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Pylorus-preserving pancreatoduodenectomy
Pylorus-Preserving Pancreatoduodenectomy Michael B. Farnell, MD
ince its introduction in 1978 by Traverso and Longmire, 1 pylorus-preserving pancreatoduodenectomy has become a well-established alternative to the standard pancreatoduodenectomy for diseases of the periampullary area and proximal pancreas. Otherwise identical to the standard pancreatoduodenectomy, it differs in preserving the entire stomach, pylorus, and a proximal segment of duodenum. This has the theoretic advantage of maintaining the entire gastric reservoir and the pyloric sphincter and antral pump mechanisms. In appropriately selected patients, the pylorus-preserving pancreatoduodenectomy is probably technically easier to perform, as transection of the duodenum and duodenojejunostomy is simpler than antrectomy and gastrojejunostomy. Many surgeons consider pylorus-preserving pancreatoduodenectomy a procedure of choice for periampullary malignancy, chronic pancreatitis, and benign tumors of the head of the pancreas. Given that pyloric and perigastric nodes are not removed if the pylorus is preserved, some surgeons favor standard pancreatoduodenectomy (with distal gastrectomy) for carcinoma of the head of the pancreas. 2 Moreover, pylorus-preserving pancreatoduodenectomy has been associated with an increased incidence of early delayed gastric emptying; however, in most patients, this is usually short-lived and resolves spontaneously. 3'4 Pylorus-preserving pancreatoduodenectomy is performed for most cystic neoplasms of the head of the pancreas and for those intraductal papillary mucin-producing tumors that are focal within the head of the gland. Very large cystic neoplasms or nonfunctioning islet cell tumors that encroach on the antrum are best managed by standard pancreatoduodenectomy. Finally, pylorus-preserving pancreatoduodenectomy has been my surgical treatment of choice for those patients with small duct chronic pancreatitis, and both an inflammatory mass within the pancreatic head and intractable pain. 5 In the past, pancreatoduodenectomy was associated with prohibitive morbidity and mortality rates and thus had an unfavorable reputation. Today because of advances in intraoperative and postoperative care, as well as
S
From the Department of Surgery, Mayo Clinic, Rochester, MN. Address reprint requests to Michael B. Farnell, MD, Professor of Surgery, Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Copyright 9 2001 by W.B. Saunders Company 1524-153X/01/0301-0003535.00/0 doi:10.1053/otgn.2001.21543
Operative Techniques
technical refinements in performance of the procedure, mortality rates are 3% or less from high-volume specialty centers. 3'6'7 Morbidity can be minimized by the performance of both a tidy, hemostatic dissection and a secure pancreaticojejunostomy. Although the "dunking" technique for pancreaticojejunostomy is preferred by many, my preference, regardless of pancreatic duct size, is for a duct-to-mucosa technique.
Preoperative Evaluation Candidates for pylorus-preserving pancreatoduodenectomy should be good candidates for a major abdominal extirpative procedure. An adequate hemoglobin level should be ensured in patients presenting with anemia from either gastrointestinal blood loss or chronic disease. Many patients present with obstructive jaundice; I administer vitamin K prophylactically to such patients, even if the international normalized ratio is normal, because clotting factors may be depleted rapidly by the consumption associated with an extensive dissection. In addition to an appropriate history and physical examination designed to determine both the patient's physiologic capacity to undergo a major procedure and to detect evidence of metastatic disease, imaging studies are critical in selecting appropriate candidates for operation. Multiphase spiral computed tomography (CT) with thin cuts through the pancreas provides perhaps the most information and may be the only imaging study, other than a chest radiograph, needed before operation. The abdominal CT provides information relative to the presence of distant metastases as well as information regarding both diagnosis and local resectability. In the patient presenting with a clinical history consistent with a periampullary or a pancreatic head mass (ie, painless obstructive jaundice and both bile and pancreatic duct dilation [abdominal CT "double-duct" sign]), this is all the information necessary to both plan and recommend operation. In the absence of a pancreatic mass or an abdominal CT "double-duct" sign on high-quality CT, further diagnostic imaging is necessary; my preference is to obtain endoscopic retrograde cholangiopancreatography (ERCP). ERCP will detect a duodenal or ampullary neoplasm and define stricturing of the bile or pancreatic ducts. In my practice, patients who otherwise have resectable lesions based on CT criteria are not denied operation based on endoscopic ultrasound findings. In addition to an obvious search for evidence of extrapancreatic metastases on abdominal CT, particular at-
in General Surgery, Vol 3, No 1 (March), 2001: pp 31-44
31
32 tention should be directed to the relationship of the pancreatic mass to the superior mesenteric vein-portal vein confluence (SMV-PV) and superior mesenteric artery (SMA). The preservation of a fat plane around both the SMV-PV and SMA is strong evidence that the surgeon will find the lesion to be locally resectable at the operating table. Evidence of direct extension beyond the pancreas should be sought, as should the presence of enlarged lymph nodes, particularly those outside the field of dissection. I consider thrombosis of the SMV-PV to be a contraindication to resection, whereas segmental involvement of the SMV-PV confluence should prompt operation only by those prepared to perform SMV-PV resection and reconstruction at the time of operation. Finally, abdominal CT findings are helpful in anticipating the technical challenges that the surgeon will face when performing the reconstructive phase of the procedure. If the pancreatic duct is dilated, then the surgeon can expect to encounter a firm pancreas providing solid purchase for suture and a safer pancreatojejunostomy. A nondilated duct will suggest a nonobstructed, soft pancreas and a technically challenging pancreaticoenteric anastomosis. Angiography is no longer used routinely, but is reserved for patients in whom arterial collaterals in the head of the pancreas suggest celiac artery stenosis or in those patients in whom either neoadjuvant chemoradiation or recent operation would result in loss of tissue planes and hinder identification of arterial anomalies. I prefer to avoid endoscopic biliary stents, if possible, in patients who otherwise have resectable lesions. Placement of indwelling stents may be complicated by bleeding, perforation, or pancreatitis; is associated with periductal fibrosis, which may complicate the development of tissues planes; and has been linked to an increased risk of perioperative infection. 8 Endoscopic stents to ameliorate
Michael B. Farnell
pruritus are reserved for those patients in whom operation has been delayed because of either the patient's condition or scheduling considerations. Although preoperative endoscopic biopsy of ampullary and duodenal lesions is useful when positive, percutaneous biopsy of mass lesions within the head of the pancreas is meddlesome and unnecessary. Percutaneous biopsy is associated with a significant risk of false-negative findings, as well as potential complications such as hemorrhage or fat necrosis, and may well make dissection more difficult. As the safety of pancreatoduodenectomy has improved, as noted earlier, most pancreatic surgeons no longer routinely attempt to achieve a tissue diagnosis intraoperatively before proceeding with resection. False-negative findings may well occur with needle biopsy, particularly in patients with the smallest lesions and best chance of cure. Thus my current practice is to make a decision relative to resection based on clinical presentation, radiographic imaging, and findings at operation. My current approach is to perform limited staging laparoscopy in a selective manner. Current evidence suggests that state-of-the-art helical abdominal CT will miss small hepatic or peritoneal metastases in fewer than 20% of patients with clinically resectable tumors. 9q ~ Performing a staging laparoscopy adds unnecessary operating time and expense for the remaining 80% of patients with lesions that are either resectable or, if locally irresectable, best palliated surgically. For patients with clinically resectable proximal pancreatic lesions who, for various reasons, have already had an endobiliary stent placed, or for any patient in whom a palliative procedure is not required (eg, proximal lesions without obstructive jaundice or duodenal obstruction, body or tail lesion), limited preliminary laparoscopy under the same anesthetic is an integral component of the procedure.
33
Pylorus-Preserving Pancreatoduodenectomy
SURGICAL TECHNIQUE
@ MAYO
1 Adequate exposure is mandatory for a safe pylorus-preserving pancreatoduodenectomy. Ideally, the patient is positioned supine on the operating table with both arms tucked at the side to allow unrestricted surgical access. I prefer to make a bilateral subcostal incision, except in those few patients who have a particularly verticallyoriented costal arch, for whom I prefer a midline incision. A fixed-abdominal retractor is placed to allow secure retraction of both costal margins in a cephalad direction. The inferior flap of the bilateral subcostal incision is secured to the anterior abdominal wall with a heavy silk suture. A thorough abdominal exploration assesses for the presence of peritoneal or hepatic metastases, with particular attention directed to the pelvis for drop metastases. Adhesions to the undersurface of the right lobe of the liver are lysed to prevent traction-related capsular tears of the liver.
34
Michael B. Farnell
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2 The hepatic flexure of the colon is released inferiorly, and a Kocher maneuver is performed to elevate the duodenum and the head of the pancreas. The dissection is carried cephalad above the retrocholedochal lymph node, inferiorly to the transverse duodenum and medially to the aorta. The posterior aspect of the tumor is palpated and its relationship to the SMA ascertained. Pliable tissue posterior to the SMA indicates that the vessel is not encased. (IVC, inferior vena cava.)
Pylorus-Preserving Pancreatoduodenectomy
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The omentum is freed from the transverse colon in an avascular manner. The omental dissection is carried from left to right, completely separating the omentum from the right transverse mesocolon. The lesser sac is entered, and the entire anterior aspect of the head, neck and proximal pancreas is exposed.
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Michael B. Farnell
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Assessing local resectability. (A) After the right half of the omentum is mobilized and the proximal pancreas exposed, the middle colic vein is identified and, in an avascular manner, is followed down to its junction with the SMV. The transverse mesocolon is then further dissected from its enfolding over the uncinate process of the pancreas, thereby exposing the SMV. Overlying investing tissue is incised, exposing the lateral aspect of the SMV. The right lateral superior mesenteric vein is followed in a cephalad direction to the gastrocolic venous trunk. The gastrocolic venous trunk is dissected very carefully, as vigorous dissection or overretraction will cause copious venous bleeding. The gastrocolic trunk is ligated in continuity with fine suture and divided. (B) With a blunt clamp alter+ nately advancing and spreading, a plane is then developed between the neck of the pancreas anteriorly and the SMV-PV confluence posteriorly. Note that the ability to accomplish this maneuver does not necessarily rule out the involvement of the SMV-PV confluence either laterally or posteriorly.
37
Pylorus-Preserving Pancreatoduodenectomy
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5 Attention is then directed beneath the left lobe of the liver and the gastrohepatic omentum incised in an avascular manner carefully protecting the nerves of Latarjet. (A) The tissues anterior to the hepatoduodenal ligament are carefully incised and the right gastric artery clamped, divided and ligated. (B) The gastroduodenal artery is then identified and doubly ligated in continuity, with one of the ligations transfixing and divided. (C) The common hepatic artery is identified, protected, and retracted cephalad. A plane is sought between the superior border of the pancreas inferiorly and the common hepatic artery superiorly, and the PV is identified. This maneuver allows passage of a blunt clamp between the SMV-PV confluence posteriorly and the neck of the pancreas anteriorly. (D) The neck of the pancreas is then surrounded with a tape, and the gallbladder is mobilized from its bed from above downward. The cystic artery is clamped, divided, and ligated. If the gallbladder is markedly distended due to biliary obstruction, then it may be removed at this stage. The common bile duct is palpated posteriorly to determine the presence of an accessory or replaced right hepatic artery arising from the SMA. It is usually sought posterior and lateral to the common bile duct and should be protected. The bile duct is then mobilized by developing a plane between the PV and the common hepatic duct. The common hepatic duct is surrounded with a tape.
38
Michael B. Farnell
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6 Duodenal skeletonization. (A) The right gastroepiploic artery and vein are clamped, divided, and ligated, thereby freeing the inferior aspect of the duodenum. (B) Next, the stomach is retracted directly anteriorly, placing the duodenum on traction, and the retroduodenal arteries are clamped, divided, and ligated with fine sutures, skeletonizing the duodenum for approximately three centimeters beyond the pylorus.
39
Pylorus-Preserving Pancreatoduodenectomy
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7 Attention is then directed beneath the transverse mesocolon. The transverse colon is retracted cephalad, and the small bowel is packed outside of the abdomen with rightward traction of the duodenojejunal junction. (A) The ligament of Treitz is mobilized, and the tissues to the right o[ the inferior mesenteric vein are incised, thereby communicating the inframesocolic dissection with the previously performed Kocher maneuver. (B) The bowel is then transilluminated approximately 20 cm beyond the ligament of Treitz, and a mesenteric window is fashioned. (C) The bowel is stapled and transected. This is an important step, as choosing a point of division that will allow adequate mobility of the jejunal limb is useful in allowing the limb to be brought through the transverse mesocolon to the right of the middle colic vessels in preparation for both the pancreatic and biliary anastomoses at a later stage of the operation. The proximal jejunal branches are then serially clamped, divided, and ligated proximally to the fourth portion of the duodenum. (D) With anterior and lateral traction on the duodenum, the dissection is carried to a point at which the uncinate process becomes visible. This mobilized proximal jejunum (as part of the eventual en bloc specimen) is then passed beneath the SMA into the supramesocolic compartment. The opening at the ligament of Treitz is then closed with running suture. The duodenum is transected with a stapling device approximately three centimeters beyond the pylorus.
40
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C 8 Division of the pancreas. (A) Hemostatic sutures are placed on both sides of the line of planned division of the pancreas on the inferior and superior borders to control branches of the dorsal pancreatic artery. A right angle clamp is then placed behind the neck of the pancreas and slightly elevated. The pancreatic neck is divided with cautery. The consistency of the pancreas and the size of the pancreatic duct is noted, and a specimen from the neck of the pancreas is removed and submitted as margin. Bleeding from the transected pancreas is controlled with cautery or suture ligatures as necessary. A bulldog clamp is placed on the common hepatic duct, and the common hepatic duct or common bite duct is transected sharply remote from the tumor. A specimen is submitted from the transected duct as margin. (B) A plane is then developed between the SMV-PV confluence and the groove in the pancreas just to the right of the vein. Venous structures coursing from both the portal and superior mesenteric veins into the pancreas are carefully ligated in continuity and divided. (C) Vein retractors are then applied to the SMV-PV confluence, and the PV is retracted to the patient's left. A large venous trunk is typically encountered on the posterior aspect of the SMV, the anterior inferior pancreatoduodenal vein, and this is carefully ligated in continuity and divided. This allows retraction of the SMV-PV confluence to the left and anteriorly and affords access to the anterior aspect of the SMA. The adventitia of the SMA is incised carefully, exposing the SMA. (D) Dissection is then carried posteriorly along the right side of the SMA, thereby controlling the branches coursing from the SMA into the uncinate process of the pancreas. It should be noted that the arterial branches originating from the posterolateral aspect of the SMA are very friable, easily avulsed and may cause troublesome hemorrhage (inset). They are carefully clamped, divided, and suture ligated with fine vascular suture. The specimen, consisting of most of the duodenum, the head and uncinate process of the pancreas, a portion of bile duct, and a portion of jejunum is removed from the abdomen, and a specimen is harvested from the uncinate process as a margin.
41
Pylorus-Preserving Pancreatoduodenectomy
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9 The reconstruction. An opening is made in the mesocolon to the right of the middle colic vessels. The jejunum passed through this opening, and preparations are made for the end-to-side pancreaticojejunostomy. Magnification (X 2.5) is used. The anastomosis is facilitated by mobilizing the stump of the pancreas posteriorly to allow elevation of the stump anteriorly. (A) With interrupted 3-0 or 4-0 nonabsorbable suture, the capsule and parenchyma of the pancreas are sutured to the seromuscular layer of the jejunum in a transverse manner. A small opening is made with an insulated point cautery full thickness in the jejunum adjacent to the pancreatic duct. A Silastic catheter of a diameter somewhat smaller than the pancreatic duct is placed in the opening in the jejunum to direct suture placement, helping to ensure that all layers of the jejunal wall are incorporated. The anastomosis is done with interrupted 6-0 absorbable sutures in a mucosa-to-mucosa fashion, with the posterior row completed first and tied. (B) The Silastic catheter is then advanced into the pancreatic duct to facilitate placing the anterior row of sutures, and to prevent inadvertent suturing of anterior and posterior walls of the anastomosis. The sutures are placed outside-in on the jejunum and inside-out on the pancreatic duct, then tied. The Silastic stent is allowed to float freely and eventually is passed unnoticed in the stool. (C) The anterior row of the anastomosis (interrupted 3 = 0 or 4 = 0 nonabsorbable suture) is completed.
42
Michael B. Farnell
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9 (continued) (D) Approximately eight to ten centimeters distal to the pancreatojejunostomy, an end-to-side biliary enteric anastomosis is performed. For a small, thin-walled duct, a single layer of absorbable interrupted suture is used, whereas for those dilated ducts that are quite thick-walled, a continuous inner absorbable and interrupted outer nonabsorbable layer are chosen. The jejunum is secured to the mesocolon with interrupted silk suture. (E) Finally, an antecolic, end-to-side duodenojejunostomy is fashioned with an inner layer of running 3-0 absorbable suture and an outer layer of interrupted 3-0 nonabsorbable suture. The anastomosis is performed at a distance from the pylorus that ensures adequate blood supply. Two drains are placed in the peritoneal cavity, one in Morison's pouch and another beneath the left lobe of the liver brought through stab wounds below the incision. Nasogastric tube placement within the stomach is verified, and the wound is closed in layers.
Pylorus-Preserving Pancreatoduodenectomy
43
10 A 58-year-old brick mason presented with painless obstructive jaundice. Nine years before his referral, he had undergone a transduodenal excision of a 5 • 4 • 3-cm tubulovillons adenoma of the ampulla of Vater with mild to severe dysplasia. In subsequent years, recurrent tubulovillous adenoma was managed by endoscopic ablation. He subsequently developed obstructive jaundice, and further investigations were undertaken. ERCP (A) showed marked dilation of the biliary tree and a polypoid mass extending three centimeters up the terminal bile duct (arrow). Endoscopic biopsy confirmed the presence of invasive adenocarcinoma. A biliary stent was placed and an abdominal CT obtained (B). The abdominal CT with oral and IV contrast showed a dilated bile duct with an indwelling biliary stent (left arrow), a dilated pancreatic duct (middle arrow), and a preserved fat plane around the SMA and SMV (right arrow). The patient underwent pylorus-preserving pancreatoduodenectomy as described herein. He was found to have a 2.3 • 2 • 0.6-cm invasive adenocarcinoma invading into, but not through the muscularis propria. Lymph nodes were negative. His postoperative course was uneventful.
Postoperative Care Although venting tubes were formerly used in the jejunal limb or traversing the hepaticojejunostomy, analysis of our experience led to the conclusion that these venting tubes are of no benefit. 12 We place gastrostomy tubes or feeding jejunostomy tubes very selectively, as most patients can quickly resume oral intake. Admission to the intensive care unit is not routine, as most patients can be managed on a standard general surgical care unit. Postoperative care includes IV fluids to maintain adequate hydration, peptic ulcer prophylaxis, and perioperative antibiotic prophylaxis (less than 24 hr).
The nasogastric tube is removed within 12 to 24 hours, and ambulation begins on the day after the operation. Oral intake is resumed on the return of bowel function and appetite. The surgical drains are typically removed six to seven days after the operation, unless the character of the drainage suggests leakage. In those instances, when a very high volume of serous drain output is present, if there is truly no clinical evidence of leakage or elevated amylase level in the drainage fluid, the drains are similarly removed. Those patients who have difficulty resuming oral intake and need a nasogastric tube for delayed gastric emptying should be carefully assessed for occult anastomotic leakage. Abdominal pain, fever, or leukocytosis should
44
Michael B. Farnell
prompt an abdominal CT, even if the deep drainage appears harmless. Prokinetic agents are used selectively in those patients with delayed gastric emptying in whom an occult leak has been excluded. Prophylactic therapy with octreotide is not routine. The serum glucose level is carefully monitored postoperatively as patients may require insulin supplementation. Postoperative complications, observed in up to 46% of patients, include urinary tract (2%), pulmonary (7%) or incisional infections (7%), bleeding (8%), abscess (10%), anastomotic leakage (17% pancreatic, 9% biliary), and pancreatitis. 6'7 Although the morbidity following pancreatoduodenectomy is significant, the average length of hospitalization is approximately 10 days for patients without a major complication. Outcomes The outcome of pylorus-preserving pancreatoduodenectomy is more a function of the presence of recurrent disease than of physiologic abnormalities inherent to the procedure. Investigation suggests that patients' quality of life after a pancreatoduodenectomy procedure is similar to that after cholecystectomy. 13 Patients should be followed carefully both for disease recurrence and for late complications such as diabetes, steatorrhea, cholangitis, or stomal ulcer) 4 The pancreaticojejunal anastomosis may stricture over time and result in delayed onset of glucose intolerance or steatorrhea. Insulin and/or enzyme therapy may be indicated. Long-term survival after pancreatoduodenectomy is a function of the tumor type and stage at the time of resection. The five-year survival after pancreatoduodenectomy for pancreatic and periampullary adenocarcinomas at Mayo Clinic is shown in Table 1.
Table 1. Outcome Following Pancreatoduodenectomy for Pancreatic and Periampullary Malignancy at the Mayo Clinic Tumor Type
Number of Patients
Operative Mortality
Five-Year Survival
Pancreas 7 Bile duct is Ampulla16 Duodenum ~7
186 22 104 50
3% 5% 6% 1%
7% 43% 34% 54%
NOTE. Not all patients in each group had pylorus-preserving pancreatoduodenectomy.
REFERENCES 1. Traverso LW, Longmire WP Jr: Preservation of the pylorus in pancreatoduodenectomy. SG&O 146:959-962, 1978 2. Jones LC, Russell C, Mosca F, et al: Standard Kausch-Whipple pancreatoduodenectomy (Review) Digestive Surg 16:297-304, 1999 3. Yeo CJ, CameronJL, Sohn TA, et al: Six hundred fifty consecutive pancreatoduodenectomies in the 1990s: Pathology, complications, and outcomes. Ann Surg 226:248-260, 1997 4. Horstmann O, Becket H, Post S, et al: Is delayed gastric emptying following pancreaticoduodeuectomy related to pylorus preservation? Langenbecks Arch Surg 384:354-359, 1999 5. Sakorafas GH, Sarr MG, Rowland CM, et al: Post-obstructive chronic pancreatitis: Results with distal resection. Presented at the 108th Annual Scientific Session of the Western Surgical Association, Dana Point, CA November 12-15, 2000 6. Miedema BW, Sarr MG, van Heerden JA, et al: Complications following pancreaticoduodenectomy: Current management. Arch Surg 127:945-950, 1992 7. Nitecki SS, Sarr MG, Colby TV, et al: Long-term survival after resection for ductal adenocarcinoma of the pancreas. Is it really improving? Ann Surg 221:59-66, 1995 8. Povoski SP, Karpeh MS Jr, Conlon KC, et al: Preoperative biliary drainage: Impact on intraoperative bile cultures and infectious morbidity and mortality after pancreaticoduodenectomy. J Gastrointestinal Surg 3:496-505, 1999 9. Freiss H, Uhl W, SilvaJC, et al: Preoperative laparoscopy: Do we need it in patients with pancreatic malignancies: AmJ Surg 175: 172-178, 1998 10. Holzman MD, Reintgen KL, Tyler DS, et al: The role of laparoscopy in the management of suspected pancreatic and periampullary malignancies. J Gastrointest Surg 1:236-244, 1997 11. Rumstadt B, Schwab M, Schuster K, et al: The role of laparoscopy in the preoperative staging of pancreatic carcinoma. J Gastrointest Surg 1:245-250, 1997 12. Fallick JS, Farley DR, Farnell MB, et al: Venting intraluminal drains in pancreaticoduodenectomy. J Gastrointest Surg 3:156161, 1999 13. McLeod RS: Quality of life, nutritional status and gastrointestinal hormone profile following Whipple procedure. Ann Oncol 4 (suppl):S281-284, 1999 14. Yamaguchi K, Tanaka M, Chijiiwa K, et al: Early and late complications of pancreaticoduodenectomy in Japan 1998. J Hepatobiliary Pancreat Surg 6:303-311, 1999 15. Nagorney DM, Donohue JH, Farnell MB, et al: Outcomes after curative resections of cholangiocarcinoma. Arch Surg 128:871879, 1993 16. Monson JR, Donohue JH, McEntee G, et al: Radical resection for carcinoma of the ampulla of Vater. Arch Surg 126:353-357, 1991 17. Bakaeen FG, Murr M, Sarr MG, et al: What prognostic factors are important in duodenal adenocarcinoma? Arch Surg 135:635-642, 2000
ince its introduction in 1978 by Traverso and Longmire, 1 pylorus-preserving pancreatoduodenectomy has become a well-established alternative to the standard pancreatoduodenectomy for diseases of the periampullary area and proximal pancreas. Otherwise identical to the standard pancreatoduodenectomy, it differs in preserving the entire stomach, pylorus, and a proximal segment of duodenum. This has the theoretic advantage of maintaining the entire gastric reservoir and the pyloric sphincter and antral pump mechanisms. In appropriately selected patients, the pylorus-preserving pancreatoduodenectomy is probably technically easier to perform, as transection of the duodenum and duodenojejunostomy is simpler than antrectomy and gastrojejunostomy. Many surgeons consider pylorus-preserving pancreatoduodenectomy a procedure of choice for periampullary malignancy, chronic pancreatitis, and benign tumors of the head of the pancreas. Given that pyloric and perigastric nodes are not removed if the pylorus is preserved, some surgeons favor standard pancreatoduodenectomy (with distal gastrectomy) for carcinoma of the head of the pancreas. 2 Moreover, pylorus-preserving pancreatoduodenectomy has been associated with an increased incidence of early delayed gastric emptying; however, in most patients, this is usually short-lived and resolves spontaneously. 3'4 Pylorus-preserving pancreatoduodenectomy is performed for most cystic neoplasms of the head of the pancreas and for those intraductal papillary mucin-producing tumors that are focal within the head of the gland. Very large cystic neoplasms or nonfunctioning islet cell tumors that encroach on the antrum are best managed by standard pancreatoduodenectomy. Finally, pylorus-preserving pancreatoduodenectomy has been my surgical treatment of choice for those patients with small duct chronic pancreatitis, and both an inflammatory mass within the pancreatic head and intractable pain. 5 In the past, pancreatoduodenectomy was associated with prohibitive morbidity and mortality rates and thus had an unfavorable reputation. Today because of advances in intraoperative and postoperative care, as well as
S
From the Department of Surgery, Mayo Clinic, Rochester, MN. Address reprint requests to Michael B. Farnell, MD, Professor of Surgery, Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905. Copyright 9 2001 by W.B. Saunders Company 1524-153X/01/0301-0003535.00/0 doi:10.1053/otgn.2001.21543
Operative Techniques
technical refinements in performance of the procedure, mortality rates are 3% or less from high-volume specialty centers. 3'6'7 Morbidity can be minimized by the performance of both a tidy, hemostatic dissection and a secure pancreaticojejunostomy. Although the "dunking" technique for pancreaticojejunostomy is preferred by many, my preference, regardless of pancreatic duct size, is for a duct-to-mucosa technique.
Preoperative Evaluation Candidates for pylorus-preserving pancreatoduodenectomy should be good candidates for a major abdominal extirpative procedure. An adequate hemoglobin level should be ensured in patients presenting with anemia from either gastrointestinal blood loss or chronic disease. Many patients present with obstructive jaundice; I administer vitamin K prophylactically to such patients, even if the international normalized ratio is normal, because clotting factors may be depleted rapidly by the consumption associated with an extensive dissection. In addition to an appropriate history and physical examination designed to determine both the patient's physiologic capacity to undergo a major procedure and to detect evidence of metastatic disease, imaging studies are critical in selecting appropriate candidates for operation. Multiphase spiral computed tomography (CT) with thin cuts through the pancreas provides perhaps the most information and may be the only imaging study, other than a chest radiograph, needed before operation. The abdominal CT provides information relative to the presence of distant metastases as well as information regarding both diagnosis and local resectability. In the patient presenting with a clinical history consistent with a periampullary or a pancreatic head mass (ie, painless obstructive jaundice and both bile and pancreatic duct dilation [abdominal CT "double-duct" sign]), this is all the information necessary to both plan and recommend operation. In the absence of a pancreatic mass or an abdominal CT "double-duct" sign on high-quality CT, further diagnostic imaging is necessary; my preference is to obtain endoscopic retrograde cholangiopancreatography (ERCP). ERCP will detect a duodenal or ampullary neoplasm and define stricturing of the bile or pancreatic ducts. In my practice, patients who otherwise have resectable lesions based on CT criteria are not denied operation based on endoscopic ultrasound findings. In addition to an obvious search for evidence of extrapancreatic metastases on abdominal CT, particular at-
in General Surgery, Vol 3, No 1 (March), 2001: pp 31-44
31
32 tention should be directed to the relationship of the pancreatic mass to the superior mesenteric vein-portal vein confluence (SMV-PV) and superior mesenteric artery (SMA). The preservation of a fat plane around both the SMV-PV and SMA is strong evidence that the surgeon will find the lesion to be locally resectable at the operating table. Evidence of direct extension beyond the pancreas should be sought, as should the presence of enlarged lymph nodes, particularly those outside the field of dissection. I consider thrombosis of the SMV-PV to be a contraindication to resection, whereas segmental involvement of the SMV-PV confluence should prompt operation only by those prepared to perform SMV-PV resection and reconstruction at the time of operation. Finally, abdominal CT findings are helpful in anticipating the technical challenges that the surgeon will face when performing the reconstructive phase of the procedure. If the pancreatic duct is dilated, then the surgeon can expect to encounter a firm pancreas providing solid purchase for suture and a safer pancreatojejunostomy. A nondilated duct will suggest a nonobstructed, soft pancreas and a technically challenging pancreaticoenteric anastomosis. Angiography is no longer used routinely, but is reserved for patients in whom arterial collaterals in the head of the pancreas suggest celiac artery stenosis or in those patients in whom either neoadjuvant chemoradiation or recent operation would result in loss of tissue planes and hinder identification of arterial anomalies. I prefer to avoid endoscopic biliary stents, if possible, in patients who otherwise have resectable lesions. Placement of indwelling stents may be complicated by bleeding, perforation, or pancreatitis; is associated with periductal fibrosis, which may complicate the development of tissues planes; and has been linked to an increased risk of perioperative infection. 8 Endoscopic stents to ameliorate
Michael B. Farnell
pruritus are reserved for those patients in whom operation has been delayed because of either the patient's condition or scheduling considerations. Although preoperative endoscopic biopsy of ampullary and duodenal lesions is useful when positive, percutaneous biopsy of mass lesions within the head of the pancreas is meddlesome and unnecessary. Percutaneous biopsy is associated with a significant risk of false-negative findings, as well as potential complications such as hemorrhage or fat necrosis, and may well make dissection more difficult. As the safety of pancreatoduodenectomy has improved, as noted earlier, most pancreatic surgeons no longer routinely attempt to achieve a tissue diagnosis intraoperatively before proceeding with resection. False-negative findings may well occur with needle biopsy, particularly in patients with the smallest lesions and best chance of cure. Thus my current practice is to make a decision relative to resection based on clinical presentation, radiographic imaging, and findings at operation. My current approach is to perform limited staging laparoscopy in a selective manner. Current evidence suggests that state-of-the-art helical abdominal CT will miss small hepatic or peritoneal metastases in fewer than 20% of patients with clinically resectable tumors. 9q ~ Performing a staging laparoscopy adds unnecessary operating time and expense for the remaining 80% of patients with lesions that are either resectable or, if locally irresectable, best palliated surgically. For patients with clinically resectable proximal pancreatic lesions who, for various reasons, have already had an endobiliary stent placed, or for any patient in whom a palliative procedure is not required (eg, proximal lesions without obstructive jaundice or duodenal obstruction, body or tail lesion), limited preliminary laparoscopy under the same anesthetic is an integral component of the procedure.
33
Pylorus-Preserving Pancreatoduodenectomy
SURGICAL TECHNIQUE
@ MAYO
1 Adequate exposure is mandatory for a safe pylorus-preserving pancreatoduodenectomy. Ideally, the patient is positioned supine on the operating table with both arms tucked at the side to allow unrestricted surgical access. I prefer to make a bilateral subcostal incision, except in those few patients who have a particularly verticallyoriented costal arch, for whom I prefer a midline incision. A fixed-abdominal retractor is placed to allow secure retraction of both costal margins in a cephalad direction. The inferior flap of the bilateral subcostal incision is secured to the anterior abdominal wall with a heavy silk suture. A thorough abdominal exploration assesses for the presence of peritoneal or hepatic metastases, with particular attention directed to the pelvis for drop metastases. Adhesions to the undersurface of the right lobe of the liver are lysed to prevent traction-related capsular tears of the liver.
34
Michael B. Farnell
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2 The hepatic flexure of the colon is released inferiorly, and a Kocher maneuver is performed to elevate the duodenum and the head of the pancreas. The dissection is carried cephalad above the retrocholedochal lymph node, inferiorly to the transverse duodenum and medially to the aorta. The posterior aspect of the tumor is palpated and its relationship to the SMA ascertained. Pliable tissue posterior to the SMA indicates that the vessel is not encased. (IVC, inferior vena cava.)
Pylorus-Preserving Pancreatoduodenectomy
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The omentum is freed from the transverse colon in an avascular manner. The omental dissection is carried from left to right, completely separating the omentum from the right transverse mesocolon. The lesser sac is entered, and the entire anterior aspect of the head, neck and proximal pancreas is exposed.
35
36
Michael B. Farnell
colic
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Assessing local resectability. (A) After the right half of the omentum is mobilized and the proximal pancreas exposed, the middle colic vein is identified and, in an avascular manner, is followed down to its junction with the SMV. The transverse mesocolon is then further dissected from its enfolding over the uncinate process of the pancreas, thereby exposing the SMV. Overlying investing tissue is incised, exposing the lateral aspect of the SMV. The right lateral superior mesenteric vein is followed in a cephalad direction to the gastrocolic venous trunk. The gastrocolic venous trunk is dissected very carefully, as vigorous dissection or overretraction will cause copious venous bleeding. The gastrocolic trunk is ligated in continuity with fine suture and divided. (B) With a blunt clamp alter+ nately advancing and spreading, a plane is then developed between the neck of the pancreas anteriorly and the SMV-PV confluence posteriorly. Note that the ability to accomplish this maneuver does not necessarily rule out the involvement of the SMV-PV confluence either laterally or posteriorly.
37
Pylorus-Preserving Pancreatoduodenectomy
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5 Attention is then directed beneath the left lobe of the liver and the gastrohepatic omentum incised in an avascular manner carefully protecting the nerves of Latarjet. (A) The tissues anterior to the hepatoduodenal ligament are carefully incised and the right gastric artery clamped, divided and ligated. (B) The gastroduodenal artery is then identified and doubly ligated in continuity, with one of the ligations transfixing and divided. (C) The common hepatic artery is identified, protected, and retracted cephalad. A plane is sought between the superior border of the pancreas inferiorly and the common hepatic artery superiorly, and the PV is identified. This maneuver allows passage of a blunt clamp between the SMV-PV confluence posteriorly and the neck of the pancreas anteriorly. (D) The neck of the pancreas is then surrounded with a tape, and the gallbladder is mobilized from its bed from above downward. The cystic artery is clamped, divided, and ligated. If the gallbladder is markedly distended due to biliary obstruction, then it may be removed at this stage. The common bile duct is palpated posteriorly to determine the presence of an accessory or replaced right hepatic artery arising from the SMA. It is usually sought posterior and lateral to the common bile duct and should be protected. The bile duct is then mobilized by developing a plane between the PV and the common hepatic duct. The common hepatic duct is surrounded with a tape.
38
Michael B. Farnell
Retroduodenala~eries
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6 Duodenal skeletonization. (A) The right gastroepiploic artery and vein are clamped, divided, and ligated, thereby freeing the inferior aspect of the duodenum. (B) Next, the stomach is retracted directly anteriorly, placing the duodenum on traction, and the retroduodenal arteries are clamped, divided, and ligated with fine sutures, skeletonizing the duodenum for approximately three centimeters beyond the pylorus.
39
Pylorus-Preserving Pancreatoduodenectomy
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7 Attention is then directed beneath the transverse mesocolon. The transverse colon is retracted cephalad, and the small bowel is packed outside of the abdomen with rightward traction of the duodenojejunal junction. (A) The ligament of Treitz is mobilized, and the tissues to the right o[ the inferior mesenteric vein are incised, thereby communicating the inframesocolic dissection with the previously performed Kocher maneuver. (B) The bowel is then transilluminated approximately 20 cm beyond the ligament of Treitz, and a mesenteric window is fashioned. (C) The bowel is stapled and transected. This is an important step, as choosing a point of division that will allow adequate mobility of the jejunal limb is useful in allowing the limb to be brought through the transverse mesocolon to the right of the middle colic vessels in preparation for both the pancreatic and biliary anastomoses at a later stage of the operation. The proximal jejunal branches are then serially clamped, divided, and ligated proximally to the fourth portion of the duodenum. (D) With anterior and lateral traction on the duodenum, the dissection is carried to a point at which the uncinate process becomes visible. This mobilized proximal jejunum (as part of the eventual en bloc specimen) is then passed beneath the SMA into the supramesocolic compartment. The opening at the ligament of Treitz is then closed with running suture. The duodenum is transected with a stapling device approximately three centimeters beyond the pylorus.
40
Michael B. Famell
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C 8 Division of the pancreas. (A) Hemostatic sutures are placed on both sides of the line of planned division of the pancreas on the inferior and superior borders to control branches of the dorsal pancreatic artery. A right angle clamp is then placed behind the neck of the pancreas and slightly elevated. The pancreatic neck is divided with cautery. The consistency of the pancreas and the size of the pancreatic duct is noted, and a specimen from the neck of the pancreas is removed and submitted as margin. Bleeding from the transected pancreas is controlled with cautery or suture ligatures as necessary. A bulldog clamp is placed on the common hepatic duct, and the common hepatic duct or common bite duct is transected sharply remote from the tumor. A specimen is submitted from the transected duct as margin. (B) A plane is then developed between the SMV-PV confluence and the groove in the pancreas just to the right of the vein. Venous structures coursing from both the portal and superior mesenteric veins into the pancreas are carefully ligated in continuity and divided. (C) Vein retractors are then applied to the SMV-PV confluence, and the PV is retracted to the patient's left. A large venous trunk is typically encountered on the posterior aspect of the SMV, the anterior inferior pancreatoduodenal vein, and this is carefully ligated in continuity and divided. This allows retraction of the SMV-PV confluence to the left and anteriorly and affords access to the anterior aspect of the SMA. The adventitia of the SMA is incised carefully, exposing the SMA. (D) Dissection is then carried posteriorly along the right side of the SMA, thereby controlling the branches coursing from the SMA into the uncinate process of the pancreas. It should be noted that the arterial branches originating from the posterolateral aspect of the SMA are very friable, easily avulsed and may cause troublesome hemorrhage (inset). They are carefully clamped, divided, and suture ligated with fine vascular suture. The specimen, consisting of most of the duodenum, the head and uncinate process of the pancreas, a portion of bile duct, and a portion of jejunum is removed from the abdomen, and a specimen is harvested from the uncinate process as a margin.
41
Pylorus-Preserving Pancreatoduodenectomy
C
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9 The reconstruction. An opening is made in the mesocolon to the right of the middle colic vessels. The jejunum passed through this opening, and preparations are made for the end-to-side pancreaticojejunostomy. Magnification (X 2.5) is used. The anastomosis is facilitated by mobilizing the stump of the pancreas posteriorly to allow elevation of the stump anteriorly. (A) With interrupted 3-0 or 4-0 nonabsorbable suture, the capsule and parenchyma of the pancreas are sutured to the seromuscular layer of the jejunum in a transverse manner. A small opening is made with an insulated point cautery full thickness in the jejunum adjacent to the pancreatic duct. A Silastic catheter of a diameter somewhat smaller than the pancreatic duct is placed in the opening in the jejunum to direct suture placement, helping to ensure that all layers of the jejunal wall are incorporated. The anastomosis is done with interrupted 6-0 absorbable sutures in a mucosa-to-mucosa fashion, with the posterior row completed first and tied. (B) The Silastic catheter is then advanced into the pancreatic duct to facilitate placing the anterior row of sutures, and to prevent inadvertent suturing of anterior and posterior walls of the anastomosis. The sutures are placed outside-in on the jejunum and inside-out on the pancreatic duct, then tied. The Silastic stent is allowed to float freely and eventually is passed unnoticed in the stool. (C) The anterior row of the anastomosis (interrupted 3 = 0 or 4 = 0 nonabsorbable suture) is completed.
42
Michael B. Farnell
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9 (continued) (D) Approximately eight to ten centimeters distal to the pancreatojejunostomy, an end-to-side biliary enteric anastomosis is performed. For a small, thin-walled duct, a single layer of absorbable interrupted suture is used, whereas for those dilated ducts that are quite thick-walled, a continuous inner absorbable and interrupted outer nonabsorbable layer are chosen. The jejunum is secured to the mesocolon with interrupted silk suture. (E) Finally, an antecolic, end-to-side duodenojejunostomy is fashioned with an inner layer of running 3-0 absorbable suture and an outer layer of interrupted 3-0 nonabsorbable suture. The anastomosis is performed at a distance from the pylorus that ensures adequate blood supply. Two drains are placed in the peritoneal cavity, one in Morison's pouch and another beneath the left lobe of the liver brought through stab wounds below the incision. Nasogastric tube placement within the stomach is verified, and the wound is closed in layers.
Pylorus-Preserving Pancreatoduodenectomy
43
10 A 58-year-old brick mason presented with painless obstructive jaundice. Nine years before his referral, he had undergone a transduodenal excision of a 5 • 4 • 3-cm tubulovillons adenoma of the ampulla of Vater with mild to severe dysplasia. In subsequent years, recurrent tubulovillous adenoma was managed by endoscopic ablation. He subsequently developed obstructive jaundice, and further investigations were undertaken. ERCP (A) showed marked dilation of the biliary tree and a polypoid mass extending three centimeters up the terminal bile duct (arrow). Endoscopic biopsy confirmed the presence of invasive adenocarcinoma. A biliary stent was placed and an abdominal CT obtained (B). The abdominal CT with oral and IV contrast showed a dilated bile duct with an indwelling biliary stent (left arrow), a dilated pancreatic duct (middle arrow), and a preserved fat plane around the SMA and SMV (right arrow). The patient underwent pylorus-preserving pancreatoduodenectomy as described herein. He was found to have a 2.3 • 2 • 0.6-cm invasive adenocarcinoma invading into, but not through the muscularis propria. Lymph nodes were negative. His postoperative course was uneventful.
Postoperative Care Although venting tubes were formerly used in the jejunal limb or traversing the hepaticojejunostomy, analysis of our experience led to the conclusion that these venting tubes are of no benefit. 12 We place gastrostomy tubes or feeding jejunostomy tubes very selectively, as most patients can quickly resume oral intake. Admission to the intensive care unit is not routine, as most patients can be managed on a standard general surgical care unit. Postoperative care includes IV fluids to maintain adequate hydration, peptic ulcer prophylaxis, and perioperative antibiotic prophylaxis (less than 24 hr).
The nasogastric tube is removed within 12 to 24 hours, and ambulation begins on the day after the operation. Oral intake is resumed on the return of bowel function and appetite. The surgical drains are typically removed six to seven days after the operation, unless the character of the drainage suggests leakage. In those instances, when a very high volume of serous drain output is present, if there is truly no clinical evidence of leakage or elevated amylase level in the drainage fluid, the drains are similarly removed. Those patients who have difficulty resuming oral intake and need a nasogastric tube for delayed gastric emptying should be carefully assessed for occult anastomotic leakage. Abdominal pain, fever, or leukocytosis should
44
Michael B. Farnell
prompt an abdominal CT, even if the deep drainage appears harmless. Prokinetic agents are used selectively in those patients with delayed gastric emptying in whom an occult leak has been excluded. Prophylactic therapy with octreotide is not routine. The serum glucose level is carefully monitored postoperatively as patients may require insulin supplementation. Postoperative complications, observed in up to 46% of patients, include urinary tract (2%), pulmonary (7%) or incisional infections (7%), bleeding (8%), abscess (10%), anastomotic leakage (17% pancreatic, 9% biliary), and pancreatitis. 6'7 Although the morbidity following pancreatoduodenectomy is significant, the average length of hospitalization is approximately 10 days for patients without a major complication. Outcomes The outcome of pylorus-preserving pancreatoduodenectomy is more a function of the presence of recurrent disease than of physiologic abnormalities inherent to the procedure. Investigation suggests that patients' quality of life after a pancreatoduodenectomy procedure is similar to that after cholecystectomy. 13 Patients should be followed carefully both for disease recurrence and for late complications such as diabetes, steatorrhea, cholangitis, or stomal ulcer) 4 The pancreaticojejunal anastomosis may stricture over time and result in delayed onset of glucose intolerance or steatorrhea. Insulin and/or enzyme therapy may be indicated. Long-term survival after pancreatoduodenectomy is a function of the tumor type and stage at the time of resection. The five-year survival after pancreatoduodenectomy for pancreatic and periampullary adenocarcinomas at Mayo Clinic is shown in Table 1.
Table 1. Outcome Following Pancreatoduodenectomy for Pancreatic and Periampullary Malignancy at the Mayo Clinic Tumor Type
Number of Patients
Operative Mortality
Five-Year Survival
Pancreas 7 Bile duct is Ampulla16 Duodenum ~7
186 22 104 50
3% 5% 6% 1%
7% 43% 34% 54%
NOTE. Not all patients in each group had pylorus-preserving pancreatoduodenectomy.
REFERENCES 1. Traverso LW, Longmire WP Jr: Preservation of the pylorus in pancreatoduodenectomy. SG&O 146:959-962, 1978 2. Jones LC, Russell C, Mosca F, et al: Standard Kausch-Whipple pancreatoduodenectomy (Review) Digestive Surg 16:297-304, 1999 3. Yeo CJ, CameronJL, Sohn TA, et al: Six hundred fifty consecutive pancreatoduodenectomies in the 1990s: Pathology, complications, and outcomes. Ann Surg 226:248-260, 1997 4. Horstmann O, Becket H, Post S, et al: Is delayed gastric emptying following pancreaticoduodeuectomy related to pylorus preservation? Langenbecks Arch Surg 384:354-359, 1999 5. Sakorafas GH, Sarr MG, Rowland CM, et al: Post-obstructive chronic pancreatitis: Results with distal resection. Presented at the 108th Annual Scientific Session of the Western Surgical Association, Dana Point, CA November 12-15, 2000 6. Miedema BW, Sarr MG, van Heerden JA, et al: Complications following pancreaticoduodenectomy: Current management. Arch Surg 127:945-950, 1992 7. Nitecki SS, Sarr MG, Colby TV, et al: Long-term survival after resection for ductal adenocarcinoma of the pancreas. Is it really improving? Ann Surg 221:59-66, 1995 8. Povoski SP, Karpeh MS Jr, Conlon KC, et al: Preoperative biliary drainage: Impact on intraoperative bile cultures and infectious morbidity and mortality after pancreaticoduodenectomy. J Gastrointestinal Surg 3:496-505, 1999 9. Freiss H, Uhl W, SilvaJC, et al: Preoperative laparoscopy: Do we need it in patients with pancreatic malignancies: AmJ Surg 175: 172-178, 1998 10. Holzman MD, Reintgen KL, Tyler DS, et al: The role of laparoscopy in the management of suspected pancreatic and periampullary malignancies. J Gastrointest Surg 1:236-244, 1997 11. Rumstadt B, Schwab M, Schuster K, et al: The role of laparoscopy in the preoperative staging of pancreatic carcinoma. J Gastrointest Surg 1:245-250, 1997 12. Fallick JS, Farley DR, Farnell MB, et al: Venting intraluminal drains in pancreaticoduodenectomy. J Gastrointest Surg 3:156161, 1999 13. McLeod RS: Quality of life, nutritional status and gastrointestinal hormone profile following Whipple procedure. Ann Oncol 4 (suppl):S281-284, 1999 14. Yamaguchi K, Tanaka M, Chijiiwa K, et al: Early and late complications of pancreaticoduodenectomy in Japan 1998. J Hepatobiliary Pancreat Surg 6:303-311, 1999 15. Nagorney DM, Donohue JH, Farnell MB, et al: Outcomes after curative resections of cholangiocarcinoma. Arch Surg 128:871879, 1993 16. Monson JR, Donohue JH, McEntee G, et al: Radical resection for carcinoma of the ampulla of Vater. Arch Surg 126:353-357, 1991 17. Bakaeen FG, Murr M, Sarr MG, et al: What prognostic factors are important in duodenal adenocarcinoma? Arch Surg 135:635-642, 2000