Saudi Journal of Gastroenterology
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Year : 2004  |  Volume : 10  |  Issue : 3  |  Page : 144-149
Outcome of pancreaticoduodenectomy: Comparing the classic whipple with pyloric preservation


Guilan University of Medical Sciences, Rasht, Iran

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Date of Submission19-Feb-2003
Date of Acceptance04-May-2004
 

   Abstract 

Background: The majority of patients presenting with periampullary neoplasms are operative candidates and are treated surgically. Aim of the study: To assess the complications, morbidity, mortality and 2-year survival rates, and safety of pancreaticoduodenectomy for periampullary carcinomas in a non-oncology surgical set-up. Patients and methods: Records of 23 patients underwent pancreaticoduodenectomy for periampullary cancers between July 1995 and April 2001 in Guilan, Iran, were reviewed. Results: Among 23 consecutive patients who underwent pancreaticoduodenectomy, 16 were men and 7 were women, and the mean age was 58 +/-10.2years. All the patients had a malignant neoplasm. Mean operative time was 7.3 hours. The surgical procedure was pylorus-preserving pancreaticoduodenectomy (PPPD) in 65%. The median intraoperative blood loss was 625 ml and no transfusion was required. There was no intraoperative mortality, and the overall 30-day postoperative mortality rate was 4.5%. Delayed gastric emptying was the most common postoperative complication. The 2-year survival rates for periampullary cancers were 93% in PPPD and 62.5% in classic Whipple procedure. Conclusion: Pancreaticoduodenectomy for periampullary tumors remains a formidable procedure in our set-up. It can be performed safely with low mortality and morbidity rates

Keywords: Periampullary carcinoma, Whipple procedure, PPPD

How to cite this article:
Kohsari MR, Riazi H, Akbar MH. Outcome of pancreaticoduodenectomy: Comparing the classic whipple with pyloric preservation. Saudi J Gastroenterol 2004;10:144-9

How to cite this URL:
Kohsari MR, Riazi H, Akbar MH. Outcome of pancreaticoduodenectomy: Comparing the classic whipple with pyloric preservation. Saudi J Gastroenterol [serial online] 2004 [cited 2019 Dec 11];10:144-9. Available from: http://www.saudijgastro.com/text.asp?2004/10/3/144/33328


Cancer of the exocrine pancreas is the fourth leading cause of cancer death in men and the fifth in women. In the US about 280,000 cases are diagnosed each year, and almost as many patients die of this advanced disease. Ductal adenocarcinoma of the pancreas accounts for approximately 90 percent of exocrine tumors, and it is a characteristically aggressive lesion [1] . Pancreaticoduodenectomy (Whipple resection) is the most commonly performed operation for carcinoma of the pancreatic head. It includes resection of the distal stomach, gallbladder, and common bile duct, head of the pancreas, duodenum, proximal jejunum and regional lymphatic. Restoration of gastrointestinal continuity requires pancreaticojejunostomy, choleduchojejunostomy, and gastrojejunostomy. The operative mortality rate in expert hands is less than 5% [2] . Most often death occurs due to complications like postoperative pancreatic or biliary fistulas, hemorrhage, and infection [1],[2] . A modification of the Whipple procedure in which the stomach and pylorus are preserved (PPPD) has become one of the standard treatments used for benign and malignant diseases of the pancreatoduodenal region, surpassing ordinary pancreaticoduodenectomy in terms of technical ease, mortality rate, and postoperative nutrition. PPPD is usually associated with gastroduodenal artery division, which presents potential risks of insufficient duodenal vascularity and lethal postoperative bleeding from the gastroduodenal artery stump. The latter complication particularly occurs after resection of bile duct or ampullary cancer in a patient whose pancreas remains functionally and morphologically normal to have much more pancreatic secretion than the fibrotic pancreas seen in pancreatic cancer. This operation is preferred by some because it is believed that it avoids the undesirable nutritional sequences such as weight lose, dumping syndrome or diarrhea which may follow the standard Whipple procedure. Although the lymphatic dissection is less radical than with the standard operation, there is no evidence as yet that it is associated with a lower survival rate [1],[3].


   Patients and Methods Top


A descriptive comparative study of presenting features, complications and review of mortality and morbidity for pancreaticoduodenectomy was performed for 23 consecutive patients at the surgical unit of Razi Hospital in Rasht, Iran between 1995 and 2001. Information on vital status and demography of the cases were extracted from the medical files. All cases were regularly monitored in hospital and in our postoperative clinic. The variables studied included age at the time of diagnosis, clinical presentation, type of surgery, operation time, blood loss, immediate and late complications such as pancreatic leakage, fistula. and mortality. The patients with periampullary carcinoma away from pylorus were selected for PPPD to avoid gastrectomy complications and the dumping syndrome. In this technique, instead of distal gastrectomy, duodenum is resected distal to pylorus making a duodenojejunostomy.The classic Whipple technique was reserved for the cases of large neoplasms of head of the pancreas with or without periampullary lymphatic involvement. This technique was also applied for the tumors in duodenum and common bile duct. The patients were divided into two groups on the basis of two different types of surgical procedure and their outcome was compared. Sex distribution, or mean weight loss likewise, preoperative laboratory data were similar for both groups of patients. In addition, mean tumor size for patients with pancreatic cancer and patients with non­pancreatic periampullary cancer were similar in both groups, as was the incidence of positive lymph nodes. Statistical analysis was performed using statistical package for social sciences.


   Results Top


The patients had a mean age of 63 +/- ­12.8 years, with 84% male and 16% female [Table - 1]. Clinical presentations at the time of first consultation has been listed in [Table - 2] in decreasing frequency. Serum biochemistry confirmed the jaundice; alkaline phosphatase and glutamyl transferase were predominantly raised in 17 patients (74%). Disproportionate elevation of the aminotransferases (transaminases) leading to suspicion of hepatocellular involvement was found in three patients.

Ultrasonography was the initial investigation for patients with jaundice. A dilated common bile duct or intra hepatic ducts differentiating obstructive (post hepatic) jaundice was reported in 100% of cases. Computed tomography scan further assessed the primary tumor and detected lymph node involvement and hepatic or pulmonary metastases if any. Pathologic examination results showed pancreatic cancer in 14 (61 %), ampullary cancer in six (26%), distal common bile duct cancer in two (8.7%), and periampullary adenoma in one (4.5%) of the patients [Table - 3]. Complications are listed in [Table - 4].

During this period, 23 consecutive pancreaticoduodenectomies were performed without intraoperative mortality. The surgical procedure involved pylorus preservation in 65%, partial pancreatectomy in 91%, and portal or superior mesenteric venous resection in 4.5%. Pancreatic­enteric reconstruction was via pancreaticojejunostomy in all patients. Internal stenting of the hepaticojejunostomy and pancreaticojejunostomy was performed in 11 consecutive patients undergoing pancreatoduodenectomy to promote earlier discharge from hospital. Although minor leakage of the pancreaticojejunostomy occurred in 4 patients, this resolved within a short period and all 11 patients could be discharged by the 29th postoperative day in good health and without any intubations.

Follow-up abdominal x-ray and computed tomography (CT) scans proved that all of the stenting tubes had spontaneously fallen out postoperative. No complication related to the stenting tubes occurred in any of our patients. The median intraoperative blood loss was 625 mL, median units of red cells transfused was zero, and the median operative time was 7 hours. Three patients (37.5%) required reoperation in the immediate postoperative period most commonly for bleeding, abscess, or dehiscence. The median postoperative length of hospital stay was 13 days.


   Discussion Top


Age and gender incidence and demography of the oases in the present study was not different from previously described texts. Though the male gender and the age group of younger than 60 years comprised the majority of pancreatic carcinoma cases in our study. Pancreatic cancer occurs in the head of the pancreas in 75 percent of cases and in the body and tail of the gland in the rest. This distinction is important because lesions of the head, close to the bile duct, may produce obstructive jaundice when they are still small and curable [1],[4] In present study jaundice was found in 91.3 %. The classic presentation is painless, progressive, obstructive jaundice. Most patients also have epigastric discomfort or dull back pain. A large carcinoma of the head of the pancreas may obstruct the gastric outlet. Symptoms from a carcinoma of the body or tail of the pancreas are usually more vague, and the tumor is often locally advanced by the time of diagnosis [1],[4] . The patient is usually jaundiced and may be anemic or cachectic. There may be an epigastric mass or an irregular, enlarged liver because of metastases. Courvoisier's law states that, in the presence of jaundice, a palpable gall bladder is unlikely to be due to gallstones. This is because stones usually result in a fibrotic gall bladder, which will not distend in the presence of obstruction of the common bile duet [4] . pylorus-preserving pancreaticoduodenectomy is an important advance in the history of pancreatic surgery. The operation can be performed with a low operative mortality and morbidity, is technically easier than the standard Whipple resection [5] , and it minimizes the long-term physiological disturbance to the patient [6] . Clinical and experimental evidence has substantiated the view that preservation of the pylorus reduces the incidence of marginal anastomotic ulceration following pancreatectomy. Although gastric emptying may be prolonged transiently in the immediate postoperative period, this complication is easily managed, and is hardly a frequent long-term problem. PPPD is associated with a lower incidence of enterogastric reflux, dumping, and diarrhea than the classic Whipple operation [7] . The patients who have had PPPD are more likely to regain their preoperative and preillness weight [6],[7] . Similar results were obtained in this study too. Initial concerns about the use of PPPD in malignant disease have not been borne out, and should now be considered for curative or palliative resections of lesions in the periampullary region including the head of the pancreas. Present data suggest that PPPD does not compromise the long-term survival in patients with periampullary cancers. There is little doubt that the excellent results reported with this procedure as with other forms of major pancreatic surgery, are not simply related to improvements in surgical technique but to establishment of specialist pancreatic surgery. These findings suggest that the recent decline in operative morbidity and mortality may be due to fewer surgeons performing more Whipple resections in less time and with less blood loss.

Cameron JL, Crist DW and coworkers from the department of surgery at John Hopkins Oncology center, Baltimore have extensive experience in pancreaticoduodenectomy in 20th century. They have published several papers [3],[4] . Our experience in Guilan in a small surgical center, with limited facilities has shown the results similar to the Baltimore one. Japanese workers in a recent publication have reported a 100% 36-month postoperative satisfactory quality of life without operative mortality [8] . It appears that decreased in-hospital mortality in PPPD is due to less operative time and less blood loss [4] . Absence of lymph node involvement and blood vessel invasion favored long-term survival [3] ; the same has been suggested by the present study.

Since Whipple's successful resection of the head of the pancreas and duodenum in 1935, pancreaticoduodenectomy has become a standard operation for periampullary cancers. Although the operative mortality has decreased dramatically in the recent years, it continues to be associated with high morbidity; with anastomotic leakage remaining a major problem. Leakage at the pancreaticoenteric anastomosis remains a common and serious complication after pancreaticoduodenectomy. Over the past decade, various measures directed towards prevention of pancreatic leakage have been studied [9] . Grobmyer et al from New York report pancreatic anastomotic failure and clinical leak rate as 8.5% [10] . Clinical leakage was 8.7% as a whole in our cases but comparative study suggested 7% leakage in PPPD cases versus 12.5% in classic Whipple cases. Indian surgeons have also reported the similar results with their experience in a third world set-up [11]

Conclusion: Results of this study suggest significantly better results of PPPD with respect to morbidity and 2-year survival. With appropriate preoperative selection, virtually any patient in any age group, with benign or malignant disease, can undergo pancreaticoduodenectomy with minimal risk of hospital mortality.

 
   References Top

1.Reber H A; Pancreas; In: Schwartz S I (ed.) principles of surgery, Seventh Ed.McGraw Hill, New York, 1999; 1467-99.  Back to cited text no. 1    
2.Crist D W, Cameron J L; The current status of the Whipple operation for periampullary carcinoma.Adv. Surg 1992; 25: 21-49.  Back to cited text no. 2    
3.Cameron JL, Pitt HA, Yeo CJ, Lillemoe KD, Kaufman HS, Coleman J. 145 consecutive pancreaticoduodenectomies without mortality. Ann Surg 1993; 217: 430-8.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Pitt HA, Grace PA. Pylorus preserving resection of the pancreas. In: Neoptolemos JP(ed.); Clinical Gastroenterology. London: Billiare Tindell 1991; 4:917-30.  Back to cited text no. 4    
5.Trede M, schwall G, saeger HD: survival after pancreatoduodenectomy. 118 consecutive resections without an operative mortality. Ann surg 1990; 211:447.  Back to cited text no. 5    
6.Yeo CJ, Cameron JL, Lillemoe KD, et al; Pancreaticoduodenectomy for cancer of the head of the pancreas: Ann Surg 1995; 221:721-33.  Back to cited text no. 6    
7.Livingston EH, welton ML, Reber HA: surgical treatment of pancreatic cancer.The United States experience. Int J Pancreatol 1191; 9:153.  Back to cited text no. 7    
8.Isaji S, Kawarada Y;Pancreatic head resection with second portion duodenectomy;Am. J. Surg, 2001; 18: 172-6.  Back to cited text no. 8    
9.Poon RT, Lo SH, Fong D, Fan ST, Wong; Prevention of pancreatic anastomotic leakage after pancreaticoduodenectomy. Am J Surg 2002; 183: 42-52.  Back to cited text no. 9    
10.GrobmyerS R; Rivadeneira D E; Goodman C A;Pancreatic anastomatic failure after pylorus preserving pancreaticoduodenectomy; Am. J. Surg, 2000; 180; 117-20.  Back to cited text no. 10    
11.Wagle Pk; Joshi R M, Mathur S K; Pancreaticoduodenectomy for periampullary carcinoma. Ind. J. Gastroenterol. 2001; 20: 45-6.  Back to cited text no. 11    

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Correspondence Address:
Mohammed Reza Kohsari
Department of General Surgery, Razi Hospital, P 0 Box 41448-95655, Rasht
Iran
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Source of Support: None, Conflict of Interest: None


PMID: 19861838

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    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4]



 

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