Pancreas: Pancreaticoduodenectomy (Whipple Procedure)

Basics

• Resection of Pancreatic Head & Duodenum
• Avoid Preoperative Biliary Drainage (ERCP/Stent)
  • Increased Risk of Wound Infection & Pancreatic Fistula
  • No Improved Morbidity or Mortality

Indications

• Chronic Pancreatitis with Small-Normal Ducts & Isolated to Head
• Head Cyst Concerning for Malignancy
• Head Pancreatic Exocrine Cancer
• Head PNET
• Metastases
• Trauma (Never Emergent)
• Distal CBD Cholangiocarcinoma
• Periampullary Duodenal Adenocarcinoma

Unresectable Definition

• *See Pancreas: Pancreatic Adenocarcinoma

Resection

• Pancreatic Head & Duodenum
• Gallbladder & CBD
• Gastric Antrum & Pylorus
• Proximal Jejunum (15 cm)

Classic Pancreaticoduodenectomy

• Preform an Initial Staging Laparoscopy If Concerned for Malignancy
• Mobilize Duodenum, Pancreatic Head & Stomach
  • Requires Kocher Maneuver
• Isolate Portal Structures
• Divide Right Gastric Artery & GDA
• Cholecystectomy & Common Hepatic Duct Transection
• Transect Stomach 2 cm Proximal to Pylorus
• Mobilize Proximal Jejunum & Transect
• Transect Neck of Pancreas
  • Transection Plane Created by Developing a Tunnel Anterior to SMV
• Retract Specimen Medially Off the SMV-Portal Vein Confluence
  • Exposes Inferior Pancreaticoduodenal Arteries – Carefully Ligate Branches to Avoid Avulsion
• Reconstruction:
  • Pancreaticojejunostomy (PJ)
    • At Most Proximal Aspect
    • Responsible for Majority of Postoperative Morbidity
  • Hepaticojejunostomy (HJ)
    • Distal to PJ Anastomosis to Prevent Backflow
  • Gastrojejunostomy (GJ)
    • ≥ 30-40 cm (Often 45-60 cm) Distally to Prevent Food Reflux into Biliary/Pancreatic Anastomoses

Pylorus-Preserving Pancreaticoduodenectomy

• Preserves:
  • Gastric Antrum & Pylorus
  • Proximal Duodenum (3-4 cm)
• Contraindications: Involvement of First Portion of Duodenum, Pylorus or Antrum
• Comparison to Classic Whipple:
  • Faster Procedure & Lower Blood Loss
    • Often Preferred Method
  • No Significant Difference in Outcomes

Complications

• Gastroparesis (17%)
  • Most Common Complication
  • Tx: Reglan or Erythromycin
• Pancreatic Fistula (5-10%)
  • Most Common Serious Complication
  • High Mortality
• Bile Leak (1-3%)
• Bleeding
  • Usually from GDA Leak
  • Friable and Difficult to Control in OR
  • Tx: Angioembolization
• Marginal Ulcer
  • Tx: PPI
• Endocrine Insufficiency – New-Onset DM