- Howard A Reber, MD
Howard A Reber, MD
- Professor of Surgery
- David Geffen School of Medicine at UCLA
Pancreaticoduodenectomy is a complex, high-risk surgical procedure. The conventional operation for removal of lesions from within the head or uncinate process of the pancreas is pancreaticoduodenectomy, also called the "Whipple procedure." Although first performed by the German surgeon Kausch in 1909, the operation was popularized by Dr. Allen Whipple, who performed 37 pancreaticoduodenectomies during his career [1,2].
Conventional pancreaticoduodenectomy involves a distal gastrectomy with removal of the pancreatic head, duodenum, first 15 cm of the jejunum, common bile duct, and gallbladder (figure 1). A modification of the conventional procedure, pylorus-preserving pancreaticoduodenectomy preserves the gastric antrum, pylorus, and the proximal 2 to 3 cm of the duodenum, which is anastomosed to the jejunum to restore gastrointestinal continuity (figure 2). This procedure was initially done by the British surgeon Kenneth Watson in 1943 for a patient with carcinoma of the ampulla of Vater  and then reintroduced by Traverso and Longmire at UCLA for a patient who required a Whipple for chronic pancreatitis . The authors surmised that preservation of gastric emptying may be more physiologic and, since it was performed for pancreatitis, the additional gastric tissue and prepyloric lymph nodes would not be needed for staging purposes. Since the rapid adoption of this modification, it has been applied to both benign and malignant disease.
Pylorus-preserving pancreaticoduodenectomy may decrease the incidence of postoperative dumping, marginal ulceration, and bile reflux gastritis that can occur in many patients undergoing partial gastrectomy, which is employed in the conventional pancreatectomy technique. In our experience, the incidence of delayed gastric emptying following either standard or pylorus-preserving pancreaticoduodenectomy is about 15 percent. Several randomized trials and a metaanalysis have demonstrated that pylorus-preserving pancreaticoduodenectomy has similar long-term survival and outcomes as conventional pancreaticoduodenectomy, but is associated with shorter operative times and blood loss . The lowest perioperative mortality rates and best long-term cancer outcomes for pancreaticoduodenectomy occur at high-volume centers [6,7]. In experienced hands, the median operative time is about five hours, with a median blood loss of 350 mL and perioperative mortality of less than 4 percent .
The technique of pylorus preserving pancreaticoduodenectomy will be discussed here. An overview of resection of lesions of the pancreatic head is presented in detail elsewhere. (See "Overview of surgery in the treatment of exocrine pancreatic cancer and prognosis".)
PATIENT SELECTION AND PREPARATION
The most common indication for pancreaticoduodenectomy is the presence of a malignant or premalignant neoplasm in the head of the pancreas or one of the other periampullary structures (bile duct, ampulla, or duodenum) [8-10]. Other conditions that may require resection of the pancreatic head, preoperative evaluation and preparation, and options for managing lesions of the pancreatic head are discussed in detail elsewhere. (See "Surgical resection of lesions of the head of the pancreas", section on 'Indications for pancreatic head resection' and "Surgical resection of lesions of the head of the pancreas", section on 'Preoperative evaluation' and "Surgical resection of lesions of the head of the pancreas", section on 'Preparation'.)
- Whipple AO, Parsons WB, Mullins CR. TREATMENT OF CARCINOMA OF THE AMPULLA OF VATER. Ann Surg 1935; 102:763.
- Cameron JL, Riall TS, Coleman J, Belcher KA. One thousand consecutive pancreaticoduodenectomies. Ann Surg 2006; 244:10.
- Watson K. Carcinoma of ampulla of vater successful radical resection. Br J Surg 1944; 31:368.
- Traverso LW, Longmire WP Jr. Preservation of the pylorus in pancreaticoduodenectomy. Surg Gynecol Obstet 1978; 146:959.
- Diener MK, Fitzmaurice C, Schwarzer G, et al. Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev 2011; :CD006053.
- Birkmeyer JD, Sun Y, Wong SL, Stukel TA. Hospital volume and late survival after cancer surgery. Ann Surg 2007; 245:777.
- Fong Y, Gonen M, Rubin D, et al. Long-term survival is superior after resection for cancer in high-volume centers. Ann Surg 2005; 242:540.
- Duffy JP, Hines OJ, Liu JH, et al. Improved survival for adenocarcinoma of the ampulla of Vater: fifty-five consecutive resections. Arch Surg 2003; 138:941.
- Ryder NM, Ko CY, Hines OJ, et al. Primary duodenal adenocarcinoma: a 40-year experience. Arch Surg 2000; 135:1070.
- Ashley SW, Reber HA. The Whipple operation: The classical surgical procedure to treat chronic pancreatitis. Digestive Surgery 1996; 13:113.
- Patel AG, Toyama MT, Kusske AM, et al. Pylorus-preserving Whipple resection for pancreatic cancer. Is it any better? Arch Surg 1995; 130:838.
- Diener MK, Heukaufer C, Schwarzer G, et al. Pancreaticoduodenectomy (classic Whipple) versus pylorus-preserving pancreaticoduodenectomy (pp Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev 2008; :CD006053.
- MILLBOURN E. On the excretory ducts of the pancreas in man, with special reference to their relations to each other, to the common bile duct and to the duodenum. Acta Anat (Basel) 1950; 9:1.
- Hines OJ, Reber HA. Technique of pancreaticojejunostomy reconstruction after pancreaticoduodenectomy. J Hepatobiliary Pancreat Surg 2006; 13:185.
- PATIENT SELECTION AND PREPARATION
- PANCREATIC ANATOMY AND PHYSIOLOGY
- Ductal anatomy
- Neurovascular supply
- SUMMARY OF SURGICAL STEPS
- Assessment of metastatic disease
- Mobilization of the duodenum and pancreatic head
- - Identification of the superior mesenteric vein (SMV)
- Mobilization of the stomach and proximal duodenum
- - Transection of the proximal duodenum or stomach
- Skeletonization of the portal structures
- - Cholecystectomy and division of the bile duct
- Mobilization and division of the proximal jejunum
- Transection of the pancreatic neck
- - Division of attachments to the SMV, SMA, and PV
- Gastrointestinal reconstruction
- - Pancreatic anastomosis
- - Biliary anastomosis
- - Duodenal anastomosis
- Drains and closure
- POSTOPERATIVE CARE AND FOLLOW-UP
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS