56 - Pancreatoduodenal resection

Summary

Pancreatoduodenal resection (Whipple procedure) is performed for attempted cure of periampullary carcinomas (head of pancreas, ampulla of Vater, duodenal wall, or distal common bile duct); malignant islet cell neoplasms in the head of the pancreas; mucinous cystic neoplasms or mucinous cystadenocarcinoma of the head of the pancreas; benign masses from chronic pancreatitis in the head of the pancreas with secondary pancreatic duct, common bile duct, or duodenal obstruction; and, rarely, major trauma to the pancreatoduodenal complex.

Patients with obstructive jaundice (dilated hepatic ductal system) and no evidence of gallstones on ultrasound or computed tomography (CT) should undergo abdominal helical CT or MRI to determine whether there is a mass in the periampullary area and whether hepatic metastases or regional invasion has occurred. Further work-up to localize the area of obstruction in patients without a periampullary mass should include an MRCP and, if necessary, endoscopic retrograde cholangiopancreatogram or transhepatic cholangiogram. In patients in whom there is the need to differentiate between chronic pancreatitis and ductal carcinoma of the pancreas, PET scanning may be useful. Percutaneous preoperative pancreatic biopsy is not indicated in patients who are at low operative risk and who may have resectable tumors. In patients with suspected islet cell neoplasms, transduodenal ultrasound is helpful for localization.

Percutaneous transhepatic drainage of the obstructed biliary ductal system in the preoperative period is no longer performed because prospective trials have not demonstrated improvement in postoperative survival.