Pylorus-Preserving Proximal Pancreaticoduodenectomy
Four Cases
Abstract
At the University Hospital of the West Indies four patients recently had pylorus preserving proximal pancreaticoduodenectomy (PPPPD) for varied lesions of the duodenum and head of pancreas. Two patients had delayed gastric emptying postoperatively but no sequelae on follow-up up to one year.
Introduction
Until recently high morbidity and mortality attended the Whipple’s procedure. The pylorus preserving proximal pancreaticoduodenectomy (PPPPD) is a lesser procedure with fewer sequelae. The case histories of four patients who had PPPPD at the University Hospital, Kingston, Jamaica are presented and PPPPD is discussed.
Case I
This thirty-year-old lady had a two-year history of pain and an 11-cm mass in the right upper abdominal quadrant. Her haemoglobin concentration was 10.8 g/dl, white blood cell count 5.7×109/L, serum bilirubin was 9 mol/L, alkaline phosphatase 47 IU/L, SGOT 17 IU/L, GGT 31 IU/L, and amylase 578 IU/L.
Computed tomography showed the 11 cm diameter cystic mass under the liver and barium meal demonstrated a widened duodenal ‘C’ loop with duodenal compression. Aspiration of the mass was performed under ultrasonographic guidance and the aspirate was found to have total bilirubin of 257 mol/L, amylase of 12.5 IU/L, red blood cells and lymphocytes.
At laparotomy the mass was found replacing the head of the pancreas but not associated with enlarged lymph nodes. PPPPD with a ‘dunking’ pancreaticojejunostomy, cholecystectomy, gastrostomy and jejunostomy were performed.
Postoperatively the patient had delayed gastric emptying and jejunostomy feeding for two weeks. Histological examination of the tumour showed it to be a papillary cystic tumour of the pancreas. The fibrous capsule of the tumour had focal invasion but no complete penetration. Resection margins and six identified lymph nodes were free of tumour. One year after discharge she had no complaints, no clinical evidence of tumour recurrence and no weight loss.
Case II
This forty-year-old female presented with a six-month history of intermittent epigastric and back pain, jaundice, dark urine, pruritus, fever, anorexia and weight loss. On examination she was found to be pale, icteric and emaciated. Epigastric tenderness and a palpable gallbladder were noted. Her haemoglobin concentration was 8.8 g/dl, white blood cell count 12.1×109/L, serum albumin 35 g/L, bilirubin 18 mol/L, alkaline phosphatase 1110 IU/L, SGOT 149 IU/L and GGT 984 IU/L. Abdominal ultrasonography showed a mass in the lumen of the distal common bile duct, dilated common bile duct (1.2 cm) and distended gallbladder. Barium meal showed a filling defect in the second part of the duodenum.
An 8-cm periampullary tumour with no gross evidence of infiltration into adjacent organs or of metastases was found at laparotomy. Frozen section histology of this tumour was of an intestinal polyp with dysplastic changes. PPPPD, cholecystectomy, gastrostomy and jejunostomy were performed.
Postoperatively jejunostomy feeding produced diarrhoea, which diphenoxylate controlled. Delayed gastric emptying lasted 7 days and otherwise recovery was uneventful. Histopathological examination of the pancreaticoduodenectomy specimen showed a well-differentiated duodenal adenocarcinoma. The tumour infiltrated the muscularis propria but did not extend to involve the serosa. Both resection margins were free of tumour and lymph nodes were not involved.
The patient was discharged two weeks after surgery. At one-year follow-up she had no complaints, had gained nine pounds in weight, and had no clinical evidence of tumour recurrence or metastasis.
Case III
Two hours after being shot by an assailant using a handgun, F.B., a nineteen-year-old male, presented to the Accident and Emergency Department at the University Hospital. He was in pain but not in shock. He had a 1-cm bullet entry-wound in the left upper abdominal quadrant but no exit wound. Haemoglobin concentration was 16.2 g/dl, haematocrit 0.49, serum amylase 390 IU/L, serum electrolytes, urea and creatinine normal.
Anti-tetanus and antibiotic prophylaxes were given. Nasogastric tube and urethral catheters were passed. At laparotomy blood was evacuated from the peritoneal cavity and operative findings were penetrating injuries to transverse colon, stomach, jejunum, pancreas, duodenum and liver. The penetrating injury to the liver was not bleeding. The main pancreatic duct was transected across the neck of the pancreas. The penetrating injuries to stomach and jejunum were repaired. A limited transverse colectomy, PPPPD, cholecystectomy, gastrostomy and jejunostomy were also performed. The repaired jejunum with a retrocolic `dunking’ pancreaticojejunostomy twisted and occluded the superior mesenteric vascular pedicle producing ischaemia of the small bowel. The small bowel and right colon were mobilized and de-rotated. Bowel perfusion was then restored. Incidental appendicectomy was performed and left iliac double-barrel colostomy fashioned.
Postoperative pyrexia de-effervesced on day 4 and the patient was discharged on day ten. Six months later he had uneventful closure of colostomy.
Case IV
This 31 year-old woman, M.D., was treated for menorrhagia at the University Hospital. Two years later she had a cerebro-vascular accident with transient left hemiparesis and residual numbness in the left upper limb. Within the following three years she had two spontaneous abortions and subsequently a successful pregnancy. Postpartum she had operative drainage of a psoas abscess. At this time she had iron deficiency anaemia and was positive for anti-phospholipid antibody. Other tests for collagen vascular diseases were negative. She was treated with Choroquine 250 mgs daily for 6 months. The following year she presented with recurrent upper gastrointestinal bleeding and severe anaemia requiring repeated transfusions. Gastroduodenoscopy showed mild duodenitis on two occasions. Technicium labelled red blood cell scan was normal. On her last admission haemoglobin concentration was 5.4 g/dl, platelet count 177,000/L, PT 15.2 secs (control 13.7 secs), PTT 29.7 secs (control 27.7 secs). Gastroduodenoscopy, barium small intestinal enteroclysis, colonoscopy and blood pool scan were normal. Selective arteriography showed a tumour blush in the duodenum.
At laparotomy a large haemangioma was found involving the second part of the duodenum and the head of the pancreas. A PPPPD, cholecystectomy, gastrostomy and jejunostomy were performed. Postoperative pyrexia lasted for 48 hours and oral fluids were commenced on the sixth postoperative day. The patient was discharged 10 days after surgery. She was last seen 9 months after surgery when no weight loss was noted.
Discussion
Whipple described pancreaticoduodenectomy for ampullary carcinoma and adenocarcinomas of the head of the pancreas (Whipple 1935, Whipple 1941). The morbidity and mortality associated with this operation has been reported to be as high as 40% (Hunt 1941). With improvements in surgical technique, antibiotic therapy, anaesthetic and intensive perioperative care, morbidity in the region of 10% and mortality of less than 3% are now reported. The `dunking’ pancreaticojejunostomy is probably the single most important factor accounting for the decrease in morbidity and mortality. Traverso and Longmire reported the pylorus preserving proximal pancreaticoduodenectomy (PPPPD) in 1978. Their patients with PPPPD had periampullary tumours and tumours of the head of the pancreas (Traverso and Longmire 1980). Preservation of the pylorus obviates the post-gastrectomy sequelae of the Whipple’s operation. Dumping, diarrhoea, weight loss, peptic ulcerations and their complications occur less often. Another advantage of the PPPPD is its speed of performance (Pellegrini et al 1989, Braasch and Rossi 1985; Newman et al 1983; Warren et al 1962; Grant and Van Heerden 1979).
One in two patients post-PPPPD will have gastric dysmotility (Newman et al 1983, Braasch et al 1986) requiring gastric decompression and enteral nutrition. Cases I&II had gastric dysmotility.
PPPPD is acceptable treatment for periampullary tumours and benign tumours of the head of the pancreas. Its use in the treatment of ductal carcinoma of the head of the pancreas is not universally accepted. Braasch and co-workers (1986) reported their use of PPPPD for adenocarcinomas of the head of the pancreas. The survival figures for PPPPD were comparable to those for Whipple’s procedure in the treatment of pancreatic carcinoma. Recently Sharp et al reported a PPPPD case who had recurrence of tumour at the pylorus and suggested the possibility of intramural duodenal tumour spread. If frozen section histology of the duodenal resection margin of a PPPPD reveals microscopic disease, a Whipple’s resection is completed (Sharp et al 1989).
Conclusion
One patient presented had a periampullary adenocarcinoma of the duodenum, the other had a papillary cystic neoplasm of the pancreas, the third had major pancreaticoduodenal trauma associated with multiple intra-abdominal organ injury, and the fourth had a pancreaticoduodenal haemangioma. All were young adults who had PPPPD with minimal morbidity and no mortality. PPPPD is recommended for resectable benign and malignant periampullary and pancreatic head lesions and pancreaticoduodenal trauma as an alternative to Whipple’s operation.
References
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