The classic technique of PD consists of the en-bloc removal of the distal segment of the stomach (antrum), the first and the second portions of the duodenum, specifically the head of the pancreas, the distal CBD, and the gallbladder. Another approach to this procedure is known as the pylorus-sparing PD. In this approach, a small segment of the duo denum is left in situ with the entire stomach to preserve the pylorus and prevent the post–gastrectomy-related symptoms and complications. The classic Whipple and the pylorus-preserving operations are associated with comparable operation times, blood loss, hospital stays, mortality, morbidity, and the incidence of delayed gastric emptying (Mathur et al., 2015). The overall long-term and the disease-free survival is comparable in both groups.

1. Pancreaticoduodenectomy or
Whipple Procedure: Overview
BY Dr. SREEREMYA.S
FACULTY OF BIOLOGY

2. • The classic technique of PD consists of the en-bloc removal of the
distal segment of the stomach (antrum), the first and the second
portions of the duodenum, specifically the head of the pancreas,
the distal CBD, and the gallbladder. Another approach to this
procedure is known as the pylorus-sparing PD. In this approach, a
small segment of the duo denum is left in situ with the entire
stomach to preserve the pylorus and prevent the post–
gastrectomy-related symptoms and complications. The classic
Whipple and the pylorus-preserving operations are associated with
comparable operation times, blood loss, hospital stays, mortality,
morbidity, and the incidence of delayed gastric emptying (Mathur
et al., 2015). The overall long-term and the disease-free survival is
comparable in both groups.

3. • Although the mortality allied with this procedure has remained low,
around 2% at major surgical centers, significant morbidity of 22% to
50% still occurs after this operation (Zogg et al., 2015).Several series
have demonstrated that the results are improved when the
procedure is performed by high-volume surgeons, defined as those
surgeons that mainly perform more than approx. 24 procedures per
year. Common complications after PD are postoperative pancreatic
fistula (POPF), gastroparesis, the wound infection, hemorrhage, and
pancreatitis. Complications of the procedure generally result in the
prolonged hospital stay, delayed adjuvant therapy, the diminished
quality of life, or death. The most common complication after PD is
POPF. The occurrence of POPF with the release of autolytic
digestion enzymes in the peritoneal cavity is an underlying source
of other complications such as the peripancreatic collections,
abscess, and hemorrhage.

4. • Many series have demonstrated the fistula rates ranging from 1% to 21%. The wide
range of this reported complication is likely a result of varying definitions of POPF
as well as some patient and the surgeon factors. Currently, the International Study
Group Pancreatic Fistula (ISGPF) definition of the POPF remains the most useful for
the diagnosis. This definition includes any amount of drainage fluid that has an
amylase level greater than three times the normal limit of the serum amylase. The
definition further or specifically classifies POPF into subcategories based on the
clinical consequences and periodic clinical phases of the fistula.
• Risk factors for the development of the POPF after PD include patients with soft
texture of the gland, small pancreatic ducts, and the low preoperative albumin and
prealbumin. 5 in pancreatic adenocarcinoma and the chronic pancreatitis, the
pancreas has a more fibrotic consistency and is more likely to maintain the
anastomotic integrity. Anastomoses are mainly observed between blood vessels
(Sreeremya, 2019). In patients with duodenal, neuroendocrine, or the small bile
duct tumours, the duct remains small and the gland maintains the soft normal
gland consistency. Small duct size has also been shown to result in the higher
incidence of POPF. However, duct size may be a surrogate for gland consistency
because small ducts are more often seen and observed in patients with soft
glands.

5. • Pancreaticoduodenectomy (PD) is the standard surgical treatment
for the respectable periampullary and the pancreatic head
malignancies as well as some benign conditions confined to the
pancreatic head (Langan et al., 2016). This procedure was first
delineated by Krauch in 1917 and subsequently popularized by the
Dr. A. O. Whipple in the 1940s. Over time, the procedure has
undergone multiple technical modifications but is still generally
referred to as the “Whipple” procedure. The operative mortality
rate has typically decreased from 30% to 1% during the past 3
decades. Refinements in the surgical technique and the
regionalization of PD to high-volume centers have been the key
factors for improving outcomes. Hospital volume and the surgeon
expertise have been correlated with reduced perioperative
mortality (Langan et al., 2015).

6. • SURGICAL TECHNIQUE
• The selection of patients for the PD and feasibility of tumor respectability are no longer determined
only at the time of the operation. General consensus supports the concept that tumors should be
evaluated with the preoperative clinical and radiographic staging. This is largely done with
computed tomography (CT) scanning availing a pancreas-dedicated protocol to assess tumor size,
the loco regional vessel involvement, and the absence of distant disease. The accuracy of the
preoperative imaging in assessing tumor respectability is well established and has eliminated the
role of the laparotomy as an initial step to assess tumor respectability (Greenblatt et al., 2011).The
traditional PD specifically involves resection of the pancreatic head, duodenum, the distal common
bile duct, gallbladder, and gastric antrum. A more recent modification of this specific procedure is
to preserve the pylorus and gastric antrum. This is referred to as the pylorus-preserving
pancreaticoduodenectomy (PPPD). The surgical techniques of PD and the PPPD involve aggressive
approaches to resect all pancreatic tissue to the hepatic side of superior mesenteric artery. The
resection is then followed by the conventional loop reconstruction to reestablish GI continuity using
3 separate anastomoses to the remaining pancreas, the biliary duct, and stomach. The jejunum is
used for each anastomosis, and therefore the pancreaticojejunostomy, a hepaticojejunostomy, and
the gastrojejunostomy (or duodenojejunostomy in the case of PPPD) are completed.

7. • Journal of Research in Medical and Surgical
Nursing, Pancreaticoduodenectomy or
Whipple Procedure: Overview ,
Dr.S.Sreeremya ,2019.Vol 1(2):1-11.