Pancreaticoduodenectomy (Whipple Procedure)
This procedure is performed for cancer of the pancreatic head and ampulla.

A pancreaticoduodenectomy, also known as a Whipple procedure, involves the removal of the pancreas head due to a tumor in the pancreas or bile duct, or pancreatitis. If a tumor exists in the head of the pancreas, it is usually necessary to remove the pancreatic head, duodenum, gall-bladder and a portion of the bile duct .Sometimes, part of the stomach is also removed. The end of a patient’s bile duct and the remaining pancreas are then connected to the small bowel to ensure flow of bile and enzymes into the intestines.

Distal Pancreatectomy (laparoscopic or open)
Indicated for tumors in the body and tail of the pancreas, a distal pancreatectomy involves the removal of neoplasms either laparoscopically or with open surgery. With both laparoscopic and open distal pancreatectomy procedures, surgeons attempt to preserve the spleen.

Drainage Procedures

• With chronic pancreatitis, a dilated pancreatic duct usually reflects obstruction. Quite often these patients present with stones in the pancreas.

Procedures to improve ductal drainage include:
Longitudinal Pancreaticojejunostomy (Puestow Procedure)
The pancreatic duct is opened from the tail to the head of the pancreas and attached to the small bowel.

Distal Pancreaticojejunostomy (Du Val Procedure)
The pancreas is divided transversely at the neck, and the body and tail are drained via attachment to the small bowel.

Sphincteroplasty
When endoscopic sphincterotomy is unsuccessful, surgical sphincteroplasty may be required of the minor or major papilla..

Gallbladder stones are an extremely common disorder and are usually asymptomatic. Some patients experience biliary colic, an intermittent and often severe pain in the epigastrium or right upper quadrant, and at times between the scapula because of temporary obstruction of the cystic duct with a gallstone. If the cystic duct obstruction persists, the gallbladder becomes inflamed and the patient develops cholecystitis, an acute inflammation and infection of the gallbladder.

Signs and Symptoms
The vast majority of patients with gallstones are asymptomatic. Symptomatic gallstones typically manifest with right upper quadrant abdominal pain, often accompanied by nausea and vomiting. The pain is often severe, may abate over several hours (biliary colic), or may progress to cholecystitis, with persistent pain and fever. On examination, there is pain to palpation in the right upper quadrant (Murphy's sign).

Diagnosis
The imaging study of choice is a right upper quadrant ultrasound, which, in the presence of cholecystitis, typically shows the presence of gallstones, a thickened gallbladder wall, and pericholecystic fluid. In those patients with symptomatic gallstones and a negative ultrasound examination, endoscopic ultrasound may be helpful. 2 To confirm the suspicion of cholecystitis, a hydroxyiminodiacetic acid (HIDA) scan can be useful. The radionuclide material is concentrated in the liver and excreted into the bile but does not fill the gallbladder because of cystic duct obstruction.

Summary: Acute Cholecystitis

• Right upper quadrant abdominal pain, nausea, and vomiting
• Ultrasound reveals
• Thickened gallbladder wall
• Pericholecystic fluid collection
• HIDA scan reveals non-visualized gallbladder

Treatment
The primary treatment for symptomatic gallstone disease is cholecystectomy. Prophylactic cholecystectomy for silent gallstones is not warranted. Most cholecystectomies in the World are done laparoscopically. A patient with an acute episode that resolves should see a surgeon within a few weeks and elective cholecystectomy should be considered. Patients who have persistent right upper quadrant tenderness and develop fever or an elevated white blood cell count should be seen more urgently.

The imaging study of choice is a right upper quadrant ultrasound, which, in the presence of cholecystitis, typically shows the presence of gallstones, a thickened gallbladder wall, and pericholecystic fluid. In those patients with symptomatic gallstones and a negative ultrasound examination, endoscopic ultrasound may be helpful. 2 To confirm the suspicion of cholecystitis, a hydroxyiminodiacetic acid (HIDA) scan can be useful. The radionuclide material is concentrated in the liver and excreted into the bile but does not fill the gallbladder because of cystic duct obstruction.