Whipple Pancreatoduodenectomy Research Articles

Comparative analysis of surgical treatment of patients with locally advanced tumors right anatomical segment of pancreas

Radical resection of pancreas during pancreatic ductal adenocarcinoma has a favorable effect on the patient’s survival rate and disease prognosis. Performance of PV/SMV resection during pancreatoduodenectomy is a routine procedure in leading pancreatology centers, increasing the possibility of R0 resections.
 Purpose of the study. Is to evaluate the criteria for the diagnosis of vascular invasion at the preoperative stage, to increase the proportion of R0 resections.The study included 73 patients with locally advanced tumors of the pancreatic head operated on in the pancreatic surgery department from 2019 to 2022. The range of operations included: Whipple pancreatoduodenectomy, pyloruspreserving pancreatoduodenectomy, and total pancreatoduodenectomy.The presence or suspicion of vascular invasion, the size, and the stage of the tumor at the preoperative stage were diagnosed according to the data of MSCT, MRI, ultrasonography, and endosonography. Histological examination was carried out according to the recommendations of the College of American Pathologist 2020.
 The first group 44 of patients who were made pancreatoduodenectomy with resection of PV/SMV, and the second group 29 patients without vascular resection. In the second group, a positive venous (smv) resection margin, R1 resection, had all patients according to the planned histological examination.During the preoperative examination, vascular invasion was suspected in 68,2% of patients in the first group, and 58.6% in the second, 58,6%, (x2 = 0,696; p = 0,403). According to histological examination, damage to the vascular wall was confirmed in 81,8% of cases among the first group of patients.A comparative assessment of the indicators of the two groups indicates that there is no significant difference in tumor size (t = 1,38; p = 0,085), localization, intraoperative data (operation time) (t = 1,19; p = 0,117), the number of postoperative complications (x2 = 0,027; p = 0,869), and the histological type of the tumor. Only intraoperative blood loss had statistical significant.
 Conclusions. The nowaday preoperative examination protocol allows diagnosing vascular or suspicion of it with sufficient probability and planning adequate surgical intervention.
 Performing a resection of PV/SMV during pancreaticoduodenectomy with pre- or intraoperative suspicion of vascular invasion allows to increase the number of R0 resections and improve the prognosis of the disease.

Preoperative Hypoalbuminemia as a Predictor of Severe Postoperative Complications in Patients Undergoing Whipple Pancreatoduodenectomy.

Pancreaticoduodenectomy (PD) known as Whipple procedure is still one of the most complex abdominal surgeries used for treatment of periampullary tumors. PD is often followed with postoperative complications (pancreatic, biliar or intestinal fistula, haemorrhage, intraabdominal abscess, delayed gastric empting. Severe postoperative complications (SPC) can be reason for reoperation and reason of bad outcome of treatment and life treathening condition. To investigate predicitive value of preoperative hypoalbuminemia for severe postoperative complications (SPC) in patients who have undergone Whipple pancreaticoduodenetomy (PD). However, no similiar study has been ever reported from our country until now. In this retrospective-prospective study, 100 patients who have had Whipple pancreaticoduodenectomy for malignant periampullary tumors at the Department for Surgery of University Clinic Center Tuzla, Bosnia and Herzegovina were enrolled, from january of 2009 to decembre of 2021. All patients were preoperatively analysed according to serum albumine levels and presensce of hypolabuminemia (serum albumine levels <32g/l). Serum albumine biochemical test were done 1-2 days preoperatively. Clavien Dindo classification was used for determination patients with SPC. Patients who did not have SPC belonged to (I-II) Clavien Dindo group of patients while those who had SPC belonged to( III-V) Clavien Dindo group of patients. Out of 100 patients who have undergone pancreaticoduodenetomy, in 55 (55%) patients postoperative complications were noticed. Mortality rate was 18 (18%) and reoperation has been done in 20 cases (20%). SPC were noticed in 19 patients and most often were: delayed gastric emptying (20%), pancreatic fistula (13%) and intraabdominal collections (9%). Hypoalbuminemic patients had a significantly higher rate of severe postoperative complications ( p<0.05). Using hypoalbuminemia-SPC correlation analaysis, there is confirmed statistically significant correlation between hypoalbuminemia and SPC (ρ= 0.236; p<0.05). Preoperative hypoalbuminemia can be used as predictor and prognostic factor for severe postoperative complications after Whipple pancreaticoduodenectomy. Identification and optimization of serum albumin level prior to Whipple pancreatoduodenectomy may improve surgical outcomes.

Paediatric pancreatoduodenectomy – A video vignette

Pancreatoduodenectomy (PD) is rarely required in the paediatric population but is the only curative option for certain pathologies such as pancreatoblastoma of the head of the pancreas. Pancreatoblastoma is a rare childhood tumour originating from pancreatic exocrine epithelial cells. It is the most common malignant pancreatic tumour in children. We describe the case of a 3-year-old girl with Beckwith-Wiedemann (BW) syndrome, with a background of liver resection aged 18 months for hepatoblastoma. On surveillance imaging, a mass lesion was identified in the head of her pancreas, which was further characterised on dedicated MRI pancreas and endoscopic ultrasound. Fine needle aspirate confirmed the diagnosis of pancreatoblastoma. Because of portal and superior mesenteric venous abutment on the initial imaging, a neo-adjuvant approach was taken with good tumour response to cisplatin and doxorubicin, followed by a Whipple's pancreatoduodenectomy (PD). Using intraoperative video footage, we detail the operative technique of pancreatoduodenectomy in the paediatric population. Modifications to standard reconstruction included a dunking pancreatojejunostomy instead of the more standard Blumgart technique. The patient's background of BW renders a lifelong risk of further solid-organ tumour formation. This case demonstrates how each tumour should be individually assessed with a full MDT approach despite any perceived complexity.

Whipple's Pancreatoduodenectomy in the Background of Chronic Liver Disease (CLD): An Institutional Experience.

Introduction Whipple's pancreatoduodenectomy (PD) is a formidable operation, associated with a high risk of morbidity and mortality. In the setting of an underlying chronic liver disease, the incidence of complications and mortality increases manifold. Patients and Outcomes. Of the 112 Whipple's PD performed between 2018 to 2020 at a high-volume HPB and liver transplant centre, 4 patients underwent the surgery in the background of an underlying chronic liver disease (CLD). All except one were performed in Child's A cirrhotics. There was a single 30-day mortality in this series of 4 patients that occurred in the background of Child's B cirrhosis. On follow-up at 1 year, there was one more mortality in the series, owing to liver decompensation following chemotherapy. Conclusion Judicious preoperative selection criteria, adequate preoperative nutritional and physiological optimisation, and prudent weighing of risk vs. benefit of undergoing Whipple's PD in periampullary malignancies in the setting of CLD are the major determinants of the surgical outcome.

Pre-operative Prediction of Outcome in Patients Undergoing Whipple's Pancreatoduodenectomy: Prospective Validation of a Novel Risk Scoring

Introduction: Despite a high morbidity following Whipple's pancreatoduodenectomy, there is a lack of an objective pre-operative tool, based only on clinical and biochemical parameters to predict the outcome following pancreatoduodenectomy that could be implemented on an outpatient basis.

Surgical and oncological implications of aberrant arterial anatomy in patients undergoing pancreatoduodenectomy.

Whipple's pancreatoduodenectomy is a complex surgical procedure and any aberrant arterial anatomy may have serious surgical implications. The objective of our study was to analyse the frequency of aberrant hepatic artery and compare the outcomes in patients with normal anatomy. Clinical data and computed tomography scans of 45 consecutive patients who underwent Whipple's procedure from 2007 to 2016 were reviewed. Group 'A' included patients with aberrant hepatic artery while group 'B' with normal anatomy. Aberrant hepatic artery was present in 11 (24%) patients and type V was the most common variant (n=5, 45%). Morbidity rate in group A was 82% and group B was 62% (p= 0.288), while 30-day mortality rate was 18% and 9% respectively (p=0.582). There was no difference in the oncological clearance in both the groups. Aberrant hepatic artery does not seem to influence the morbidity, mortality and tumour resection margins in patients undergoing Whipple's procedure.

Iatrogenic Non-Reconstructable Duodenal Injury Presenting without Peritonitis: An Indication of Pancreatoduodenectomy in the Presence of Safe Hands. A Case Report

Iatrogenic duodenal injuries are rare complications of upper gastrointestinal endoscopic procedures, gallbladder, and right kidney operations. Management includes diverse options depending on a number of factors that include the size of the injury, timing of presentation, degree of peritoneal contamination, and presence of peritonitis and/or sepsis, etc. While most duodenal injuries are small, large complex non-reconstructable injuries may occasionally occur, requiring complex surgical procedures rather than primary repair which if done in the latter cases, may lead to further morbidity and mortality. Whipple’s pancreatoduodenectomy has rarely been performed for complex duodenal injuries especially in the iatrogenic setting. Here a case is reported of an iatrogenic duodenal injury that presented 12 days after a right open nephrectomy, with a dehisced right lumber incision having greater than one liter per day bilious discharge, for which Whipple’s pancreatoduodenectomy was performed. A discussion regarding factors which influenced per-operative decision making and probably led to a successful patient outcome is presented.

Whipple pancreatoduodenectomy: surgical technique and perioperative management, 10-year experience

Whipple pancreatoduodenectomy: surgical technique and perioperative management, 10-year experience

Tu1788 Preoperative Nutritional Assessment in Patients Undergoing Whipple Pancreatoduodenectomy and Its Relationship to Early Outcome

Tu1788 Preoperative Nutritional Assessment in Patients Undergoing Whipple Pancreatoduodenectomy and Its Relationship to Early Outcome

Pancreatic Adenocarcinoma in a Patient With Multiple Endocrine Neoplasia 1 Syndrome

To the Editor We present the rare occurrence of a concurrent pancreatic neuroendocrine tumor (pNET) and pancreatic ductal adenocarcinoma (PDAC) in a patient with multiple endocrine neoplasia 1 (MEN1) syndrome. It is important for clinicians to consider the possibility of PDAC in patients with MEN1 because aggressive early surgical intervention provides the only chance of cure. Multiple endocrine neoplasia 1 is characterized by parathyroid adenomas, pNETs, and anterior pituitary tumors.1 Multiple endocrine neoplasia 1–associated pNETs are usually slowly progressive and associated with low malignant potential. In the context of MEN1, pancreatic NET size correlates with prognosis and the presence of metastases,2 and lesions of more than 2 cm are associated with greater genetic instability and malignant behaviour.3 The European Neuroendocrine Tumour Society recommendations for management of pancreatic lesions in a patient with MEN1 state that early diagnosis and surgical excision of MEN1-related pNET improve survival, preventing or delaying the development of distant metastases.4 It is mandatory to operate on MEN1-related nonfunctioning pancreatic tumors with metastases, size of more than 2 cm, or yearly increased size of more than 0.5 cm. Management of pNETs of less than 2 cm is controversial, current recommendation being intensive surveillance to avoid repeated intervention where lesions are typically multiple and behave in an indolent fashion.

Giant mucinous cystic neoplasms of pancreas and liver with unusual adipose tissue component: a case report.

Simultaneous occurrence of pancreatic and hepatic mucinous cystic neoplasms is very rarely reported in the literature. We present a case with extensive fatty component of the pancreatic tumour arising from the head of the pancreas and attaining a huge size before being treated by Whipple's pancreatoduodenectomy and subsequently by a right hepatectomy for the hepatic tumour.

Pancreatobiliary and pancreatoduodenal fistulae in intraductal papillary mucinous neoplasm of the pancreas: Report of a case

Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas present more commonly in the elderly. This report describes a case of IPMN in a 36-year-old man who presented with obstructive jaundice and weight loss. The initial investigation by computed tomography scan revealed a cystic lesion in the head of pancreas fistulating into the duodenum and the common bile duct (CBD). Subsequent endoscopic retrograde cholangiopancreatography revealed a low CBD stricture with proximal filling defects. Mucin was observed extruding from the biliary orifice following an endoscopic sphincterotomy. A classic Whipple's pancreatoduodenectomy was performed to excise the lesion. A histological examination of the lesion confirmed the presence of a malignant IPMN of the pancreas complicated by pancreatobiliary and pancreatoduodenal fistulae.

Hemorrhagic Complications After Whipple Surgery: Imaging and Radiologic Intervention

The aim of this pictorial essay is to illustrate the radiologic patterns, sites of bleeding, and vascular interventional techniques used in the management of postpancreatectomy hemorrhage. Hemorrhagic complications occur in fewer than 10% of patients after Whipple pancreatoduodenectomy but account for as many as 38% of deaths. Bleeding typically occurs from the stump of the gastroduodenal artery, but other sites of bleeding are increasingly recognized.

Organ-preserving surgery for benign lesions and low-grade malignancies of the pancreatic head: A matched case-control study

To compare the postoperative results of various preservative surgery (PS) techniques with those of two types of pancreatoduodenectomy (PD). The subjects of this study were 65 patients treated surgically for chronic pancreatitis, or benign or borderline tumors. We defined PS as any of the following: duodenum-preserving pancreatic head resection (DPPHR), uncinatectomy (UC), and cystic tumor enucleation (EN). The two types of PD were Whipple pancreatoduodenectomy (WPD) and pylorus-preserving pancreatoduodenectomy (PPPD). Benign lesions were treated with PD in 41 patients and PS in 24 patients. Whipple pancreatoduodenectomy was performed in 17 patients, PPPD in 24, DPPHR in 20, EN in 3, and UC in 1. The main indication for surgery was chronic pancreatitis (66%). Delayed gastric emptying (DGE) was seen in 41% of patients in the PD group but none in the PS group (P = 0.04). However, there were no differences between the two groups in the incidence of pancreatic fistulas or other complications. Reoperation was required in five of the PD patients, but none of the PS patients. Surgical techniques for preserving pancreatic tissue are effective for carefully selected patients with benign pancreatic disorders.

Management of postoperative arterial hemorrhage after pancreato-biliary surgery according to the site of bleeding: re-laparotomy or interventional radiology

Intra-abdominal arterial hemorrhage is still one of the most serious complications after pancreato-biliary surgery. We retrospectively analyzed our experiences with 15 patients in order to establish a therapeutic strategy for postoperative arterial hemorrhage following pancreato-biliary surgery. Between August 1981 and November 2007, 15 patients developed massive intra-abdominal arterial bleeding after pancreato-biliary surgery. The initial surgery of these 15 patients were pylorus-preserving pancreatoduodenectomy (PPPD) (7 patients), hemihepatectomy and caudate lobectomy with extrahepatic bile duct resection or PPPD (4 patients), Whipple's pancreatoduodenectomy (PD) (3 patients), and total pancreatectomy (1 patient). Twelve patients were managed by transcatheter arterial embolization and three patients underwent re-laparotomy. Patients were divided into two groups according to the site of bleeding: SMA group, superior mesenteric artery (4 patients); HA group, stump of gastroduodenal artery, right hepatic artery, common hepatic artery, or proper hepatic artery (11 patients). In the SMA group, re-laparotomy and coil embolization for pseudoaneurysm were performed in three and one patients, respectively, but none of the patients survived. In the HA group, all 11 patients were managed by transcatheter arterial embolization. None of four patients who had major hepatectomy with extrahepatic bile duct resection survived. Six of seven patients (85.7%) who had pancreatectomy survived, although hepatic infarction occurred in four. Management of postoperative arterial hemorrhage after pancreato-biliary surgery should be done according to the site of bleeding and the initial operative procedure. Careful consideration is required for indication of interventional radiology for bleeding from SMA after pancreatectomy and hepatic artery after major hepatectomy with bilioenteric anastomosis.

Gastrointestinal function and quality of life after pylorus-preserving pancreatoduodenectomy

The pylorus-preserving pancreatoduodenectomy (PPPD) has taken the place of the conventional Whipple pancreatoduodenectomy as the standard procedure for various periampullary disease. With recent advances in surgical techniques and improvements in perioperative management, the number of long-term survivors after PPPD is increasing. As a result, surgeons should pay more attention to the patients' postoperative gastrointestinal function, nutrition, and quality of life (QOL). Gastric stasis, which is a frequent complication during the early postoperative period after PPPD, prolongs the hospital stay and impairs the QOL in the intermediate term. Several possible pathogeneses for this gastric stasis have been postulated; however, the precise mechanism remains unclear. The gastric emptying function gradually recovers to the preoperative level by 6 months after PPPD. Pancreatic functions are likely to be maintained for at least 1 year after PPPD; however, in some cases, they tend to gradually deteriorate over time after the operation, depending on the type of pancreatic reconstruction or the preoperative condition of the pancreas. It is important to note that preoperative and postoperative pancreatic exocrine function strongly influence the postoperative outcome regarding such factors as pancreatic fistula, body weight maintenance, nutrition, and the QOL. The QOL, as assessed by questionnaire, normally returns to the preoperative level within 6 months after PPPD, and this correlates with the changes in gastrointestinal function and nutritional status. It still remains an unresolved question, however, whether the Billroth-I PPPD really leads to better long-term nutritional status, but worse early gastric emptying function, than the Billroth-II type of reconstruction.

Early and enduring nutritional and functional results of pylorus preservation vs classic Whipple procedure for pancreatic cancer

There have been many supportive data that the pylorus-preserving pancreatoduodenectomy (PPPD) might be equal to the classic Whipple pancreatoduodenectomy (PD) in terms of oncological radicality. However, few reports are available on the early postoperative and enduring functional changes, nutritional status, body composition, and quality of life years after surgery. The aim of this study was to compare nutritional and functional results of the different techniques in a retrospective evaluation and prospective cohort study. In May 1998, the standard surgical approach in the Department of Surgery, University-Hospital Mannheim, changed from PD to PPPD. The early postoperative and enduring functional changes, quality of life, oncological radicality, and nutritional status after years were compared between 128 patients after PD and 111 patients after PPPD. In a retrospective manner, the intra- and postoperative course was evaluated. In survivors, we prospectively analyzed the functional, nutritional, and oncological outcomes after 54 months (mean) in PD and after 24 months (mean) in PPPD patients. The PPPD and PD groups did not differ according to age, gender, preoperative condition, or tumor localization. The PPPD group demonstrated favorable results (p<0.05) for operation time (PPPD 341+/-74 vs PD 386+/-89 min), blood loss (793+/-565 vs 1,000+/-590 ml), blood transfusions (416+/-691 vs 653+/-776 ml), delayed gastric emptying (6 vs 13%), and hospital stay (20 vs 24 days). However, a possible bias has to be mentioned since more T4 stages were diagnosed in the PD group (3 vs 11%), and even more extended (venous) resections were performed in the PD group (7 vs 24%). Morbidity (32 vs 30%) and mortality (5 vs 3%) did not differ between the two groups. After 24 months (PPPD, n=22) and 54 months (PD, n=16), there was no difference in global quality of life in recurrence-free patients. While the preoperative body weight was reached after 4 months (median) in the PPPD group, it was reached after 6 months (p<0.05) in the PD group. Bioelectrical impedance analysis (BIA) revealed a significantly (p<0.05) lower total body water (55 vs 60%) and significantly higher total body fat (26 vs 18%) in PPPD than in PD patients. Long-term follow-up showed no significant statistical differences in survival between both groups. Besides favorable postoperative outcome in specific aspects and equal oncological outcome of PPPD, pylorus preservation seems to have advantages in enduring functional and nutritional status years after surgery for pancreatic cancer.

Comparison between pylorus-preserving and Whipple pancreatoduodenectomy.

Between 1989 and 1993, 62 patients underwent Whipple pancreatoduodenectomy and 75 pylorus-preserving pancreatoduodenectomy (PPPD); 35 patients in the first group and 37 in the second had pancreatic adenocarcinoma while 17 and 21 patients respectively had periampullary adenocarcinoma. The aim of this retrospective study was the comparison of operative outcome, nutritional recovery and survival of patients who underwent these two operations. No significant differences were found between the two groups in operative mortality or morbidity, duration of gastric aspiration and time to start of solid meals. Patients who underwent PPPD had a better nutritional recovery: the increase of both body-weight and serum albumin level at 6 months after discharge was significantly higher for those who had preservation of the whole stomach (P < 0.001 and P < 0.05 respectively). No significant difference in survival was found between the two procedures when patients with pancreatic or periampullary adenocarcinoma were analysed separately.

Quality of Life in Chronic Pancreatitis: A Prospective Trial Comparing Classical Whipple Procedure and Duodenum-Preserving Pancreatic Head Resection

Few data are available with respect to quality of life after pancreatic head resection in patients with chronic pancreatitis. The aim of this study was to compare the classical Whipple pancreatoduodenectomy (PD) with the Beger duodenum-preserving pancreatic head resection (DPPHR), in terms of quality of life, using standardized, valid, and reliable questionnaires. Sixty-five consecutive patients were included in this study. The PD procedure was chosen when pancreatic cancer could not be ruled out (n = 30); otherwise DPPHR was performed (n = 35). Quality of life was measured prospectively three times with the European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life Questionnaire (QLQ-C30) and the Gastrointestinal Quality-of-Life Index (GIQLI). Both procedures led to a significant improvement in quality of life, especially with regard to pain status. However, at the second follow-up examination (18 to 24 months postoperatively), all functional scales and the most important symptom scales of the EORTC QLQ-C30 revealed a better quality of life in the DPPHR group compared to the PD group. After classical PD, more patients seem to develop diabetes mellitus. The EORTC QLQ-C30 was found to be a better tool for quality-of-life assessment than the GIQLI in patients with chronic pancreatitis. ( J Gastrointest Surg 2002;6:173–180.)

Treatment concept of adenomas of Vater's ampulla

The most common benign ampullary tumors are adenomas (80%). They are considered as premalignant lesions with a transformation rate to carcinoma of up to 30%. From 1 January 1997 to 28 February 1999 we treated 11 patients with adenoma of the ampulla of Vater. An ampullectomy was performed in 10 cases. One poor-risk patient could not be operated on. No operative mortality occurred. In two patients a pT1 adenocarcinoma was diagnosed postoperatively. One of the two patients with a high-risk carcinoma underwent a second operation, a Whipple pancreatoduodenectomy. Nine of 10 patients had no recurrence with a median follow-up of 12 months. One patient died of glioblastoma. We would therefore recommend ampullectomy as the first-line treatment for benign tumors of the ampulla of Vater. In low-risk pT1 carcinoma (G1/G2, L0) and R0 resection, local excision is acceptable. In high-risk pT1 carcinoma (G3 and/or L1) Whipple pancreatoduodenectomy is mandatory.