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Pancreas, Whipple procedure

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IntroductionEdit

Usually done for tumor, however, some cases of pancreatitis can produce focal obstruction that is clinically necessary to resect.

Fresh HandlingEdit

  1. Orient the specimen in its correct anatomic position. (Often, the specimen is received fresh for frozen sections and the pertinent margins are taken for frozen section analysis. The specimen is then usually fixed. Further dissection at the cutting bench occurs following adequate formalin fixation. Adapt the following dissection as necessary to account for the procedure at the frozen bench.)
  2. Measure the specimen
    1. Note overall dimensions of the specimen.
    2. Note organs present in specimen and their respective dimensions.
    3. Measure the tumor mass (if visible) and its distance from the margin of resection.
  3. Before opening the specimen, ink the anterior portion of the pancreas green and the posterior portion blue.
  4. Open the duodenum along the side opposite the pancreas. If present, open the stomach along the greater curvature beginning at the proximal end. Note any duodenal/stomach masses, ulcers or other lesions.
  5. Mark the proximal margin of the common bile duct (CBD) with ink and take a shave section of the proximal margin.
  6. Insert a probe into the proximal end (margin) of the bile duct until it passes out the ampulla. Using sharp scissors, open the CBD longitudinally from its proximal margin to ampulla, superior (proximal) to the pancreas, along the probe (use a grooved guide probe, if possible); if not completely patent, open the bile duct as far as possible from the proximal end, then insert probe into ampulla and open it from the distal end. Note any dilatations, strictures or masses in the CBD or ampulla.
  7. If the gallbladder is present, open it from its dome through the cystic duct into the CBD. Process gallbladder as usual (see Gallbladder).
  8. Mark the pancreatic neck (distal) resection margin with ink and take a shave section of the margin. Ink and then take a perpendicular section of the uncinate margin to include the vascular groove.
  9. Make several transverse cuts through pancreas (breadloaf the pancreas into 3 mm slices) from proximal to distal, parallel to the cut pancreatic margin (Note: cut down to but not through the common bile duct, which should be deep to the cuts).
  10. Measure the tumor (if present) and note its site of origin (pancreatic parenchyma? ampulla? bile duct?) and its relation to the margins of resection.
  11. Describe tumor characteristics (involvement of ampulla, duodenal mucosa, stomach, bile duct, pancreatic duct, and pancreas; size, shape--papillary? flat? cystic? ulcerated? multifocal?, color, consistency).
  12. Photograph and diagram pertinent findings. Take photo to illustrate pathology, often this is best done after specimen is dissected. Sometimes a thin cross section through the entire organ laid flat on the board best illustrates the pathology, this is especially true for cystic lesions
  13. Pin specimen out and fix in formalin.

Grossing InEdit

  1. If you have followed the steps above on the fresh specimen, then all that is left is to take sections.
    1. Pancreatic parenchyma - 3 sections, including 1 from the distal margin
    2. Bile duct - 2 sections, 1 from the bile duct margin
    3. Ampulla - one section should include the long axis of the bile duct, the duodenum, ampulla and pancreas all in one block
    4. Tumor
      1. In general, submit enough sections to adequately stage the tumor (size and extension into adjacent and distant structures (duodenum, bile duct, peripancreatic tissues, and/or stomach). Remember the general rule: 1 section per 1 cm of tumor.
      2. In many cases, the features will be best illustated by submitting the entire lesion. This is especially true for mucinous lesions (mucinous cystic lesion, intraductal papillary mucinous neoplasm) where focal invasive carcinoma needs to be ruled out.
    5. Uninvolved Duodenum - 2 sections (including 1 from proximal margin if not stomach), 1 from distal surgical margin
    6. Stomach (if present) - 2 sections, including 1 from proximal surgical margin.
    7. Lymph nodes (at least 10 regional lymph nodes (peripancreatic))
    8. Search the peripancreatic fat at the junction of the pancreas and the duodenum, and also the mesentery around the bile duct. Need to find a minimum of 10 lymph nodes! These do not need to be separated out by specific anatomic location.
    9. Submit other organs (e.g., gallbladder) per protocol.


Sample DictationEdit

The specimen is received fresh, labeled with the patient's name and medical record number, designated "_". The specimen consists of a portion of pancreas, duodenum and stomach measuring overall _ x _ x _ cm. The portion of pancreas measures _ x _ x _ cm; the portion of duodenum measures _ cm in length x _ cm in diameter; the portion of stomach (if present) measures _ x _ x _ cm. The duodenum and stomach are opened along the anti-pancreatic side to reveal _ (ie. no discrete lesions, a stent in the common bile duct). The bile duct and distal pancreatic margins are inked and shave margins are taken. The uncinate margin is inked and a perpendicular margind is taken. The bile duct is opened along its length to reveal _ (ie. a stricture 1 cm from the ampulla). The pancreas is breadloafed to reveal _ (ie. an ill-defined sclerotic mass in the head of the pancreas measuring _x_x_ cm, located _ cm from the distal pancreatic margin and _ cm from the ampulla). The mass appears to extend/ does not extend into the peripancreatic fat and approaches the ink posteriorly. The mass does/does not invade the duodenum (?other structures, common bile duct, pancreatic duct). _ (ten) regional lymph nodes are dissected. Representative sections are submitted as follows: …

Review and SignoutEdit

Remember, the main three things to report are diagnosis, stage and margins.

  1. Pancreas, duodenum and distal stomach, pancreaticoduodogastrectomy:
A. Mucinous cystic neoplasm/Intraductal papillary mucinous neoplasm, X cm, pancreas, no invasive carcinoma identified.
B. Pancreatic, duodenal, bile ductular resection margins free of tumor.
C. X lymph nodes, no carcinoma identified (0/X).
D. Non-neoplastic pancreas with chronic pancreatitis.
E. Duodenum with no specific pathologic change.
F. Stomach with no specific pathologic change.
  1. Pancreas, duodenum and distal stomach, pancreaticoduodogastrectomy:
A. Adenocarcinoma, X cm, (moderately, poorly) differentiated, no lymphovascular or perineural invasion identified, confined to pancreas.
B. Pancreatic, duodenal, bile ductular resection margins free of tumor.
C. X lymph nodes, no carcinoma identified (0/X). OR Metastatic adenocarcinoma in X of Y lymph nodes, (X/Y).
D. Non-neoplastic pancreas with chronic pancreatitis.
E. Duodenum with no specific pathologic change.
F. Stomach with no specific pathologic change.

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