Pylorus preserving pancreaticoduodenectomy

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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.

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 pylorus‐preserving modification (PPPD) in 1978.3 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

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, 0.72‐7.61; P = .16)	No difference
Pancreatic fistula	OR, 0.86 (95% CI, 0.41‐1.81; P = .868)	No difference
Bile leak	OR, 1.35 (95% CI, 0.10‐15.55; P =.82)	No difference
Wound infection	OR, 0.85 (95% CI, 0.35‐2.05; P = .72)	No difference
Perioperative characteristics
Blood loss	MD, 76 L (95% CI, 0.95‐0.56; P < .001)	Decreased blood loss
Blood transfusion	MD, 65 units (95% CI, 1.92‐0.61; P = .31)	No difference
Operative time	MD, 68.26 min (95% CI,105.7‐30.83 min; P < .001)	Decreased Operative Time
Length of stay	MD, 1.8 days (95% CI, 8.94‐5.34; P = .62)	No difference
Postoperative mortality	OR, 0.49 (95% CI, 0.17‐1.40; P = .18)	No difference
Survival	OR, 0.84 (95% CI, 0.61‐1.16; P = .29)	No difference

MD, mean difference; min, minutes.

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

Figure 1.

Classic versus pylorus‐preserving pancreaticoduodenectomy.

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 test‐clamping 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.

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 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.

Figure 2.

Pancreaticojejunostomy.

Figure 3.

Duodenojejunostomy.

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.