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Pancreaticoduodenectomy
Intervention:
Pancreaticoduodenectomy
ICD-10 code:
ICD-9 code: 52.7
MeSH D016577
Other codes:

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, an Italian surgeon, 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 Allen Whipple who devised a
perfected[citation needed] version of the surgery in 1935[2] and subsequently came up with multiple refinements to
his technique.

Anatomy involving the procedure

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.

The basic concept behind the pancreaticoduodenectomy is that the head of the pancreas and the duodenum
share the same arterial blood supply (the gastroduodenal 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.

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 and its cystic duct (cholecystectomy), 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 hepatic duct to the jejunum (hepaticojejunostomy) 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 five percent in the
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United States (less than two percent in high-volume academic centers).[3] The original description of
Whipple's operation together with a modern commentary [4] is available on-line.

Pancreaticoduodenectomy versus total pancreatectomy

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 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 (also known as 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.[5] 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.[6]

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 percent vs. 3.8 percent) 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.[7]

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.[8]