POSTOPERATIVE CARE OF THE PANCREATIC SURGICAL PATIENT

The past decade has seen a marked diminution of the role of the surgical critical care physician in the postoperative management of patients undergoing procedures for pancreatic and periampullary cancers. Improved preoperative patient selection based on advanced radiologic techniques has eliminated high-risk patients from surgery and increased resectability rates. Increased experience with pancreaticoduodenectomy in the hands of many surgeons and improved standardized techniques have led to a reduction in mortality rates to less than 3% in some series.16, 36, 39 Despite reductions in mortality rates, postoperative complication rates remain significant in most series.39, 7, 25 Complications most often occurring in the first two postoperative weeks include hemorrhage, pancreatic fistula, wound infection, intra-abdominal abscess, and delayed gastric emptying.

It might be argued that the improved results after pancreatic surgery are caused by better preoperative preparation, intensive postoperative care, and improved intensive care units; however, in many institutions, most pancreaticoduodenectomy patients do not require intensive care after surgery. Therefore, what is the role for the intensivist in the care of these patients? To answer this question, one must look to two specific areas of care. The first involves the controversial area of the preoperative physiologic “fine-tuning” of high-risk surgical patients; the second concerns the care of the two most common postoperative life-threatening complications: hemorrhage and intra-abdominal sepsis, usually secondary to a pancreaticojejunostomy leak.