The most common indication for a pancreaticoduodenectomy is resection of a tumor of the head, neck, or uncinate process of the pancreas or periampullary tumors. Another indication is chronic pancreatitis with imflammatory changes localized to the head of the pancreas. Preoperative evaluation includes imaging for diagnosis, as well as staging and determination of resectability.
The most common imaging modalities used include transabdominal ultrasound, endoscopic ultrasound, computed tomography (CT) scan, magnetic resonance imaging (MRI), and endoscopic retrograde cholargiopancreatography ERCP. CT scan is useful both for the diagnosis and staging of pancreatic cancer. Endoscopic ultrasound is most sensitive for evaluation of the local extent of the primary tumor.
Metastatic disease to the liver, peritoneum, and local invasion are contraindications for a pancreaticoduodenctomy. However, various centers have different levels of aggressiveness regarding portomesenteric vessel invasion and resection.
Another important aspect of preoperative evaluation is the determination of a patient's ability to survive the procedure. Debilitating acute or chronic diseases make the risk of surgery unacceptable.
The procedure begins with an exploration of the abdomen for evidence of metastatic disease or advanced local disease. This exploration may be initiated with a laparoscope. The peritoneal cavity is inspected for ascitic fluid and peritoneal implantation of metastasis. The liver surface is inspected. Following this, the extent of the tumor is determined by mobilizing the head of the pancreas and the duodenum. The lesser sac is entered, and the body and tail of the pancreas are examined, as well as the area of the superior mesenteric vein, which passes under the neck of the pancreas. Invasion of adjacent organs, superior mesenteric vessels, or portal vein is a contraindication for resection in most centers. Once a determination has been made to resect the tumor, the stomach is divided approx 5-7 cm from the pylorus. The biliary tract is then divided at the common hepatic duct level. A cholecystectomy is performed. Next, the pancreas
^ Gastro jejunostomy
Fig. 1. Whipple procedure. (A) Standard Whipple procedure. (B) Pylorus sparing Whipple procedure.
is transected at the level of the superior mesenteric vein. Transection of the jejunum 10-15 cm distal to the ligament of Treitz completes the resection. Reconstruction is achieved by bringing the jejunal limb either anterior to the transverse colon (antecolic) or through the mesocolon (retrocolic). A pancreatico-jejunostomy is performed first, followed by a choledacojejunostomy. Finally, a gastrojejunostomy is performed.
Given that most complications arise from the pancreaticojejunostomy, several different techniques have been described. As an alternative to the pancreaticojejunostomy reconstruction, some surgeons perform a pancreaticogastrostomy. Both techniques yield similar results.
A modification of the standard Whipple procedure involves preservation of the pylorus and the proximal 2 cm of the duodenum (Fig. 1B). The advantages over the classical Whipple procedure include preservation of the stomach reservoir and the pylorus, and theoretically, maintaining a more normal gastric emptying, and hormonal control. The reconstruction is similar to the classical pancreaticoduodenctomy except that instead of a gastrojejunostomy, a duodenojejunostomy is performed. The theoretical disadvantage is the inadequacy of margins during a resection for cancer. Randomized trials of the pylorus-sparing and standard Whipple procedure have failed to reveal any differences in outcome or morbidity.
The postoperative mortality rate is about 2-5%. The morbidity rate is about 20-50% (1-3). Advanced age is no longer a contraindication, and recent series have increasingly included octogenarians. Complications not specific to the procedure include cardiopulmonary events, postoperative bleeding, and infectious complications. Because of the complex nature of the resection and reconstruction, complications can originate from
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