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Standard Pancreatoduodenectomy for Resectable Pancreatic Cancer

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Textbook of Pancreatic Cancer

Abstract

Pancreatoduodenectomy offers at present the only chance for a cure for cancer of the pancreatic head. A meticulous surgical technique, proper patient selection, an all-inclusive perioperative care and multimodal treatment approaches are essential to achieving the best possible clinical and oncologic outcomes. Open pancreatoduodenectomy is the standard surgical procedure for pancreatic head carcinoma, which can be broken down into several steps, with the three major phases exploratory, resection and the reconstruction phase. Despite numerous trials that compared diverse steps of pancreatoduodenectomy, no specific technique can reproducibly lower the relatively high morbidity and mortality rates of this complex procedure. In particular, the prevention of a clinically relevant postoperative pancreatic fistula, the most troublesome complication after pancreatoduodenectomy, remains a challenge to date. This chapter will focus on the open technique of pancreatoduodenectomy and describe the essential steps as well as variations for performing a safe resection of a cancer of the pancreatic head. Relevant references will give direction to further details, to help guide the reader through the extensive literature on this topic.

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References

  1. Ryan DP, Hong TS, Bardeesy N. Pancreatic adenocarcinoma. N Engl J Med. 2014;371(22):2140–1.

    PubMed  Google Scholar 

  2. Lennon AM, Wolfgang CL, Canto MI, Klein AP, Herman JM, Goggins M, et al. The early detection of pancreatic cancer: what will it take to diagnose and treat curable pancreatic neoplasia? Cancer Res. 2014;74(13):3381–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2018. CA Cancer J Clin. 2018;68(1):7–30.

    Article  PubMed  Google Scholar 

  4. Dimitrakopoulos C, Vrugt B, Flury R, Schraml P, Knippschild U, Wild P, et al. Identification and validation of a biomarker signature in patients with resectable pancreatic cancer via genome-wide screening for functional genetic variants. JAMA Surg. 2019;154(6):e190484.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Heestand GM, Murphy JD, Lowy AM. Approach to patients with pancreatic cancer without detectable metastases. J Clin Oncol. 2015;33(16):1770–8.

    Article  PubMed  Google Scholar 

  6. Kausch W. Das Carcinom der Papilla duodeni und seine radikaleEntfernung. In: Von Schmiedebach H-P, Winau R, Häring R, editors. Erste Operationen Berliner Chirurgen 1817–1931. Berlin: De Gruyter; 2015. p. 40–51.

    Google Scholar 

  7. Tenani O. Contributo alla chirurgia della papilla del Vater. Policlinico. 1922;29:291–333.

    Google Scholar 

  8. Whipple AO. The rationale of radical surgery for cancer of the pancreas and ampullary region. Ann Surg. 1941;114(4):612–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Cameron JL, He J. Two thousand consecutive pancreaticoduodenectomies. J Am Coll Surg. 2015;220(4):530–6.

    Article  PubMed  Google Scholar 

  10. He J, Ahuja N, Makary MA, Cameron JL, Eckhauser FE, Choti MA, et al. 2564 resected periampullary adenocarcinomas at a single institution: trends over three decades. HPB (Oxford). 2014;16(1):83–90.

    Article  Google Scholar 

  11. Tempero MA, Malafa MP, Al-Hawary M, Asbun H, Bain A, Behrman SW, et al. Pancreatic adenocarcinoma, version 2.2017, NCCN clinical practice guidelines in oncology. J Natl Compr Cancer Netw. 2017;15(8):1028–61.

    Article  Google Scholar 

  12. Povoski SP, Karpeh MS, Conlon KC, Blumgart LH, Brennan MF. Association of preoperative biliary drainage with postoperative outcome following pancreaticoduodenectomy. Ann Surg. 1999;230(2):131–42.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Gianotti L, Besselink MG, Sandini M, Hackert T, Conlon K, Gerritsen A, et al. Nutritional support and therapy in pancreatic surgery: a position paper of the International Study Group on Pancreatic Surgery (ISGPS). Surgery. 2018;164(5):1035–48.

    Article  PubMed  Google Scholar 

  14. Munting KE, Klein AA. Optimisation of pre-operative anaemia in patients before elective major surgery – why, who, when and how? Anaesthesia. 2019;74(Suppl 1):49–57.

    Article  CAS  PubMed  Google Scholar 

  15. Safety WAfP. WHO surgical safety checklist and implementation manual. Geneva: WHO; 2008. https://www.who.int/patientsafety/safesurgery/ss_checklist/en/.

    Google Scholar 

  16. Ironside N, Barreto SG, Loveday B, Shrikhande SV, Windsor JA, Pandanaboyana S. Meta-analysis of an artery-first approach versus standard pancreatoduodenectomy on perioperative outcomes and survival. Br J Surg. 2018;105(6):628–36.

    Article  CAS  PubMed  Google Scholar 

  17. Sanjay P, Takaori K, Govil S, Shrikhande SV, Windsor JA. ‘Artery-first’ approaches to pancreatoduodenectomy. Br J Surg. 2012;99(8):1027–35.

    Article  CAS  PubMed  Google Scholar 

  18. Puppala S, Patel J, McPherson S, Nicholson A, Kessel D. Hemorrhagic complications after Whipple surgery: imaging and radiologic intervention. AJR Am J Roentgenol. 2011;196(1):192–7.

    Article  PubMed  Google Scholar 

  19. Tol JA, Gouma DJ, Bassi C, Dervenis C, Montorsi M, Adham M, et al. Definition of a standard lymphadenectomy in surgery for pancreatic ductal adenocarcinoma: a consensus statement by the International Study Group on Pancreatic Surgery (ISGPS). Surgery. 2014;156(3):591–600.

    Article  PubMed  Google Scholar 

  20. Yamaue H, Tani M, Kawai M, Hirono S, Okada K, Miyazawa M. Pancreatic dissection in the procedure of pancreaticoduodenectomy (with videos). J Hepatobiliary Pancreat Sci. 2012;19(2):95–9.

    Article  PubMed  Google Scholar 

  21. Takahashi S, Gotohda N, Kato Y, Konishi M. Measure of pancreas transection and postoperative pancreatic fistula. J Surg Res. 2016;202(2):276–83.

    Article  PubMed  Google Scholar 

  22. Okabayashi T, Hanazaki K, Nishimori I, Sugimoto T, Yoshioka R, Dabanaka K, et al. Pancreatic transection using a sharp hook-shaped ultrasonically activated scalpel. Langenbeck's Arch Surg. 2008;393(6):1005–8.

    Article  Google Scholar 

  23. Sugiyama M, Abe N, Izumisato Y, Tokuhara M, Masaki T, Mori T, et al. Pancreatic transection using ultrasonic dissector in pancreatoduodenectomy. Am J Surg. 2001;182(3):257–9.

    Article  CAS  PubMed  Google Scholar 

  24. Koga R, Yamamoto J, Saiura A, Natori T, Katori M, Kokudo N, et al. Clamp-crushing pancreas transection in pancreatoduodenectomy. Hepato-Gastroenterology. 2009;56(89):89–93.

    PubMed  Google Scholar 

  25. Peparini N, Chirletti P. Mesopancreas: a boundless structure, namely R1 risk in pancreaticoduodenectomy for pancreatic head carcinoma. Eur J Surg Oncol. 2013;39(12):1303–8.

    Article  CAS  PubMed  Google Scholar 

  26. Agrawal MK, Thakur DS, Somashekar U, Chandrakar SK, Sharma D. Mesopancreas: myth or reality? JOP. 2010;11(3):230–3.

    PubMed  Google Scholar 

  27. Peparini N. Mesopancreas: a boundless structure, namely the rationale for dissection of the paraaortic area in pancreaticoduodenectomy for pancreatic head carcinoma. World J Gastroenterol. 2015;21(10):2865–70.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Esposito I, Kleeff J, Bergmann F, Reiser C, Herpel E, Friess H, et al. Most pancreatic cancer resections are R1 resections. Ann Surg Oncol. 2008;15(6):1651–60.

    Article  PubMed  Google Scholar 

  29. Japan Pancreas Society. Classification of pancreatic carcinoma. 2nd English ed. Tokyo: Kanehara & Co. Ltd; 2003.

    Google Scholar 

  30. Yeo CJ, Cameron JL, Lillemoe KD, Sohn TA, Campbell KA, Sauter PK, et al. Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma, part 2: randomized controlled trial evaluating survival, morbidity, and mortality. Ann Surg. 2002;236(3):355–66. discussion 66–8

    Article  PubMed  PubMed Central  Google Scholar 

  31. Riall TS, Cameron JL, Lillemoe KD, Campbell KA, Sauter PK, Coleman J, et al. Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma—part 3: update on 5-year survival. J Gastrointest Surg. 2005;9(9):1191–204; discussion 204–6.

    Article  PubMed  Google Scholar 

  32. Farnell MB, Pearson RK, Sarr MG, DiMagno EP, Burgart LJ, Dahl TR, et al. A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma. Surgery. 2005;138(4):618–28; discussion 28–30.

    Article  PubMed  Google Scholar 

  33. Nimura Y, Nagino M, Takao S, Takada T, Miyazaki K, Kawarada Y, et al. Standard versus extended lymphadenectomy in radical pancreatoduodenectomy for ductal adenocarcinoma of the head of the pancreas: long-term results of a Japanese multicenter randomized controlled trial. J Hepatobiliary Pancreat Sci. 2012;19(3):230–41.

    Article  PubMed  Google Scholar 

  34. Shrikhande SV, Sivasanker M, Vollmer CM, Friess H, Besselink MG, Fingerhut A, et al. Pancreatic anastomosis after pancreatoduodenectomy: a position statement by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2017;161(5):1221–34.

    Article  PubMed  Google Scholar 

  35. Daamen LA, Smits FJ, Besselink MG, Busch OR, Borel Rinkes IH, van Santvoort HC, et al. A web-based overview, systematic review and meta-analysis of pancreatic anastomosis techniques following pancreatoduodenectomy. HPB (Oxford). 2018;20(9):777–85.

    Article  Google Scholar 

  36. Hua J, He Z, Qian D, Meng H, Zhou B, Song Z. Duct-to-mucosa versus invagination pancreaticojejunostomy following pancreaticoduodenectomy: a systematic review and meta-analysis. J Gastrointest Surg. 2015;19(10):1900–9.

    Article  PubMed  Google Scholar 

  37. Lyu Y, Li T, Cheng Y, Wang B, Chen L, Zhao S. Pancreaticojejunostomy versus pancreaticogastrostomy after pancreaticoduodenectomy: an up-to-date meta-analysis of RCTs applying the ISGPS (2016) criteria. Surg Laparosc Endosc Percutan Tech. 2018;28(3):139–46.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Wang W, Zhang Z, Gu C, Liu Q, Liang Z, He W, et al. The optimal choice for pancreatic anastomosis after pancreaticoduodenectomy: a network meta-analysis of randomized control trials. Int J Surg. 2018;57:111–6.

    Article  PubMed  Google Scholar 

  39. Crippa S, Cirocchi R, Randolph J, Partelli S, Belfiori G, Piccioli A, et al. Pancreaticojejunostomy is comparable to pancreaticogastrostomy after pancreaticoduodenectomy: an updated meta-analysis of randomized controlled trials. Langenbeck’s Arch Surg. 2016;401(4):427–37.

    Article  Google Scholar 

  40. Hüttner FJ, Fitzmaurice C, Schwarzer G, Seiler CM, Antes G, Büchler MW, et al. Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev. 2016;2:CD006053.

    PubMed  Google Scholar 

  41. Karanicolas PJ, Davies E, Kunz R, Briel M, Koka HP, Payne DM, et al. The pylorus: take it or leave it? Systematic review and meta-analysis of pylorus-preserving versus standard whipple pancreaticoduodenectomy for pancreatic or periampullary cancer. Ann Surg Oncol. 2007;14(6):1825–34.

    Article  PubMed  Google Scholar 

  42. Wu W, Hong X, Fu L, Liu S, You L, Zhou L, et al. The effect of pylorus removal on delayed gastric emptying after pancreaticoduodenectomy: a meta-analysis of 2,599 patients. PLoS One. 2014;9(10):e108380.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Tamandl D, Sahora K, Prucker J, Schmid R, Holst JJ, Miholic J, et al. Impact of the reconstruction method on delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy: a prospective randomized study. World J Surg. 2014;38(2):465–75.

    Article  PubMed  Google Scholar 

  44. Bell R, Pandanaboyana S, Shah N, Bartlett A, Windsor JA, Smith AM. Meta-analysis of antecolic versus retrocolic gastric reconstruction after a pylorus-preserving pancreatoduodenectomy. HPB (Oxford). 2015;17(3):202–8.

    Article  Google Scholar 

  45. Eshuis WJ, van Eijck CH, Gerhards MF, Coene PP, de Hingh IH, Karsten TM, et al. Antecolic versus retrocolic route of the gastroenteric anastomosis after pancreatoduodenectomy: a randomized controlled trial. Ann Surg. 2014;259(1):45–51.

    Article  PubMed  Google Scholar 

  46. Gangavatiker R, Pal S, Javed A, Dash NR, Sahni P, Chattopadhyay TK. Effect of antecolic or retrocolic reconstruction of the gastro/duodenojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: a randomized controlled trial. J Gastrointest Surg. 2011;15(5):843–52.

    Article  PubMed  Google Scholar 

  47. Joliat GR, Labgaa I, Demartines N, Schäfer M, Allemann P. Effect of antecolic versus retrocolic gastroenteric reconstruction after pancreaticoduodenectomy on delayed gastric emptying: a meta-analysis of six randomized controlled trials. Dig Surg. 2016;33(1):15–25.

    Article  PubMed  Google Scholar 

  48. Van Buren G, Bloomston M, Hughes SJ, Winter J, Behrman SW, Zyromski NJ, et al. A randomized prospective multicenter trial of pancreaticoduodenectomy with and without routine intraperitoneal drainage. Ann Surg. 2014;259(4):605–12.

    Article  PubMed  Google Scholar 

  49. Villafane-Ferriol N, Shah RM, Mohammed S, Van Buren G, Barakat O, Massarweh NN, et al. Evidence-based management of drains following pancreatic resection: a systematic review. Pancreas. 2018;47(1):12–7.

    Article  PubMed  Google Scholar 

  50. Bassi C, Molinari E, Malleo G, Crippa S, Butturini G, Salvia R, et al. Early versus late drain removal after standard pancreatic resections: results of a prospective randomized trial. Ann Surg. 2010;252(2):207–14.

    Article  PubMed  Google Scholar 

  51. Ven Fong Z, Correa-Gallego C, Ferrone CR, Veillette GR, Warshaw AL, Lillemoe KD, et al. Early drain removal—the middle ground between the drain versus no drain debate in patients undergoing pancreaticoduodenectomy: a prospective validation study. Ann Surg. 2015;262(2):378–83.

    Article  PubMed  Google Scholar 

  52. Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg. 1995;221(5):469–76; discussion 76–8

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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Correspondence to Stefan Breitenstein .

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Grochola, L.F., Seeger, N., Stättner, S., Søreide, K., Breitenstein, S. (2021). Standard Pancreatoduodenectomy for Resectable Pancreatic Cancer. In: Søreide, K., Stättner, S. (eds) Textbook of Pancreatic Cancer. Springer, Cham. https://doi.org/10.1007/978-3-030-53786-9_53

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  • DOI: https://doi.org/10.1007/978-3-030-53786-9_53

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