Pylorus-Preserving Pancreaticoduodenectomy (Whipple Procedure)

Updated: Aug 30, 2016
  • Author: Roshni L Venugopal, MD, MS; Chief Editor: Kurt E Roberts, MD  more...
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Overview

Background

Pancreaticoduodenectomy has evolved since Kausch performed the first successful procedure as a two-stage operation in 1912. He was preceded by Codivilla in Italy, who performed the first pancreaticoduodenectomy in the 1890s; however, the patient unfortunately died in the immediate postoperative period.

The modern colloquial name for this operation (ie, Whipple procedure) refers to Dr Allen Oldfather Whipple, the surgeon who reported his series of pancreaticoduodenectomies in 1935. He had performed the procedure on three patients as a two-stage operation for periampullary neoplasms, then later refined his methodology to a one-stage procedure.

In 1937, Brunschwig extended the indications for pancreaticoduodenectomy by performing the operation for pancreatic head lesions.

In 1946, Waugh and Clagett described a formal en-bloc resection of the gallbladder with the common bile duct (CBD), gastric antrum, duodenum, and pancreatic head performed as a one-stage procedure, which we recognize today as the classic pancreaticoduodenectomy. However, the operation, though refined since Codivilla and Kausch, was utilized sparingly; perioperative mortality continued to be prohibitive, estimated as being close to 25% into the 1960s.

As advances in medicine yielded better perioperative outcomes across surgical applications, interest in the Whipple procedure was revitalized, and pancreaticoduodenectomy was performed increasingly often. In an effort to decrease postgastrectomy syndromes in post-Whipple patients, Traverso and Longmire described a pylorus-preserving modification in 1978. Important subsequent advances included the application of new technologies (ie, laparoscopic and robotic approaches to pancreaticoduodenectomy). [1, 2, 3, 4, 5, 6]

Although innumerable details of pancreaticoduodenectomy yield to continued innovation, a comprehensive discussion of intraoperative variants (ie, duct to mucosa vs invagination of the pancreaticojejunal anastomosis, diverse approaches to vein reconstructions, nuances of each enteric anastomosis, and modifications of Roux-en-Y reconstructions, to name a few) is beyond the scope of this article. We will focus on the technical aspects and perioperative impacts of the Traverso modification.

See also Ampullary CarcinomaPancreatic CancerPancreatic Trauma, and Carcinoma of the Ampulla of Vater.

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Indications

Pylorus-preserving pancreaticoduodenectomy (PPPD) is indicated for the following benign conditions:

  • Benign periampullary neoplasms not amenable to local resection with ampullectomy
  • Duodenal neoplasms
  • Trauma (rare)

PPPD is also indicated for the following malignant conditions:

  • Pancreatic ductal adenocarcinoma
  • Pancreatic islet cell carcinoma
  • Malignant intraductal papillary-mucinous neoplasm (IPMN) (pancreatic mucinous cystic neoplasms)
  • Ampullary carcinoma
  • Distal CBD carcinoma (cholangiocarcinoma)
  • Duodenal carcinoma
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Contraindications

Resectability is best described as the absence of contraindications to resection (see Technical Considerations). Computed tomography (CT) with thin collimation will detect anatomic contraindications to surgical resection.

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Technical Considerations

Anatomy

The pancreas is prismoid in shape and appears triangular in cut section, with superior, inferior, and anterior borders as well as anterosuperior, anteroinferior, and posterior surfaces.

The head of the pancreas lies in the duodenal C loop in front of the inferior vena cava (IVC) and the left renal vein (see the images below). The uncinate process is an extension of the lower (inferior) half of the head toward the left; it is of varying size and is wedged between the superior mesenteric vessels (vein on the right, artery on the left) in front and the aorta behind it.

Duodenum and pancreas. Duodenum and pancreas.
Pancreas and duodenum, posterior view. Pancreas and duodenum, posterior view.

For more information about the relevant anatomy, see Pancreas Anatomy.

See Pancreatic Adenocarcinoma Imaging: What You Need to Know, a Critical Images slideshow, to help identify which imaging studies to use to identify and evaluate this disease.

Procedural planning

Head-to-head comparison between the classically described pancreaticoduodenectomy and PPPD has not detected any significant differences with regard to operating time, perioperative morbidity, perioperative mortality, and long-term survival at 1, 3, and 5 years. Operative blood loss is slightly lower with PPPD, but the clinical significance of this is not clear.

Thus, PPPD can be considered a technical variant of pancreaticoduodenectomy, in which blood supply to the proximal duodenum is preserved. Therefore, it is important to emphasize that broad indications for resection will not differ between the two approaches. [1, 2, 3, 4]  The two main points of difference between pancreaticoduodenectomy and PPPD that merit discussion are the following:

  • Postoperative delayed gastric emptying (DGE)
  • Achievement of R0 oncologic resection (ie, surgical margins negative for tumor)

Patients who undergo PPPD have a much higher incidence of DGE than those who undergo classic pancreaticoduodenectomy. This is the primary morbidity with PPPD patients, leading to more medical interventions and thus increased cost postoperatively, related to hospital stay, cost of jejunal feedings, and jejunal tube maintenance (eg, home nursing for tube care, emergency department [ED] visits for dislodgment, and tube replacement for dysfunction). If aspiration then complicates the matter, there can be a threat to the patient's life as well.

From an oncologic perspective, PPPD should not be performed with large, bulky tumors or with any tumor that may involve the first or second portion of the duodenum. In addition, with the gastric antrectomy performed in classic pancreaticoduodenectomy, an average of four more nodes are harvested than would be with PPPD. These will be positive for nodal metastases approximately 5% of the time. The question therefore arises as to whether the incidence of non-R0 resection in this small cadre of patients should bias the surgeon against PPPD.

In view of the aforementioned considerations and the lack of statistical difference with regard to patient morbidity, mortality, and survival after classic pancreaticoduodenectomy and the pylorus-preserving modification, the individual patient profile and specific tumor characteristics should weight the surgeon’s choice of approach.

Determination of resectability

Tumor resectability must be assessed well before the patient arrives at the operating room. The tumor is considered resectable if it is locally confined (ie, if there is no distant disease). Preoperative imaging studies are the cornerstone of evaluation.

As noted, CT with thin collimation is the most effective tool for identifying local extension. The tumor can be evaluated in relation to important vascular structures. A fat plane should be seen between the low-density tumor and surrounding structures.

The disease is considered resectable if the following conditions are met:

  • The tumor does not encase celiac axis or SMA (cannot involve >180º circumference)
  • There exists a patent superior mesenteric vein (SMV), portal vein (PV), and SMV-PV confluence (no thrombosis)
  • There is no extraregional nodal disease
  • There is no distant metastatic disease

Additional imaging is usually not necessary, but in certain cases, endoscopic ultrasonography (EUS), fine-needle aspiration (FNA), or both may be employed for tissue diagnosis before the initiation of neoadjuvant therapy.

Complication prevention

The following are considerations in preventing complications:

  • Thorough preoperative evaluation (see Periprocedural Care)
  • Intravenous antibiotics for cholangitis or biliary sepsis
  • Prophylactic mechanical bowel preparation
  • Sequential compression devices for deep venous thrombosis (DVT) prevention
  • Preoperative biliary decompression if delay to surgery or preoperative cholangitis
  • Nasogastric decompression
  • Promotility agents, selective mu-receptor antagonists, pancreatic enzyme replacement
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Outcomes

A 2014 Cochrane review examined six randomized controlled trials (RCTs) comparing classic Whipple pancreaticoduodenectomy with PPPD in a total of 465 patients with periampullary or pancreatic carcinoma. [7] The authors found no relevant differences in mortality, morbidity, or survival between the two operations.

This review was updated in 2016 to include eight RCTs with a total of 512 participants. [8]  Again, the investigators found no evidence of any relevant differences in mortality, morbidity, and survival between the two operations, though some perioperative outcome measures favored PPPD to a significant degree.

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