Gastrointestinal: Surgical

Question 1

What is resected in the standard Whipple procedure?

Answer 1

• Pancreatic hear
• Duodenum
• Gastric antrum
• Gallbladder (almost always)

Question 2

What anastomoses are created during a Whipple procedure?

Answer 2

• Gastrojejunal
• Choledochojejunal
• Hepaticojejunal
• Pancreaticojejunal

Note: Stomach, CBD, hepatic duct, and pancreatic duct all need to be attached to the duodenum.

Question 3

How does a pylorus-sparing Whipple differ from the standard Whipple?

Answer 3

Only the pancreatic head and part of the duodenum are removed

Note: The stomach and proximal duodenum are left and a duodenojejunal anastomosis is created.

Question 4

Complications of the Whipple procedure

Answer 4

• Delayed gastric emptying (necessitating an NG tube for > 1 day post op)
• Pancreatic fistula
• Wound infection

Question 5

Indications for pancreas transplant

Answer 5

Severe type 1 diabetes

Note: Usually accompanied by a renal transplant (renal failure is a common complication of type 1 diabetes).

Question 6

Where does a transplanted Pancreas receive arterial inflow from?

Answer 6

• The donor SMA (supplying the head)
• The donor splenic artery (supplying the body and tail)

Question 7

Where does a transplanted pancreas venous blood flow drain to?

Answer 7

• Donor portal vein
• Recipient SMV

Question 8

Most common causes of pancreas transplant failure

Answer 8

• Acute rejection (most common)
• Donor splenic vein thrombosis (second most common)

Note: Arterial thrombus actually isn’t as big of a deal due to the dual blood supply of a transplanted pancreas.

Question 9

Imaging signs of acute rejection or donor splenic vein thrombosis in a transplanted pancreas

Answer 9

Reversed diastolic flow

Note: resistive indices don’t matter for pancreas transplants because they last a capsule

Question 10

Mild peripancreatic fat stranding surrounding a transplanted pancreas 2 weeks after transplant…

Answer 10

Mild pancreatitis is a common complication within 4 weeks of pancreas transplant

Question 11

Pancreas transplant getting progressively smaller over years…

Answer 11

Think chronic rejection

Question 12

Where is a transplanted pancreas usually placed?

Answer 12

Right lower quadrant (near the aortic bifurcation)

Note: Donor pancreas arteries are attached to the external iliac artery. There is also usually a kidney transplant on the contralateral side.