Pancreas-Preserving Total Duodenectomy

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1 How I do it Dig Surg 1998;15: Gregory G. Tsiotos Michael G. Sarr Division of Gastroenterologic and General Surgery, Department of Surgery, Mayo Clinic, Rochester, Minn., USA Pancreas-Preserving Total Duodenectomy OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO Key Words Duodenectomy, pancreas-preserving Pancreatectomy Whipple operation Familial adenomatous polyposis Duodenal tumors Duodenum OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO Abstract The concept of operations to be as resective as necessary and as organpreserving as possible has led to the novel technique of resection of the entire duodenum, with complete preservation of the head of the pancreas, as a better alternative to the classic pancreaticoduodenectomy. This operation requires meticulous technique and precise knowledge of pancreatic and peripancreatic anatomy. Indications include benign or premalignant conditions confined to the duodenal mucosa, usually familial adenomatous polyposis. When appropriately performed, pancreas-preserving total duodenectomy leads to shorter operative time, requires less and safer anastomoses, and optimizes postoperative endoscopic surveillance. The available long-term results are encouraging. OOOOOOOOOOOOOOOOOOOOOO Introduction During the last decade, pancreatic resection has been performed with ever-decreasing perioperative morbidity and mortality at centers with extensive experience [1]. As surgeons have become more familiar with pancreatic and peripancreatic anatomy, this new understanding has led to novel procedures. Pylorus-preserving pancreaticoduodenectomy, first performed by Waugh in 1944, was reintroduced by Traverso and Longmire in 1978, and now has become common practice for both benign and malignant conditions of the head of the pancreas, comparing very well as a cancer operation with its classic counterpart of distal gastrectomy [2]. Technical expertise and the concept of operations to be as resective as necessary and as organ-preserving as possible have led to newer procedures such as the spleen-preserving distal pancreatectomy, local resection of the ampulla for benign ampullary neoplasms [3], duodenum-preserving resection of the head of the pancreas [4] and, more recently, segmental pancreatic resection or central pancreatectomy [5, 6]. The pancreas-preserving total duodenectomy (PPTD), first described by Chung et al. [7] in 1995 and which involves complete resection of the duodenum with preservation of the entire head of the pancreas, is one such organ-preserving resection potentially applicable to selected patients with mucosal diseases of the duodenum as an alternative to pancreaticoduodenectomy. Since October 1996, we have performed PPTD in 4 patients. Others [8] have also used the term pancreas-preserving duodenectomy, but a complete duodenectomy was not performed and resection involved only the third and fourth portions of the duodenum distal to the ampulla. PPTD is a challenging procedure requiring meticulous and refined surgical technique and very thorough and detailed knowledge of the peripancreatic anatomy. When performed appropriately and for the right indications, PPTD offers many advantages to the more classical pancreaticoduo- ABC Fax karger@karger.ch S. Karger AG, Basel /98/ $15.00/0 Accessible online at: Gregory G. Tsiotos, MD Gastroenterology Research Unit, Mayo Clinic 200 First Street, SW Rochester, MN (USA)

2 denectomy. PPTD removes the duodenal mucosa in its entirety while preserving a more normal upper gut function. Moreover, PPTD decreases the number of reconstructive anastomoses from three to two, prevents the risk of anastomosis between the jejunum and a normal nondilated common hepatic duct, prevents the risk of anastomosis of the jejunum to a small pancreatic duct in a soft normal pancreas, shortens operative time, and allows for optimal postoperative surveillance of the entire upper gastrointestinal system. Indications Although PPTD has been performed for blunt trauma of the duodenum [7], the usual indications are neoplastic or preneoplastic processes which involve diffusely, but are confined exclusively to the duodenal mucosa without any potential for spread along the periduodenal lymphatics. The most common indication is familial adenomatous polyposis (FAP) of the duodenum. Also, the presence of a solitary, broad-based villous adenoma of the supra-ampullary duodenum is another good indication. When PPTD is performed for FAP, it is essential to insure that an invasive carcinoma arising from FAP is not overlooked in the specimen and the extent of involvement of the rest of the gastrointestinal tract, primarily the colon, is fully assessed prior to and at the time of operation. Fig. 1. A dissection plane is developed between the duodenum and the pancreas. Small, well-defined vessels traverse between the two organs and are individually controlled using meticulous technique. Operative Technique Before describing the operation, it is important to recognize the anatomic principles upon which PPTD is based. Pertinent Anatomic Points Vascular Supply. The duodenum and the head of the pancreas in large part share the same arterial inflow and venous drainage. As demonstrated in several recent autopsy studies [9], the arterial system of both organs consists of anterior and posterior arcades, which are comprised of the anterior superior and anterior inferior pancreaticoduodenal arteries, and posterior superior and posterior inferior pancreaticoduodenal arteries, respectively. Both superior arteries arise from the gastroduodenal artery (celiac axis) via the superior pancreatoduodenal artery. In contrast, the inferior branches arise ultimately from the superior mesenteric artery via the inferior pancreatoduodenal artery. The pattern of venous drainage may vary, but all small tributaries eventually drain into the superior mesenteric or portal veins. As will become evident, and this is crucial for the performance of PPTD, both the arterial supply and the venous drainage of the duodenum consist of terminal vessels arising from vessels more centrally located within or around the pancreatic head. Thus, despite the common blood supply of the duodenum and pancreatic head, resection of the former does not devascularize the latter. Relation between Duodenum and Pancreas. There is a well-defined difference in the relation between the two organs proximal and distal to the level of the ampulla of Vater [7, 9]. The pancreas is attached, but not adherent, to the duodenum, distal to the ampulla, and thus a dissection plane can be developed between the external surface of the infra-ampullary duodenum and the head and uncinate process of the pancreas. This plane is traversed by small, friable vessels along the whole width of the pancreatic head (fig. 1). This anatomic relationship is dis- Pancreas-Preserving Total Duodenectomy Dig Surg 1998;15:

tinctly different from the supra-ampullary duodenum. For 1.

3 Fig. 2. Histologic appearance of the relation of the pancreas to the duodenum in the region between the minor and major papillas. The pancreatic parenchyma appears to be invading through the muscular to the submucosal layer of the duodenal wall. Reprinted with permission from Kimura and Nagai [9]. tinctly different from the supra-ampullary duodenum. For cm superior to the major papilla and around the minor papilla, the duodenum is intimately adherent to the pancreatic head along their common surface. The pancreatic parenchyma grows into the muscular and submucosal layers of the duodenum (fig. 2), described by some as invading the duodenal wall in that region [9]. A welldefined plane between the two organs is impossible to develop in this region. Separation can be achieved only by intramural duodenal dissection of the duodenum leaving the outer muscular layers of the duodenal wall attached to the pancreatic head. This intramural plane has been described by others as subserosal [7], but this term is not accurate, since the duodenum lacks a serosal layer between it and the pancreas in the supra-ampullary region. Along this intramural dissection plane, no defined vessels are present and only easily controlled oozing may occur. Resection After the celiotomy and abdominal exploration, the hepatic flexure of the colon is mobilized off of the duodenum inferiomedially. An extended Kocher maneuver is performed from the hepatoduodenal ligament proximally to the root of the mesentery distally, the ligament of Treitz is divided and the fourth portion of the duodenum is fully mobilized inferiorly and posteriorly. The level of distal intestinal transection is primarily dictated by the extent of Fig. 3. Dissection between the pancreas and the duodenum is completed in the infra-ampullary region. The traversing vessels are divided and an area of dense tissue (the inferior edge of the papilla) becomes apparent. the underlying disease as assessed preoperatively. If any uncertainty still exists, intraoperative upper endoscopy, facilitated by manipulation of the scope by the surgeon, can define the distal extent of the pathologic process. The proximal jejunum is transected with care taken to preserve the vascular arcades supplying the remaining proximal jejunum. The vessels supplying the distal duodenum, which, unlike the mid to distal small intestine, travel in pairs (one each towards the anterior and posterior wall) are individually divided and ligated. We prefer to ligate these vessels close to the bowel wall to avoid injury to other branches of the superior mesenteric artery supplying the remaining intestine. After the fourth and distal third portions of the duodenum are completely devascularized, the distal duodenum is passed behind the superior mesenteric vessels toward the patient s right. Dissection of the third portion of the duodenum off the uncinate process of the pancreatic head proceeds in a similar fashion and is rather easy 400 Dig Surg 1998;15: Tsiotos/Sarr

4 because the duodenum is only loosely attached to the pancreas with thin connective tissue. As dissection proceeds toward the ampullary region, however, the pancreas becomes more closely attached. At this point meticulous technique is necessary to identify and divide the small, friable vessels traversing the plane between the pancreas and the duodenum (fig. 1). Dissection should start anteriorly by dividing the first traversing vessels and then proceed deeper to separate the two organs and expose the more posteriorly located vessels (fig. 3). We suture-ligate the vessels on the pancreas side and use clips for the duodenal side. Localization of the major papilla by transmural palpation or passage of a biliary Fogarty catheter into the duodenum via the cystic duct helps to prevent inadvertent injury to this structure. At this point, the infraampullary portion of the duodenum has been completely separated from the pancreas and an area of dense tissue is encountered superiorly in the region of the ampulla (fig. 3). The dissection now shifts to the proximal duodenum which is transected just distal to the pylorus using a stapler. The first and proximal second portions of the duodenum are dissected off the superior aspect of the pancreatic head by ligating the small traversing vessels. As dissection moves distally, the two organs become increasingly adherent such that the plane distally disappears. This signifies the region of the minor papilla and, from here to the major papilla, an intramural plane of dissection should be created and followed within the duodenal wall (fig. 4). If the surgeon tries to follow the plane created previously, further dissection will lead the surgeon into the pancreatic parenchyma and difficult to control bleeding. In contrast blood loss in the intramural plane is minimal and easily controlled with electrocautery. Every attempt should be made to identify and ligate the minor papilla within this plane to avoid the risk of pancreatic leak postoperatively. Further dissection proceeds easily, safely and quickly down to the major papilla, which can now be circumferentially dissected from inside the duodenal wall, thereby gaining more length. The papilla is transected as far away from the pancreas as possible, and the duodenum is submitted for pathologic examination. During the dissection of the duodenum, no attempts are made to remove lymph nodes or periduodenal adipose and lymphatic tissue, since PPTD should be performed for conditions not associated with invasive carcinoma. PPTD is not a cancer operation. Fig. 4. The intramural duodenal plane of dissection is developed and followed from superior to inferior and anterior to posterior until the papilla is encountered. The minor papilla is identified and ligated. The outer layer of the duodenal wall is left attached to the pancreas. Reconstruction Restoration of gastrointestinal continuity proceeds by bringing the proximal jejunum under the small bowel mesentery in the bed of the duodenum, thereby creating a neoduodenum. This reconstruction sets the stomach in series with the entire intestine and facilitates subsequent surveillance of the gastrointestinal tract, which is particularly important for patients with FAP. We first perform the end-to-end pylorojejunostomy for two reasons: (1) the appropriate length of intestine between the pylorojejunostomy and the site for reimplantation of the ampullary region is much more easily assessed and undue tension (because of shorter intestinal segment) or kinking (because of longer segment) is avoided, and (2) undue manip- Pancreas-Preserving Total Duodenectomy Dig Surg 1998;15:

5 orly, minimizing its tension and facilitating exposure for reconstruction. After completing the pylorojejunostomy, attention is directed at the ampullojejunostomy. The optimal site on the jejunal wall facing the isolated ampulla is chosen and a 1-cm transmural incision is made. If the ampulla does not have a common channel, a septotomy is performed to widen and facilitate the anastomosis. A temporary stent may be introduced into the ampulla and passed up the bile duct to optimize exposure of the anterior and posterior wall of the ampulla, but this is not essential. We prefer a one-layer anastomosis using interrupted absorbable monofilament sutures (4-0 PDS). We first construct the posterior layer taking full-thickness bites (2 3 mm) of the posterior ampullary wall (inside-out) and full-thickness bites of the posterior duodenal wall (outside-in) for a mucosa-to-mucosa anastomosis (fig. 5). All stitches are placed in the posterior layer before they are tied leaving the knots inside the anastomosis. The anterior layer is performed in a similar fashion, only now sutures are placed outside-in on the anterior ampullary wall and inside-out on the duodenal wall and the knots are tied outside the anastomosis after removing the stent (fig. 6). A new ligament of Treitz is constructed to prevent internal herniation. A soft, closed-suction drain is placed behind the anastomoses and a needle-catheter jejunostomy is placed to allow enteral feeding, which should provide a great benefit to the patient if an ampullojejunostomy leak occurs [10]. Clinical Experience Fig. 5. The pylorojejunostomy is completed. The jejunal mesentery is not seen, since it lies posteriorly. The posterior layer of the ampullojejunostomy is constructed with interrupted sutures which are tied only after all have been placed. ulation on the more delicate ampullojejunostomy with the risk of disruption is avoided. Positioning of the mesentery of the neoduodenum is important. It should not be positioned medially (towards the pancreas) or anteriorly because exposure for construction of the ampullojejunostomy will become cumbersome. Positioning the mesentery laterally increases the distance from the root of the mesentery, and thus the tension is greater. We prefer to position the jejunal loop such that its mesentery is located posteri- Between October 1996 and August 1997, we have performed PPTD in 4 patients at our institutions. Two patients had FAP of the duodenum and 2 had extensive, broad-based villous adenomas, located at the supra-ampullary (4 cm in diameter) and contra-ampullary (3 cm in diameter) portions of the duodenum. The mean age of the patients was 44 (range 32 79) years. The mean operative time was 217 (range ) min. No patient received blood transfusion or was admitted in the intensive care unit. The mean hospital stay was 12 (range 8 24) days. One patient developed a leak at the ampullojejunostomy, which later closed spontaneously with controlled drainage. At follow-up (mean 6.5, range 1 11 months), all 4 patients are in good condition and have excellent functional status. 402 Dig Surg 1998;15: Tsiotos/Sarr

6 Fig. 6. Completed pylorojejunostomy and ampullojejunostomy. Conclusion PPTD is a novel surgical technique entailing total duodenectomy with preservation of the entire pancreas. This technique requires excellent knowledge of the pancreatic and peripancreatic anatomy and should be performed by experienced surgeons familiar with pancreatic surgery. When performed for appropriate indications, PPTD offers several advantages compared to conventional treatment by pancreaticoduodenectomy. PPTD removes all the duodenal mucosa without the need of the more risky pancreaticojejunostomy (to a normal pancreas), but much more, decreases the number (and risk) of anastomoses, decreases operative time, and allows optimal postoperative endoscopic surveillance. The long-term results encourage the use of this technique in selected patients. OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO References 1 Nitecki SS, Sarr MG, Colby TV, van Heerden JA: Long term survival after resection for ductal adenocarcinoma of the pancreas: Is it really improving? Ann Surg 1995;221: Mosca F, Giulianotti PC, Balestracci T, Di Candio G, Pietrabissa A, Sbrana F, Rossi G: Long-term survival in pancreatic cancer: Pylorus-preserving versus Whipple pancreatoduodenectomy. Surgery 1997;122: Bjork KJ, Davis CJ, Nagorney DM, Mucha P Jr: Duodenal villous tumors. Arch Surg 1990; 125: Buchler MW, Friess H, Bittner R, Roscher R, Krautzberger W, Muller MW, Malfertheiner P, Beger HG: Duodenum-preserving pancreatic head resection: Long-term results. J Gastrointest Surg 1997;1: Iacono C, Bortolasi L, Serio G: Is there a place for central pancreatectomy in pancreatic surgery? (abstract). Gastroenterology 1997;112: Z graggen K, Rattner DW, Fernandez-del Castillo C, Warshaw AL: Middle segment pancreatectomy: A novel technique for conserving pancreatic tissue (abstract). Pancreas Club, 1997, p Chung RS, Church JM, van Stolk R: Pancreassparing duodenectomy: Indications, surgical technique, and results. Surgery 1995;117: Maher MM, Yeo CJ, Lillemoe KD, Roberts JR, Cameron JL: Pancreas-sparing duodenectomy for infra-ampullary duodenal pathology. Am J Surg 1996;171: Kimura W, Nagai H: Study of surgical anatomy for duodenum-preserving resection of the head of the pancreas. Ann Surg 1995;221: Sarr MG, Mayo S: Needle catheter jejunostomy: An unappreciated and misunderstood advance in the care of patients after major abdominal operations. Mayo Clin Proc 1988;63: Pancreas-Preserving Total Duodenectomy Dig Surg 1998;15:

The Whipple Operation Illustrations

The Whipple Operation Illustrations Fig. 1. Illustration of the sixstep pancreaticoduodenectomy (Whipple operation) as described in a number of recent text books by Dr. Evans. The operation is divided