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?
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To specify the need for pancreaticoduodenectomy.
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Define the procedure of pancreaticoduodenectomy.
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Check the probable complications of pancreaticoduodenectomy.
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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?
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If the cancer is located at the head of the pancreas.
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PNETs - pancreatic neuroendocrine tumors.
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GIST - gastrointestinal stromal tumors.
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IPMN - intraductal papillary mucinous neoplasms.
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Duodenal adenocarcinoma, pancreatic trauma.
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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.
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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.
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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.
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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?
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Before putting an incision on the skin, antibiotics should be given intravenously.
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Based on the preference of the surgeon, octreotide is administered.
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Colonic bowel preparation is done only if colonic bowel resection is needed.
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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.
