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Pylorus-preserving pancreaticoduodenectomy

Howard A Reber, MD
Section Editor
Stanley W Ashley, MD
Deputy Editor
Wenliang Chen, MD, PhD


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 [3] and then reintroduced by Traverso and Longmire at UCLA for a patient who required a Whipple for chronic pancreatitis [4]. 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 approximately 15 percent. Several randomized trials and a meta-analysis have demonstrated that pylorus-preserving pancreaticoduodenectomy when performed for cancer has similar long-term survival and outcomes as conventional pancreaticoduodenectomy but is associated with shorter operative times and blood loss [5]. 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 approximately five hours, with a median blood loss of 350 mL and perioperative mortality of less than 4 percent [2].

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".)


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'.)

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Literature review current through: Nov 2017. | This topic last updated: Mar 27, 2017.
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