Pancreaticoduodenectomy

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Pancreaticoduodenectomy
Diagram showing how the pancreas and bowel is joined back together after a Whipple's operation CRUK 140.svg
The pancreas, stomach, and bowel are joined back together after a pancreaticoduodenectomy
Other namesPancreatoduodenectomy, [1] Whipple procedure, Kausch-Whipple procedure
ICD-9-CM 52.7
MeSH D016577

A pancreaticoduodenectomy, also known as a Whipple procedure, is a major surgical operation most often performed to remove cancerous tumours from the head of the pancreas. [2] It is also used for the treatment of pancreatic or duodenal trauma, or chronic pancreatitis. [2] Due to the shared blood supply of organs in the proximal gastrointestinal system, surgical removal of the head of the pancreas also necessitates removal of the duodenum, proximal jejunum, gallbladder, and, occasionally, part of the stomach. [2]

Contents

Anatomy involved in the procedure

The tissue removed during a pancreaticoduodenectomy Diagram showing the parts removed with a Whipple's operation CRUK 337.svg
The tissue removed during a pancreaticoduodenectomy
Whipple surgery Whipple Surgery.png
Whipple surgery

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. Lymph nodes in the area are often removed during the operation as well (lymphadenectomy). However, not all lymph nodes are removed in the most common type of pancreaticoduodenectomy because studies showed that patients did not benefit from the more extensive surgery. [3]

At the very beginning of the procedure, after the surgeons have gained access to the abdomen, the surfaces of the peritoneum and the liver are inspected for disease that has metastasized. This is an important first step as the presence of active metastatic disease is a contraindication to performing the operation.

The vascular supply of the pancreas is from the celiac artery via the superior pancreaticoduodenal artery and the superior mesenteric artery from the inferior pancreaticoduodenal artery. There are additional smaller branches given off by the right gastric artery which is also derived from the celiac artery. The reason for the removal of the duodenum along with the head of the pancreas is that they share the same arterial blood supply (the superior pancreaticoduodenal artery and inferior pancreaticoduodenal 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.

While the blood supply to the liver is left intact, the common bile duct is removed. This means that while the liver remains with a good blood supply the surgeon must make a new connection to drain bile produced in the liver. This is done at the end of the surgery. The surgeon will make a new attachment between the pancreatic duct and the jejunum or stomach. During the surgery, a cholecystectomy is performed to remove the gallbladder. This portion is not done en bloc, as the gallbladder is removed separately.

Relevant nearby anatomy not removed during the procedure include the major vascular structures in the area: the portal vein, the superior mesenteric vein, and the superior mesenteric artery, the inferior vena cava. These structures are important to consider in this operation especially if done for resection of a tumor located in the head of the pancreas. If the tumor encases (wraps around 50% or more of the vessel) the celiac artery, superior mesenteric artery, or inferior vena cava it is considered unresectable due to the lack of patient benefit from the operation while having very high risk. [4] [5] Occasionally a portion of the superior mesenteric vein or portal vein is attached or inseparable from the tumor. In this setting vascular surgeons resect the involved portion of the vessel, and the vessel is repaired either via end-to-end anastomosis, repair of the side wall of the vein, or a vein graft.

Medical indications

Pancreaticoduodenectomy is most often performed as a curative treatment for periampullary cancer, which includes cancer of the bile duct, duodenum, ampulla or head of the pancreas. [6] The shared blood supply of the pancreas, duodenum and common bile duct necessitates en bloc resection of these multiple structures. Other indications for pancreaticoduodenectomy include chronic pancreatitis, benign tumors of the pancreas, cancer metastatic to the pancreas, multiple endocrine neoplasia type 1 [7] and gastrointestinal stromal tumors. [6]

Pancreatic cancer

Pancreaticoduodenectomy is the only potentially curative intervention for malignant tumors of the pancreas. [8] However, the majority of patients with pancreatic cancer present with metastatic or locally advanced un-resectable disease; [9] thus only 15–20% of patients are candidates for the Whipple procedure. Surgery may follow neoadjuvant chemotherapy, which aims to shrink the tumor and increase the likelihood of complete resection. [10] Post-operative death and complications associated with pancreaticoduodenectomy have become less common, with rates of post-operative mortality falling from 30 to 10% in the 1980s to less than 5% in the 2000s. [11]

Ampullary cancer

Ampullary cancer arises from the lining of the ampulla of Vater. [12]

Duodenal cancer

Duodenal cancer arises from the lining of the duodenal mucosa. Majority of duodenal cancers originate in the second part of the duodenum, where ampulla is located. [12]

Cholangiocarcinoma

Cholangiocarcinoma, or cancer of the bile duct, is an indication for the Whipple procedure when the cancer is present in the distal biliary system, usually the common bile duct that drains into the duodenum. Depending on the location and extension of the cholangiocarcinoma, curative surgical resection may require hepatectomy, or removal of part of the liver, with or without pancreaticoduodenectomy. [13]

Chronic pancreatitis

Treatment of chronic pancreatitis typically includes pain control and management of exocrine insufficiency. Intractable abdominal pain is the main surgical indication for surgical management of chronic pancreatitis. [14] Removal of the head of the pancreas can relieve pancreatic duct obstruction associated with chronic pancreatitis. [15]

Trauma

Damage to the pancreas and duodenum from blunt abdominal trauma is uncommon. In rare cases when this pattern of trauma has been reported, it has been seen as a result of a lap belt in motor vehicle accidents. [16] Pancreaticoduodenectomy has been performed when abdominal trauma has resulted in bleeding around the pancreas and duodenum, damage to the common bile duct, pancreatic leakage, or transection of the duodenum. [17] Due to the rarity of this procedure in the setting of trauma, there is not robust evidence regarding post-operative outcomes.

Contraindications

Absolute contraindications for the procedure are metastatic disease in the abdominal cavity or nearby organs. These are found most often on the peritoneum, in the liver, and in the omentum. In order to determine if there are metastases, surgeons will inspect the abdomen at the beginning of the procedure after gaining access. Alternatively, they may perform a separate procedure called a diagnostic laparoscopy which involves insertion of a small camera through a small incision to look inside the abdomen. This may spare the patient the large abdominal incision that would occur if they were to undergo the initial part of a pancreaticoduodenectomy that was cancelled due to metastatic disease. [18]

Further contraindications include encasement of major vessels (such as celiac artery, inferior vena cava, or superior mesenteric artery) as mentioned above.

Surgical considerations

Pylorus-sparing pancreaticoduodenectomy

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 mellitus 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. In recent years the pylorus-preserving pancreaticoduodenectomy (also known as Traverso-Longmire procedure/PPPD) has been gaining popularity, especially among European surgeons. The main advantage of this technique is that the pylorus, and thus normal gastric emptying, should in theory be preserved. [19] There is conflicting data as to whether pylorus-preserving pancreaticoduodenectomy is associated with increased likelihood of gastric emptying. [20] [21] 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. [21]

Compared to the standard Whipple procedure, the pylorus preserving pancreaticoduodenectomy technique is associated with shorter operation time and less intraoperative blood loss, requiring less blood transfusion. Post-operative complications, hospital mortality and survival do not differ between the two methods. [22] [23] [24]

Morbidity and mortality

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 v. 3.8%) 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. [25] de Wilde et al. have reported statistically significant mortality reductions concurrent with centralization of the procedure in the Netherlands. [26]

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. [27]

Postoperative complications

Three of the most common post-operative complications are delayed gastric emptying, bile leak, and pancreatic leak. Delayed gastric emptying, normally defined as an inability to tolerate a regular diet by the end of the first post-op week and the requirement for nasogastric tube placement, occurs in approximately 17% of operations. [28] [29] During the surgery, a new biliary connection (normally a choledochal-jejunal anastamosis connecting the common bile duct and jejunum) is made. This new connection may leak in 1-2% of operations. As this complication is fairly common, it is normal in this procedure for the surgeon to leave a drain in place at the end. [30] This allows for detection of a bile leak via elevated bilirubin in the fluid drained. Pancreatic leak or pancreatic fistula, defined as fluid drained after postoperative day 3 that has an amylase content greater than or equal to 3 times the upper limit of normal, occurs in 5-10% of operations, [31] [32] although changes in the definition of fistula may now include a much larger proportion of patients (upwards of 40%). [33]

Recovery after surgery

Immediately after surgery, patients are monitored for return of bowel function and appropriate closed-suction drainage of the abdomen.

Return of bowel function

Ileus, which refers to functional obstruction or aperistalsis of the intestine, is a physiologic response to abdominal surgery, including the Whipple procedure. [34] While post-operative ileus is typically self-limited, prolonged post-operative ileus occurs when patients develop nausea, abdominal distention, pain or intolerance of food by mouth. [35] Various measures are taken in the immediate post-operative period to minimize prolonged post-operative ileus. A nasogastric tube is typically maintained to suction, to drain gastric and intestinal contents. Ambulation is encouraged to stimulate return of bowel function. Use of opioid medications, which interfere with intestinal motility, is limited. [36]

History

This procedure was originally described by Alessandro Codivilla, an Italian surgeon, in 1898. [37] The first resection for a periampullary cancer was performed by the German surgeon Walther Kausch in 1909 and described by him in 1912. It is often called Whipple's procedure or the Whipple procedure, after the American surgeon Allen Whipple who devised an improved version of the surgery in 1935 while at Columbia-Presbyterian Medical Center in New York [38] and subsequently came up with multiple refinements to his technique.

Nomenclature

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, as strictly speaking pancreaticoduodenectomy should refer to the resection of the duodenum and pancreatic duct rather than the pancreas itself. [1]

See also

Related Research Articles

<span class="mw-page-title-main">General surgery</span> Medical specialty

General surgery is a surgical specialty that focuses on alimentary canal and abdominal contents including the esophagus, stomach, small intestine, large intestine, liver, pancreas, gallbladder, appendix and bile ducts, and often the thyroid gland. General surgeons also deal with diseases involving the skin, breast, soft tissue, trauma, peripheral artery disease and hernias and perform endoscopic as such as gastroscopy, colonoscopy and laparoscopic procedures.

<span class="mw-page-title-main">Pancreas</span> Organ of the digestive system and endocrine system of vertebrates

The pancreas is an organ of the digestive system and endocrine system of vertebrates. In humans, it is located in the abdomen behind the stomach and functions as a gland. The pancreas is a mixed or heterocrine gland, i.e., it has both an endocrine and a digestive exocrine function. 99% of the pancreas is exocrine and 1% is endocrine. As an endocrine gland, it functions mostly to regulate blood sugar levels, secreting the hormones insulin, glucagon, somatostatin and pancreatic polypeptide. As a part of the digestive system, it functions as an exocrine gland secreting pancreatic juice into the duodenum through the pancreatic duct. This juice contains bicarbonate, which neutralizes acid entering the duodenum from the stomach; and digestive enzymes, which break down carbohydrates, proteins and fats in food entering the duodenum from the stomach.

<span class="mw-page-title-main">Duodenum</span> First section of the small intestine

The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In mammals it may be the principal site for iron absorption. The duodenum precedes the jejunum and ileum and is the shortest part of the small intestine.

<span class="mw-page-title-main">Small intestine</span> Organ in the gastrointestinal tract

The small intestine or small bowel is an organ in the gastrointestinal tract where most of the absorption of nutrients from food takes place. It lies between the stomach and large intestine, and receives bile and pancreatic juice through the pancreatic duct to aid in digestion. The small intestine is about 5.5 metres long and folds many times to fit in the abdomen. Although it is longer than the large intestine, it is called the small intestine because it is narrower in diameter.

<span class="mw-page-title-main">Pancreatic cancer</span> Type of endocrine gland cancer

Pancreatic cancer arises when cells in the pancreas, a glandular organ behind the stomach, begin to multiply out of control and form a mass. These cancerous cells have the ability to invade other parts of the body. A number of types of pancreatic cancer are known.

<span class="mw-page-title-main">Cholecystectomy</span> Surgical removal of the gallbladder

Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is a common treatment of symptomatic gallstones and other gallbladder conditions. In 2011, cholecystectomy was the eighth most common operating room procedure performed in hospitals in the United States. Cholecystectomy can be performed either laparoscopically, or via an open surgical technique.

<span class="mw-page-title-main">Gastrectomy</span> Surgical removal of the stomach

A gastrectomy is a partial or total surgical removal of the stomach.

<span class="mw-page-title-main">Suspensory muscle of duodenum</span> Muscle between the duodenum and jejunum

The suspensory muscle of duodenum is a thin muscle connecting the junction between the duodenum and jejunum, as well as the duodenojejunal flexure to connective tissue surrounding the superior mesenteric and coeliac arteries. The suspensory muscle most often connects to both the third and fourth parts of the duodenum, as well as the duodenojejunal flexure, although the attachment is quite variable.

<span class="mw-page-title-main">Pancreatectomy</span> Surgical removal of the pancreas

In medicine, a pancreatectomy is the surgical removal of all or part of the pancreas. Several types of pancreatectomy exist, including pancreaticoduodenectomy, distal pancreatectomy, segmental pancreatectomy, and total pancreatectomy. In recent years, the TP-IAT has also gained respectable traction within the medical community. These procedures are used in the management of several conditions involving the pancreas, such as benign pancreatic tumors, pancreatic cancer, and pancreatitis.

The Kocher manoeuvre is a surgical procedure to expose structures in the retroperitoneum behind the duodenum and pancreas. In vascular surgery, it is described as a method to expose the abdominal aorta. It usually has been in contrast to midline laparotomy and right retroperitoneal space dissection. These two procedures have been used for diverse cases, but have approximately equivalent outcomes.

<span class="mw-page-title-main">Duodenal cancer</span> Medical condition

Duodenal cancer is a cancer in the first section of the small intestine known as the duodenum. Cancer of the duodenum is relatively rare compared to stomach cancer and colorectal cancer. Its histology is usually adenocarcinoma.

<span class="mw-page-title-main">Inferior pancreaticoduodenal artery</span> Branch of the superior mesenteric artery that supplies parts of the pancreas and the duodenum

The inferior pancreaticoduodenal artery is a branch of the superior mesenteric artery. It supplies the head of the pancreas, and the ascending and inferior parts of the duodenum. Rarely, it may have an aneurysm.

<span class="mw-page-title-main">Hemosuccus pancreaticus</span> Medical condition

Hemosuccus pancreaticus is a rare cause of hemorrhage in the gastrointestinal tract. It is caused by a bleeding source in the pancreas, pancreatic duct, or structures adjacent to the pancreas, such as the splenic artery, that bleed into the pancreatic duct, which is connected with the bowel at the duodenum, the first part of the small intestine. Patients with hemosuccus may develop symptoms of gastrointestinal hemorrhage, such as blood in the stools, maroon stools, or melena, which is a dark, tarry stool caused by digestion of red blood cells. They may also develop abdominal pain. It is associated with pancreatitis, pancreatic cancer and aneurysms of the splenic artery. Hemosuccus may be identified with endoscopy (esophagogastroduodenoscopy), where fresh blood may be seen from the pancreatic duct. Alternatively, angiography may be used to inject the celiac axis to determine the blood vessel that is bleeding. This may also be used to treat hemosuccus, as embolization of the end vessel may terminate the hemorrhage. However, a distal pancreatectomy—surgery to remove of the tail of the pancreas—may be required to stop the hemorrhage.

<span class="mw-page-title-main">Hepatic lymph nodes</span> Lymph nodes on the common hepatic artery

The hepatic lymph nodes consist of the following groups:

<span class="mw-page-title-main">Roux-en-Y anastomosis</span> Type of surgery

In general surgery, a Roux-en-Y anastomosis, or Roux-en-Y, is an end-to-side surgical anastomosis of bowel used to reconstruct the gastrointestinal tract. Typically, it is between stomach and small bowel that is distal from the cut end.

<span class="mw-page-title-main">Periampullary cancer</span> Disease

Periampullary cancer is a cancer that forms near the ampulla of Vater, an enlargement of the ducts from the liver and pancreas where they join and enter the small intestine. It consists of:

  1. ampullary tumour from ampulla of Vater
  2. cancer of lower common bile duct
  3. duodenal cancer adjacent to ampulla
  4. carcinoma head of pancreas

An exploratory laparotomy is a general surgical operation where the abdomen is opened and the abdominal organs are examined for injury or disease. It is the standard of care in various blunt and penetrating trauma situations in which there may be life-threatening internal injuries. It is also used in certain diagnostic situations, in which the operation is undertaken in search of a unifying cause for multiple signs and symptoms of disease, and in the staging of some cancers.

A pancreatic injury is some form of trauma sustained by the pancreas. The injury can be sustained through either blunt forces, such as a motor vehicle accident, or penetrative forces, such as that of a gunshot wound. The pancreas is one of the least commonly injured organs in abdominal trauma.

<span class="mw-page-title-main">Choledochoduodenostomy</span>

Choledochoduodenostomy (CDD) is a surgical procedure to create an anastomosis, a surgical connection, between the common bile duct (CBD) and an alternative portion of the duodenum. In healthy individuals, the CBD meets the pancreatic duct at the ampulla of Vater, which drains via the major duodenal papilla to the second part of duodenum. In cases of benign conditions such as narrowing of the distal CBD or recurrent CBD stones, performing a CDD provides the diseased patient with CBD drainage and decompression. A side-to-side anastomosis is usually performed.

<span class="mw-page-title-main">Antrectomy</span> Type of gastric resection surgery

Antrectomy, also called distal gastrectomy, is a type of gastric resection surgery that involves the removal of the stomach antrum to treat gastric diseases causing the damage, bleeding, or blockage of the stomach. This is performed using either the Billroth I (BI) or Billroth II (BII) reconstruction method. Quite often, antrectomy is used alongside vagotomy to maximise its safety and effectiveness. Modern antrectomies typically have a high success rate and low mortality rate, but the exact numbers depend on the specific conditions being treated.

References

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  38. ↑ synd/3492 at Who Named It?
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