Pancreaticoduodenectomy

Interventions infobox
Name = PAGENAME


Caption =
ICD10 =
ICD9 = 52.7
MeshID = D016577
OtherCodes =
A pancreaticoduodenectomy, pancreatoduodenectomycite journal |author=Fingerhut A, Vassiliu P, Dervenis C, Alexakis N, Leandros E |title=What is in a word: Pancreatoduodenectomy or pancreaticoduodenectomy? |journal=Surgery |volume=142 |issue=3 |pages=428–9 |year=2007 |pmid=17723902 |doi=10.1016/j.surg.2007.06.002 |url=http://linkinghub.elsevier.com/retrieve/pii/S0039-6060(07)00305-4] , Whipple procedure, or Kausch-Whipple procedure, is a major surgical operation involving the pancreas, duodenum, and other organs. This operation is performed to treat cancerous tumours on the head of the pancreas or cancerous tumors on ducts or vessels near the pancreas.

History

This procedure was originally described by Alessandro Codivilla in 1898 and Walther Kausch in 1912, and later perfected by Allen Oldfather Whipple in the 1930s. [WhoNamedIt|synd|3492]

This technique is often called the "Whipple procedure" since it was named after American surgeon Dr. Allen Whipple who devised the procedure in 1935 and subsequently came up with multiple refinements to his technique (surgeons in training are often quizzed on the refinement he made that provided the most improvement in outcomes to that date: the use of non-absorbable silk over absorbable catgut suture). Fact|date=April 2007 The first resection for a periampullary cancer was performed by the German surgeon Kausch in 1909.

Anatomy involving the procedure

The basic concept behind the pancreaticoduodenectomy is that the head of the pancreas and the duodenum share the same arterial blood supply. These arteries run through the head of the pancreas, so that both organs must be removed. If only the head of the pancreas were removed it would compromise blood flow to the duodenum.

The most common technique of a pancreaticoduodenectomy consists of the en bloc removal of the distal segment (antrum) of the stomach; the first and second portions of the duodenum; the head of the pancreas; the common bile duct; and the gallbladder.

Pancreaticoduodenectomy in modern medicine

The Whipple procedure today is very similar to Whipple's original procedure. It consists of removal of the distal half of the stomach (antrectomy), the gall bladder (cholecystectomy), the distal portion of the common bile duct (choledochectomy), the head of the pancreas, duodenum, proximal jejunum, and regional lymph nodes. Reconstruction consists of attaching the pancreas to the jejunum (pancreaticojejunostomy) and attaching the common bile duct to the jejunum (choledochojejunostomy) to allow digestive juices and bile to flow into the gastrointestinal tract and attaching the stomach to the jejunum (gastrojejunostomy) to allow food to pass through.

Originally performed in a two-step process, Whipple refined his technique in 1940 into a one-step operation. Using modern operating techniques, mortality from a Whipple procedure is around 5% nationwide (<2% in high volume academic centers). [ [http://www.ddc.musc.edu/ddc_pub/patientInfo/surgeries/whipple.htm Public Information Site | MUSC Digestive Disease Center ] ]

Pancreaticoduodenectomy versus total pancreatectomy

Some authors advocate the removal of the whole pancreas (total pancreatectomy) instead of just the head.Fact|date=April 2007 However, clinical trials have failed to demonstrate significant survival benefits, mostly because patients who submit to this operation tend to develop a particularly severe form of diabetes (so-called [http://www.medterms.com/script/main/art.asp?articlekey=18392 "brittle diabetes"] ). Sometimes the pancreaticojejunostomy may not hold properly after the completion of the operation and infection may spread inside the patient. This may lead to another operation shortly thereafter in which the remainder of the pancreas (and sometimes the spleen) is removed to prevent further spread of infection and possible morbidity.

Pylorus-sparing pancreaticoduodenectomy

More recently, the pylorus-sparing pancreaticoduodenectomy (a.k.a. Traverso-Longmire procedure / PPPD) is growing increasingly popular, especially among European surgeons. The main advantage of this technique is that the pylorus, and thus normal gastric emptying, is preserved.cite journal |author=Testini M, Regina G, Todisco C, Verzillo F, Di Venere B, Nacchiero M |title=An unusual complication resulting from surgical treatment of periampullary tumours |journal=Panminerva Med |volume=40 |issue=3 |pages=219–22 |year=1998 |pmid=9785921 |doi=] However, some doubts remain on whether it is an adequate operation from an oncological point of view. In practice, it shows similar long-term survival as a Whipple's (pancreaticoduodenectomy + hemigastrectomy), but patients benefit from improved recovery of weight after a PPPD, so this should be performed when the tumour does not involve the stomach and the lymph nodes along the gastric curvatures are not enlarged.cite journal
author = Michalski, C.W.
coauthors = Weitz, J.; Büchler, M.W.; Others,
year = 2007
title = Surgery Insight: surgical management of pancreatic cancer
journal = Nature Clinical Practice Oncology
volume = 4
issue = 9
pages = 526–535
doi = 10.1038/ncponc0925]

Another controversial point is whether patients benefit from retroperitoneal lymphadenectomy.

Morbidity and mortality

Pancreaticoduodenectomy is considered, by any standard, a major surgical procedure. In some hospitals, it carries a terrible reputation for high rates of morbidity. Mortality rates are improved in high-volume hospitals, however this procedure still carries a significant degree of risk (~10%). [cite journal |author=Urbach DR, Bell CM, Austin PC |title=Differences in operative mortality between high- and low-volume hospitals in Ontario for 5 major surgical procedures: estimating the number of lives potentially saved through regionalization |journal=CMAJ |volume=168 |issue=11 |pages=1409–14 |year=2003 |pmid=12771069 |doi=] One study reported actual risk to be 2.4 times greater than the risk reported in the medical literature, with additional variation by type of institution.cite journal
author = Syin D, Woreta T, Chang DC, Cameron JL, Pronovost PJ, Makary MA
title = Publication bias in surgery: implications for informed consent
journal = J. Surg. Res.
volume = 143
issue = 1
pages = 88–93
year = 2007
month = November
pmid = 17950077
doi = 10.1016/j.jss.2007.03.035
url = ]

In popular culture

* The early 1970s medical drama television series "Medical Center" had an episode in which Dr. Gannon performed a full Whipple procedure on a young lady, unsuccessfully- as she died of complications shortly thereafter. It was one of the very few of Dr. Gannon's fictitious patients to ever die under his knife.
* The Whipple procedure is mentioned sporadically on the popular medical drama "ER".
* There is an episode of the comedy television series "Scrubs" where the intern surgeon Turk is upset because he didn't get assigned a Whipple procedure and shouts, "What's a brother gotta do to get a Whipple around here?!"
* There is an episode of "Grey's Anatomy" in which intern surgeon Christina Yang is trying to get a Whipple procedure (Season 1 Episode 4).

List of notable people who have had this surgery

* 2001 Chris Rea
* 2004 Steve Jobs
* 2006 Randy Pausch
* 2006 Luciano Pavarotti

Nomenclature

Fingerhut "et al" argue that while the terms "pancreatoduodenectomy" and "pancreaticoduodenectomy" are often used interchangeably in the medical literature, scrutinizing their etymology yields different definitions for the two terms. As a result, the authors prefer "pancreatoduodenectomy" over "pancreaticoduodenectomy" for the name of this procedure.

References

External links

* [http://www.cancercompass.com/message-board/message/all,4849,0.htm Whipple Surgery Message Board]
* [http://www.pancreasdiseases.com Whipple Operation and Other Surgical Treatments for Pancreatic Diseases including Cancer]