Pancreaticoduodenectomy: Past and Present

The surgical treatment of periampullary carcinoma has evolved greatly over the last 100 years, as has been summarized in several recent texts (1–3). The first reported successful resection of an ampullary carcinoma was performed by William S. Halsted at the Johns Hopkins Hospital in 1899 (Fig. 17.1). In a patient who presented with obstructive jaundice, he described a local, transduodenal approach to resection with reanastomosis of the pancreatic and bile ducts to the duodenum (4). Three months after the initial operation, the obstructive jaundice recurred, necessitating a re-exploration and cholecystoduodenostomy for decompression. The patient expired 6 months later and an autopsy revealed recurrence of the ampullary carcinoma into the head of the pancreas and duodenum.

This transduodenal approach to resection became the procedure of choice for most surgeons dealing with ampullary cancers in the early twentieth century. However, during this same time period, some surgeons were reporting the use of an en bloc pancreaticoduodenectomy for treatment of this disease. The first such resection was credited to Codivilla, but this patient did not survive the postoperative period ( 5 ). In 1912, Walther Carl Eduard Kausch, a German surgeon, performed the first successful two-stage pancreaticoduodenectomy (Fig. 17.2 ) ( 6 ). In the second stage of Kausch’s operation, he anastomosed the distal pancreatic remnant to the distal end of a partially resected duodenum. Two years later, Hirschel described the first one-stage pancreaticoduodenectomy, wherein he reimplanted the pancreatic duct into the duodenum, created a gastrojejunostomy, and connected the common bile duct to the duodenum using a rubber tube ( 7 ).