INTRODUCTION

A pancreaticoduodenectomy (PD) or Whipple procedure is one of the most complex general surgical operations. Owing to the complexity of this procedure, pitfalls that lead to major complications can occur. In this operation, experience of the surgeon is paramount to successful outcomes. This operation is most commonly performed to remove benign and malignant tumors that involve the head of the pancreas, duodenum, periampullary region, or distal common bile duct (CBD). The classic technique of PD consists of the en-bloc removal of the distal segment of the stomach (antrum), the first and second portions of the duodenum, the head of the pancreas, the distal CBD, and the gallbladder. Another approach to this procedure is known as a pylorus-sparing PD. In this approach, a small segment of duodenum is left in situ with the entire stomach to preserve the pylorus and prevent post–gastrectomy-related symptoms and complications. The classic Whipple and pylorus-preserving operations are associated with comparable operation times, blood loss, hospital stays, mortality, morbidity, and incidence of delayed gastric emptying. The overall long-term and disease-free survival is comparable in both groups. Both surgical procedures are equally effective for the treatment of pancreatic and periampullary carcinoma.¹

Although the mortality associated with this procedure has remained low, around 2% at major surgical centers,¹ significant morbidity of 20% to 50% still occurs after this operation.^1,² Several series have demonstrated that results are improved when the procedure is performed by high-volume surgeons, defined as those surgeons that perform more than 24 procedures per year.³ Common complications after PD are postoperative pancreatic fistula (POPF), gastroparesis, wound infection, hemorrhage, and pancreatitis.^1,⁴ Complications of the procedure generally result in prolonged hospital stay, delayed adjuvant therapy, diminished quality of life, or death. The most common complication after PD is POPF. The occurrence of POPF with release of autolytic digestion enzymes in the peritoneal cavity is an underlying source of other complications such as peripancreatic collections, abscess, and hemorrhage.⁵ Many series have demonstrated fistula rates ranging from 1% to 20%.^6,⁷ The wide range of this reported complication is likely a result of varying definitions of POPF as well as some patient and surgeon factors. Currently, the International Study Group Pancreatic Fistula (ISGPF) definition of POPF remains the most useful for diagnosis.⁸ This definition includes any amount of drainage fluid that has an amylase level greater than three times the normal limit of serum amylase. The definition further classifies POPF into subcategories based on the clinical consequences of the fistula.⁶

Risk factors for the development of POPF after PD include patients with soft texture of the gland, small pancreatic ducts, and low preoperative albumin and prealbumin.⁵ In pancreatic adenocarcinoma and chronic pancreatitis, the pancreas has a more fibrotic consistency and is more likely to maintain anastomotic integrity. In patients with duodenal, neuroendocrine, or small bile duct tumors, the duct remains small and the gland maintains a soft normal gland consistency.⁵ Small duct size has also been shown to result in a higher incidence of POPF. However, duct size may be a surrogate for gland consistency because small ducts are more often seen in patients with soft glands.