Pylorus Preserving Pancreaticoduodenectomy

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Caroline Simmons
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1 REVIEW Pylorus Preserving Pancreaticoduodenectomy Jacqueline M. Garonzik-Wang, M. B. Majella Doyle Pancreaticoduodenectomy (PD) has become the standard of care for resectable pancreatic cancer and premalignant lesions in the periampullary region. 1,2 Intraoperatively, the surgeon has many technical and reconstructive options that must be considered. Pylorus-preserving pancreatoduodenectomy (PPPD) is one such option. To decrease postgastrectomy syndromes of dumping, diarrhea, and weight loss after PD, Traverso and Longmire described a pyloruspreserving modification (PPPD) in Patients whose tumor does not involve the proximal duodenum, pylorus, or distal stomach are candidates for a PPPD. In comparison with a conventional pancreaticoduodenectomy, PPPD has been associated with decreased blood loss, shorter operating times, and similar morbidity and mortality. 4 Reported disadvantages of PPPD include increased delayed gastric emptying (DGE) and difficulty in attaining negative tumor margins. The reported incidence of DGE ranges from 5% to 70% because of variations in the definition of this entity. 5,6. A recent meta-analysis of the randomized, controlled trials comparing the major morbidity and mortality of PD to PPPD is summarized in Table 1. 4 Anatomy and Surgical Technique The conventional pancreaticoduodenectomy, often referred to as a classic Whipple, includes a distal gastrectomy and resection of the pancreatic head, common hepatic duct (CHD), gallbladder, duodenum, and first portion of the jejunum. In comparison, a PPPD preserves the distal stomach, pylorus, and first portion of the duodenum. Instead of a gastrojejunostomy for gastric continuity, the duodenum is anastamosed directly to the jejunum (Fig. 1). The key surgical maneuvers are listed in Table 2. Although there are many technical variations, the importance of meticulous dissection and reconstruction is imperative. 7 A bilateral subcostal or midline incision provides adequate exposure. On entry, a thorough exploration must be performed to rule out metastatic disease or local invasion precluding resection. Next, the duodenum is extensively kocherized, and the duodenum, along with the head of the pancreas, is mobilized and elevated medially. This maneuver allows for palpation of the superior mesenteric artery (SMA) to rule out local invasion. Although not the standard of care, there are reports of en bloc resection and reconstruction of the SMA if invasion is present. 8 Next, the surgeon should identify the portal vein (PV) and confirm that it is tumor free. Mobilization of the gallbladder and subsequent identification and division of the CHD can aid in PV visualization. Hepaticojejunostomy (HJ) is the preferred palliative bypass method, so CHD division is acceptable at this point. 9 The gastroduodenal artery (GDA) can also be divided; however, first the surgeon must temporarily occlude it and confirm continued pulsation in the hepatic artery. Patients with celiac axis stenosis are often reliant on the GDA for collateral flow. Ligation in these patients would be devastating. This is also an appropriate time to assess for aberrant arterial anatomy, specifically, a replaced or accessory right hepatic artery. After transection of the CHD and GDA, the pancreas can be mobilized from the anterior wall of the PV. The superior mesenteric vein (SMV) should be identified as it crosses anterior to the third portion of the duodenum. A tunnel under the pancreas between the PV and SMV should be created bluntly. If PV invasion is present, resection and reconstruction can be considered. 8 Next, the first portion of the duodenum is mobilized off the neck of the pancreas and divided with a gastrointestinal stapler (GIA). If the duodenal cuff is short, preservation of the right gastric artery is unnecessary, but should be Abbreviations: CHD, common hepatic duct; DGE, delayed gastric emptying; GDA, gastroduodenal artery; GIA, gastrointestinal stapler; HJ, hepaticojejunostomy; PD, pancreaticoduodenectomy; PJ, pancreaticojejunostomy; PPPD, pylorus-preserving pancreaticoduodenectomy; PV, portal vein; SMA, superior mesenteric artery; SMV, superior mesenteric vein. From the Washington University School of Medicine, St. Louis, MO Potential conflict of interest: Nothing to report. View this article online at wileyonlinelibrary.com VC 2015 by the American Association for the Study of Liver Diseases doi: /cld Clinical Liver Disease, Vol 5, No 3, March 2015 An Official Learning Resource of AASLD

2 TABLE 1 Risks and Benefits of Pancreaticoduodenectomy (PD) Versus Pylorus-Preserving Pancreaticoduodenectomy (PPPD) PD vs PPPD Conclusion Perioperative complications Delayed gastric emptying OR, 2.35 (95% CI, ; P 5.16) No difference Pancreatic fistula OR, 0.86 (95% CI, ; P 5.868) No difference Bile leak OR, 1.35 (95% CI, ; P 5.82) No difference Wound infection OR, 0.85 (95% CI, ; P 5.72) No difference Perioperative characteristics Blood loss MD, 76 L (95% CI, ; P <.001) Decreased blood loss Blood transfusion MD, 65 units (95% CI, ; P 5.31) No difference Operative time MD, min (95% CI, min; P <.001) Decreased Operative Time Length of stay MD, 1.8 days (95% CI, ; P 5.62) No difference Postoperative mortality OR, 0.49 (95% CI, ; P 5.18) No difference Survival OR, 0.84 (95% CI, ; P 5.29) No difference MD, mean difference; min, minutes. TABLE 2 Key Surgical Maneuvers in a Pylorus-Preserving Pancreaticoduodenectomy Incision Bilateral subcostal or midline Thorough exploration Rule out metastatic or locally invasive disease Mobilize duodenum and head of pancreas Extensive kocherization Elevate uncinate process Palpate SMA and rule out local invasion Mobilization of gallbladder and division of CHD Identification of PV Identification and ligation of GDA Prior to ligation, ensure hepatic artery not reliant on GDA flow by testclamping GDA Mobilize pancreas of anterior surface of PV Create tunnel under pancreas between PV and SMV Ensure PV free of local tumor invasion Mobilize duodenum off anterior neck of pancreas and divide Transect neck of pancreas Send neck margin for frozen analysis Mobilize uncinate process off SMA Transect jejunum past ligament of treitz Complete mesenteric transection between duodenum and jejunum and remove specimen Reconstruction Pancreaticojejunostomy Hepaticojejunostomy Duodenojejunostomy Bolded items are crucial steps, pearls or pitfalls to the dissection or reconstruction. SMA, superior mesenteric artery; CHD, common hepatic duct; PV, portal vein; ggda, gastroduodenal artery; SMV, superior mesenteric vein. attempted if technically feasible. The pancreas should then be divided and the neck margin sent for frozen analysis. After division of the pancreatic neck, the uncinate should be freed from the SMA. There are often several arterial braches to the uncinate that need to be identified and ligated. Finally, a segment of jejunum should be identified distal to the ligament of Treitz and divided with a GIA. This portion of small bowel can be passed below the SMA and SMV and the remaining mesentery between the duodenum and jejunum ligated. The specimen is then removed and sent to pathology for frozen margin analysis. Reconstruction proceeds first with a pancreaticojejunostomy (PJ). The jejunum is passed through mesocolon, usually in a bare area to the right of the mesenteric vessels. There are many reported PJ variations with similar outcomes. 7,10.We prefer an end-to-side PJ consisting of a back layer of interrupted silk sutures, an inner duct-to-mucosal layer, using 6-0 PDS, and an outer layer of interrupted silk sutures (Fig. 2). Some authors recommend routine utilization of a PJ stent; however, there is no consensus. 7,10,11 Next, an HJ is created approximately 5-10 cm distal to the PJ. Again, there are many reported techniques; however, we prefer an interrupted layer of 4-0 or 5-0 absorbable sutures. Finally, a two-layer, handsewn end-to-side duodenojejunostomy is created (Fig. 3). We usually perform this anastomosis antecolic, as there is some evidence this decreases delayed gastric emptying. 4,12 The duodenum must be inspected prior to anastomosis to ensure it is not dusky and still viable. If there is concern, a partial gastrectomy with gastrojejunostomy should be performed. We routinely leave two drains near the PJ and HJ. Conclusion and Future Directions Previous trials comparing PD with PPPD have demonstrated no difference in mortality and morbidity. PPPD does appear to be associated with decreased blood loss and operative time. 4 However, these studies were relatively small and heterogeneous; therefore, additional well-designed trials are still necessary to delineate the differences between these surgical options. CORRESPONDENCE Majella Doyle, 660 S. Euclid Ave, Campus Box 8109, St. Louis, MO doylem@wudosis.wustl.edu. 55 Clinical Liver Disease, Vol 5, No 3, March 2015 An Official Learning Resource of AASLD

3 Figure 1 Classic versus pylorus-preserving pancreaticoduodenectomy. 56 Clinical Liver Disease, Vol 5, No 3, March 2015 An Official Learning Resource of AASLD

4 Figure 2 Pancreaticojejunostomy. Figure 3 Duodenojejunostomy. 57 Clinical Liver Disease, Vol 5, No 3, March 2015 An Official Learning Resource of AASLD

5 References 1. Winter JM, Cameron JL, Campbell KA, Arnold MA, Chang DC, Coleman J, et al pancreaticoduodenectomies for pancreatic cancer: A singleinstitution experience. J Gastrointest Surg 2006;10: ; discussion Kim CB, Ahmed S, Hsueh EC. Current surgical management of pancreatic cancer. J Gastrointest Oncol. 2011;2: Traverso LW, Longmire WP Jr. Preservation of the pylorus in pancreaticoduodenectomy. Surg Gynecol Obstet 1978;146: Diener MK, Fitzmaurice C, Schwarzer G, Seiler CM, Antes G, Knaebel HP, et al. Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev 2011;(5): CD Sugiyama M, Abe N, Ueki H, Masaki T, Mori T, Atomi Y. A new reconstruction method for preventing delayed gastric emptying after pylorus-preserving pancreatoduodenectomy. Am J Surg 2004;187: Murakami Y, Uemura K, Sudo T, Hayashidani Y, Hashimoto Y, Nakagawa N, et al. An antecolic Roux-en Y type reconstruction decreased delayed gastric emptying after pylorus-preserving pancreatoduodenectomy. J Gastrointest Surg 2008;12: Kennedy EP, Brumbaugh J, Yeo CJ. Reconstruction following the pylorus preserving Whipple resection: PJ, HJ, and DJ. J Gastrointest Surg 2010;14: He J, Page AJ, Weiss M, Wolfgang CL, Herman JM, Pawlik TM. Management of borderline and locally advanced pancreatic cancer: where do we stand? World J Gastroenterol 2014;20: Scott EN, Garcea G, Doucas H, Steward WP, Dennison AR, Berry DP. Surgical bypass vs. endoscopic stenting for pancreatic ductal adenocarcinoma. HPB (Oxford) 2009;11: Cameron JL. Atlas of Gastrointestinal Surgery. 2nd ed. Hamilton: BC Decker Inc; Winter JM, Cameron JL, Campbell KA, Chang DC, Riall TS, Schulick RD, et al. Does pancreatic duct stenting decrease the rate of pancreatic fistula following pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg 2006;10: ; discussion Cordesmeyer S, Lodde S, Zeden K, Kabar I, Hoffmann MW. Prevention of delayed gastric emptying after pylorus-preserving pancreatoduodenectomy with antecolic reconstruction, a long jejunal loop, and a jejuno-jejunostomy. J Gastrointest Surg 2014;18: Clinical Liver Disease, Vol 5, No 3, March 2015 An Official Learning Resource of AASLD

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