| Pancreaticoduodenectomy | |
|---|---|
| Intervention | |
| ICD-9-CM | 52.7 |
| MeSH | D016577 |
A pancreaticoduodenectomy, pancreatoduodenectomy,[1] Whipple procedure, or Kausch-Whipple procedure, is a major surgical operation involving the pancreas, duodenum, and other organs. This operation is performed to treat cancerous tumours on the head of the pancreas, malignant tumors involving common bile duct, duodenal papilla, or duodenum near the pancreas.
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This procedure was originally described by Alessandro Codivilla, an Italian surgeon, in 1898. The first resection for a periampullary cancer was performed by the German surgeon Walther Kausch in 1909 and described by Kausch in 1912.
It is often called the Whipple procedure, after the American surgeon Allen Whipple who devised an improved version of the surgery in 1935[2] and subsequently came up with multiple refinements to his technique.
The most common technique of a pancreaticoduodenectomy consists of the en bloc removal of the distal segment (antrum) of the stomach; the first and second portions of the duodenum; the head of the pancreas; the common bile duct; and the gallbladder.
The basic concept behind the pancreaticoduodenectomy is that the head of the pancreas and the duodenum share the same arterial blood supply (the gastroduodenal artery). These arteries run through the head of the pancreas, so that both organs must be removed if the single blood supply is severed. If only the head of the pancreas were removed it would compromise blood flow to the duodenum, resulting in tissue necrosis.
The Whipple procedure today is very similar to Whipple's original procedure. It consists of removal of the distal half of the stomach (antrectomy), the gall bladder and its cystic duct (cholecystectomy), the common bile duct (choledochectomy), the head of the pancreas, duodenum, proximal jejunum, and regional lymph nodes. Reconstruction consists of attaching the pancreas to the jejunum (pancreaticojejunostomy) and attaching the hepatic duct to the jejunum (hepaticojejunostomy) to allow digestive juices and bile respectively to flow into the gastrointestinal tract and attaching the stomach to the jejunum (gastrojejunostomy) to allow food to pass through. Whipple originally used the sequence: bile duct, pancreas and stomach, whereas presently the popular method of reconstruction is pancreas, bile duct and stomach, also known as Child's operation.
Originally performed in a two-step process, Whipple refined his technique in 1940 into a one-step operation. Using modern operating techniques, mortality from a Whipple procedure is around five percent in the United States (less than two percent in high-volume academic centers).[3] The original description of Whipple's operation together with a modern commentary [4] is available on-line.
Clinical trials have failed to demonstrate significant survival benefits of total pancreatectomy, mostly because patients who submit to this operation tend to develop a particularly severe form of diabetes called brittle diabetes. Sometimes the pancreaticojejunostomy may not hold properly after the completion of the operation and infection may spread inside the patient. This may lead to another operation shortly thereafter in which the remainder of the pancreas (and sometimes the spleen) is removed to prevent further spread of infection and possible morbidity.
More recently, the pylorus-sparing pancreaticoduodenectomy (also known as Traverso-Longmire procedure/PPPD) is growing increasingly popular, especially among European surgeons. The main advantage of this technique is that the pylorus, and thus normal gastric emptying, is preserved.[5] However, some doubts remain on whether it is an adequate operation from an oncological point of view. In practice, it shows similar long-term survival as a Whipple's (pancreaticoduodenectomy + hemigastrectomy), but patients benefit from improved recovery of weight after a PPPD, so this should be performed when the tumour does not involve the stomach and the lymph nodes along the gastric curvatures are not enlarged.[6]
Another controversial point is whether patients benefit from retroperitoneal lymphadenectomy.
A prospective, randomized, multicenter analysis was published in 2004 comparing the standard Whipple (SW) procedure to the pylorus preserving pancreaticoduodenectomy technique (PPPD) to treat patients with suspected pancreatic or periampullary cancer. The study found no significant difference in median blood loss (2.0 L, range 0.3-9.5L for SW and 2.0L, range 0.4-21.0L for PPPD, p= 0.70) or duration of the operation (300 minutes, range 160-480 for SW and 300 minutes, range 130-600 for PPPD, p= 0.10). Delayed gastric emptying was equal in the two groups. Patients were followed for a maximum period of 115 months without a significant difference in survival between the two groups.[7]
A systematic review and meta-analysis published in 2007, which included 6 trials and a total of 574 patients, showed that operation time for PPPD was 72 minutes faster with 284ml less blood loss compared to SW. PPPD also required 0.66 fewer units of blood transfusion.[8]
Another systematic review and meta-analysis published in 2007 showed no statistically significant difference in morbidity, hospital mortality, or survival between PPPD or SW. But once again the operation time and intraoperative blood loss were reduced in patients undergoing PPPD.[9]
Meta-analysis published in 2008 included 2822 patients (1335 SW and 1487 PPPD). Again, patients undergoing PPPD were found to have a shorter operation time and required less blood transfusion compared to the SW group. There were no differences found in post-operative complications between the two groups.[10]
Pancreaticoduodenectomy is considered, by any standard to be a major surgical procedure.
Many studies have shown that hospitals where a given operation is performed more frequently have better overall results (especially in the case of more complex procedures, such as pancreaticoduodenectomy). A frequently cited study published in The New England Journal of Medicine found operative mortality rates to be four times higher (16.3 percent vs. 3.8 percent) at low-volume (averaging less than one pancreaticoduodenectomy per year) hospitals than at high-volume (16 or more per year) hospitals. Even at high-volume hospitals, morbidity has been found to vary by a factor of almost four depending on the number of times the surgeon has previously performed the procedure.[11]
One study reported actual risk to be 2.4 times greater than the risk reported in the medical literature, with additional variation by type of institution.[12]
Fingerhut et al. argue that while the terms pancreatoduodenectomy and pancreaticoduodenectomy are often used interchangeably in the medical literature, scrutinizing their etymology yields different definitions for the two terms.[1] As a result, the authors prefer pancreatoduodenectomy over pancreaticoduodenectomy for the name of this procedure.[1]
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