Pyloric Preservation with the Whipple Procedure

Symposium on Surgical Practices at the Lahey Clinic II

Pyloric Preservation with the Whipple Procedure John W. Braasch, MD.,* and Ricardo L. Rossi, MD.*

In the 85 years since the turn of this century, surgeons have considered the operative treatment of periampullary cancer and chronic pancreatitis, which is most severe in the head of the pancreas. The indications for surgery and the operative procedures performed for these diseases are continuously evolving. This scrutiny has resulted in dissatisfaction with the risks and results of surgical therapy. Initially in this century, the operative mortality rate for any form of excisional therapy was spectacularly excessive, and mortality rates of 25 to 40 per cent were not uncommon. S The pancreatic anastomosis, the method of dealing with the cut edge of the neck of the pancJ;eas, was gradually shown to be responsible for most postoperative deaths. 6, 10 Basically, the pancreas remaining after resection of the head can be classified with respect to the friability of the gland and size of the pancreatic duct, Soft glands and small pancreatic ducts have been shown to present a danger in the two-layer sutured anastomosis with anastomosis of the pancreatic duct to the bowel. The development of an alternative dunking procedure has provided a: method that is safe for soft glands. Therefore, the surgeon undertaking Whipple's pancreatoduodenectomy now has available the necessary techniques to anastomose both types of residual pancreata. The realization of these facts has been followed by a marked decline in the postoperative mortality rate for pancreatoduodenectomy. Another problem with pancreatoduodenectomy has been the relatively high postoperative incidence of jejunal ulceration, hemorrhage, and perforation. 4, 9 In addition, the nutritional status of the patient after WhippIe's operation was less than ideal because of the loss of the reservoir and mixing functions of the stomach, occasional bile reflux, and dumping. In 1978, Traverso and Longmire8 suggested that the pylorus could be preserved in patients undergoing pancreatoduodenectomy for benign disease (Fig. 1). They presented two patients who underwent this procedure, but they were hesitant to apply the procedure in persons with periampul-

*Staff, Department of Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts

Surgical Clinics of North America-Vol. 65, No.2, April 1985

263

264

JOHN

W.

BRAASCH AND RICARDO

L.

ROSSI

~----------------~~~~

,~o

~

Figure 1. Original illustration of pylorus-preserving procedure. (From Traverso, L. W., and Longmire, W. P., Jr.: Preservation of the pylorus in pancreaticoduodenectomy. Surg. Gynecol. Obstet., 146:961; 1978, with permission.)

lary malignancy. On short-term follow-up, jejunal ulceration was not encountered. Operative experience suggested that this modification of pancreatoduodenectomy could help to avoid the problem of jejunal ulceration and would simplify the operative procedure because no gastric resection or vagotomy would be performed. Also, the patient would retain an intact gastric mechanism that might lead to better nutrition over the long term. To test these hypotheses, we undertook application of this operative procedure in suitable patients with chronic pancreatitis and in certain patients with periampullary malignancy.

TECHNIQUE

The only difference between the pylorus-preserving procedure and the standard Whipple operation, or pancreatoduodenectomy as we know it today, is the point of sectioning of the upper gastrointestinal tract. About 1 cm of proximal duodenum is. preserved along with the pylorus, but the

265

PYLORIC PRESERVATION

gastroduodenal, right gastric, and right gastroepiploic arteries are severed in the course of resection of the head of the pancreas and the periampullary area. The only blood supply to the duodenum and pylorus must, of necessity, descend from the left gastric artery down the lesser curvature aspect of the stomach (Fig. 2). It is therefore of vital importance to guard this blood supply during resection. Gastric emptying depends in part on an intact vagal innervation to the antrum. The branches to be preserved come from the nerves of Latarjet and from vagus branches to the liver and celiac plexus. Resection of the periampullary area and the head of the pancreas demands an accurate knowledge of the anatomy of the right upper quadrant of the abdomen. Five planes must be developed to enable resection of this area. These include the plane between the hepatic artery and the distal common bile duct anterior to the portal vein. This plane is carried down to the gastroduodenal artery, which must be severed (Fig. 3). Others include the plane lateral to the superior mesenteric vein that proceeds cephalad toward the inferior edge of the neck of the pancreas (Fig. 4); the plane posterior to the duodenum and head of the pancreas and anterior to the vena cava, aorta, and the gonadal vein (Fig. 5); the plane around the ligament of Treitz that requires severing the first portion of the jejunum and dissection of the blood supply of the duodenojejunal junction to allow passage of the intestine under the mesenteric vessels to the right side of the abdomen; and the plane under the neck of the pancreas. After development of these planes, the pancreatic head can be dissected from the superior mesenteric and portal veins, thus allowing removal of the specimen. The order of reconstruction from the proximal jejunum distally is as follows: first, the pancreaticojejunostomy by either the dunking (Fig. 6) or two-layer suture method (Fig. 7); the end-to-side hepaticojejunostomy using a single layer of nonabsorbable sutures; and the end-to-side duodenojejunostomy with care taken to preserve the blood supply to the duodenum and to avoid narrowing of the anastomosis. If a leak-free series of anastomoses has been constructed and no vital structures have been compromised, the most serious postoperative complication is a delay in gastric emptying, which commonly follows preservation of the pylorus. In our experience, gastric suction usually is required for about 8 days; however, several of our patients have required gastric suction for 3 weeks. At times, we place a needle catheter jejunostomy distal to the gastrojejunostomy for enteral feeding until gastric function resumes.

CLINICAL SERIES Since September 1979 our experience to date includes 58 pyloruspreserving pancreatic resections. Of these, 44 were of the Whipple variety and 14 were total or completion total pancreatectomies. Seventeen resec-

266

JOHN

W.

BRAASCH AND RICARDO

L.

ROSSI

STOM.

LESSER CURVATURE " LEFT GASTRIC BLOOD SUPPLY

Figure 2.

Point of duodenal section with blood supply to duodenum and pylorus.

tions were for chronic pancreatitis, and 41 were for periampullary malignancy. Of the latter, 3 included resection of the portal vein. This sequential series was accomplished with no postoperative deaths for the entire series in the hospital and no deaths related to the operation in follow-up period. The nutritional status of these patients has been favorable. Body weight is perhaps the best indicator of nutrition; 93 per cent of preillness weight and 106 per cent of preoperative weight had been regained at postoperative follow-up periods ranging from 4 to 43 months (a median of 24 months). Of those patients with periampullary malignancy who were followed for 6 months or more, 10 of 12 patients with cancer of the pancreas died at a median period of 12 months after operation. Two patients survive, one at 16 months after operation and another at 24 months; both are without clinical evidence of disease. Of the remaining patients with periampullary malignancy, only one patient has died of disease, that is, cancer of the ampulla of Vater. The median follow-up period for this group is 26 months. Jejunal ulceration developed in only three patients. Of these three, one patient who was being treated by external beam radiotherapy for recurrent cancer of the pancreas died of cancer 12 days after jejunal ulcer

267

PYLORIC PRESERVATION

Figure 3.

The plane between hepatic artery and distal common bile duct.

was diagnosed. Another patient was treated successfully with cimetidine (Tagamet) and is asymptomatic. In a third patient who required partial gastrectomy, evidence for ulceration in the resected specimen was questionable although the endoscopist believed that an ulcer could be visualized before operation. One additional patient required reoperation because of a poorly emptying stomach. No definite physical obstruction was demonstrated at the time of reoperation; this patient has done well after partial gastrectomy. DISCUSSION

Pancreatoduodenectomy, or the Whipple procedure, can be performed safely when attention is paid to detail, especially with respect to pancreaticojejunostomy. This anastomosis is the key to a low mortality

268

JOHN

W.

BRAASCH AND RICARDO

L.

ROSSI

SUP.MES. VEIN

Figure 4. The plane lateral to superior mesenteric vein extending to inferior edge of the neck of the pancreas.

rate. If no leakage occurs at this or the other two anastomoses, operative mortality should be the result only of cardiovascular complications. The two-layer sutured anastomosis is particularly suitable for firm pancreatic tissue and large dilated pancreatic ducts. The alternative procedure, that is, end-to-end pancreaticojejunostomy using the dunking technique, is useful for soft pancreatic glands. The choledochojejunostomy can easily be made leak-proof by using a one-layer through-and-through permanent suture technique. The pylorus-preserving modification simplifies the operative procedure considerably. A vagotomy or gastrectomy with a Hofmeister modification is unnecessary. The anastomosis of the duodenum to the jejunum is simple and saves operative time. At the cost of modest prolongation of the requirement for gastric suction, satisfactory weight gains are noted after operation. A comparison of our experience using the pylorus-preservation technique with patients who underwent the standard Whipple procedure shows a more favorable weight gain after pylorus preservation. 3, 7, 11 This

PYLORIC PRESERVATION

269

advantage is probably based on preservation of the gastric mixing and storage functions plus a lack of dumping and other problems after gastrectomy. Thus far, and with a maximum follow-up period of 5 years, jejunal ulceration is not a noteworthy complication of the procedure. Our follow-up studies are insufficient with respect to length of time and numbers of patients and do not enable us to judge the effect of preservation of the pylorus on cancer survival. However, preliminary data show promise that survival will be comparable to that for the standard Whipple procedure. 1o Examination of the basic difference between the py_ lorus-preserving procedure and the gastric resection that accompanies standard pancreatoduodenectomy reveals that the tissue preserved is only the wall of the antrum of the stomach with some blood vessels and lymphatics on the lesser curvature side of the stomach along with a I-cm segment of the duodenum. Preservation of this tissue, which in some patients may include involvement with malignant tumor, seems unlikely to constitute the difference between recurrence of tumor and cure of the patient. Pathologic studies of pancreatoduodenectomy specimens revealed an absence of malignant tumor in the tissues that were retained by the pyloruspreserving procedure. 2

Figure 5. maneuver).

The plane posterior to the duodenum and head of the pancreas (Kocher

270

JOHN

W.

BRAASCH AND RICARDO

L.

ROSSI

Figure 6. Dunking method of pancreaticojejunostomy. A, Traction sutures, which draw end of pancreas into open end of jejunum. B, Completed anastomosis with seromuscularis of jejunal end sutured to capsule of pancreas.

To date, pancreatoduodenectomy has been reserved for those patients with malignant tumors in whom a cure was possible or for those patients with pancreatitis in whom resection could relieve most of the problem of pain. With an associated mortality rate for pancreatoduodenectomy of less than 3 per cent, the indications for use of this procedure perhaps may be broadened to include consideration of palliation of tumors.

SUMMARY The pylorus-preserving pancreatoduodenectomy simplifies resection, allows a satisfactory postoperative weight gain, prevents postgastrectomy symptoms, is followed by a low rate of jejunal ulceration, and can be performed with an extremely low postoperative mortality rate, providing that the pancreatic and biliary anastomoses are constructed so that no leakage occurs. Preliminary data indicate a satisfactory survival rate when this procedure is used for periampullary cancer, and reasonable relief of pain is achieved when the procedure is used in chronic pancreatitis.

271

PYLORIC PRESERVATION

Figure 7.

Two-layer anastomotic pancreaticojejunostomy.

REFERENCES 1. Braasch, J. W., Gongliang, J., and Rossi, R. L.: Pancreatoduodenectomy with preservation of the pylorus. World J. Surg., 8:900--905,1984. 2. Cooperman, A. M.: Cancer of the pancreas: A dilemma in treatment. Surg. Clin. North Am., 61:107-115, 1981. 3. Fish, J. C., Smith, L. B., and Williams, R. D.: Digestive function after radical pancreaticoduodenectomy. Am. J. Surg., 117:40-45, 1969. 4. Grant, C. S., and Van Heerden, J. A.: Anastomotic ulceration follOwing subtotal and total pancreatectomy. Ann. Surg., 190:1-5, 1979.

5. Hunt, V. C.: Surgical management of carcinoma of the ampulla of Vater and of the periampullary portion of the duodenum. Ann. Surg., 114:570--602, 1941. 6. Monge, J. J., Judd, E. S., and Gage, R. P.: Radical pancreatoduodenectomy: A 22-year experience with the complications, mortality rate, and survival rate. Ann. Surg., 160:711-722, 1964. 7. Newman, K. D., Braasch, J. W., Rossi, R. L., et al.: Pyloric and gastric preservation with pancreatoduodenectomy.· Am. J. Surg., 145:152--156, 1983. 8. Traverso, L. W., and Longmire, W. P., Jr.: Preservation of the pylorus in pancreaticoduodenectomy. Surg. Gynecol. Obstet., 146:959-962, 1978. 9. Warren, K. W., Cattell, R. B., Blackburn, J. P., et al.: A long-term appraisal ofpancreaticoduodenal resection for periampullary carcinoma. Ann. Surg., 155:653--662, 1962. 10. Warren, K. W., Choe, D. S., Plaza, J., et al.: Results of radical resection for periampullary cancer. Ann. Surg., 181:534-540, 1975. 11. Wollaeger, E. E., Comfort, M. W., Clagett, O. T., et al.: Efficiency of the gastrointestinal tract after resection of head of pancreas. J.A.M.A., 137:83~48, 1948. Department of Surgery Lahey Clinic Medical Center 41 Mall Road Box 541 Burlington, Massachusetts 01805