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Pylorus-preserving pancreaticoduodenectomy

Pylorus-preserving pancreaticoduodenectomy
Literature review current through: Jan 2024.
This topic last updated: Jul 22, 2022.

INTRODUCTION — Pancreaticoduodenectomy is a complex, high-risk surgical procedure. The conventional operation for removal of lesions from within the head or uncinate process of the pancreas is pancreaticoduodenectomy, also called the "Whipple procedure." Although first performed by the German surgeon Kausch in 1909, the operation was popularized by Dr. Allen Whipple, who performed 37 pancreaticoduodenectomies during his career [1,2].

Conventional pancreaticoduodenectomy involves a distal gastrectomy with removal of the pancreatic head, duodenum, first 15 cm of the jejunum, common bile duct, and gallbladder (figure 1). A modification of the conventional procedure, pylorus-preserving pancreaticoduodenectomy preserves the gastric antrum, pylorus, and the proximal 2 to 3 cm of the duodenum, which is anastomosed to the jejunum to restore gastrointestinal continuity (figure 2). This procedure was initially done by the British surgeon Kenneth Watson in 1943 for a patient with carcinoma of the ampulla of Vater [3] and then reintroduced by Traverso and Longmire at UCLA for a patient who required a Whipple for chronic pancreatitis [4]. The authors surmised that preservation of gastric emptying may be more physiologic and, since it was performed for pancreatitis, the additional gastric tissue and prepyloric lymph nodes would not be needed for staging purposes. Since the rapid adoption of this modification, it has been applied to both benign and malignant disease.

Pylorus-preserving pancreaticoduodenectomy may decrease the incidence of postoperative dumping, marginal ulceration, and bile reflux gastritis that can occur in many patients undergoing partial gastrectomy, which is employed in the conventional pancreatectomy technique. In our experience, the incidence of delayed gastric emptying following either standard or pylorus-preserving pancreaticoduodenectomy is approximately 15 percent. Several randomized trials and a meta-analysis have demonstrated that pylorus-preserving pancreaticoduodenectomy when performed for cancer has similar long-term survival and outcomes as conventional pancreaticoduodenectomy but is associated with shorter operative times and blood loss [5]. The lowest perioperative mortality rates and best long-term cancer outcomes for pancreaticoduodenectomy occur at high-volume centers [6,7]. In experienced hands, the median operative time is approximately five hours, with a median blood loss of 350 mL and perioperative mortality of less than 4 percent [2].

The technique of pylorus-preserving pancreaticoduodenectomy will be discussed here. An overview of resection of lesions of the pancreatic head is presented in detail elsewhere. (See "Overview of surgery in the treatment of exocrine pancreatic cancer and prognosis".)

PATIENT SELECTION AND PREPARATION — The most common indication for pancreaticoduodenectomy is the presence of a malignant or premalignant neoplasm in the head of the pancreas or one of the other periampullary structures (bile duct, ampulla, or duodenum) [8-10]. Other conditions that may require resection of the pancreatic head, preoperative evaluation and preparation, and options for managing lesions of the pancreatic head are discussed in detail elsewhere. (See "Surgical resection of lesions of the head of the pancreas", section on 'Indications for pancreatic head resection' and "Surgical resection of lesions of the head of the pancreas", section on 'Preoperative evaluation' and "Surgical resection of lesions of the head of the pancreas", section on 'Preparation'.)

Some surgeons prefer to begin the operation with laparoscopy, which permits examination of the liver and peritoneal surfaces, and biopsy of any suspicious areas. If a metastatic tumor is found, laparotomy may be avoided. Whether to perform staging laparoscopy prior to proceeding with pancreaticoduodenectomy is discussed elsewhere. (See "Surgical resection of lesions of the head of the pancreas", section on 'Staging laparoscopy' and "Clinical manifestations, diagnosis, and staging of exocrine pancreatic cancer", section on 'Staging laparoscopy'.)

Most of our patients with pancreatic adenocarcinoma are candidates for pylorus-preserving pancreaticoduodenectomy [11,12]. However, a conventional pancreaticoduodenectomy (ie, Whipple operation) should be performed if tumor involves the proximal duodenum, pylorus, or gastric antrum.

PANCREATIC ANATOMY AND PHYSIOLOGY — The pancreas is a compound exocrine and endocrine gland located in the retroperitoneum at the level of the second lumbar vertebrae. Exocrine pancreatic secretion is composed of enzymes, water, and electrolytes (chiefly bicarbonate), which are delivered to the duodenum via the pancreatic duct of Wirsung and aid with digestion. Endocrine secretions, the hormones insulin, glucagon, and somatostatin, are secreted by the islets of Langerhans (beta cells, alpha cells, and delta cells, respectively). Removal of the head of the pancreas may result in diabetes in up to 20 percent of cases [13].

The pancreas is divided into five parts, including the head, uncinate process, neck, body, and tail (figure 3). The head of the pancreas lies to the right of the superior mesenteric artery. The uncinate process is a variable posterolateral extension of the head that passes behind the retropancreatic vessels and lies anterior to the inferior vena cava and aorta. The neck is defined as the portion of the gland overlying the superior mesenteric vessels. The body and tail lie to the left of the mesenteric vessels; there is no meaningful anatomic division between the body and tail.

Ductal anatomy — The pancreatic duct, which is located on the posterior aspect of the gland, one-third of the distance from the superior border, joins the common bile duct to drain into the duodenum via the major papilla (ampulla of Vater) (figure 4 and picture 1). The anatomy of these ducts can vary. In 85 percent of individuals, the pancreatic duct and the common bile duct enter the duodenum through a common channel. In 5 percent of patients, both ducts enter the duodenum through the same ampulla but via separate channels. In the remaining 10 percent of patients, each duct enters the duodenum through a separate ampulla (pancreas divisum) [14]. The entry of the common bile duct into the pancreatic tissue posteriorly can also vary (figure 5).

Neurovascular supply — The arterial supply to the duodenum and pancreas is derived from the celiac artery (figure 6) providing the superior pancreaticoduodenal arteries (anterior and posterior branches) and the superior mesenteric artery providing the inferior pancreaticoduodenal arteries (anterior and posterior branches) (figure 7). The right gastric artery also gives branches to the duodenum and the splenic artery and supplies primarily the body and tail of the pancreas. The venous drainage (figure 8) follows the arteries to provide tributaries to the splenic vein and superior mesenteric vein, which drain into the portal vein.

The pancreas is innervated by sympathetic fibers from the splanchnic nerves (figure 9) and parasympathetic fibers from the vagus, both of which give rise to intrapancreatic periacinar nerve plexuses. The parasympathetic fibers stimulate exocrine and endocrine function, whereas the sympathetic fibers have an inhibitory effect.

SUMMARY OF SURGICAL STEPS — The following maneuvers are performed, usually in the following sequence (figure 10):

Each of the following surgical steps is described in detail below:

Assessment of the abdomen for metastatic disease

Mobilization of the duodenum and the head of the pancreas, with identification of the superior mesenteric vein (SMV)

Mobilization of the stomach and proximal duodenum, with transection of the proximal duodenum (or stomach) as soon as the decision for resection has been made

Skeletonization of the structures of the porta hepatis

Cholecystectomy and division of the bile duct

Mobilization and division of the proximal jejunum

Transection of the neck of the pancreas and division of the remaining attachments of the specimen to the SMV and portal vein (PV), and the superior mesenteric artery (SMA)

Reconstruction of gastrointestinal continuity (figure 11)

TECHNIQUE — Technical details, such as suture choice, presented here reflect the author's preferences and are not meant to imply that these are requirements for successful surgical outcomes.

The patient is placed in the supine position. The operation is performed through a midline or a bilateral subcostal incision. The latter is preferred in patients with obesity. (See "Incisions for open abdominal surgery".)

Assessment of metastatic disease — After the abdomen has been entered, an initial assessment of the peritoneal cavity is performed. Both lobes of the liver are inspected and palpated, and all of the peritoneal surfaces are assessed for metastatic disease. The transverse colon is elevated, and its mesocolon, especially overlying the duodenum and head of the pancreas, is inspected.

Occasionally the tumor will have grown through the mesocolon at this point, where it can be seen and palpated as a firm nodularity. If this is present, it suggests the possibility that the superior mesenteric vein (SMV) may also be involved by tumor. The areas of the ligament of Treitz, the proximal jejunum, and the root of the small bowel mesentery are also inspected.

A biopsy with frozen section should be taken of any suspicious lesion to rule out metastatic disease. If none is found, any adhesions that may interfere with later exposure are cut, and a self-retaining retractor is placed.

Mobilization of the duodenum and pancreatic head — We use a self-retaining Bookwalter-type retractor. Two deep Richardson retractors are placed first:

Retractor 1 – Retracts the gallbladder and the right lobe of the liver cranially

Retractor 2 – Retracts the left lobe

We usually begin by performing an extensive Kocher maneuver to mobilize the duodenum and the head of the pancreas. The vena cava and the aorta are cleaned of soft tissue in the process; the left renal vein is exposed, but we do not routinely remove the soft tissue and nodes between the vena cava and aorta. Indeed, if the tumor is adherent to these structures or if the nodes are firm and appear to be involved by tumor, we confirm the presence of cancer by biopsy. Tumor involvement here is considered a contraindication to resection.

As the duodenal mobilization proceeds distally, the hepatic flexure of the colon must be separated from it, which begins to identify its mesocolon as a distinct structure.

It is helpful at this point to place another retractor:

Retractor 3 – Pulls the hepatic flexure and right colon caudally

Now the mobilization of the third and fourth portions of the duodenum continues until an opening is made in the peritoneum caudal to the duodenum and anterior to the aorta, to the left side of the peritoneal cavity. This allows the surgeon to place a finger through to the area where the ligament of Treitz and proximal jejunum will be dealt with later in the operation. This maneuver usually signals the end of the duodenal mobilization, and attention is now turned to the anterior aspect of the head of the pancreas and the still-adherent portion of the transverse mesocolon, which needs to be separated further to expose the SMV.

Identification of the superior mesenteric vein — Careful inspection of the anterior aspect of the exposed pancreatic head will reveal the avascular line of fusion between the mesocolon and the pancreas. The mesocolon should be separated from the head of the pancreas along this line and reflected medially to expose the SMV that runs along the right lateral margin of this tissue.

The SMV limits further medial separation of the transverse mesocolon from the neck of the pancreas and the retroperitoneal third part of the duodenum. The plane of dissection on the vein should be at the level of its adventitia, and it is important to incise through the fibrous and avascular capsule that surrounds the vein in order to reach this plane. Several venous tributaries from the head of the pancreas run directly into the vein, and the larger ones should be ligated in continuity and divided at this point. The middle colic vein usually is preserved (it can be sacrificed if it is involved by tumor), but either now or at a later stage in the dissection, the large gastroepiploic vein from the greater curve of the stomach should be divided close to where it enters the SMV. The gastroepiploic vein may also join the middle colic vein where the two run together for a short distance as the gastrocolic trunk, which then enters the SMV as a single vessel.

Once the SMV has been cleaned of adherent tissue and the larger tributaries from the pancreas proximal to the middle colic vein have been divided, we usually begin the dissection of the stomach and proximal duodenum. Separation of the neck of the pancreas from the vein is usually postponed until after that dissection has been done.

Mobilization of the stomach and proximal duodenum — The stomach is elevated and pulled caudally and the gastrocolic omentum is opened to enter the lesser sac, taking care to preserve the gastroepiploic arcade of vessels along the greater curve. Major vessels are ligated and divided, and an opening is created so that the avascular adhesions from the posterior surface of the stomach to the pancreas can be exposed and lysed with electrocautery. As we develop the dissection distally toward the pylorus, the avascular attachments of the transverse mesocolon to the gastrocolic omentum can be separated. Transillumination of the tissue allows for identification of the gastroepiploic vein, which should be ligated and divided before it enters the SMV or joins with the middle colic vein.

The gastroepiploic artery should also be ligated and divided. The dissection of the posterior duodenum should continue at least 1 to 2 cm past the gastroduodenal artery where it can be seen and felt on the surface of the pancreas. By this time, the dissection should have reached the same level and be in the same plane as the earlier dissection of the SMV and where the vein disappears beneath the neck of the pancreas. Now we incise along the inferior margin of the pancreas for a distance of approximately 3 to 4 cm along the body of the gland. This allows us to deepen the dissection to the left of the neck of the gland and to reach the level where the later pancreaticojejunal anastomosis will take place. At this point, the dissection is usually through fatty areolar tissue, but occasionally a vessel will be encountered that should be ligated and divided.

Transection of the proximal duodenum or stomach — By this time, it is often evident that the tumor is resectable (ie, the tumor mass can be palpated and its position away from the SMV and portal vein [PV] can be confirmed). If this is the case, we next mobilize the lesser curve side of the distal stomach and proximal duodenum and ligate and divide the right gastric and duodenal vessels to a point opposite where the duodenum was mobilized and its surface cleaned on the greater curve side. This is done a centimeter or so away from the duodenum so as to preserve collateral vessels to the gastroduodenal wall, and in a fashion that avoids injury to the nerve of Latarjet. When the duodenum has been cleaned circumferentially, it is then transected with a stapling device.

Over 90 percent of our resections are done as pylorus-preserving operations, but if a standard pancreaticoduodenectomy is to be done, the duodenal dissection just described is not necessary, and the stomach is transected at the level of the gastric antrum. Then the gastric staple line starting from the lesser curve side is buried using 3-0 seromuscular nonabsorbable (silk) sutures, stopping approximately 4 to 5 cm from the greater curve margin. This will be the site of the eventual gastrojejunostomy (Hofmeister) during the later gastrointestinal reconstruction.

Retractor 4 – The preserved stomach (and duodenum) is then retracted toward the left upper quadrant. This provides wide exposure of the hepatoduodenal ligament, which is dissected next.

If it is still uncertain whether resection is possible after the duodenum has been cleaned circumferentially, we would delay duodenal transection until later in the operation.

Skeletonization of the portal structures — The hepatoduodenal ligament is dissected next. The soft tissue of the gastrohepatic ligament is opened in an avascular area to the left of the hepatic artery. The hepatic artery is then cleaned of its attached tissues, which contain fat, lymphatic channels, and lymph nodes. The right gastric and gastroduodenal arteries are ligated and divided close to their origins; the gastroduodenal artery stump is secured with both a 2-0 silk tie and a metal clip. (Occasionally, the right gastric artery is particularly large and well developed, which suggests that it should be preserved to maintain the blood supply of the distal stomach and duodenum.) This dissection is carried caudally to the superior border of the pancreas, which is also cleaned of adherent tissue.

The lymph nodes that typically are found along the superior border of the neck of the pancreas, where the pancreatic transection will later occur, should be removed. This dissection should be sufficiently deep to expose the splenic artery as it begins its course toward the spleen and the anterior surface of the PV. If there is still a question about whether the tumor is adherent to the anterior surface of the PV, this can be resolved since the SMV below and the PV above are now exposed. The anterior surface of the PV is then cleaned cranially along with the right and left hepatic arteries to the level at which the bile duct will be transected.

Cholecystectomy and division of the bile duct — Next, the gallbladder is removed. This requires replacement of retractor 1 with a shallower retractor to expose the undersurface of the liver (see 'Mobilization of the duodenum and pancreatic head' above). The original retractor is replaced after the cholecystectomy.

We next transect the common hepatic duct. A right-angled dissecting clamp is inserted behind it, keeping close to its posterior surface, and a vessel loop is pulled through the opening. At this time, the surgeon should feel for arterial pulsation along the right lateral or posterior surface of the bile duct. This may be due to the presence of a replaced right hepatic artery or an early division of the hepatic artery into the right and left hepatic arteries. One must be careful to not injure the artery during this and subsequent dissection. The duct is elevated so that a curved bulldog clamp can be applied to its proximal portion. The distal part is clamped and the duct is cut. If a stent had been placed preoperatively, it is removed at this time. The distal duct is suture ligated and the ends of the sutures cut long to aid the pathologist in identifying the bile duct margin after the specimen has been removed. The proximal duct usually does not bleed, since the bulldog clamp effectively compresses the vessels that run along its wall, and it remains in place until later.

Finally, the soft tissue and lymph nodes behind the bile duct are cut, separated from it, and allowed to remain in continuity with the specimen. Because this tissue is quite vascular, it needs to be ligated as it is separated piece by piece from the tissues that are to remain.

Mobilization and division of the proximal jejunum — Next, the ligament of Treitz and the proximal jejunum are exposed, which requires modifying the original exposure. The transverse and splenic flexures of the colon are retracted cranially, and the distal small bowel, covered with moist laparotomy pads, is retracted caudally.

Next, the transverse and splenic flexures of the colon should be retracted cranially by repositioning retractors 2 and 4 so that the colon can be placed behind them (see 'Mobilization of the duodenum and pancreatic head' above). This allows for the exposure of the opening in the peritoneum created earlier during the Kocher maneuver, the entire root of the small bowel mesentery, the ligament of Treitz, and the inferior mesenteric vein.

Staying anterior and medial to the vein at all times, the avascular peritoneal folds that form the ligament of Treitz are cut with electrocautery. Then the mesentery of the proximal jejunum is displayed, and the vascular arcades of the bowel are ligated and divided beginning approximately 6 to 8 inches from the ligament of Treitz. When a large enough opening has been created in the mesentery, an automatic stapler is inserted through it and the jejunum is divided. Then the stapled end of the distal segment is turned in with seromuscular silk sutures. With an Allis clamp providing tension on the proximal stapled end of the jejunum, the vessels in the mesentery are ligated and divided, progressing proximally until the retroperitoneal portion of the duodenum has been reached. These repetitive maneuvers are hastened with the use of the Harmonic scalpel.

Now the proximal duodenal-jejunal segment, which is part of the specimen, is delivered to the right side through the peritoneal opening. We then release the retractors holding the colon and small bowel and reposition them for the final phase of the resection. The small bowel is returned to the peritoneal cavity, the transverse and splenic flexures of the colon are released from retractors 2 and 4, and the colon, too, is replaced into the abdomen covering the small bowel. Retractors 1, 2, and 4 are repositioned to elevate the right and left lobes of the liver and retract the stomach, as they did initially. (See 'Mobilization of the duodenum and pancreatic head' above and 'Transection of the proximal duodenum or stomach' above.)

Retractors 5 and 6 – These retractors are then placed along the patient's left side to flatten and keep in place the colon and its mesocolon. Even in patients with obesity, this provides excellent exposure.

Transection of the pancreatic neck — Now we pass a 1/4 inch Penrose drain behind the neck of the pancreas and anterior to the SMV/PV. The neck of the pancreas is elevated from the underlying vein with the help of the drain. In a soft pancreas, hemostatic synthetic, nonabsorbable polypropylene sutures (Prolene) (3-0) are placed through the pancreatic parenchyma at both the inferior and superior margin of the pancreas, on either side of the proposed line of transection (ie, four sutures total), which usually overlies the vein. On the specimen side, the sutures can be placed so as to occlude most or all of the pancreatic parenchyma and the duct.

On the side of the pancreas that will remain, the surgeon should try to avoid placing the superior margin suture in a way that might obstruct the pancreatic duct, which normally is situated closer to that margin and quite posterior in the gland. All of the sutures are tied tightly, but care should be taken to avoid tearing the pancreatic parenchyma. Next, the pancreatic parenchyma is divided with electrocautery. Any bleeding can usually be stopped with electrocoagulation; if not, vascular suture should be used (4-0 or 5-0). When the transection is complete, the Penrose drain is removed.

Division of attachments to the superior mesenteric vein, superior mesenteric artery, and portal vein — The surgeon, who stands on the patient's left side, grasps the duodenum and head of the pancreas in the left hand and retracts it away from the PV. The dissection begins at the cranial end of the specimen progressing distally, and the remaining attachments to the PV/SMV and retroperitoneal tissues are ligated and divided. The surgeon defines each bit of tissue for transection by separating it from surrounding structures with a right-angled clamp, into which the first assistant places 2-0 silk ties that are pulled through the opening. The clamp is then applied to the side of the tissue that is to remain, the assistant ties the specimen side, the surgeon cuts the tissue, and the assistant then ties the tissue in the clamp. This process is repeated until the entire specimen is free. Individual vessels that can be seen entering into the SMV or PV are tied in continuity, usually with 4-0 silk, and cut. Occasionally, vascular suture ligatures of 4-0 or 5-0 synthetic, nonabsorbable polypropylene suture (Prolene) may be required to stop bleeding from the veins themselves or tissue deep to them (figure 10).

Occasionally, the tumor will be found to be adherent to the right lateral or posterior part of the SMV or PV, which was not suspected before the neck of the pancreas was divided. In this circumstance, the segment of involved vein should be resected, either as a lateral venorrhaphy or a segmental resection of a cylinder of the vessel. In the latter case, end-to-end anastomoses are almost always possible even if a length of 2 to 3 cm of vein is removed. Vascular clamps prevent bleeding, while venous continuity is restored with suture of 5-0 Prolene.

The entire specimen is then sent to the pathology laboratory for frozen section examination of the resection margins (duodenal, jejunal, pancreas, bile duct). If invasive cancer is seen in any of them, more tissue is resected until a negative margin is obtained. During the time that it takes for the specimen to be examined, the operative field is irrigated with warm saline, meticulous hemostasis is assured, and the pancreatic anastomosis is begun.

Gastrointestinal reconstruction

Pancreatic anastomosis — An end-to-side pancreaticojejunostomy is performed first, usually by bringing the jejunum behind the superior mesenteric artery (SMA) and SMV, in a position similar to that occupied originally by the retroperitoneal duodenum [15]. However, in patients with cancers arising in the third or fourth part of the duodenum, we prefer to bring the jejunum through a hole in the transverse mesocolon instead. This minimizes the potential for later obstruction of the jejunum if the cancer should recur in the retroperitoneum (figure 11).

The cut end of the pancreas is mobilized from the retroperitoneal tissues for a distance of 2 to 3 cm, which may require ligation and division of a few venous tributaries to the splenic vein. The pancreatic duct is probed and its patency assured past the point where the Prolene hemostatic suture had been placed earlier in the superior margin of the gland. Depending on the size of the duct, a 5 or 8 French Pediatric Feeding tube is inserted well into the duct so that it can be easily seen during the anastomosis (French refers to a measurement of tubing circumference. One French is approximately one-third of a millimeter: 0.013 inch). We do not use a pancreatic duct stent, so this tube will be removed when the anastomosis is almost complete.

The two-layer anastomosis is begun by placing a posterior row of three or four 3-0 or 4-0 horizontal silk mattress sutures from the pancreas to the bowel; after they are all placed, the sutures are tied as the first assistant brings the bowel to the pancreas to minimize the chances that the pancreatic parenchyma will tear. They are placed horizontally so that when they are tied, any pancreatic parenchymal vessels (which generally run transversely) are likely to be compressed; this minimizes bleeding from needle placement. The jejunum is then opened with electrocautery approximately 1 cm anterior to the line where the silk sutures have been tied. Two 3-0 or 4-0 polydioxanone (PDS) sutures are then placed at the posterosuperior margin of the anastomosis, each end is tied, and the short end is cut. Both of these sutures are placed from the mucosal side of the bowel and then through the pancreatic parenchyma approximately 1 cm back from the cut edge of the pancreas. The first suture will be continued as the posterior row and should be placed through the lumen of the pancreatic duct as it passes near the duct, and then through the full thickness of the bowel wall approximately 5 mm from the cut edge. This usually requires two or three sutures placed into the duct lumen in this fashion, even with the largest ducts. This posterior row suture is held after the inferior corner of the anastomosis is completed. Then the second suture is brought from the inside of the bowel lumen where it was tied through the bowel wall so that the anterior row of sutures can be placed. Again, the sutures are placed through the lumen of the pancreatic duct before traversing the full thickness of the anterior bowel wall.

The feeding tube helps to identify the duct lumen and aids in suture placement. When the sutures progress past the duct, the feeding tube should be removed. When the anterior row of sutures reaches the posterior one, the two PDS sutures are tied to each other. The anastomosis is completed with the placement of the anterior row of 3-0 or 4-0 silk sutures in a fashion similar to that of the posterior row. The assistant again brings the bowel wall up to the pancreas as the sutures are tied to minimize the chance that the pancreas will tear. This anastomosis results in the invagination of the cut end of the pancreas into the lumen of the bowel.

Biliary anastomosis — The hepatico(choledocho)jejunal anastomosis is performed next at a sufficient distance from the pancreas to avoid tension on the suture line, but not too long to allow kinking of the bowel. The bulldog clamp is removed from the bile duct, a bile culture is taken, and hemostasis is obtained. A single-layer anastomosis using interrupted sutures of 4-0 or 5-0 polydioxanone (PDS) is performed. (If the duct is 2 cm or more in diameter, running sutures are also satisfactory.) Initially, the sutures are placed through the anterior wall of the duct approximately 2 to 3 mm from the edge, and from the outside of the duct into its lumen. The corner sutures are placed first, then the middle, etc, so as to place them evenly along the length of the anastomosis and at a distance of approximately 4 to 5 mm from each other. These sutures are held with the needles attached until the posterior row of sutures has been placed, which is done next.

The bowel lumen is opened with electrocautery for a length equivalent to that of the bile duct diameter, and the sutures are placed between the duct and the jejunum and tied with the knots placed inside the lumen of the duct. Finally, the anterior row of sutures that had been placed on the bile duct side is placed through the bowel wall and tied. Here, the knots are on the outside. If the duct is smaller than 1 cm in diameter, a small T-tube can be inserted through the wall of the bile duct proximal to the anastomosis. We find this is uncommonly needed. The distal limb of the T-tube lies in the jejunal limb. The tube is removed in the office three to four weeks later, usually without a prior cholangiogram.

Duodenal anastomosis — Finally, an antecolic duodeno(gastro)jejunostomy is constructed approximately 30 cm distal to the choledochojejunostomy, in a standard two-layer fashion.

Drains and closure — A closed suction drain (eg, #10 Jackson Pratt) is placed close to both the pancreatic and hepatic duct anastomoses. The drain is led behind the stomach, between the pancreaticojejunostomy and the left lobe of the liver, with the tip placed behind the hepaticojejunostomy, then brought out of the abdomen on the left side. The T-tube is brought out of the abdomen on the right side. The drain and T-tube are sutured to the skin. After this, the abdomen is irrigated and closed. (See "Principles of abdominal wall closure".)

POSTOPERATIVE CARE AND FOLLOW-UP — Postoperative care and follow-up after pancreaticoduodenectomy is discussed separately. (See "Surgical resection of lesions of the head of the pancreas".)

COMPLICATIONS — Complications following pancreaticoduodenectomy are discussed elsewhere. (See "Surgical resection of lesions of the head of the pancreas", section on 'Perioperative morbidity and mortality'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pancreatic cancer".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Beyond the Basics topics (see "Patient education: Pancreatic cancer (Beyond the Basics)" and "Patient education: Chronic pancreatitis (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Definition – Pylorus-preserving pancreaticoduodenectomy preserves the gastric antrum, pylorus, and proximal 2 to 3 cm of the duodenum, which is anastomosed to the jejunum to restore gastrointestinal continuity. (See 'Introduction' above.)

Indications for surgery – The most common indication for pancreaticoduodenectomy is the presence of a neoplasm in the head of the pancreas or one of the other periampullary structures (bile duct, ampulla, or duodenum). A pylorus-preserving pancreaticoduodenectomy (ie, Whipple operation) is not appropriate if tumor involves the proximal duodenum, pylorus, or gastric antrum. Under this circumstance, a standard Whipple operation should be done. (See 'Patient selection and preparation' above and "Surgical resection of lesions of the head of the pancreas", section on 'Indications for pancreatic head resection'.)

Techniques – Pylorus-sparing pancreaticoduodenectomy (figure 10) is performed typically using the following sequence of steps, which are described in detail above. (See 'Technique' above.)

Assessment of the abdomen for metastatic disease

Mobilization of the duodenum and the head of the pancreas, with identification of the superior mesenteric vein (SMV)

Mobilization of the stomach and proximal duodenum, with transection of the proximal duodenum (or stomach) as soon as the decision for resection has been made

Skeletonization of the structures of the porta hepatis

Cholecystectomy and division of the bile duct

Mobilization and division of the proximal jejunum

Transection of the neck of the pancreas and division of the remaining attachments of the specimen to the SMV and portal vein (PV) and the superior mesenteric artery (SMA)

Reconstruction of gastrointestinal continuity (figure 11)

  1. Whipple AO, Parsons WB, Mullins CR. TREATMENT OF CARCINOMA OF THE AMPULLA OF VATER. Ann Surg 1935; 102:763.
  2. Cameron JL, Riall TS, Coleman J, Belcher KA. One thousand consecutive pancreaticoduodenectomies. Ann Surg 2006; 244:10.
  3. Watson K. Carcinoma of ampulla of vater successful radical resection. Br J Surg 1944; 31:368.
  4. Traverso LW, Longmire WP Jr. Preservation of the pylorus in pancreaticoduodenectomy. Surg Gynecol Obstet 1978; 146:959.
  5. Diener MK, Fitzmaurice C, Schwarzer G, et al. Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev 2011; :CD006053.
  6. Birkmeyer JD, Sun Y, Wong SL, Stukel TA. Hospital volume and late survival after cancer surgery. Ann Surg 2007; 245:777.
  7. Fong Y, Gonen M, Rubin D, et al. Long-term survival is superior after resection for cancer in high-volume centers. Ann Surg 2005; 242:540.
  8. Duffy JP, Hines OJ, Liu JH, et al. Improved survival for adenocarcinoma of the ampulla of Vater: fifty-five consecutive resections. Arch Surg 2003; 138:941.
  9. Ryder NM, Ko CY, Hines OJ, et al. Primary duodenal adenocarcinoma: a 40-year experience. Arch Surg 2000; 135:1070.
  10. Ashley SW, Reber HA. The Whipple operation: The classical surgical procedure to treat chronic pancreatitis. Digestive Surgery 1996; 13:113.
  11. Patel AG, Toyama MT, Kusske AM, et al. Pylorus-preserving Whipple resection for pancreatic cancer. Is it any better? Arch Surg 1995; 130:838.
  12. Diener MK, Heukaufer C, Schwarzer G, et al. Pancreaticoduodenectomy (classic Whipple) versus pylorus-preserving pancreaticoduodenectomy (pp Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev 2008; :CD006053.
  13. Kusakabe J, Anderson B, Liu J, et al. Long-Term Endocrine and Exocrine Insufficiency After Pancreatectomy. J Gastrointest Surg 2019; 23:1604.
  14. MILLBOURN E. On the excretory ducts of the pancreas in man, with special reference to their relations to each other, to the common bile duct and to the duodenum. Acta Anat (Basel) 1950; 9:1.
  15. Hines OJ, Reber HA. Technique of pancreaticojejunostomy reconstruction after pancreaticoduodenectomy. J Hepatobiliary Pancreat Surg 2006; 13:185.
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