Auto text: “Insert Pancreas Whipple”
The Whipple Procedure is a resection of the head of the pancreas, common bile duct (+/- gallbladder), and duodenum (+/- distal stomach). The organs are anastomosed as pictured:
- Measure the segment of duodenum, pancreatic tissue and length of bile duct (measure stomach and gallbladder if present).
- Identify and ink pancreatic neck resection margin (blue) and uncinate resection margin (black).
- Identify the common bile duct margin if present. Shave a cross section and save in cassette for gross day. Alternatively, do after fixation.
- Identify the duodenal and/or stomach margins.
- Open the duodenum carefully along the anti-mesenteric border, away from the Ampulla of Vater.
- Describe and measure any duodenal lesions and measure their closest approach to resection margin.
- Either probe through the Ampulla into the main pancreatic duct & bile duct and fix OR open them longitudinally. Document patency/stenosis.
- Open stomach or gallbladder if present.
- Fix in formalin.
How to evaluate the opened specimen
Pancreatic ductal adenocarcinoma (red), ampullary carcinoma (blue), and distal common bile duct carcinoma (green) all arise within close proximity to one another and can therefore overlap in terms of the anatomic space they occupy. Furthermore, pancreatic ductal adenocarcinoma can secondarily involve the ampulla or common bile duct, and ampullary carcinoma and distal common bile duct carcinoma can similarly invade structures from which they did not originate. Careful consideration of the size, epicenter, presentation, and histology of each lesion should allow for accurate diagnosis.
Gonzalez RS et al. Modern Pathology 2016; 29: 1358-69.
- Orient the specimen.
- If not done during triage, submit all margins:
- Pancreatic neck margin: ink, shave, serially section
- Pancreatic uncinate margin: ink, shave, serially section
- Bile duct margin: shave cross section (place face down in cassette)
- Duodenal margins: longitudinal proximal and distal sections
- (Stomach margin: longitudinal proximal section if present)
- Serially section the pancreas perpendicular to pancreatic and bile ducts.
- Describe the bile duct and pancreatic ducts, noting whether lesion involves the main pancreatic duct and/or the side ducts.
- Determine whether tumor impinges upon the distal common bile duct.
- Describe tumor including:
- relation to anatomic structures
- color, consistency
- distance from margins
- any obstruction of ducts
- Describe the remaining pancreas looking for necrosis, cysts, stones.
- Describe duodenum, stomach, gallbladder.
- If untreated: submit multiple sections of tumor in relation to adjacent structures
- If treated: submit the entire visualized lesion
- If IPMN based on pre-operative cytology: submit the entire lesion
- If tumor impinges upon the distal common bile duct, submit a section from the area most suspicious for invasion into the duct
- section of Ampulla of Vater
- uninvolved pancreas, duodenum, stomach
- uninvolved gallbladder (one cassette if age <50; two cassettes if age >=50)
- Carefully dissect and submit all peripancreatic lymph nodes and those in the perigastric fat as well. Several are usually attached to the pancreas or in the fat immediately adjacent to the pancreas.