There are a number of techniques for restoring gastrointestinal continuity after a pancreaticoduodenal

resection. Our preferred technique is to bring the end of the divided jejunum through the transverse

mesocolon in a retrocolic fashion and perform an end-to-side pancreaticojejunostomy. The anastomosis

is begun by placing a series of interrupted 3-0 silk sutures between the side of the jejunum and the

posterior capsule of the end of the pancreas. A small enterotomy is then made in the jejunum to match

the size of the pancreatic duct and an inner layer of interrupted 5-0 absorbable monofilament sutures

are used to create a duct-to-mucosa anastomosis. Some surgeons prefer to stent this anastomosis with

either a short indwelling pancreatic stent or an externalized pancreatic stent. The anastomosis is

completed with an outer layer of 3-0 silk sutures placed between the anterior pancreatic capsule and the

jejunum. An alternative to this duct-to-mucosa technique is to create an enterotomy approximately the

same size as the pancreatic neck and to complete a running anastomosis circumferentially around the

entire gland. This technique then allows invagination of the neck 1 to 2 cm into the lumen of the bowel

by the outer anterior layer of the anastomosis. The biliary–enteric anastomosis is performed 10 cm

distal to the pancreaticojejunostomy. An end-to-side hepaticojejunostomy is performed with a single

interrupted layer of 4-0 absorbable synthetic suture material. No T tube or stent is generally necessary.

Approximately 20 cm distal to the biliary–enteric anastomosis, an end-to-side duodenojejunostomy is

performed in an antecolic manner with an inner continuous layer of 3-0 absorbable synthetic suture

material and an outer interrupted layer of 3-0 silk. The final reconstruction is shown in Figure 55-6C.

Extent of Resection

Several technical aspects of PD remain controversial. These controversies include: (1) whether or not a

radical lymph node dissection is necessary, (2) should a pylorus preserving or classic PD be performed,

and (3) is there a role for laparoscopic pancreatic resections.

Several nonrandomized retrospective studies have advocated adding a radical (extended)

retroperitoneal lymph node dissection to PD in an attempt to improve survival. However, results from

four randomized prospective trials (Table 55-11)18–22 have shown extended lymph node dissections not

to be beneficial. The prospective trial performed by Pedrazzoli et al.18 suggested a survival advantage

to extended retroperitoneal lymph node dissection in patients with positive lymph nodes. Eighty-one

patients with pancreatic adenocarcinoma were randomized to either standard or radical

lymphadenectomy over 3 years at six different institutions. While the two groups were similar with

respect to preoperative parameters, operative morbidity, and overall survival, a subgroup analysis of

the 48 patients with positive lymph nodes showed a statistically significant survival advantage for

patients undergoing the extended lymph node dissection. However, the largest prospective randomized

trial from the Johns Hopkins Hospital failed to demonstrate a survival advantage for a radical resection

as compared with a classic PD.19 Two hundred and ninety-four patients undergoing resection for

periampullary adenocarcinoma were randomized between a standard resection (pylorus preserving PD

with en bloc resection of the anterior and posterior pancreaticoduodenal lymph nodes, lower

hepatoduodenal lymph nodes, and nodes along the right lateral aspect of the superior artery and vein)

and a radical resection (standard resection plus distal gastrectomy and retroperitoneal lymph node

dissection extending from the right renal hilum to the left lateral border of the aorta and from the

portal vein to the inferior mesenteric artery). The groups did not differ with respect to age, gender, site

of primary tumor, lymph node status, or margin status. There were no significant differences in 1-, 3-,

or 5-year and median survival when comparing the standard and radical groups (Fig. 55-7). However,

the radical group had a higher overall morbidity (43% vs. 29%) with significantly higher rates of

delayed gastric emptying and pancreatic fistula in addition to a longer postoperative hospital stay.

In 1978, Traverso and Longmire23 popularized the pylorus-preserving modification of the Whipple

procedure. Preserving antral and pyloric function, the pylorus-preserving Whipple procedure reduces

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the incidence of troublesome postgastrectomy symptoms. A number of studies have documented that

gastrointestinal function is better preserved in the pylorus-sparing modification than in the traditional

operation. In addition, compared with the classic Whipple operation, the pylorus-preserving procedure

is less time-consuming and technically easier to perform. Concerns exist in the use of the pyloruspreserving Whipple procedure for the management of periampullary tumors because of the possibility

of compromising the already small proximal surgical margin of resection. This question has been

addressed by a number of authors, and no difference appears to be found in survival among those

patients treated with the pylorus-sparing Whipple procedure and those managed by the traditional

Whipple resection.24–26 Therefore, many pancreatic surgeons favor pylorus-preserving PD because it

shortens the operative time, retains the entire stomach as a reservoir, and has a similar survival rate as

compared with the classic PD.

Figure 55-7. Actuarial survival for standard versus radical pancreaticoduodenectomy. From Yeo CJ, Cameron JL, Lillemoe KD, 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;236:355–366; discussion 366–368, with permission.

In recent years, significant advances have been made in the application of minimally invasive

techniques to the management of both benign and malignant pancreatic disorders. Initially, laparoscopic

pancreatic surgery was limited to diagnostic staging in patients with pancreatic cancer prior to

resection. More recently, minimally invasive techniques have been used to manage benign and

malignant lesions of the pancreas. While laparoscopic distal pancreatic resections are being performed

with increasing frequency,27 the role of minimally invasive PD remains controversial. Laparoscopic or

robotic PD is a technically demanding procedure due to the retroperitoneal location of the pancreas, its

intimate association with surrounding gastrointestinal and major vascular structures, and the need for

three separate anastomoses to complete the reconstruction. In addition, it is unclear whether an

adequate cancer operation can be performed with respect to lymph node harvest and margin status in

patients with malignancy. Currently, laparoscopic PD is only performed in a handful of specialized

centers (Table 55-12). The procedures are performed as either robotic, pure laparoscopic, hand assisted,

or as laparoscopic-assisted procedures with the resection being performed laparoscopically and the

reconstruction being completed via a “mini” laparotomy or through a hand port.

Carcinoma of the Body and Tail

The surgical management of adenocarcinoma of the body and tail of the pancreas is much more limited

than that of the head of the pancreas because of the extent of the disease usually present at the time of

symptomatic presentation. Most patients are unable to undergo resection, based on findings of major

vascular involvement on CT or peritoneal or liver metastases on laparoscopy. If an attempt at open

exploration for possible cure is undertaken, the exploration should be started with a search for evidence

of either metastatic disease to the liver or peritoneal implants. If this is not the case, the lesser sac is

opened, and the SMV is identified as it passes under the neck of the pancreas. If this vessel is normal,

and if the splenic vein does not appear to be obstructed preoperatively, a distal pancreatectomy with

splenectomy is performed. The spleen is mobilized, as is the distal pancreas, and an en bloc resection of

the structure, including the mass, is obtained. The resection should be extended as proximally as

possible, with the transected pancreas simply oversewn. The tumor bed should be marked with the

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