need your dieticians. You will need your intensive care, doctor. You need a good initiatives. You need your microbiologist and know when all these people who can manage the patient conservatively are not enough. And therefore you have to take responsibility and be brave and take the patient back to the theater. So this is what I used as, um my references this very, very, very, very good books. Um uh, for reading. And then, um, the European Society of Surgical Oncology. I mean, I can advise you enough actually to go and attend their courses in Europe. They have amazing category courses, uh, for pancreatic and liver surgery. Um, for junior, uh, surgical trainees. And really, you learn a lot from them, and they will give you a lot of hands on experience. And I wouldn't I wouldn't recommend them. Um, enough, really. It's an amazing community. And remember Theodore Billroth We said first Central pancreatectomy. Yeah. So he said something really clever and Yes, God has put the pancreas in the back because he didn't want surgery is messing up with it. So you really need to be really, really good. If you want to do a hepatobiliary surgery, it starts early. And, uh, and therefore, I use this as an opportunity in your first surgical rotation HPB to learn the anatomy, to learn the operation steps, the management of complications, um, get the chance to go to theater as much as you can. Thank you. Questions very much of Angelea. That was a really nice presentation. I wish I knew all of this before I had my HPV rotation. Well, I I wish I knew that before I had mine. I'm not quite sure if you guys have any questions. Just give me the chat group and sorry for looking up all the time, but I have my screen quite high and the laptop camera is low. So that's why I kept looking high during the, uh, during this presentation. Does anyone want to ask any questions guys just write down in the chat group? Have you all fallen asleep? Probably. You know, I mean, I've been talking and talking and talking about that was a really nice, but I didn't know a way to put things in a simpler way because we're talking about quite complicated, uh, matters and and and, uh, issues. Uh, so Hassan says he's a final year medical student. So, um well, maybe he's more familiar with the anatomy rather than us. Definitely. Thank you. Vandalia. Okay, I will. Are you Are you okay? Are you happy if I share the presentation? Definitely. Yeah, yeah. Maybe I will just send you the updated version. Uh, tips for assisting an operation. Okay, well, look, it depends who you are assisting. You may have, like, surgeons are extremely fast, and therefore you need to not only to use your hands, but actually your legs to assist them. You know, that's not really the case, but a good thing. In the UK, the majority of HPV centers have very good retractors, so you do not need to retract. Therefore, your assistance is mainly needed during the cauterization of the duodenum. When you literally need to lift the duodenum up from from from the back. Um, and, uh, the operating surgeon will explain to you how to lift it up. You really need to be gentle when you're retracting tissues because all the blood vessels are very friable in this area and they can actually cause a catastrophically that were very difficult to control. Then what else are you assisting with? Um, you need to suck a lot. Like to use a section a lot, because there is a lot of bleeding. Um, you need to follow, uh, surgeon, when they are when they are, uh, suturing, uh, basically, hold the sutures, Uh, and make sure that they're not getting messed up mixed up because obviously, we're using a very, very fine sutures in order to perform the pancreatic jejunostomy. And actually, you have to wash their figures and you have to wash basically there. Yeah, yeah, it's better not to do much if you're not asked to do much. And it's better to just be honest and say it's my first time here. Please let me know what you want me to do and how I can make this operation easier for you. The last thing that, uh, senior surgeon wants when they're, uh, doing a very stressful part of the operation is actually to have someone who's like messing up with your hands here and there all the time. Yeah. Thank you, Evangelina. That was a very nice presentation of you. Okay, Enjoy the Have a good rest of the night. Okay. You too. Bye. Bye Bye. So, guys, I will send you the feedback link and the recorded version as well as the Power Point presentation. And let me know if I can assist with anything else. Thank you for joining us. Uh, we will see you again next Tuesday. Thank you.