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Pancreaticoduodenectomy - Indications and Contraindications

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Pancreaticoduodenectomy - Indications and Contraindications

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Pancreaticoduodenectomy is also called the Whipple procedure for treating pancreatic cancer. Refer to this article to know more about it.

Medically reviewed by

Dr. Rajesh Gulati

Published At February 6, 2023
Reviewed AtJuly 11, 2023

Introduction:

Pancreatic cancer is a common cancer-causing death. Despite advanced treatments for cancer, like chemotherapy and radiotherapy, the death rate is more with cancer of the pancreas. Pancreaticoduodenectomy is also called the Whipple procedure; a complex surgical procedure is done to remove benign and malignant cancers of the head of the pancreas, duodenum, and periampullary region, or distal common bile duct, gallbladder, and associated lymph nodes.

There are two main types of Whipple procedure, conventional and pylorus-sparing Whipple procedure. The conventional Whipple procedure includes the removal of the head of the pancreas, the duodenum, a portion of the stomach and gallbladder, and a portion of the bile duct. And the remaining stomach, pancreas, and bile duct are reconnected to a tract of the digestive system to restore function. In pylorus-sparing Whipple surgery, a portion of the stomach is not removed. This treatment requires the role of interprofessional team management of cancer patients.

What Are the Objectives of Pancreaticoduodenectomy or Whipple Procedure?

  • To specify the need for pancreaticoduodenectomy.

  • Define the procedure of pancreaticoduodenectomy.

  • Check the probable complications of pancreaticoduodenectomy.

  • Outline interprofessional team methods for enhancing care coordination and transmission in pancreatic cancer patients undergoing pancreaticoduodenectomy.

What Is Pancreaticoduodenectomy or Whipple Procedure?

It is a surgical procedure to treat resectable or borderline resectable pancreatic ductal adenocarcinoma. The difficulty in surgeries is due to their complex intra-abdominal dissection and difficulty repairing the digestive system. Due to its complexity previously, it was associated with high mortality and perioperative morbidity. Two types of pancreaticoduodenectomy are classical or conventional pancreaticoduodenectomy and pylorus-sparing pancreaticoduodenectomy. This procedure can be performed laparoscopically as well as in an open method. Recent studies found that the laparoscopic approach is associated with lower blood loss, adequate recovery, shorter hospital stays, and more suitable lymph node dissection. Physicians found difficulty with the laparoscopic approach may be due to its difficulty with dissection and anastomosis in this approach.

What Are the Anatomy and Physiology to Be Considered in Pancreaticoduodenectomy or Whipple Procedure?

The pancreas is a retroperitoneal organ located within the loop, which is C shaped by the duodenum. Dividing into the head, uncinate process, neck, body, and tail. Superior and inferior pancreaticoduodenal arteries supply the head and uncinate processes. The splenic artery supplies the neck, body, and tail through the dorsal pancreatic artery, greater pancreatic artery, and transverse pancreatic artery. Four veins supply the head of the pancreas. They drain into the superior mesenteric vein (SMV) or portal vein (PV). Venous drainage of the body, neck, and tail into the splenic veins.

The main duct of the pancreas is Wirsung which starts in the tail, drives the whole distance of the pancreas, and extends into the second portion of the duodenum concurrently with the bile duct on the major duodenal papilla. Several anatomical factors should be taken into account before pancreas surgery. The pancreas and c loop of the duodenum have the same blood supply; thus, that part should be removed along with the pancreas. The uncinate process extends superiorly and posteriorly behind the superior mesenteric vein. Tumor involving the uncinate process has been associated with vascular invasion and has a poor prognosis compared with the others.

What Are the Indications of Pancreaticoduodenectomy Procedure?

  • If the cancer is located at the head of the pancreas.

  • PNETs - pancreatic neuroendocrine tumors.

  • GIST - gastrointestinal stromal tumors.

  • IPMN - intraductal papillary mucinous neoplasms.

  • Duodenal adenocarcinoma, pancreatic trauma.

  • Adenocarcinoma of the ampulla of Vater.

What Are the Contraindications of Pancreaticoduodenectomy Procedure?

The contraindications of pancreaticoduodenectomy are based on multifarious factors. Three grades of resectability are found for localized pancreatic ductal adenocarcinoma.

They are resectable, borderline resectable, and unresectable.

  • In localized and resectable procedures, there will be no distant metastasis and no evidence of distortion of the portal or superior mesenteric vein radiographically. There is an obvious dissection plane around the celiac axis, hepatic artery, and superior mesenteric artery.

  • In borderline resectable, superior mesenteric vein and portal vein involvement with distortion and occlusion but the existence of appropriate vessels proximally and distally for reconstruction. Gastroduodenal artery encasement up to the hepatic artery with brief component encasement of the hepatic artery without spreading to the celiac axis. Tumor abutment of superior mesenteric artery not expanding greater than one hundred and eighty degrees of the circumference of the vessel wall.

  • Unresectable for head cancer or contraindication of the procedure includes celiac abutment, metastasis distantly, involvement of IVC, aorta, and Irreparable SMV or PV occlusion.

What Are the Preparations Done Before Pancreaticoduodenectomy Procedure?

  • Before putting an incision on the skin, antibiotics should be given intravenously.

  • Based on the preference of the surgeon, octreotide is administered.

  • Colonic bowel preparation is done only if colonic bowel resection is needed.

  • Vascular surgeon consultation should be done if vascular resection and reconstruction are planned.

How Is the Pancreaticoduodenectomy Procedure Done?

This procedure begins with a vertical midline incision or bilateral subcostal incision. Then a self-retaining retractor is placed. First, understand the extent of the disease. Staging laparoscopy is used to define resectability. The liver is examined to find metastasis by palpation if suspected imaging techniques are used. The parietal and visceral peritoneal surfaces, the ligament of Treitz, the omentum, and the entire intestine are reviewed for metastasis. The celiac axis was checked for lymph node involvement.

The proper hepatic artery and common hepatic artery are evaluated for any existence of tumor tissue. Kocher maneuver is committed by elevating the duodenum and head of the pancreas out of the retroperitoneum. Cattell-Braasch maneuver is usually not required besides for mobilization and resection of SMV. The gallbladder is dissected from the liver, and the distal common hepatic duct is split near the level of the cystic duct entrance location. The bile duct is retracted caudally, and portal dissection is resumed at the front part of the portal vein. The portal structures should be evaluated for a substituted right hepatic artery and saved during these schemes.

The gastroduodenal artery is ligated to reduce the possibility of erosion. The sectioning of the gastroduodenal artery also reveals the front surface of the portal vein and enables the dissection of the portal vein behind the neck of the pancreas. The surgeon recognizes the portal vein above the neck of the pancreas and SMV inferior to the pancreas neck. Blunt dissection downwards along the portal vein is desired to create a plane anterior to the portal vein and behind the neck of the pancreas. Kocher maneuver will reveal SMV inferior to the pancreas neck. PV and SMV junctions should be visualized.

In the Whipple procedure, antrectomy is done by sectioning the right gastric and gastroepiploic arteries and dividing by a stapler. Pylorus is preserved by the pylorus-preserving procedure.

Conclusion:

Pancreaticoduodenectomy is the curative treatment of pancreatic cancer. Early detection of cancer is very much needed in these types of cancer. The rate of morbidity and mortality associated with this procedure is high. Its complications include delayed gastric emptying, pancreatic fistula, postoperative hemorrhage, wound infection, etc. Early detection and organized multiple team management of the patient is necessary in this case of disease.

Frequently Asked Questions

1.

Why Is a Pancreaticoduodenectomy Called a Whipple?

Whipple surgery is named after Allen Oldfather Whipple, the former chairman of the Department of Surgery at Columbia University, who pioneered the treatment. The surgery removes the pancreatic head, the first section of the small intestine, the liver, and the bile duct. It is used in the treatment of pancreatic tumors.

2.

What Is a Frequent Complication of Pancreaticoduodenectomy?

Delayed gastric emptying, pancreatic fistulae, hemorrhage, chyle leaks, endocrine and exocrine pancreatic insufficiency, and surgical site infections are the most common consequences of pancreaticoduodenectomy. Common complications include pancreatic leak or fistula, intra-abdominal abscess, bile leak, postoperative bleeding, and wound infection.

3.

What Is the Purpose of Whipple Surgery?

The Whipple operation, a pancreaticoduodenectomy, is a surgery used to treat tumors and other problems with the pancreas, intestine, and bile duct.

4.

What Is the Difference Between a Whipple Surgery and a Pancreatectomy?

The Whipple technique is a specific type of pancreatic surgery, while the more general word "pancreatectomy" refers to removing the entire pancreas or a portion of it. When the pancreas is removed, including the body and tail, it is called a distal pancreatectomy.

5.

What Are the Different Types of Whipple Surgery?

The traditional Whipple procedure and the pylorus-preserving Whipple procedure are the two types of Whipple surgeries. The Whipple process, also called a pancreaticoduodenectomy, is a complicated surgery to remove the head of the pancreas, the duodenum, the gallbladder, and the bile duct.

6.

Can You Live 20 Years After Whipple Surgery?

The Whipple procedure is a major surgery that can extend life and potentially cure pancreatic cancer. The five-year survival rate after a successful Whipple procedure is about 20 to 25 %, but a study found that 18 % of patients survived for five years and 13 % survived for ten years. One in eight patients could achieve ten-year survival with a potential for cure.

7.

How Will the Recovery from Pancreaticoduodenectomy?

Pancreaticoduodenectomy (Whipple procedure) recovery time depends on the patient and surgical complexity. Patients are made to stay in the hospital for one to two weeks after surgery.

8.

How Long Does Recovery From Pancreaticoduodenectomy Take?

Recovery can take two to six months. After surgery, patients may experience pain, tiredness, and other symptoms. Following the doctor's instructions and attending follow-up appointments are essential to ensure a successful recovery.

9.

Can One Live Without a Pancreas?

Living without a pancreas involves medical care and lifestyle modifications. Removing the pancreas causes diabetes and affects food digestion since it produces survival hormones like insulin. Diabetes medication and a low-sugar, low-carbohydrate diet are necessary for pancreas-less people. Hormone-producing pancreatic cell transplantation is rare. Life expectancy following pancreas removal surgery is rising, although it depends on the cause.

10.

What Will Life Be Like After Whipple Surgery?

The Whipple treatment is a major surgery that takes about a week to recover from in the hospital. Returning to a good quality of life can take two to six months. Patients may feel pain and have to stay on a liquid diet before they can start eating solid foods. The number of deaths after a Whipple operation has decreased from 1 % to 3 %. Patients with a successful Whipple treatment have a 25 % chance of being alive after five years. Finally, people should be able to do everything before surgery.

11.

What Are the Risks of Whipple Surgery?

The risks include infection at the incision site or inside the belly, bleeding, delayed emptying of the stomach, leakage from the pancreas or bile duct connection, and diabetes (temporary or permanent). The surgery is technically hard and demanding, so it is performed by a skilled and experienced surgeon who can handle any problems. Other possible problems with pancreatic surgery include heart problems, breathing problems, kidney problems, and asthma.

12.

Is Chemo Necessary After Whipple Surgery?

Surgery, such as the Whipple procedure, can eliminate pancreatic cancer, but the Pancreatic Cancer Association UK recommends chemotherapy following surgery to lessen the likelihood of cancer returning. After pancreatic resection, adjuvant chemotherapy improves long-term survival, as the World Journal of Surgical Oncology reports.

13.

What Is an Alternative to Whipple Surgery?

There are Whipple surgery alternatives for treating pancreatic cancer. Chemotherapy and radiation therapy are examples of such treatments. A pylorus-preserving pancreatoduodenectomy, similar to the Whipple technique but does not include any stomach removal, is another possibility. Surgery may not be necessary for some circumstances, and alternative therapy may be utilized instead. Additionally, prospective novel medicines for pancreatic cancer, such as targeted therapies and immunotherapies, are being researched. Treatment should be reviewed with a healthcare practitioner based on individual situations.

14.

What not to eat after Whipple surgery?

It is best to avoid hot, greasy, and fatty foods after Whipple surgery because they are hard to digest with a changed pancreas. Instead, choose foods that are baked, fried, or broiled. People are also told to eat no more than 40–60 grams of fat daily. Also, it would be best if the individuals avoid foods that give them gas, like broccoli, cabbage, beans, and legumes. Since it is normal to feel full quickly after surgery, eating at least six small meals or snacks daily is best.

15.

What Is the First Step in a Whipple Procedure?

The first step of a Whipple operation is the hepatic flexure of the colon that is taken down through the lesser sac. The proximal body of the pancreas is where the lower body of the gland lies.
Dr. Rajesh Gulati
Dr. Rajesh Gulati

Family Physician

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