Pancreaticoduodenectomy

Excerpt

Pancreatic cancer is the fourth common cause of cancer death, and its 5-year survival rate is only about 12% despite the advancement in medical care, chemotherapy, radiotherapy, and molecular biology. The pancreatoduodenectomy, also known as the Whipple procedure, is the surgical procedure of choice for the resectable and the borderline resectable pancreatic ductal adenocarcinomas. This surgical procedure poses immense difficulties to the surgeons due to the complex as well as highly difficult intra-abdominal dissection and likewise the repair of the digestion system. Due to its complex nature, this procedure has historically been associated with higher mortality and perioperative morbidity.

Historically, the first pancreaticoduodenectomy was performed by Dr. Alessandro Codivilla, an Italian surgeon, in 1898 and was later modified by Dr. Walter Kausch in 1912. The surgery was then performed as a two-stage procedure, and Dr. Allen Whipple further improved it into a one-stage Whipple procedure in 1940. Later on, it was established that this procedure is associated with a high mortality rate; however, with improving medical knowledge and surgical advancement, there has been a significant drop in mortality. With an experienced surgeon in high-load hospitals, the mortality rate drops to about 3% to 5%.

Broadly, there are two types of pancreatoduodenectomies; the more extensive "classical Whipple (CW)" and the "pylorus sparing pancreatoduodenectomy (PSD)." The CW entails the removal of the pancreatic head, the duodenum, a section of the stomach, the gallbladder, and a part of the bile duct while in the PSD the part of the stomach is spared.

Moreover, the pancreaticoduodenectomy can be performed using the laparoscopic, as well as the open approach. Although, the recent data related to the feasibility and the shorter postoperative outcomes following both open and laparoscopic approaches for pancreatoduodenectomy have suggested that the laparoscopic approach is associated with shorter length of stay, less blood loss, and better lymph node dissection. However, the physicians around the globe are still hesitating in the global adaptation of the laparoscopic strategy, which may be most likely as a result of the highly challenging dissection and the anastomosis in this procedure. Also, the oncological end results following the open and laparoscopic strategy for pancreatoduodenectomy are still vague and even questionable.

This article describes in detail the surgical anatomy, indications, contraindications, technical steps in the pancreaticoduodenectomy, and its clinical significance.