Pancreaticoduodenectomy – A Brief Review of Past Experiences and Sharing of Recent Experience and Learning
Pancreaticoduodenectomy – A Brief Review of Past Experiences and Sharing of Recent Experiences
Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg
March 11, 2012
Pancreaticoduodenectomy is an operation that removes the pancreas and its intimately adjacent duodenum or vice versa, the duodenum and its intimately adjacent pancreas.
The indications for such an operation are resection of malignant tumor in the area (pancreaticoduodenal area), extensive trauma to the area, and extensive necrosis to the duodenum as a result of swallowing of corrosive substances such as muriatic acid.
I reviewed my records on pancreaticoduodenectomy from my surgical residency years up to the present.
During my residency years in the Philippine General Hospital from 1976 to 1981, I have done only 3 pancreaticoduodenectomy, one for malignant tumor and 2 for extensive pancreaticoduodenal injuries.
In 1989, I wrote a paper, “Factors affecting outcome in pancreatic injuries,” which was published in the Philippine Journal of Surgical Specialties. [Factors affecting outcome in pancreatic injuries. Joson RO. Philipp J Surg Spec 1989; 44(1); 24-29.]
After finishing my residency from the Philipppine General Hospital, from 1981 up to the present, I have done only a few cases of pancreaticoduodenectomy. I cannot recall the exact number. My estimate is about 5 cases and mainly for periampullary carcinoma.
The few cases that I have may be due to few referrals and few cases of periampullary carcinomas in the community. Ampullary carcinomas are usually amenable to pancreaticodudenectomy at the time of diagnosis as compared to malignancies in the head of the pancreas. The latter usually are not amenable to pancreaticoduodenectomy at the time of diagnosis and a bypass is just done. Between ampullary malignancies and pancreatic head malignancies, the former is not very common.
A pancreaticoduodenectomy for ampullary carcinoma entails cutting at the distal part of the stomach or first portion of the duodenum, common hepatic duct, neck of the pancreas, and proximal part of the jejunum. There are usually three reconstructions after the pancreaticoduodenectomy, namely, pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy.
Below are some pictures on pancreaticoduodenectomy that I recently did on a 61-year-old female with ampullary carcinoma.
The specimen showing the part of the stomach at the right upper portion of the picture, the proximal end of the jejunum at the right lower portion, the gallbladder and the common bile duct at the left upper portion and the duodenum with head and neck of the pancreas at the left lower portion.
The specimen cut open showing a stent protruding through the ampulla of Vater and with a bulge in the area of the ampulla signifying the presence of a mass about 1.5 cm. Note also the erythematous lesion at the opening of the ampulla.
A close-up view of the lesion and bulge at the ampulla of Vater.
Intraoperative picture of the field after the pancreaticoduodenectomy – the cut hepatic duct with silk sutures at the left upper portion; the clamped jejunal end at the left lower portion; the clamped gastric end at the right lower portion; the cut end of the pancreas pointed to by a clamp in the right upper portion; and the portal vein-superior mesenteric vein just to the left of the transected pancreas.
Reconstructions done (illustration courtesy of http://www.findthatfile.com/search-7720422-hPDF/download-documents-1550092707.pdf.htm)
In the pancreaticojejunostomy, a duct to mucosa anastomosis was done. See illustrations below courtesy of http://www.findthatfile.com/search-7720422-hPDF/download-documents-1550092707.pdf.htm.
Another method of pancreaticoduodenostomy (invagination into the jejunum) which I have done before is illustrated below.
A liberal mobilization of the duodenum facilitates the operation.
The operative time can range from 4 to 8 hours.