Classic Whipple Resection Research Articles

Outcome of Pancreaticoduodenectomy at Low-Volume Centre in Tier-II City of India.

Currently, pancreaticoduodenectomy (PD) is considered a common and feasibly performed surgery for periampullary tumours, but it is still a high-risk surgical procedure with potential morbidity and mortality rates. Previously, it was emphasised for the need of high-volume centres to perform specialised surgery such as PD. The authors have made an attempt to know the relation between low-volume centre and outcomes of PD. The study was conducted in a Tier-II city referral hospital located in Karnataka, India. A total of 37 patients with suspected periampullary neoplasms underwent surgical exploration with curative intent over a period of 4years, i.e. from May 2012 to May 2016. Out of 37 patients, 26 underwent PD, either classic Whipple resection (n = 01) or pylorus-preserving modification (n = 25). In 11 patients, resection was not possible, where biliary and gastric drainage procedures were done. All patients were treated by standardised post-operative care protocols for pancreatic resection used at our centre. We recorded the perioperative outcome along with demographics, indications for surgery, and pre- and intra-operative factors of PD. Post-operative pancreatic fistulae were evident in 4 patients. Two patients had hepaticojejunostomy leak. One patient had chyle leak. Three patients had infection at the surgical site. One patient had post-operative pneumonia leading to mortality. None of the patients had post-op haemorrhage. The surgeon volume and surgeon experience may have minimal contributing factor in post-operative morbidity, especially if there is availability of well-equipped ICU and imaging facilities, along with well-experienced personnel like oncosurgeon, anaesthesiologist, intensivist, radiologist, and nursing staff. There is a need of a multicentre study from Tier-II city hospitals/low-volume centres and high-volume centres to come with perioperative surgical outcomes following PD.

Surgery for pancreatic disease

Surgery for pancreatic diseases is one of the most studied fields in general surgery and continues to evolve. This review focuses on recent advances in pancreatic surgery and summarizes the published research. Surgery for pancreatic diseases is an evolving field with a wide range of innovations. Especially, contributions by high-volume pancreas centers have greatly improved outcomes in pancreatic surgery. In chronic pancreatitis, recent studies demonstrate that early surgical treatment should be favored over repeated endoscopic interventions, and local organ-preserving resection techniques should be preferred over classic Whipple resection. Major advances have also been made on the diagnosis of pancreatic cystic lesions; however, the assessment of the current guidelines is still evolving. In pancreatic cancer, neoadjuvant treatment regimens appear to be promising, and extended pancreatic resections with vascular resection can now be offered with lower mortality and morbidity rates. Minimal-invasive laparoscopic and robotic surgical techniques are being used more frequently for the resection of pancreatic tumors and have seen major progress. In recent years, the outcome of patients undergoing pancreatic surgery improved due to better knowledge about the biology of the disease, more accurate diagnostic modalities, the application of organ-preserving surgical techniques in benign disorders and new advances in management strategies.

Tres años de Experiencia en Pancreatoduodenectomía en un Servicio de Cirugía del Hospital Nacional Guillermo Almenara - Instituto Peruano de Seguridad Social

OBJETIVO: Describir la experiencia de nuestro servicio en el empleo de la pancreatoduodenectomía u operación de Whipple para el tratamiento de Patologías malignas periampulares, su tiempo operatorio y la mortalidad operatoria. MATERIAL Y MÉTODOS: Se revisó la historia clínica de los pacientes sometidos a pancreatoduodenectomía durante 1994-97 en el Servicio de Cirugía V del Hospital Nacional Guillermo Almenara. RESULTADOS: Se encontraron 9 pacientes; el 56% (n=5) eran varones y el 44% (n=4) mujeres; el promedio de edad fue 69 años. El tiempo operatorio promedio fije 270 min (rango 360-724 min). Los diagnósticos histopatológicos fueron: 66,7% (n=6) adenocarcinoma de cabeza de páncreas; 11,1% (n=1) adenocarcinoma de la ampolla de Vater; 11,1% adenocarcinoma de tipo intersticial de duodeno; 11,1% adenocarcinorna primario de colédoco terminal. La técnica operatoria empleada fue resección de Whipple con anastomosis pancreático yeyunal termino-lateral en el 66,7% (n=6), anastomosis pancreático gástrica término-lateral en el 22,2% (n=2) y anastomosis pancreático yeyunal término-terminal con telescopaje en el 11,1%. La técnica de Whipple clásica sin conservación del píloro fije empleada en el 22,2% y la Whipple modificada con conservación de píloro en el 77,8% (n=7). En ningún caso se reoperó. El tiempo de hospitalización postoperatorio promedio fije 25 días. Mortalidad operatoria 22% a los 30 días de postoperatorio. CONCLUSIONES: Se utilizo preferentemente la operación de Whipple modificada con preservación de píloro, y en el manejo del muñón pancreático, las anastomosis al yeyuno.

Emergent pancreaticoduodenectomy: a dual institution experience and review of the literature

BackgroundEmergent pancreaticoduodenectomy (EPD) is an uncommon surgical procedure performed to treat patients with acute pancreaticoduodenal trauma, bleeding, or perforation. This study presents the experience of two university hospitals with EPD. MethodsClinical data on EPD in trauma and nontrauma patients from 2002–2012 were extracted from the hepatopancreatobiliary surgery databases at Thomas Jefferson University and Kaunas Medical University Hospitals. Data on indications, perioperative variables, morbidity, and mortality rates were evaluated. ResultsTen single-stage EPD patients were identified. Five underwent a classic Whipple resection, whereas five had pylorus preservation. Seven patients had traumatic indications for pancreaticoduodenectomy: three from gunshot wounds to the abdomen and four from blunt high-energy injuries (two sustained injuries by falling from height and two by direct assaults on the abdomen). Three cases of nontrauma patients had EPD surgery for massive gastrointestinal hemorrhage. The median age of the EPD cohort was 46 y (range, 19–67 y). All 10 patients were recovered and were discharged from the hospital with a median postoperative length of stay of 24 d (range, 8–69 d). There were no perioperative mortalities. ConclusionsDespite a high morbidity rate and prolonged recovery, this dual institutional review suggests that EPD can serve as a lifesaving procedure in both the trauma and the urgent nontrauma settings.

Pancreatoduodenectomy with pylorus preservation for adenocarcinoma of the head of the pancreas.

For many years, the classical Whipple procedure has been the standard operative treatment for resectable periampullary cancer. Recently, the pylorus preservation operation has also been applied to periampullary tumours. This newer procedure has potential advantages in terms of ease of performance and postoperative physiology, but has yet to be proved as an adequate cancer operation. We, therefore, undertook the present retrospective analysis to compare the outcome following the pylorus preservation operation (n = 13) with that of the classical Whipple resection (n = 13) in 26 patients with histologically proved adenocarcinoma of the head of the pancreas. The two groups of patients were comparable for age, sex, pre-operative laboratory data, and resected margins free from tumour. More patients undergoing the classical Whipple resection had Stage I disease (10 versus 4, P less than 0.05). However, this difference would not be significant if the two patients in the pylorus preservation group with carcinomas in situ were considered to have stage I disease. Mean tumour diameter in the pylorus preservation patient group (3.2 +/- 0.6 cm) was smaller (P less than 0.05) than in the classical Whipple group (4.1 +/- 1.0 cm) but more patients in the pylorus preservation group also had metastases to the regional lymph nodes (54 versus 23 per cent). Overall operative morbidity (31 per cent) and mortality (4 per cent) was acceptable and did not differ between the two groups. Five year actuarial survival for pylorus preservation (25 per cent) was comparable to that observed for the Whipple procedure in this and other series.

Randomized clinical trial of pylorus-preserving duodenopancreatectomy versus classical Whipple resection—long term results

It is not known whether pylorus-preserving duodenopancreatectomy is as effective as the classical Whipple procedure in the resection of pancreatic and periampullary tumours. A prospective randomized trial was undertaken to compare the results of the two procedures. Clinical data, histological findings, short-term results, survival and quality of life of all patients having surgery for suspected pancreatic or periampullary cancer between June 1996 and September 2001 were analysed. Two hundred and fourteen patients were randomized to undergo either a standard or a pylorus-preserving Whipple resection. After exclusion of 84 patients on the basis of intraoperative findings, 130 patients (66 standard Whipple operation and 64 pylorus-preserving resection) were entered into the trial. Of these, 110 patients with proven adenocarcinoma (57 standard Whipple and 53 pylorus-preserving resection) were analysed for long-term survival and quality of life. There was no difference in perioperative morbidity. Long-term survival, quality of life and weight gain were identical after a median follow-up of 63.1 (range 4-93) months. At 6 months, capacity to work was better after the pylorus-preserving procedure (77 versus 56 per cent; P = 0.019). Both procedures were equally effective for the treatment of pancreatic and periampullary cancer. Pylorus-preserving Whipple resection offers some minor advantages in the early postoperative period, but not in the long term.

Review

Pancreatic cancer is an aggressive disease, resistant to most cytotoxic and radiotherapeutic agents and is associated with a particularly poor prognosis – the overall five year survival is approximately 5 per cent. This European study reveals the results of a prospective audit of patients with pancreatic adenocarcinoma who underwent the potentially curative surgical resection. Two hundred and twenty one consecutive patients underwent procedures including classical Whipple resection, pylorus preserving Whipple and left pancreatic resection and total pancreatectomy. Data were analysed using univariate and multivariate models.

Pylorus-preserving pancreaticoduodenectomy in the treatment of chronic pancreatitis.

The pylorus-preserving pancreaticoduodenectomy (PPPD) is an alternative to the standard Whipple resection in the treatment of chronic pancreatitis. The operation is safe and can be performed with a low mortality rate. The most common early complication is delayed gastric emptying, which occurs in 25% to 30% of patients, and generally results in longer hospital stays than the standard Whipple procedure. Follow-up studies show that both operations are equally effective in relieving pain in approximately 75% of selected patients. In the long term, the PPPD successfully preserves physiologic gastric emptying, but at the cost of a higher marginal ulceration rate. The purported nutritional advantages of the PPPD over the classic Whipple resection have not been clearly established. At present, the PPPD is the procedure of choice for patients with chronic pancreatitis requiring panceraticoduodenectomy. Based on available information, this recommendation appears to arise form the fact that the PPPD is less radical than the regular Whipple procedure, and some surgeons find it technically easier. Our experience fails to show a distinct superiority of the PPPD over the Whipple operation.

Evidence-based surgery in chronic pancreatitis.

In the past two decades our knowledge of the pathophysiology and surgical treatment options in chronic pancreatitis has improved substantially. Surgical treatment in chronic pancreatitis has evolved from extending to organ-preserving procedures. The classical Whipple resection is no longer a standard procedure in chronic pancreatitis, and is continuously being replaced by operations such as the duodenum-preserving pancreatic head resection and pylorus-preserving Whipple. These procedures allow the preservation of exocrine and endocrine pancreatic function, provides pain relief in up to 90% of patients, and contributes to an improvement in life quality. In addition to presently available results from randomized controlled trials, new studies comparing available surgical approaches in chronic pancreatitis are needed to determine which procedure is the most effective in the treating chronic pancreatitis.

Surgical treatment and long-term follow-up in chronic pancreatitis

In the past two decades our knowledge of the pathophysiology and surgical treatment options in chronic pancreatitis have improved substantially. Surgical treatment in chronic pancreatitis has evolved from radical to organ-preserving procedures. The classic Whipple resection is no longer indicated in chronic pancreatitis, and operations like the duodenum-preserving pancreatic head resection and the pylorus-preserving Whipple have replaced it as surgical standards. These procedures allow the preservation of exocrine and endocrine pancreatic function, provide pain relief in up to 90% of patients, and contribute to an improvement in the quality of life.

Randomized prospective trial of pylorus-preserving vs. classic duodenopancreatectomy (whipple procedure): initial clinical results

During the past decades, the classic Whipple resection (cWhipple) and the pylorus-preserving Whipple (ppWhipple) operation have been advanced for the resection of cancer of the pancreatic head. However, no definitive answer exists as to whether the more conservative ppWhipple operation indeed equalizes the short- and long-term results of the cWhipple procedure. Therefore we conducted a randomized prospective trial in a nonselected series of consecutive patients. Demographics, diagnostic, intraoperative, and histologic findings (tumor type and tumor stage of these patients) as well as postoperative mortality, morbidity, and follow-up after discharge were analyzed. For statistical evaluation Kruskal-Wallis and chi-square tests were used where appropriate. Survival was analyzed according to Kaplan-Meier curves, and differences were examined using the log-rank test. From June 1996 to April 1999, a total of 114 patients with suspected pancreatic or periampullary tumors were prospectively randomized to undergo either a cWhipple or a ppWhipple (intention to treat) operation. Based on the inclusion and exclusion criteria, 77 of these patients were included in the final analysis. Forty had a cWhipple and 37 had a ppWhipple resection. There were no differences with regard to age, sex distribution, ASA classification, histologic classification, UICC stage, length of stay in the intensive care unit, and length of hospital stay. The ppWhipple group had a significantly shorter operative time, reduced blood loss, and fewer blood transfusions. There was no difference in mortality, but the cWhipple group showed a significantly higher total morbidity. The incidence of delayed gastric emptying was identical in both groups. For long-term follow-up, a total of 61 patients with histologically proven pancreatic or periampullary carcinoma were analyzed. There were no differences in tumor recurrence or in long-term survival at a median follow-up of 1.1 years (range 0.1 to 2.9 years). Our initial results demonstrate that the cWhipple and ppWhipple operations are equally radical. However, ppWhipple may be the procedure of choice for the treatment of pancreatic and periampullary cancer.

Pancreatic fistula after pancreatic head resection.

Pancreatic resections can be performed with great safety. However, the morbidity rate is reported to be 40-60 per cent with a high prevalence of pancreatic complications. The aim of this study was to analyse complications after pancreatic head resection, with particular attention to morbidity and pancreatic fistula. From November 1993 to May 1999, perioperative and postoperative data from 331 consecutive patients undergoing pancreatic head resection were recorded prospectively. Data were analysed and grouped according to the procedure performed: classic Whipple resection, pylorus-preserving pancreatoduodenectomy (PPPD) or duodenum-preserving pancreatic head resection (DPPHR). Pancreatic head resection had a mortality rate of 2.1 per cent; the difference in mortality rate between the three groups (0.9-3.0 per cent) was not significant. Total and local morbidity rates were 38.4 and 28 per cent respectively. DPPHR had a lower morbidity, both local and systemic, than pancreatoduodenectomy. The prevalence of pancreatic fistula was 2.1 per cent in 331 patients, and was not dependent on the procedure or the aetiology of the disease. Reoperations were performed in 3.9 per cent of patients, predominantly for bleeding and non-pancreatic fistula. None of the patients with pancreatic fistula required reoperation or died in the postoperative course. A standardized technique and a continuing effort to improve perioperative management may be responsible for low mortality and surgical morbidity rates after pancreatic head resection. Pancreatic complications occur with Whipple, PPPD and DPPHR procedures with a similar prevalence. Pancreatic fistula no longer seems to be a major problem after pancreatic head resection and rarely necessitates surgical treatment.

Delayed gastric emptying occurs after both classical and pylorus-preserving whipple procedure

Background: Delayed gastric emptying (DGE) after pancreatic head resection confers a serious nutritional problem to patients who often already have faced substantial weight loss prior to surgery. The reasons for the disturbed gastric motility are not yet fully understood. Aim of the study and methods: We compared the incidence of gastric emptying delay after pancreatic resection in a prospectively collected, consecutive and recent material. All pancreatic resections were done with a well standardized technique and 95% of all procedures were carried out by 3 surgeons. DGE was defined if there was at least 500 ml gastric secretion per day through a nasogastric tube for more than 5 days. If the nasogastric tube drained less than 500 ml per day, the tube was removed and patients were allowed to drink ad libitum. Results: From 1111993 to 11/1997 271 patients underwent pancreatic resection (15 total pancreatectomies and 8 local excisions excluded). There were 44 classical Whipple, 95 pylorus-preserving Whipple, 92 duodanum-preserving and 40 left resections. Overall morbidity was 30% (patients) and mortality was 1.5% in the whole series. In total, 29 patients (11%) developed DGE; 20 had pancreatic neoplasm, 6 had periampullary tumors and 3 had chronic pancreatitis. In these patients, the nasogastric tube remained for 11 days on average (range 5 to 40 days). In the DGE group, morbidity (DGE excluded) was 34% (patients) and mortality was 0. The incidence of DGE was 25% (n=ll) after classical Whipple resection and 19% (n=lg) after pyloruspreserving resection (p = 0.41). There was no occurrence of DGE in patients undergoing duodenum-preserving or left resection. One patient was reoperated due to persistent DGE, all the other patients were treated conservatively. Conclusions: Despite well-standardized technique in an referral center, there is a substantial presence of DGE in patients undergoing classical or pylorus-preserving resection. There was no difference in the incidence of DGE between these two methods of resection. All DGEs were transient and could be treated by a conservative regime in all cases but one.

Which Is the Better Operation in Chronic Pancreatitis: Pylorus-Preserving Whipple or Duodenum-Preserving Pancreatic Head Resection?

Surgical treatment in patients suffering from chronic pancreatitis is still discussed controversially. The classical Whipple resection which has been the standard operation in chronic pancreatitis for