Jeffrey M. Hardacre

Introduction

Resection of tumors of the periampullary region has its origins in the writings of Kausch (1912) and Whipple (1935). Pancreaticoduodenectomy, or pancreatoduodenectomy, previously was accompanied by a mortality rate of 20% to 25%. Currently, however, most experienced pancreatic surgery centers report a mortality rate of 3% or less. Complication rates remain 20% to 50%, with the most troublesome complication being leakage at the pancreatic anastomosis.

The most common indication for pancreaticoduodenectomy is periampullary adenocarcinoma, predominantly of pancreatic duct origin. Cystic pancreatic neoplasms, particularly intraductal papillary mucinous neoplasms (IPMNs), have become a more frequent indication for pancreatic head resection.

Principles of Pancreatic Cancer Treatment

It is well established that pancreatic cancer is best treated in a multidisciplinary manner, using surgical resection, cytotoxic chemotherapy, and radiation therapy. Despite this approach, the survival rates have not changed dramatically during the past 3 decades.

The treatment of pancreatic cancer begins with accurate staging, including a complete history and physical examination. The most important component of staging is a multiphase computed tomography (CT) scan of the abdomen using a multidetector scanner (Fig. 16-1). With CT of the chest, this allows patients to be staged clinically as resectable (15% to 25%), borderline resectable or locally advanced/unresectable (30% to 40%), or metastatic (40% to 50%). Endoscopic ultrasound is rarely needed for staging purposes, and laparoscopy is favored by some authors. Debate continues about the utility of preoperative biliary decompression in jaundiced patients. Recently, laparoscopic approaches to pancreaticoduodenectomy have been described, but these remain nascent.

Pancreaticoduodenectomy is the mainstay of pancreatic head cancer treatment. No survival benefit has been shown when an extended lymphadenectomy is added, and no survival difference is seen when a classic pancreaticoduodenectomy is performed compared with a pylorus-preserving resection.

Most centers perform surgery first, followed by adjuvant therapy; however, some prefer a neoadjuvant approach to the treatment of pancreatic cancer. In the United States, chemotherapy combined with radiation therapy has historically been used most often in the adjuvant setting, whereas in Europe, chemotherapy alone is the standard adjuvant therapy. Given the still-poor outlook for patients, even with resected pancreatic cancer, novel therapies are desperately needed.

Surgical Approach

The abdomen is explored to evaluate for metastatic disease, either through an upper midline incision, diagnostic laparoscopy, or a chevron incision. If metastatic disease is found, or after thorough assessment, if a tumor is believed to be unresectable, many surgeons favor palliative biliary and duodenal bypasses, as well as a celiac plexus block.

The dissection begins with a generous Kocher maneuver to lyse the lateral retroperitoneal attachments of the duodenum (Fig. 16-2, A and B). This elevates the duodenum and head of the pancreas out of the retroperitoneum. By taking the Kocher maneuver to its fullest extent, the surgeon identifies the superior mesenteric vein (SMV) in the groove between the head of the pancreas and the transverse mesocolon (Fig. 16-2, C). Further, the relationship of the tumor in the head of the pancreas to the SMV and superior mesenteric artery (SMA) is assessed. At this point, the surgeon should feel for evidence of a replaced or accessory right hepatic artery coming off the SMA (Fig. 16-3).

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