Pancreaticoduodenectomy (PD) is the only treatment option that potentially provides a cure for pancreatic head cancer. Various arrangements and modifications have been proposed to achieve pathological margin negative (R0) resection safely. In this article, we introduce a standard procedure for PD, including pancreaticogastrostomy with invagination and mattress sutures (video clip provided), for invasive ductal carcinoma of the pancreatic head, with a description of the need-to-know pitfalls for Board-certified HBP surgeons in Japan. The important points in performing PD for pancreatic cancer are: (1) While dissecting connective tissue and nerve plexus as well as lymph nodes, maintain a dissection plane to expose the surfaces of vessels or other organs to be preserved to achieve R0 resection: i.e., while dissecting the anterior surface of the inferior vena cava and the right side of the superior mesenteric artery, these vessels should be completely exposed with the connective tissue and nerve plexuses being attached to the resection side. (2) There should be early interruption of the afferent blood supply via the inferior pancreaticoduodenal artery to reduce blood loss by avoiding congestion of the pancreatic head and to increase the operative safety (video clip provided). (3) Eligibility for PD should be carefully evaluated because there are many “resectable” but not many “curable” cases. In addition, the clinical significance of various modifications of the surgical techniques used for PD are also discussed.
This is a preview of subscription content, access via your institution.
Japan Pancreatic Society: Pancreatic Cancer Medical Guideline 2009 edition. Kanehara-Syuppan, Tokyo, 2009 (in Japanese).
National Comprehensive Cancer Network. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp
Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, eds. AJCC Cancer Staging Manual. 7th ed. Chicago, IL: American Joint Committee on Cancer; 2010.
Ohigashi H, Ishikawa O, Eguchi H, Sasaki Y, Yamada T, Kishi K, et al. A simple and safe anastomosis in pancreaticogastrostomy using mattress sutures. Am J Surg. 2008;196(1):130–4.
Abe N, Sugiyama M, Suzuki Y, Yanagida O, Masaki T, Mori T, et al. Falciform ligament in pancreatoduodenectomy for protection of skeletonized and divided vessels. J Hepatobiliary Pancreat Surg. 2009;16(2):184–8.
Iannitti DA, Coburn NG, Somberg J, Ryder BA, Monchik J, Cioffi WG. Use of the round ligament of the liver to decrease pancreatic fistulas: a novel technique. J Am Coll Surg. 2006;203(6):857–64.
Kapoor VK, Sharma A, Behari A, Singh RK. Omental flaps in pancreaticoduodenectomy. JOP. 2006;7(6):608–15.
Maeda A, Ebata T, Kanemoto H, Matsunaga K, Bando E, Yamaguchi S, et al. Omental flap in pancreaticoduodenectomy for protection of splanchnic vessels. World J Surg. 2005;29(9):1122–6.
Walters DM, Stokes JB, Adams RB, Bauer TW. Use of a falciform ligament pedicle flap to decrease pancreatic fistula after distal pancreatectomy. Pancreas. 2011;40(4):595–9.
Ohigashi H, Ishikawa O, Eguchi H, Yamada T, Sasaki Y, Noura S, et al. Early ligation of the inferior pancreaticoduodenal artery to reduce blood loss during pancreaticoduodenectomy. Hepatogastroenterology. 2004;51(55):4–5.
Horiguchi A, Ishihara S, Ito M, Nagata H, Shimizu T, Furusawa K, et al. Pancreatoduodenectomy in which dissection of the efferent arteries of the head of the pancreas is performed first. J Hepatobiliary Pancreat Surg. 2007;14(6):575–8.
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 628–630.
Michalski CW, Kleeff J, Wente MN, Diener MK, Buchler MW, Friess H. Systematic review and meta-analysis of standard and extended lymphadenectomy in pancreaticoduodenectomy for pancreatic cancer. Br J Surg. 2007;94(3):265–73.
Pedrazzoli S, DiCarlo V, Dionigi R, Mosca F, Pederzoli P, Pasquali C, et al. Standard versus extended lymphadenectomy associated with pancreatoduodenectomy in the surgical treatment of adenocarcinoma of the head of the pancreas: a multicenter, prospective, randomized study. Lymphadenectomy Study Group. Ann Surg. 1998;228(4):508–17.
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 358–366.
Yeo CJ, Cameron JL, Sohn TA, Coleman J, Sauter PK, Hruban RH, et al. Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma: comparison of morbidity and mortality and short-term outcome. Ann Surg. 1999;229(5):613–22. discussion 614–622.
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 1196–1204.
Pisters PW, Brennan MF. Regional lymph node dissection for pancreatic adenocarcinoma. In: M.D. Anderson Solid Tumor Oncology Series, ed., by Evans DB, Pisters PWT, AbbruzzeseJL, Springer-Verlag. New York, 2001, p139–151.
Diener MK, Knaebel HP, Heukaufer C, Antes G, Buchler MW, Seiler CM. A systematic review and meta-analysis of pylorus-preserving versus classical pancreaticoduodenectomy for surgical treatment of periampullary and pancreatic carcinoma. Ann Surg. 2007;245(2):187–200.
Iqbal N, Lovegrove RE, Tilney HS, Abraham AT, Bhattacharya S, Tekkis PP, et al. A comparison of pancreaticoduodenectomy with pylorus preserving pancreaticoduodenectomy: a meta-analysis of 2822 patients. Eur J Surg Oncol. 2008;34(11):1237–45.
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.
Lin PW, Lin YJ. Prospective randomized comparison between pylorus-preserving and standard pancreaticoduodenectomy. Br J Surg. 1999;86(5):603–7.
Seiler CA, Wagner M, Bachmann T, Redaelli CA, Schmied B, Uhl W, et al. Randomized clinical trial of pylorus-preserving duodenopancreatectomy versus classical Whipple resection – long term results. Br J Surg. 2005;92(5):547–56.
Tran KT, Smeenk HG, van Eijck CH, Kazemier G, Hop WC, Greve JW, et al. Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors. Ann Surg. 2004;240(5):738–45.
Ohigashi H, Ishikawa O, Yamada T, et al. An evaluation of extended pancreatectomy with resecting pylorus alone for advanced adenocarcinoma of the pancreas. Jpn J Gastroenterol Surg. 1999;32:2432–6. (in Japanese with English abstract).
Kawai M, Tani M, Hirono S, Miyazawa M, Shimizu A, Uchiyama K, et al. Pylorus ring resection reduces delayed gastric emptying in patients undergoing pancreatoduodenectomy: a prospective, randomized, controlled trial of pylorus-resecting versus pylorus-preserving pancreatoduodenectomy. Ann Surg. 2011;253(3):495–501.
This work was partly supported by a grant from the Princess Takamatsu Cancer Research Fund and a grant from the Otsuka Research Fund.
Conflict of Interest
The authors declare that they have no conflicts of interest.
This article is based on studies first reported in Highly Advanced Surgery for Hepato-Biliary-Pancreatic Field (in Japanese). Tokyo: Igaku-Shoin, 2010.
Electronic supplementary material
Below is the link to the electronic supplementary material.
About this article
Cite this article
Takahashi, H., Ohigashi, H. & Ishikawa, O. Pancreaticoduodenectomy for invasive pancreatic cancer (with video). J Hepatobiliary Pancreat Sci 19, 100–108 (2012). https://doi.org/10.1007/s00534-011-0467-5
- Pancreatic cancer
- Retroperitoneal and nerve plexus dissection
- Preceding interruption of the afferent blood flow