Pancreaticoduodenectomy (Whipple Procedure)

David Ray Velez, MD
The Operative Review of Surgery. 2023; 1:20-28. 

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Table of Contents

General Information
Technique
Complications

Mnemonics
References

General Information

Definition

  • Resection of Pancreatic Head & Duodenum 1

Resection Contents by a Classic Pancreaticoduodenectomy 1

  • Pancreatic Head & Duodenum
  • Gallbladder & Common Bile Duct (CBD)
  • Gastric Antrum & Pylorus
    • *Some Prefer a Pylorus-Preserving Technique
  • Proximal Jejunum (15 cm)

Indications

  • Pancreatic Head Malignancy
    • Exocrine Cancer/Adenocarcinoma
    • Pancreatic Neuroendocrine Tumor (PNET)
    • Cyst Concerning for Malignancy
    • Metastases
  • Distal Common Bile Duct (CBD) Cholangiocarcinoma
  • Periampullary Duodenal Adenocarcinoma
  • Chronic Pancreatitis with Small-Normal Ducts, Isolated to the Head
  • Trauma (Never Emergent)

Unresectable Definitions

Preoperative Biliary Drainage

  • Methods:
    • Endoscopic Retrograde Cholangiopancreatography (ERCP)
    • Percutaneous Transhepatic Cholangiography (PTC)
  • Theory: Some Animal Studies Saw Improved Liver Function & Perioperative Complications (Not Seen in Human Clinical Trials) 3
  • Clinical Trials:
    • No Improved Morbidity or Mortality 3
    • Increased Risk of Wound Infection, Pancreatic Fistula, & Costs 3
  • Routine Use Should Be Avoided 3

Whipple Resection 2

Technique

Abdominal Exploration

  • Start with an Initial Staging Laparoscopy 4
    • Limited Midline Laparotomy May Also Be Considered 4
    • *Can Forgo if Procedure is Being Performed for a Non-Malignant Pathology
  • Evaluate for Evidence of Tumor Metastases
    • Examine All Visceral Surfaces, Peritoneal Surfaces, Omentum, & Bowel
    • Hepatic Lesions May Be Further Characterized by Intraoperative US or Biopsy with Frozen Section 4
  • Evidence of Metastases Should Prompt Abortion of Case

Dissection

  • Convert to an Open Laparotomy Through Midline Incision
    • *Can Consider Minimally Invasive Surgery (MIS) Approaches (Laparoscopic/Robotic)
  • Perform a Generous Kocher Maneuver
    • Extend to the Level of the Renal Veins
    • Mobilizes Duodenum, Pancreatic Head & Stomach
    • May Also Require Mobilization of the Hepatic Flexure
  • Enter the Lesser Sac Through the Gastrocolic Ligament
  • Isolate the Portal Structures (Common Hepatic/Bile Duct, Common Hepatic Artery, & Portal Vein)
    • Monitor for & Preserve a Replaced Right Hepatic Artery

Resection Mn

  • Cholecystectomy & Common Hepatic Duct (CHD) Transection
    • Divide the CHD Just Proximal to the Cystic Duct
  • Divide the Gastroduodenal Artery (GDA)
    • Divide as it Originates Off the Common Hepatic Artery (CHA)
    • Test-Clamp GDA Prior to Division – Ensure Adequate Flow in the Proper Hepatic Artery (PHA)
    • Celiac Stenosis Can Result in Hepatic Arterial Supply from the GDA in a Retrograde Fashion 5
  • Transect the Stomach
    • Transect 2 cm Proximal to the Pylorus
  • Transect the Proximal Jejunum
    • Mobilize & Transect 15-20 cm Distal to the Ligament of Treitz
    • Divide the Mesentery & Pass Bowel Underneath the Superior Mesenteric Vessels to the Patient’s Right
  • Transect the Neck of the Pancreas
    • Transection Plane Created by Developing a Tunnel Anterior to the SMV (Posterior to the Pancreatic Neck)
  • Retract Specimen Medially Off the SMV-Portal Vein Confluence
    • Exposes Inferior Pancreaticoduodenal Arteries – Carefully Ligate Branches to Avoid Avulsion
  • Lymphadenectomy
    • Include Regional Lymph Nodes Along the CBD, CHA, Portal Vein, & Pancreaticoduodenal Arteries
    • Minimum 12 Lymph Nodes Recommended 6

Reconstruction

  • Pancreaticojejunostomy (PJ)
    • At the Most Proximal Aspect
    • Responsible for the Majority of Postoperative Morbidity
    • Techniques: 7
      • Invagination Techniques
      • Duct-to-Mucosa Techniques
      • Pancreaticogastrostomy (PG) Anastomosis – Less Common 8
    • *Various Anastomotic Techniques – None Have Been Proven to Be Superior 7
  • Hepaticojejunostomy (HJ)
    • Created 5-10 cm Distal to PJ Anastomosis to Prevent Backflow
  • Gastrojejunostomy (GJ)
    • Created ≥ 30-40 cm (Often 45-60 cm) Distally to Prevent Food Reflux into Biliary/Pancreatic Anastomoses
    • Can Be Performed in an Antecolic or Retrocolic Fashion 9

Drains & Closure

  • Leave 1-2 Closed-Suction Drains Anterior/Posterior to the HJ & PJ to Monitor for Leak/Fistula
    • Can Potentially Omit Drains in Patients at Negligible- or Low-Risk for Pancreatic Fistula 11
    • Generally Prefer Early Removal Based on Drain Amylase 11
    • Drain Amylase Checked on Postoperative Day #1 & #3 (Remove if < 5000 U/L) 11
  • Close Abdomen

Whipple Reconstruction 10

Pylorus-Preserving Pancreaticoduodenectomy (PpPD)

  • Definition: A Pancreaticoduodenectomy that Preserves the Gastric Antrum, Pylorus, & Proximal Duodenum (3-4 cm) 12,13
    • Proximal Duodenum is then Anastomosed to the Jejunum (Duodenojejunostomy – DJ)
  • Theory: Preservation of the Pylorus Preserves Normal Physiologic Gastric Emptying
    • Some Believe it Could Improve Nutritional Status and Decrease the Incidence of Associated Complications Such as Dumping Syndrome, Marginal Ulcer, & Bile Reflux Gastritis (Debated) 14
  • Contraindications: Involvement of First Portion of the Duodenum, Pylorus, or Antrum
  • Comparison to Classic Pancreaticoduodenectomy for Cancer: 15
    • Faster Procedure & Lower Blood Loss 15
    • No Significant Difference in Outcomes or Long-Term Survival 15

Complications

General Risk

  • Morbidity 30-60% 16
  • Mortality < 4% (1% in High-Volume Centers) 17
  • 5-Year Survival for Complete Resection: 20-30%

Delayed Gastric Emptying (DGE/Gastroparesis)

  • The Most Common Complication After Pancreaticoduodenectomy
  • Risk: 17% 18
  • Multifactorial Causes: 17
    • Decreased Motilin (From Duodenal Resection)
    • Dissected Vagal & Sympathetic Innervation to the Antrum/Pylorus
    • Decreased Blood Flow to the Antrum/Pylorus
    • Pancreatic Fistulae
  • Risk Factors: 19,20
    • Prior Abdominal Surgery
    • History of Cholangitis
    • Diabetes
    • Preoperative Biliary Stenting
    • Pylorus Resection
    • Longer Operating Times
  • Presentation:
    • Bloating
    • Abdominal Pain
    • Nausea & Vomiting
    • Diet Intolerance & Early Satiety
  • International Study Group of Pancreatic Surgery (ISGPS) 2007 Classification: 21
    • Grade A
      • Nasogastric Tube (NGT) Required 4-7 Days
      • Unable to Tolerate Oral Diet After 7 Days
    • Grade B
      • Nasogastric Tube (NGT) Required 8-14 Days
      • Unable to Tolerate Oral Diet After 14 Days
    • Grade C
      • Nasogastric Tube (NGT) Required > 14 Days
      • Unable to Tolerate Oral Diet After 21 Days
  • Treatment: Metoclopramide (Reglan) or Erythromycin
    • Generally Self-Limiting
    • May Require Nasogastric Tube (NGT) for Decompression or Nasojejunal Tube for Enteral Nutrition

Postoperative Pancreatic Fistula (POPF)

Postpancreatectomy Hemorrhage (PPH)

  • Risk: 12.2% 16
  • High Mortality (21%) 23
  • International Study Group of Pancreatic Surgery (ISGPS) 2007 Classification: 24
    • Parameters:
      • Onset: Early (≤ 24 Hours After Index Operation) or Late (> 24 Horus)
      • Location: Intraluminal or Extraluminal
      • Severity: Mild or Severe
    • Grade A: Early & Mild
    • Grade B: Early & Severe or Late & Mild
    • Grade C: Late & Severe
  • Early Hemorrhage (< 24 Hours) is Generally Due to Inadequate Hemostasis 23
  • Late Hemorrhage (> 24 Hours) is Often Associated with a Postoperative Pancreatic Fistula (POPF) 23
    • Leakage of Pancreatic Enzymes Erodes the Peri-Pancreatic Vessels
  • Origins: 23
    • Gastroduodenal Artery (GDA) Stump (29%) – Most Common
    • Common Hepatic Artery (CHA) (19%)
    • Splenic Artery (12%)
    • Superior Mesenteric Artery (SMA)
    • Proper Hepatic Artery (PHA)
  • Diagnosis: CT Angiography (CTA)
  • Treatment:
    • Early PPH:
      • Intraluminal: Endoscopy 25
      • Extraluminal: Repeat Laparotomy 25
    • Late PPH: Angioembolization 25
      • Tissue Friable and Difficult to Control in OR
      • May Require Repeat Laparotomy If Fails 25

Early Biliary Complications

  • Bilioenteric Structure
    • Risk: 2.6% 26
    • Presentation: New Onset Jaundice with Continuously Increasing Serum Bilirubin 27
    • Diagnosis: US or CT
    • Treatment: Percutaneous Transhepatic Cholangiography (PTC) with Balloon Dilation and Stenting 26,27
      • May Consider Repeat Laparotomy & Anastomotic Revision 26
  • Biliary Leak
    • Leak from the Hepaticojejunostomy (HJ)
    • Risk: 1-3% 28
    • Treatment: Percutaneous Drainage Until Resolution 27
      • May Consider Repeat Laparotomy & Anastomotic Revision for Sepsis or Persistent High-Output Fistulas 27

Additional Complications

  • Wound Infection
    • Risk: 10-40% 4
  • Marginal Ulcer
    • Risk: 5-7% 29,30
    • Risk Factors: 29
      • Discontinuation of PPI
      • Smoking
      • Alcohol
      • Non-Steroidal Anti-Inflammatory Drugs (NSAID’s)
    • Management PPI & Endoscopic Surveillance 29
  • New-Onset Diabetes (Endocrine Insufficiency)
    • Risk of New-Onset Diabetes: 16% 31
    • Risk of Insulin-Dependent New-Onset Diabetes: 6% 31

Mnemonics

Remember the Steps of Dissection & Resection

  • Consider the Surgical Technique as the Face of a Clock
  • Procedure Moves Systematically in a Clockwise Manner
  • 1. Extended Kocher Maneuver
  • 2. Isolate the Portal Structures with Cholecystectomy & Divide the CHD
  • 3. Divide the GDA
  • 4. Transect the Stomach
  • 5. Transect the Proximal Jejunum
  • 6. Create the SMV Tunnel & Transect the Pancreas

Clockwise Approach to a Whipple 32

References

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  32. Reynolds RB, Folloder J. Clinical Management of Pancreatic Cancer. J Adv Pract Oncol. 2014 Sep-Oct;5(5):356-64. (License: CC BY-2.0) Edited by The Operative Review of Surgery