Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors

OBJECTIVE: A prospective randomized multicenter study was performed to assess whether the results of pylorus-preserving pancreaticoduodenectomy (PPPD) equal those of the standard Whipple (SW) operation, especially with respect to duration of surgery, blood loss, hospital stay, delayed gastric emptying (DGE), and survival. SUMMARY BACKGROUND DATA: PPPD has been associated with a higher incidence of delayed gastric emptying, resulting in a prolonged period of postoperative nasogastric suctioning. Another criticism of the pylorus-preserving pancreaticoduodenectomy for patients with a malignancy is the radicalness of the resection. On the other hand, PPPD might be associated with a shorter operation time and less blood loss. METHODS: A prospective randomized multicenter study was performed in a nonselected series of 170 consecutive patients. All patients with suspicion of pancreatic or periampullary tumor were included and randomized for a SW or a PPPD resection. Data concerning patients' demographics, intraoperative and histologic findings, as well as postoperative mortality, morbidity, and follow-up up to 115 months after discharge, were analyzed. RESULTS: There were no significant differences noted in age, sex distribution, tumor localization, and staging. There were no differences in median blood loss and duration of operation between the 2 techniques. DGE was observed equally in the 2 groups. There was only a marginal difference in postoperative weight loss in favor of the standard Whipple procedure. Overall operative mortality was 5.3%. Tumor positive resection margins were found for 12 patients of the SW group and 19 patients of the PPPD group (P < 0.23). Long-term follow-up showed no significant statistical differences in survival between the 2 groups (P < 0.90). CONCLUSIONS: The SW and PPPD operations were associated with comparable operation time, blood loss, hospital stay, mortality, morbidity, and incidence of DGE. The overall long-term and disease-free survival was comparable in both groups. Both surgical procedures are equally effective for the treatment of pancreatic and periampullary carcinoma.     

Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma--part 3: update on 5-year survival.

The study objective was to update the survival analysis at the 5-year mark of patients undergoing standard versus radical (extended) pancreaticoduodenectomy (PD) for periampullary adenocarcinoma (cancers of the pancreas, ampulla, common bile duct, and duodenum). A prospective randomized trial was performed (April 1996 through June 2001) comparing survival after pylorus-preserving PD resection (standard) to survival after PD with distal gastrectomy and retroperitoneal lymphadenectomy (radical). An interim report (Ann Surg 1999;229:613) and report after closing the trial (Ann Surg 2002;236:355) showed no differences in survival between the standard and radical groups. Two hundred ninety-nine patients were randomized to either the standard or radical group. Five patients were excluded from final analysis because final pathology failed to reveal adenocarcinoma. The 5-year survival of the two groups was evaluated. The median live patient follow-up is now 64 months (5.33 years). For all periampullary cancer patients, those undergoing standard resection had 1- and 5-year survival rates of 78% and 25%, respectively, compared with 76% and 31% (P = 0.57) for those patients in the radical group. For pancreatic adenocarcinoma patients, the 1- and 5-year survival rates in the standard group were 75% and 13%, respectively, compared with 73% and 29% in the radical group (P = 0.13). The increased morbidity rate, longer operative time, and similar survival for radical PD led us to conclude that pylorus-preserving PD without retroperitoneal lymphadenectomy should be the procedure of choice for most patients with resectable periampullary adenocarcinoma. While there is an intriguing trend toward improved survival in patients with pancreatic adenocarcinoma in the radical group, this trend may be largely accounted for by the higher incidence of microscopically margin positive resections in the standard resection group (21%) compared with a 5% incidence in the radical group (P = 0.002).     

Stomach saving duodenopancreatectomy. Indications and contraindications. The most important surgical steps

Discussion on pylorus-preserving pancreatoduodenectomy (PPPD) in case of ductal adenocarcinoma is controversal. Aim of the present study was the comparison of survival in patients resected by the classic Whipple operation (Whipple) or the pylorus-preserving procedure. From April 1986 to June 1998 all patients operated for proven diagnosis of ductal pancreatic cancer were documented prospectively concerning patient's characteristics, kind of surgery, complications and histopathological staging according to the UICC-classification of 1992. During the observation period 100 patients underwent pancreatoduodenectomy, 38 cases as Whipple, 62 as PPPD. Average of age was 59.9 +/- 10.3 years without significant differences. Mortality was 6.0% in total, 5.5% post Whipple, and 6.5% post PPPD. Eighty-three percent of the resected specimen were node positive. The median survival time was 9.9 and 10.5 months, 5-year survival 2.6% and 10%, respectively without significant differences. Actually, only node positive patients reached 5-year survival. Even better survival figures following PPPD than after classic Whipple procedure make the pylorus-preserving procedure the standard operation in ductal cancer of the pancreatic head. Distal gastric resection is only mandatory in case of tumor involvement of the duodenopancreatic angle. Since only node negative cases survived 5 years, extensive surgery exceeding anatomical pancreatic head resection does not appear to be beneficial.     

Evidence-based surgery in chronic pancreatitis

BACKGROUND: In the past two decades our knowledge of the pathophysiology and surgical treatment options in chronic pancreatitis has improved substantially. Surgical treatment in chronic pancreatitis has evolved from extending to organ-preserving procedures. DISCUSSION: The classical Whipple resection is no longer a standard procedure in chronic pancreatitis, and is continuously being replaced by operations such as the duodenum-preserving pancreatic head resection and pylorus-preserving Whipple. These procedures allow the preservation of exocrine and endocrine pancreatic function, provides pain relief in up to 90% of patients, and contributes to an improvement in life quality. CONCLUSIONS: In addition to presently available results from randomized controlled trials, new studies comparing available surgical approaches in chronic pancreatitis are needed to determine which procedure is the most effective in the treating chronic pancreatitis.     

Preservation of the pylorus during pancreaticoduodenectomy —Evolution and current indications

The Whipple procedure has been improved by preservation of afunctioning pylorus. A functioning pylorus is important because marginal ulceration is avoided and, compared to the standard Whipple procedure with hemigastrectomy, more patients can gain weight postoperatively. The most common indications for this procedure are severe complication of chronic pancreatitis and periampullary tumors. In patients with pancreatic adenocarcinoma, the pylorus-preserving variety results in equal or better survival rates than those of the standard Whipple procedure with hemigastrectomy. Surgery alone is not sufficient to improve survival rates in patients with adenocarcinoma of the pancreas. Improved imaging modalities are required to diagnose the disease earlier. The most likely combination of treatment to prolong survival time is a combination of resection for cure in a patient with an early diagnosis plus an aggressive adjuvant chemoradiotherapy protocol. This protocol is most likely to be completed if a patient has preserved endocrine, exocrine, and digestive ability. A radical (R1) pylorus-preserving Whipple procedure would have the following advantages to result in the best survival rates — the patients can gain weight and thereby withstand the chemoradiotherapy protocol while, at the same time, the weakest aspect of the radical resection is addressed, i.e., the retroperitoneal margin of the pancreatic head.     

Randomized prospective trial of pylorus-preserving vs. classic duodenopancreatectomy (whipple procedure): Initial clinical results

During the past decades, the classic Whipple resection (cWhipple) and the pylorus-preserving Whipple (ppWhipple) operation have been advanced for the resection of cancer of the pancreatic head. However, no definitive answer exists as to whether the more conservative ppWhipple operation indeed equalizes the short- and long-term results of the cWhipple procedure. Therefore we conducted a randomized prospective trial in a nonselected series of consecutive patients. Demographics, diagnostic, intraoperative, and histologic findings (tumor type and tumor stage of these patients) as well as postoperative mortality, morbidity, and follow-up after discharge were analyzed. For statistical evaluation Kruskal-Wallis and chisquare tests were used where appropriate. Survival was analyzed according to Kaplan-Meier curves, and differences were examined using the log-rank test. From June 1996 to April 1999, a total of 114 patients with suspected pancreatic or periampullary tumors were prospectively randomized to undergo either a cWhipple or a ppWhipple (intention to treat) operation. Based on the inclusion and exclusion criteria, 77 of these patients were included in the final analysis. Forty had a cWhipple and 37 had a ppWhipple resection. There were no differences with regard to age, sex distribution, ASA classification, histologic classification, UICC stage, length of stay in the intensive care unit, and length of hospital stay. The ppWhipple group had a significantly shorter operative time, reduced blood loss, and fewer blood transfusions. There was no difference in mortality, but the cWhipple group showed a significantly higher total morbidity. The incidence of delayed gastric emptying was identical in both groups. For long-term follow-up, a total of 61 patients with histologically proven pancreatic or periampullary carcinoma were analyzed. There were no differences in tumor recurrence or in long-term survival at a median follow-up of 1.1 years (range 0.1 to 2.9 years). Our initial results demonstrate that the cWhipple and ppWhipple operations are equally radical. However, ppWhipple may be the procedure of choice for the treatment of pancreatic and periampullary cancer.     

Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for periampullary adenocarcinomad—part 3: Update on 5-year survival

The study objective was to update the survival analysis at the 5-year mark of patients undergoing standard versus radical (extended) pancreaticoduodenectomy (PD) for periampullary adenocarcinoma (cancers of the pancreas, ampulla, common bile duct, and duodenum). A prospective randomized trial was performed (April 1996 through June 2001) comparing survival after pylorus-preserving PD resection (standard) to survival after PD with distal gastrectomy and retroperitoneal lymphadenectomy (radical). An interim report (Ann Surg 1999;229:613) and report after closing the trial (Ann Surg 2002;236:355) showed no differences in survival between the standard and radical groups. Two hundred ninety-nine patients were randomized to either the standard or radical group. Five patients were excluded from final analysis because final pathology failed to reveal adenocarcinoma. The 5-year survival of the two groups was evaluated. The median live patient follow-up is now 64 months (5.33 years). For all periampullary cancer patients, those undergoing standard resection had 1- and 5-year survival rates of 78% and 25%, respectively, compared with 76% and 31% (P = 0.57) for those patients in the radical group. For pancreatic adenocarcinoma patients, the 1- and 5-year survival rates in the standard group were 75% and 13%, respectively, compared with 73% and 29% in the radical group (P = 0.13). The increased morbidity rate, longer operative time, and similar survival for radical PD led us to conclude that pyloruspreserving PD without retroperitoneal lymphadenectomy should be the procedure of choice for most patients with resectable periampullary adenocarcinoma. While there is an intriguing trend toward improved survival in patients with pancreatic adenocarcinoma in the radical group, this trend may be largely accounted for by the higher incidence of microscopically margin positive resections in the standard resection group (21%) compared with a 5% incidence in the radical group (P = 0.002). Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (oral presentation).     

Preservation of the pylorus in resection of the head of the pancreas

Whipple's pancreatoduodenectomy was the standard operation for diseases of the head of the pancreas for more than 40 years, but the results were vitiated in part by poor gastrointestinal function and malnutrition. Reintroduced in 1978, pylorus-preserving proximal pancreatoduodenectomy (PPPP) has had an increasing impact on pancreatic surgery as its benefits have been recognized: improved nutritional status, decreased incidence of postgastrectomy syndromes, and a technically easier operation. Postoperative mortality rates and 5-year survival rates are comparable with those of the classic Whipple procedure. PPPP is indicated for most patients with chronic pancreatitis of the pancreatic head. It is also appropriate for patients with periampullary cancer and for those with pancreatic cancer arising from the lower part of ‘the head and the uncinate process. More than 650 patients have now undergone PPPP: 31% for chronic pancreatitis and 66% for periampullary and pancreatic cancers. We assess the indications for PPPP, outline the operation, and review the results.     

Duodenum-preserving pancreatic head resection (DPPHR) in chronic pancreatitis: its rationale and results

Persistent, uncontrolled pain is the most common indication for surgery in chronic pancreatitis. In the presence of an inflammatory mass in the pancreatic head or in pancreatic head-related complications of chronic pancreatitis, resection procedures are inevitable. The Whipple procedure, originally introduced for malignat lesions of the periampullary region, is commonly employed, although it represents surgical over-treatment in a benign pancreatic disorder. In this article, we discuss our long experience with duodenum-preserving pancreatic head resection (Beger procedure) for chronic pancreatitis. Prospective, randomized controlled trials suggest that this organ- and function-preserving procedure should be the gold standard for the surgical treatment of pancreatic head-related complications of chronic pancreatitis. Received: July 3, 2000 / Accepted: August 8, 2000     

Surgical experience with pancreatic and periampullary cancer

Between 1940 and 1978, 179 patients underwent pancreatic resection (64 total, 102 Whipple, 13 distal) at the Presbyterian Hospital, predominantly for carcinoma of the pancreas and periampullary area. With respect to operative morbidity and mortality and survival, these patients have been compared with 141 patients subjected to pancreatic biopsy only, and with 172 by-passed for palliation. Likewise, total pancreatectomy has been compared to pancreaticoduodenectomy (Whipple) in terms of safety and efficacy. The overall major postoperative complication rate for pancreatic resection was 36%, in contrast with 13.5% for biopsy only and 16.8% for by-pass. Of the resected cases with major complications postoperatively, roughly half died, a mortality of 17.9%. Patients who underwent Whipple resections fared significantly better than did those having total pancreatectomies; the postoperative mortality following 102 Whipples was 14.7%, as compared with 23.4% for total pancreatectomies. Intra-abdominal sepsis accounted for most of the postoperative deaths; nine pancreatic and four biliary leaks or fistulae followed Whipple resections. The later complications were of interest; 18 patients undergoing biliary-en-teric by-pass procedures later developed gastroduodenal obstruction, 15 of whom required reoperation, and in 18 survivors of pancreatic resection, upper gastrointestinal hemorrhage (mostly from marginal ulcers) developed, necessitating surgery in seven. Brittle diabetes was a problem in nine patients following pancreatectomy. Survival rates were discouraging in all categories. For ductal carcinoma of the pancreas, median survival for biopsy only was two months, for by-pass six months, for total pancreatectomy nine months, and for Whipple resection 14 months. There were three five-year survivors following resection, a rate of 4.5%. Five-year survival rates following resection for ampullary, common duct, duodenal, and islet cell cancer were 27.8, 33.3, 27.3, and 37.5%, respectively.

It is concluded that survival after resection for ductal pancreatic cancer is so rare as to be considered more a biologic aberration than a result of radical surgery. Despite theoretical advantages of total pancreatectomy over Whipple resections, our experience would suggest that the latter can be carried out with lower morbidity and mortality, and with equal chance for cure. Resection for pancreatic cancer should not be abandoned, but rather undertaken with greater selectivity. Operative morbidity and mortality can probably be improved additionally by preoperative transhepatic biliary decompression, and later complications reduced by including vagotomy with gastric resection at the time of pancreatectomy and by performing prophylactic gastroenterostomies in conjunction with by-pass procedures.

     

Periampullary tumors: Which ones should be resected?

Resection was carried out in 118 patients for periampullary lesions. Ninety-eight of these were adenocarcinomas and were treated by the Whipple operation, total pancreatectomy, or local resection (87 patients, 7 patients, and 4 patients, respectively). Diagnosis of pancreatic head carcinoma before resection was falsely positive in 27 percent of the patients. Mortality for radical resection was 4 percent. Five year survival for ampullary carcinoma was 32 percent, and for pancreatic head carcinoma it was 7 percent. Resection of all periampullary tumors is recommended, with the Whipple operation being the standard in most cases.     

Pancreatic and periampullary carcinoma: Experience with 200 patients over a 12 year period

The operative management of 200 patients with pancreatic and periampullary cancer was reviewed. Patients with metastatic disease and biliary obstruction are best treated by the nonoperative techniques of biopsy and internal biliary drainage if technically feasible. For patients who undergo exploration and are found to be candidates for a bypass procedure, both biliary and gastroduodenal bypass should be performed. Lymph node involvement and age of the patient were found to be significant variables in determining the candidates suitable for curative resection. A definite incidence of multicentricity was found in patients undergoing total pancreatectomy for ductal carcinoma of the pancreas; however, significant problems with diabetic management arose from this procedure. The primary site of the lesion as well as the intelligence and socioeconomic background of the patient should dictate the type of resection employed. Pancreatoduodenectomy (Whipple procedure) is recommended for periampullary cancers other than pancreatic carcinoma, while total pancreatectomy may be appropriate in selected patients. However, there has been no evidence thus far in this early trial with total pancreatectomy that more complete resection of the pancreas leads to longer survival.     

Pylorus-preserving total pancreatectomy. Early and late results.

BACKGROUND/AIMS: Preservation of the pylorus is an accepted alternative procedure to the classical Whipple operation for pancreatic head resection but data describing its value for total pancreatectomy are sparse. METHODS: A prospective analysis of 22 total pancreatectomies performed in a consecutive series of 436 pancreatic resections from 1.11.93 to 1.5.99. RESULTS: 11 patients underwent total pancreatectomy with preservation of the pylorus. Histopathological examination revealed pancreatic adenocarcinoma in 16 cases and duodenal adenocarcinoma in 1 patient, 5 patients had other types of pancreatic neoplasm. In-hospital mortality was 4.5% (n = 1), cumulative morbidity was 59% and reoperations were performed in 9.1% of cases (n = 2). Median follow-up was 37 months (range 5-66). 62% of patients (n = 13) developed tumor recurrence and 13 patients died during the follow-up period with 10 deaths being cancer related. There was no difference concerning postoperative and follow-up morbidity of survival between patients undergoing pylorus-preserving total pancreatectomy or pancreatectomy with gastrectomy. However, postoperative body weight was increased 3, 6, 9 and 12 months following preservation of the pylorus. CONCLUSION: Total pancreatectomy with preservation of the pylorus is a feasible type of resection for all types of pancreatic or ampullary tumors, which shows a similar morbidity and long-term survival but improved nutritional recovery compared with standard total pancreatectomy.     

Prospective randomized comparison between pylorus-preserving and standard pancreaticoduodenectomy.

BACKGROUND: Pancreaticoduodenectomy, with either gastrectomy (Whipple procedure) or pylorus-preserving pancreaticoduodenectomy (PPPD), is a complex procedure. Technical diversity, variation and sampling bias exist among surgeons. Previous reports comparing these two procedures are retrospective and not randomized. These factors should be considered seriously and eliminated in comparisons between the two procedures. METHODS: From August 1994 to August 1997, a prospective randomized comparison was conducted between the Whipple procedure and PPPD performed by the same surgeon with the same approach and same anastomotic fashion for periampullary cancer. After exclusion of seven patients, 31 patients were eligible for the study, 16 receiving PPPD and 15 a Whipple procedure. No significant difference in the age, sex distribution, tumour localization or staging was noted between the two groups. RESULTS: One operative death after PPPD and no operative death after the Whipple procedure resulted in a 3 per cent mortality rate in the 31 patients. Median duration of the Whipple operation was 235 (range 195-305) min, with a median blood loss of 500 (range 230-3100) ml and a median blood transfusion of 0 (range 0-10) units. In the patients who had PPPD, median operating time was 230 (range 170-275) min, median blood loss was 350 (range 100-1200) ml and median blood transfusion was 0 (range 0-4) units. There were two minor leaks from the pancreaticojejunostomy after the Whipple procedure and no leakage after PPPD, resulting in 6 per cent minor leakage in 31 patients. These outcomes were not significantly different. Delayed gastric emptying was observed more frequently after PPPD (six of 16 patients) than after the Whipple procedure (one of 15 patients), with marginal significance (P = 0.08, two-sided Fisher's exact test). CONCLUSION: In this prospective randomized study, both PPPD and the Whipple procedure were associated with low mortality and operative morbidity rates. There was no significant difference between PPPD and Whipple resection in terms of operative mortality and morbidity, operating time, blood loss and blood transfusion. PPPD was associated with more frequent delayed gastric emptying, although study of more patients is needed to confirm this.     

Chirurgische Standardtherapie beim Pankreaskarzinom

Approximately 150,000 people worldwide and 40,000 people in Europe die each year of pancreatic cancer,making it one of the five leading causes of cancer-related death and one of the most aggressive human tumors. Resection is still the only option that offers a chance of cure for pancreatic cancer patients. Recent studies have highlighted the correlation between the number of pancreatic resections per year and postoperative mortality. Thus, large centers of pancreatic surgery have mortality rates below 5%, whereas centers with lower caseloads have mortality rates exceeding 10%. Standards have been established for the surgical treatment of pancreatic cancer;however, these are often not based on evidence derived from randomized, controlled studies. Resection for pancreatic cancer is carried out if there are no metastases present and if the tumor is locally resectable; i.e., if there is no complex vessel invasion. However, an isolated infiltration of the portal vein is not considered a contraindication for surgery. At present, there are no evidenced-based data available on palliative (R2) resections,which might be a therapeutic option in centers with low morbidity/mortality. Three randomized controlled trials clearly show that the pylorus-preserving Whipple is equal to the classical Whipple in terms of oncological effectiveness, morbidity, and quality of life. Therefore, the pylorus-preserving Whipple is increasingly considered the standard operation for tumors of the pancreatic head. Based on randomized trials, extended lymph node dissection cannot generally be recommended for pancreatic cancer. Further prospective, randomized, multicenter trials have to be carried out in the upcoming years to find new approaches in the therapy of pancreatic cancer and to establish evidence-based treatment strategies for this disease.     

Evidence-based pancreatic head resection for pancreatic cancer and chronic pancreatitis

OBJECTIVE: To review the current status of pancreatoduodenectomy for pancreatic cancer and chronic pancreatitis using evidence-based methodology. SUMMARY BACKGROUND DATA: Despite improved results of pancreatoduodenectomy over the recent years, the reputation of the Whipple procedure and its main modifications has remained poor. In addition, the current status of newer modifications of standard pancreatoduodenectomy is still under debate. METHODS: Medline search and manual cross-referencing were performed to identify all relevant articles for classification and analysis according to their quality of evidence. The search was limited to articles published between 1990 and 2001. RESULTS: The mortality rate of pancreatoduodenectomy has declined to less than 5% for chronic pancreatitis and 3% to 8% for pancreatic cancer. In contrast, overall morbidity rates remain high, ranging between 20% and 70%. Delayed gastric emptying represents almost half of all complications. The overall 5-year survival rate for patients with pancreatic cancer remains poor, ranging between 5% and 15%, with a median survival of 13 to 17 months. Mortality and morbidity are not related to the type of pancreatoduodenectomy; however, patients with pancreatic cancer tend to be at increased risk for complications. Extended lymph node dissection and portal vein resection can be performed with similar mortality and morbidity rates as standard procedures, but without apparent survival benefits in the long term. Major relief of pain is achieved in 70% to 100% of patients with chronic pancreatitis. CONCLUSIONS: Pancreatoduodenectomy and its main modifications are safe and effective treatment modalities, especially in experienced centers with a high patient volume. For chronic pancreatitis, surgical resection provides major relief of pain and thus increased quality of life. Overall survival for patients with pancreatic cancer is determined predominantly by the pathology within the resected specimen.     

Pancreatic fistula after pancreatic head resection

BACKGROUND: Pancreatic resections can be performed with great safety. However, the morbidity rate is reported to be 40-60 per cent with a high prevalence of pancreatic complications. The aim of this study was to analyse complications after pancreatic head resection, with particular attention to morbidity and pancreatic fistula. METHODS: From November 1993 to May 1999, perioperative and postoperative data from 331 consecutive patients undergoing pancreatic head resection were recorded prospectively. Data were analysed and grouped according to the procedure performed: classic Whipple resection, pylorus-preserving pancreatoduodenectomy (PPPD) or duodenum-preserving pancreatic head resection (DPPHR). RESULTS: Pancreatic head resection had a mortality rate of 2.1 per cent; the difference in mortality rate between the three groups (0.9-3.0 per cent) was not significant. Total and local morbidity rates were 38.4 and 28 per cent respectively. DPPHR had a lower morbidity, both local and systemic, than pancreatoduodenectomy. The prevalence of pancreatic fistula was 2.1 per cent in 331 patients, and was not dependent on the procedure or the aetiology of the disease. Reoperations were performed in 3.9 per cent of patients, predominantly for bleeding and non-pancreatic fistula. None of the patients with pancreatic fistula required reoperation or died in the postoperative course. CONCLUSION: A standardized technique and a continuing effort to improve perioperative management may be responsible for low mortality and surgical morbidity rates after pancreatic head resection. Pancreatic complications occur with Whipple, PPPD and DPPHR procedures with a similar prevalence. Pancreatic fistula no longer seems to be a major problem after pancreatic head resection and rarely necessitates surgical treatment.     

What should be the standard operation in chronic pancreatitis: Whipple or duodenum-preserving pancreatic head resection?

Surgical options in the treatment of chronic pancreatitis have undergone both development and controversial discussion in the past decades. Operations such as the classical and pylorus-preserving Whipple resections are more and more being replaced by operations such as the duodenum-preserving pancreatic head resection, which preserves extrapancreatic organs like the stomach, the duodenum and the extrapancreatic bile duct. The latter operation preserves a normal food passage and glucose metabolism after surgical intervention. In addition, the duodenum-preserving pancreatic head resection provides long-term pain relief and reduction in up to 90% of chronic pancreatitis patients, as well as a general improvement in quality of life. This article will summarize and compare the surgical options in the treatment of chronic pancreatitis and will provide arguments why the duodenum-preserving pancreatic head resection should replace the classical and the pylorus-preserving Whipple resections as the standard surgical procedure used to treat chronic pancreatitis-related complications.     

Operative management in the treatment of pancreatic cancer

The carcinoma of the pancreas is one of the 10 leading causes of death in the Western countries. Because of the resistance of pancreatic cancer against radiation and/or chemotherapy surgery is still the only possibility for cure. However, about 80 % of patients with the diagnosis of pancreatic cancer are no more suitable for curative resection at the time of diagnosis because of local tumor infiltration or the presence of distant metastases. This is one reason for the unsatisfactory situation in terms of 5-year-survival rate of 3 to 24 %. In resectable tumors of the pancreas head the standard Whipple dominates still as the surgical method of choice. However, the pylorus preserving Whipple has been established as a surgical alternative to the classical Whipple. Other surgical procedures like extended or regional pancreatic resections, predominantly done by Japanese surgeons seem to fit the concept of radical resection. But compared to the classical Whipple or the pylorus preserving Whipple resection there is still no clear advantage in terms of long term survival. The prospective European multicenter study ESPAC-1 firstly demonstrated a survival advantage for adjuvant chemotherapy (5-FU and folic acid) but no gain for radiochemotherapy in the treatment of patients with R0 or R1 resected pancreatic cancer in terms of prolongation of mean survival (19.7 months vs. 14.0 months).