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Friday, July 2, 2010

Pancreaticoduodenectomy

Pancreaticoduodenectomy is performed in patients with tumors in the head, neck, or uncinate process of the pancreas. Recent advances in the surgical techniques and post operative care have improved the outcomes and even long term survival rates. The procedure of pancreaticoduodenectomy is further classified as:
  • Kausch-Whipple pancreaticoduodenectomy (Classical Whipple procedure)
  • Pylorus preserving pancreaticoduodenectomy (PPPD)
Assessment for resectibility
  • The first step in the surgical resection is to rule out distant spread of the disease. The surgeon has to explore for spread of the tumor in the liver, peritoneum, and distant lymph nodes. 
  • If the tumor shows involvement in the superior mesenteric artery (SMA), celiac trunk, or hepatic arteries resection is usually not considered while it can be carried out if the superior mesenteric vein (SMV) or the portal vein (PV) is affected. 
  • Surgery is considered only if the intraoperative assessment confirms that the tumor is localised in the head, neck and uncinate process of the pancreas. 
  • Surgery is considered only if the intraoperative assessment confirms that the tumor is localised in the head, neck and uncinate process of the pancreas. 
  • In PPPD, the pylorus is preserved and the duodenum is divided after the pyloric ring. 
  • The advantages of PPPD are shorter operative time, minimal effect on the function of pylorus and stomach as a reservoir of food and on the digestive functions of the stomach. 
  • Studies have reported that the adverse effects, hospitalisation period, survival time and safety in both the types of resection surgeries are comparable.6 PPPD is now a preferred choice for patients with pancreatic adenocarcinoma although level I evidence is lacking.
Remnant pancreas reconstruction
The remnant pancreas is anastomosed either to the jejunum or the stomach to prevent leakage of the pancreatic juices. The anastomotic techniques are:
  • Pancreaticojejunostomy
    • The duct to mucosa technique is commonly used in pancreaticojejunostomy; a number of variations are described with excellent results.
  • Pancreaticogastrostomy
    • The procedure involves lodging the pancreatic remnant or the pancreatic duct into the stomach or pancreatic duct into the gastric mucosa.
    • The alkaline juices from pancreas may alter gastric pH and affect the gastric mucosa but studies reveal comparable results in terms of survival, complications and recovery with both pancreaticojejunostomy and pancreaticogastrostomy.
    • Pancreaticoenteric anastomosis is crucial as it is the single major cause of morbidity and mortality after surgery. The choice of the technique is usually at the surgeon's discretion as it requires expertise and precise implementation.
Reconstruction for biliodigestive continuity
  • Gastrojejunostomy is performed after Kausch- Whipple procedure, while a duodenojejunostomy is performed after PPPD.
  • Studies have indicated that antrectomy does not have an advantage over PPPD in terms of delayed gastric emptying (DGE). Post surgical complications and extended radical surgery have been found to increase DGE.7
  • An antecolic duodenojejinostomy is reported to reduce the incidence of post operative DGE.

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