Pancreaticoduodenectomy

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 or duodenum near the pancreas.

History

This procedure was originally described by Alessandro Codivilla 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 Dr. Allen Oldfather Whipple who devised a perfected version of the surgery in 1935^[2] and subsequently came up with multiple refinements to his technique.

Anatomy involving the procedure

The basic concept behind the pancreaticoduodenectomy is that the head of the pancreas and the duodenum share the same arterial blood supply. These arteries run through the head of the pancreas, so that both organs must be removed. If only the head of the pancreas were removed it would compromise blood flow to the duodenum.

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.

Pancreaticoduodenectomy in modern medicine

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 (cholecystectomy), the distal portion of 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 common bile duct to the jejunum (choledochojejunostomy) 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.

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 5% in the United States (<2% in high volume academic centers).^[3]

Pancreaticoduodenectomy versus total pancreatectomy

Some authors advocate the removal of the whole pancreas (total pancreatectomy) instead of just the head.^{[citation needed]} However, clinical trials have failed to demonstrate significant survival benefits, 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.

Pylorus-sparing pancreaticoduodenectomy

More recently, the pylorus-sparing pancreaticoduodenectomy (a.k.a. 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.^[4] 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.^[5]

Another controversial point is whether patients benefit from retroperitoneal lymphadenectomy.

Morbidity and mortality

Pancreaticoduodenectomy is considered, by any standard, a major surgical procedure.

Many studies have shown that hospitals where a given operation is performed more often will have better overall results, and especially so 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% vs. 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 times the surgeon has previously performed the procedure.^[6]

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.^[7]

List of notable people who have had this surgery

• 2001: Chris Rea, singer-songwriter
• 2004: Steve Jobs,^[8] founder of Apple Inc.
• 2007: Randy Pausch,^[6] originator of the inspirational "Last Lecture"
• 2008: Candye Kane,^[9] singer and ex-pornstar

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.^[1]

References

External links

• A video of Whipple procedure