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Evidence - Cephalic pancreatoduodenectomy with Blumgart anastomosis and biliopancreatic separation

general and visceral surgery
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Anatomy Perioperative management Technique Complications Evidence Total Video

  1. Literature summary

    • Two main techniques are available in surgical treatment of cancer of the pancreatic head and (peri)ampullary carcinoma: Standard Whipple operation and pylorus-preserving pancreatoduodenectomy.

    The standard technique resects the duodenum; pancreatic head; distal bile duct; gallbladder; distal half or two-thirds of the stomach; peripancreatic lymph nodes; and the lymph nodes at the hepatoduodenal ligament. Reconstruction is performed by pancreatojejunostomy or rarely by pancreatogastrostomy together with bilioenteric and gastrojejunal anastomosis. The main difference between the standard Whipple operation and the pylorus-preserving variant is that the latter technique preserves the entire stomach and a short postpyloric duodenal segment together with its neurovascular supply.

    Since pancreatic cancer is known for its tendency to early lymphatogenous metastasis, it might be assumed that the pylorus-preserving technique without distal gastric resection and adjacent lymphadenectomy is not radical enough oncologically. On the other hand, the pylorus-sparing technique could be expected to improve gastrointestinal function and reduce morbidity.

    A systematic review with metaanalysis of the endpoints survival, mortality and quality of life after pylorus-preserving or standard Whipple procedure published in 2010 included 23 studies with 3893 patients:

      • Survival
        There was no significant difference between the two surgical techniques. Thus, the pylorus-preserving technique achieves the same oncological efficacy (radicality) as the standard Whipple procedure.
      • Postoperative mortality
        There was no significant difference between both techniques
      • Postoperative quality of life
        Some studies described it either as not different or better after pylorus-preserving surgery.

    According to the available studies, as an organ-preserving procedure the pylorus-preserving pancreatoduodenectomy does not entail any adverse effects compared to the standard procedure. Benefits include the shorter operating time and the reduced intraoperative blood loss since there is no need for partial gastric resection.

    Source: Fitzmaurice C, Seiler CM, Büchler MW, Diener MK. Survival, mortality and quality of life after pylorus-preserving or classical Whipple operation. A systematic review with meta-analysis. Chirurg. 2010 May;81(5):454-71.

    Follow this link to the current German guideline:  Cancer of the exocrine pancreas

  2. Ongoing trials on this topic

  3. References on this topic

    Büchler MW, Friess H, Wagner M, Kulli C, Wagener V, Z’Graggen K. Pancreatic fistula after pancreatic head resection. Br J Surg. 2000 Jul; 87 (7) :883-9. PubMed PMID:10931023.

    Chromik AM, Sülberg D, Belyaev O, Uhl W. Technical aspects of pancreatoenteric anastomosis. Chirurg. 2011 Jan;82(1):14-25. Review. German. PMID:21153529 PubMed – indexed for MEDLINE

    Diener MK, Fitzmaurice C, Schwarzer G, Seiler CM, Antes G, Knaebel HP, Büchler MW. Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev. 2011 May 11; PubMed PMID:21563148.

    Diener MK, Heukaeufer C, Schwarzer G, Seiler CM, Antes G, Knaebel HP, Büchler MW. WITHDRAWN: Pancreaticoduodenectomy (classic Whipple) versus pylorus-preserving pancreaticoduodenectomy (pp Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev. 2011 Feb 16; PubMedPMID:21328281.

    Diener MK, Heukaufer C, Schwarzer G, Seiler CM, Antes G, Buchler MW, Knaebel HP. Pancreaticoduodenectomy (classic Whipple) versus pylorus-preserving pancreaticoduodenectomy (pp Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev. 2008 Apr 16; PubMed PMID:18425935.

    Diener MK, Knaebel HP, Heukaufer C, Antes G, Büchler MW, Seiler CM. A systematic review and meta-analysis of pylorus-preserving versus classical pancreaticoduodenectomy for surgical treatment of periampullary and pancreatic carcinoma. Ann Surg. 2007 Feb; 245 (2) :187-200. PubMed PMID:17245171; PubMed Central PMCID: PMC1876989.

    Fitzmaurice C, Seiler CM, Büchler MW, Diener MK. Survival, mortality and quality of life after pylorus-preserving or classical Whipple operation A systematic review with meta-analysis. Chirurg. 2010 May; 81 (5) :454-71. PubMedPMID:20020091.

    Friess H, Kleeff J, Fischer L, Müller M, Büchler MW. Surgical standard therapy for cancer of the pancreas. Chirurg. 2003 Mar; 74 (3) :183-90. PubMed PMID:12647074.

    Gao HQ, Yang YM, Zhuang Y, Wang WM, Wu WH, Wan YL, Huang YT. Influencing factor analysis of delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy. Zhonghua Wai Ke Za Zhi. 2007 Aug 1; 45 (15) :1048-51. PubMed PMID:18005587.

    Gehrig T, Knebel P, Scheel V, Hinz U, Seiler CM, Müller-Stich BP, Büchler MW, Gutt CN. LigaSure Impact™ versus conventional dissection technique in pylorus-preserving pancreatoduodenectomy in clinical suspicion of cancerous tumours on the head of the pancreas: study protocol for a randomised controlled trial. Trials. 2011 Jun 29; 12:162. PubMed PMID:21714879; PubMed Central PMCID: PMC3145578.

    Glanemann M, Bahra M, Neuhaus P. Pylorus-preserving pancreatic head resection: a new standard for tumors. Chirurg. 2008 Dec; 79 (12) :1107-14. PubMed PMID:18998104.

    Hartel M, Wente MN, Hinz U, Kleeff J, Wagner M, Müller MW, Friess H, Büchler MW. Effect of antecolic reconstruction on delayed gastric emptying after the pylorus-preserving Whipple procedure. Arch Surg. 2005 Nov; 140 (11) :1094-9. PubMed PMID:16301447.

    Herzog T, Suelberg D, Belyaev O, Uhl W, Seemann M, Seelig MH. Treatment of acute delayed visceral hemorrhage after pancreatic surgery from hepatic arteries with covered stents. J Gastrointest Surg. 2011 Mar;15(3):496-502. Epub 2011 Jan 15. PMID:21240640.

    Jimenez RE, Fernandez-Del Castillo C, Rattner DW, Warshaw AL. Pylorus-preserving pancreaticoduodenectomy in the treatment of chronic pancreatitis. World J Surg. 2003 Nov; 27 (11) :1211-6. PubMed PMID:14508610.

    Karanicolas PJ, Davies E, Kunz R, Briel M, Koka HP, Payne DM, Smith SE, Hsu HP, Lin PW, Bloechle C, Paquet KJ, Guyatt GH. The pylorus: take it or leave it? Systematic review and meta-analysis of pylorus-preserving versus standard whipple pancreaticoduodenectomy for pancreatic or periampullary cancer. Ann Surg Oncol. 2007 Jun; 14 (6) :1825-34. PubMed PMID:17342566.

    Köninger J, Friess H, Müller M, Büchler MW. Duodenum preserving pancreatic head resection in the treatment of chronic pancreatitis. Rocz Akad Med Bialymst. 2004; 49:53-60. PubMed PMID:15631314.

    Lin PW, Shan YS, Lin YJ, Hung CJ. Pancreaticoduodenectomy for pancreatic head cancer: PPPD versus Whipple procedure. Hepatogastroenterology. 2005 Sep-Oct; 52 (65) :1601-4. PubMed PMID:16201125.

    Lytras D, Paraskevas KI, Avgerinos C, Manes C, Touloumis Z, Paraskeva KD, Dervenis C. Therapeutic strategies for the management of delayed gastric emptying after pancreatic resection. Langenbecks Arch Surg. 2007 Jan; 392 (1) :1-12. PubMed PMID:17021788.

    Müller MW, Dahmen R, Köninger J, Michalski CW, Hinz U, Hartel M, Kadmon M, Kleeff J, Büchler MW, Friess H. Is there an advantage in performing a pancreas-preserving total duodenectomy in duodenal adenomatosis?. Am J Surg. 2008 Jun; 195 (6) :741-8. PubMed PMID:18436175.

    Müller MW, Friess H, Martin DJ, Hinz U, Dahmen R, Büchler MW. Long-term follow-up of a randomized clinical trial comparing Beger with pylorus-preserving Whipple procedure for chronic pancreatitis. Br J Surg. 2008 Mar; 95 (3) :350-6. PubMed PMID:17933005.

    Niedergethmann M, Shang E, Farag Soliman M, Saar J, Berisha S, Willeke F, Post S. Early and enduring nutritional and functional results of pylorus preservation vs classic Whipple procedure for pancreatic cancer. Langenbecks Arch Surg. 2006 Jun; 391 (3) :195-202. PubMed PMID:16491403.

    Ohtsuka T, Tanaka M, Miyazaki K. Gastrointestinal function and quality of life after pylorus-preserving pancreatoduodenectomy. J Hepatobiliary Pancreat Surg. 2006; 13 (3) :218-24. PubMed PMID:16708298.

    Ohtsuka T, Yamaguchi K, Ohuchida J, Inoue K, Nagai E, Chijiiwa K, Tanaka M. Comparison of quality of life after pylorus-preserving pancreatoduodenectomy and Whipple resection. Hepatogastroenterology. 2003 May-Jun; 50 (51) :846-50. PubMed PMID:12828102.

    Paraskevas KI, Avgerinos C, Manes C, Lytras D, Dervenis C. Delayed gastric emptying is associated with pylorus-preserving but not classical Whipple pancreaticoduodenectomy: a review of the literature and critical reappraisal of the implicated pathomechanism. World J Gastroenterol. 2006 Oct 7; 12 (37) :5951-8. PubMed PMID:17009392.

    Sargent M, Boeck S, Heinemann V, Jauch KW, Seufferlein T, Bruns CJ. Surgical treatment concepts for patients with pancreatic cancer in Germany—results from a national survey conducted among members of the “Chirurgische Arbeitsgemeinschaft Onkologie” (CAO) and the “Arbeitsgemeinschaft Internistische Onkologie” (AIO) of the Germany Cancer Society (DKG). Langenbecks Arch Surg. 2011 Feb; 396 (2) :223-9. PubMed PMID:20711737.

    Seiler CA, Wagner M, Bachmann T, Redaelli CA, Schmied B, Uhl W, Friess H, Büchler MW. Randomized clinical trial of pylorus-preserving duodenopancreatectomy versus classical Whipple resection-long term results. Br J Surg. 2005 May; 92 (5) :547-56. PubMed PMID:15800958.

    Slezak LA, Andersen DK. Pancreatic resection: effects on glucose metabolism. World J Surg. 2001 Apr; 25 (4) :452-60. PubMed PMID:11344398.

    Srinarmwong C, Luechakiettisak P, Prasitvilai W. Standard whipple’s operation versus pylorus preserving pancreaticoduodenectomy: a randomized controlled trial study. J Med Assoc Thai. 2008 May; 91 (5) :693-8. PubMedPMID:18672634.

    Sülberg D, Chromik AM, Köster O, Uhl W. Prevention and management of postoperative complications in pancreatic surgery. Zentralbl Chir. 2010 Apr;135(2):129-38. Epub 2010 Apr 8. Review. German. PMID:20379943.

    Tran KT, Smeenk HG, van Eijck CH, Kazemier G, Hop WC, Greve JW, Terpstra OT, Zijlstra JA, Klinkert P, Jeekel H. Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors. Ann Surg. 2004 Nov; 240 (5) :738-45. PubMed PMID:15492552; PubMed Central PMCID: PMC1356476.

    Traverso LW. The pylorus preserving Whipple procedure for the treatment of chronic pancreatitis. Swiss Surg. 2000; 6 (5) :259-63. PubMed PMID:11077493.

    Yekebas EF, Wolfram L, Cataldegirmen G, Habermann CR, Bogoevski D, Koenig AM, Kaifi J, Schurr PG, Bubenheim M, Nolte-Ernsting C, Adam G, Izbicki JR. Postpancreatectomy hemorrhage: diagnosis and treatment: an analysis in 1669 consecutive pancreatic resections. Ann Surg. 2007 Aug; 246 (2) :269-80. PubMed PMID:17667506; PubMed Central PMCID: PMC1933568.

  4. literature search

    Literature search on the pages of pubmed.