Jeffrey M. Hardacre

Introduction

Resection of tumors of the periampullary region has its origins in the writings of Kausch (1912) and Whipple (1935). Pancreaticoduodenectomy, or pancreatoduodenectomy, previously was accompanied by a mortality rate of 20% to 25%. Currently, however, most experienced pancreatic surgery centers report a mortality rate of 3% or less. Complication rates remain 20% to 50%, with the most troublesome complication being leakage at the pancreatic anastomosis.

The most common indication for pancreaticoduodenectomy is periampullary adenocarcinoma, predominantly of pancreatic duct origin. Cystic pancreatic neoplasms, particularly intraductal papillary mucinous neoplasms (IPMNs), have become a more frequent indication for pancreatic head resection.

Principles of Pancreatic Cancer Treatment

It is well established that pancreatic cancer is best treated in a multidisciplinary manner, using surgical resection, cytotoxic chemotherapy, and radiation therapy. Despite this approach, the survival rates have not changed dramatically during the past 3 decades.

The treatment of pancreatic cancer begins with accurate staging, including a complete history and physical examination. The most important component of staging is a multiphase computed tomography (CT) scan of the abdomen using a multidetector scanner (Fig. 16-1). With CT of the chest, this allows patients to be staged clinically as resectable (15% to 25%), borderline resectable or locally advanced/unresectable (30% to 40%), or metastatic (40% to 50%). Endoscopic ultrasound is rarely needed for staging purposes, and laparoscopy is favored by some authors. Debate continues about the utility of preoperative biliary decompression in jaundiced patients. Recently, laparoscopic approaches to pancreaticoduodenectomy have been described, but these remain nascent.

Pancreaticoduodenectomy is the mainstay of pancreatic head cancer treatment. No survival benefit has been shown when an extended lymphadenectomy is added, and no survival difference is seen when a classic pancreaticoduodenectomy is performed compared with a pylorus-preserving resection.

Most centers perform surgery first, followed by adjuvant therapy; however, some prefer a neoadjuvant approach to the treatment of pancreatic cancer. In the United States, chemotherapy combined with radiation therapy has historically been used most often in the adjuvant setting, whereas in Europe, chemotherapy alone is the standard adjuvant therapy. Given the still-poor outlook for patients, even with resected pancreatic cancer, novel therapies are desperately needed.

Surgical Approach

The abdomen is explored to evaluate for metastatic disease, either through an upper midline incision, diagnostic laparoscopy, or a chevron incision. If metastatic disease is found, or after thorough assessment, if a tumor is believed to be unresectable, many surgeons favor palliative biliary and duodenal bypasses, as well as a celiac plexus block.

The dissection begins with a generous Kocher maneuver to lyse the lateral retroperitoneal attachments of the duodenum (Fig. 16-2, A and B). This elevates the duodenum and head of the pancreas out of the retroperitoneum. By taking the Kocher maneuver to its fullest extent, the surgeon identifies the superior mesenteric vein (SMV) in the groove between the head of the pancreas and the transverse mesocolon (Fig. 16-2, C). Further, the relationship of the tumor in the head of the pancreas to the SMV and superior mesenteric artery (SMA) is assessed. At this point, the surgeon should feel for evidence of a replaced or accessory right hepatic artery coming off the SMA (Fig. 16-3).

With the SMV identified, dissection is carried along this vessel cranially toward the inferior border of the pancreatic neck. The right gastroepiploic vein and its branches are identified and ligated, allowing the development of the plane posterior to the neck of the pancreas and anterior to the SMV (Fig 16-4).

When the plane has been developed as far as possible from the inferior aspect, attention is turned to the hepatoduodenal ligament (Fig. 16-5, A and B). Care is taken to identify and preserve a replaced or accessory right hepatic artery. The common bile duct (CBD) is identified and encircled with a vessel loop. Some surgeons prefer to divide the CBD at this point. The gastroduodenal artery (GDA) is identified and encircled with a vessel loop as well (Fig. 16-5, C). Before ligating the GDA, the surgeon must be sure that when it is occluded, there is still a pulse in the hepatic artery going to the liver. Loss of that pulse may indicate an arcuate ligament syndrome, celiac stenosis, or variant arterial anatomy (see Fig. 16-3).

With the GDA ligated and the CBD retracted laterally or transected, the portal vein is easily identified. The plane posterior to the neck of the pancreas is then fully developed, connecting the dissection from inferior and superior. A Penrose drain is placed through that plane. With this plane developed and assessment confirming lack of SMV or SMA involvement, resectability has been confirmed.

If not done previously, the CBD is transected. Either the first portion of the duodenum (for a pylorus-preserving pancreaticoduodenectomy) or the distal stomach (for a classic pancreaticoduodenectomy) are dissected out and transected with a GIA stapler. The pancreatic neck is then transected and a margin sent from the remnant for frozen-section analysis.

The duodenum and head of the pancreas are dissected away from the portal vein and SMV. There are few, if any, anterolateral small venous branches. The posterior superior pancreaticoduodenal vein is reliably identified and ligated (Fig. 16-6, A). The uncinate process is then dissected away from the SMA, taking care to ligate the pancreaticoduodenal arteries (see Fig. 16-2). Usually, one half to two thirds of the uncinate dissection is completed at this time.

Attention is then turned to the proximal jejunum, which is transected about 10 to 15 cm distal to the ligament of Treitz with a GIA stapler. The distal duodenal and proximal jejunal mesenteries are ligated, and then the bowel is fed underneath the SMA and SMV to the right upper quadrant. The uncinate dissection is completed, again flush with the SMA, and the specimen is marked and sent to pathology. While the surgeon is completing the uncinate dissection, the first jejunal branch off the SMV generally enters the vein on the right posterolateral surface and runs underneath the SMV to the patient’s left. This branch can be problematic if not identified, and it usually is ligated. With the specimen removed, the operative field appears as shown in Figure 16-6, B.

Before reconstruction, a negative margin must be confirmed by frozen section for the pancreatic neck and bile duct. A frozen section of the uncinate (SMA margin) is not necessary because no more tissue can be taken from that area.

Reconstruction is generally done in the following order: pancreas, bile duct, duodenum/stomach. The jejunum is generally brought through a defect in the transverse mesocolon. In this case the ligament of Treitz is closed. Some surgeons bring the jejunum back through the ligament, underneath the SMA and SMV. The pancreatic and biliary anastomoses are universally done in a retrocolic manner. The duodenal/gastric anastomosis may either be done in a retrocolic or antecolic manner. Most surgeons leave one or two drains near the pancreatic and biliary anastomoses, but this practice is controversial.

Suggested Readings