Periampullary Carcinoma for Whipple’s Procedure

Periampullary carcinoma carries a dismal prognosis and surgery offers the only chance of cure. Patients usually present with progressive painless jaundice and palpable gall bladder. The anaesthetic management of these cases is based on understanding of the altered pathophysiology due to obstructive jaundice. The raised bilirubin affects all the major body systems. Patients often suffer from dehydration and malnutrition with low serum albumin and total proteins. The myocardium is depressed due to the effect of bile salts, thus the myocardial contractility is reduced. There is reduced vascular reactivity to vasoactive agents, predisposing these patients to hypotension. Kidneys are at risk of developing hepato-renal syndrome, a condition where there is functional derangement of renal excretory function without any pathological changes in kidney. The coagulation tests are often abnormal due to deficiency of fat-soluble vitamins. In the preoperative period, optimization is attempted focussing on the problems enlisted above. Intravenous fluids therapy is instituted preoperatively to optimize intravascular volume. Thromboprophylaxis is advised preoperatively. Intraoperative management focuses on maintaining normothermia, intravascular volume and ensuring stable hemodynamic status. The anaesthetic drugs which depend on liver for metabolism and excretion are avoided. Thus, drugs like thiopentone, morphine, vecuronium and rocuronium are avoided while propofol, etomidate, fentanyl, remifentanil and atracurium can be administered. Volatile agents like isoflurane and desflurane can be safely used. Intravenous fluid therapy should be individualized with goal-directed fluid therapy having advantage in these high-risk surgical patients. Postoperative analgesia is managed using a multimodal approach. Epidural analgesia, whenever feasible, has many advantages. To conclude, a meticulous peri-operative management is required to ensure a safe outcome after a complex surgical procedure for patients suffering from periampullary carcinomas.