Pylorus-Preserving Pancreaticoduodenectomy

Four cases

Historical note

This is a case series from the University Hospital of the West Indies describing four patients who underwent pylorus-preserving pancreaticoduodenectomy (PPPD). The case details and discussion reflect contemporary evidence about pancreaticoduodenectomy outcomes, delayed gastric emptying, diagnosis-specific indications, and trauma management.

Abstract

Four patients at the University Hospital of the West Indies underwent PPPD for varied lesions of the duodenum and pancreatic head: solid pseudopapillary neoplasm of the pancreas, duodenal adenocarcinoma, complex pancreaticoduodenal trauma, and pancreaticoduodenal hemangioma. Two patients developed postoperative delayed gastric emptying and recovered without reported long-term sequelae at follow-up of up to one year. In contemporary reporting, delayed gastric emptying should be described using the International Study Group of Pancreatic Surgery definition and grading system (Wente et al. 2007).

Introduction

Pancreaticoduodenectomy historically carried high morbidity and mortality, but outcomes have improved substantially with better anesthesia, imaging, intensive care, interventional radiology, perioperative care, surgical technique, and concentration of complex pancreatic surgery in high-volume centers. A 2024 systematic review found significant benefit from centralization and identified approximate pancreaticoduodenectomy volume thresholds associated with mortality, morbidity, and lymph-node harvest improvements (Kotecha et al. 2024).

PPPD preserves the pylorus and avoids antrectomy. It may reduce some post-gastrectomy effects, but it should not be described simply as a lesser operation with uniformly fewer sequelae. Comparative outcomes vary by indication, anatomy, reconstruction, complication definitions, and center expertise. Delayed gastric emptying remains an important postoperative complication after pancreaticoduodenectomy and must be interpreted with standardized definitions (Martinez-Cabrera et al. 2024, Wente et al. 2007).

Case I

This thirty-year-old woman had a two-year history of pain and an 11 cm mass in the right upper abdominal quadrant. Her hemoglobin concentration was 10.8 g/dL, white blood cell count 5.7 x 10^9/L, serum bilirubin 9 micromol/L, alkaline phosphatase 47 IU/L, SGOT 17 IU/L, GGT 31 IU/L, and amylase 578 IU/L.

Computed tomography showed an 11 cm 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 contained total bilirubin 257 micromol/L, amylase 12.5 IU/L, red blood cells, and lymphocytes.

At laparotomy, the mass was found replacing the head of the pancreas without enlarged lymph nodes. PPPD with cholecystectomy, pancreaticojejunostomy, gastrojejunostomy, hepaticojejunostomy, gastrostomy and feeding jejunostomy was performed.

Postoperatively, the patient had delayed gastric emptying and received jejunostomy feeding for two weeks. Histological examination showed a papillary cystic tumor of the pancreas, now termed solid pseudopapillary neoplasm of the pancreas. The fibrous capsule showed focal invasion but no complete penetration. Resection margins and six identified lymph nodes were free of tumor. One year after discharge she had no complaints, no clinical evidence of tumor recurrence, and no weight loss.

Solid pseudopapillary neoplasm is a rare low-grade malignant pancreatic tumor. Contemporary systematic review evidence supports surgical resection as the primary treatment and reports excellent survival after resection (Pontrelli et al. 2025).

Case II

This forty-year-old woman 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 pale, icteric, and emaciated. Epigastric tenderness and a palpable gallbladder were noted. Her hemoglobin concentration was 8.8 g/dL, white blood cell count 12.1 x 10^9/L, serum albumin 35 g/L, bilirubin 18 micromol/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, a dilated common bile duct of 1.2 cm, and a distended gallbladder. Barium meal showed a filling defect in the second part of the duodenum.

At laparotomy, an 8 cm periampullary tumor was found without gross infiltration into adjacent organs or metastases. Frozen section histology suggested an intestinal polyp with dysplastic changes. PPPD, cholecystectomy, gastrostomy, and jejunostomy were performed.

Postoperatively, jejunostomy feeding produced diarrhea that was controlled with diphenoxylate. Delayed gastric emptying lasted 7 days, and recovery was otherwise uneventful. Histopathological examination showed a well-differentiated duodenal adenocarcinoma. The tumor infiltrated the muscularis propria but did not extend to the serosa. Both resection margins were free of tumor, 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, and had no clinical evidence of tumor recurrence or metastasis.

In contemporary practice, duodenal adenocarcinoma is managed within small bowel adenocarcinoma frameworks. Current guidance emphasizes staging, complete surgical resection when feasible, margin assessment, lymph node evaluation, consideration of adjuvant therapy by stage and risk features, and surveillance (Benson et al. 2019, NCI Small Intestine Cancer PDQ).

Case III

Two hours after being shot with a handgun, F.B., a nineteen-year-old man, 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 and no exit wound. Hemoglobin concentration was 16.2 g/dL, hematocrit 0.49, serum amylase 390 IU/L, and serum electrolytes, urea, and creatinine were normal.

Antitetanus and antibiotic prophylaxis were given. A nasogastric tube and urethral catheter were inserted. At laparotomy, blood was evacuated from the peritoneal cavity. Operative findings included penetrating injuries to the transverse colon, stomach, jejunum, pancreas, duodenum, and liver. The liver injury was not bleeding. The main pancreatic duct was transected across the neck of the pancreas. The gastric and jejunal injuries were repaired. Limited transverse colectomy, PPPD, cholecystectomy, gastrostomy, and jejunostomy were also performed. The repaired jejunum with a retrocolic pancreaticojejunostomy twisted and occluded the superior mesenteric vascular pedicle, producing small bowel ischemia. The small bowel and right colon were mobilized and derotated, restoring bowel perfusion. Incidental appendectomy was performed, and a left iliac double-barrel colostomy was fashioned.

Postoperative fever resolved on day 4, and the patient was discharged on day 10. Six months later he had uneventful repair of the double barrel colostomy.

Pancreaticoduodenectomy for trauma is now considered an exceptional operation. WSES-AAST guidelines emphasize that duodenopancreatic injuries are rare, associated injuries are common, morbidity is high, and pancreaticoduodenectomy is reserved for severe destructive pancreaticoduodenal injuries, often with damage-control or staged management depending on physiology and injury pattern (Coccolini et al. 2019).

Case IV

This 31-year-old woman was treated for menorrhagia at the University Hospital. Two years later she had a cerebrovascular accident with transient left hemiparesis and residual numbness in the left upper limb. Over the next three years, she had two spontaneous abortions and subsequently a successful pregnancy. Postpartum, she underwent operative drainage of a psoas abscess. At that time she had iron deficiency anemia and was positive for antiphospholipid antibody. Other tests for collagen vascular diseases were negative. She was treated with chloroquine 250 mg daily for 6 months.

The following year she presented with recurrent upper gastrointestinal bleeding and severe anemia requiring repeated transfusions. Gastroduodenoscopy showed mild duodenitis on two occasions. Technetium-labeled red blood cell scan was normal. On her last admission, hemoglobin concentration was 5.4 g/dL, platelet count 177,000/L, PT 15.2 seconds with control 13.7 seconds, and PTT 29.7 seconds with control 27.7 seconds. Gastroduodenoscopy, barium small-intestinal enteroclysis, colonoscopy, and blood pool scan were normal. Selective arteriography showed a tumor blush in the duodenum.

At laparotomy, a large hemangioma was found involving the second part of the duodenum and the head of the pancreas. PPPD, cholecystectomy, gastrostomy, and jejunostomy were performed. Postoperative fever lasted 48 hours, and oral fluids were started 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.

Duodenal hemangioma is a rare cause of gastrointestinal bleeding. Modern treatment options may include endoscopic resection, laser coagulation, sclerotherapy, and selected open or laparoscopic surgery. Pancreaticoduodenectomy is generally reserved for extensive periampullary or pancreatic-head involvement, diagnostic uncertainty, or lesions not amenable to limited treatment (Dukmak et al. 2023).

Discussion

Pancreaticoduodenectomy has evolved substantially since Whipple’s original descriptions. The operation is now performed for selected periampullary, duodenal, distal bile duct, and pancreatic-head lesions, as well as rare traumatic injuries. Modern outcomes are best understood in relation to disease indication, patient risk, operative complexity, complication definitions, and center volume.

Mortality after pancreaticoduodenectomy can be low in specialized centers, but morbidity remains substantial. Centralization is strongly associated with improved outcomes; a 2024 systematic review and spline regression analysis found approximate volume thresholds of 45 pancreaticoduodenectomies per year for mortality benefit, 55 per year for lowest morbidity, and 43 per year for lymph node harvest (Kotecha et al. 2024).

Improvements in pancreaticoduodenectomy outcomes are multifactorial. They reflect better patient selection, preoperative imaging, anesthesia, intensive care, antibiotics, nutrition, interventional radiology, surgical technique, high-volume multidisciplinary teams, and improved recognition and rescue of complications. Anastomotic technique is important, but no single reconstruction method alone explains modern reductions in mortality and morbidity.

PPPD preserves the pylorus and may reduce some post-gastrectomy symptoms such as dumping, bile reflux, and nutritional sequelae. However, PPPD is not uniformly superior to classic Whipple or other stomach-preserving variants across all outcomes. Contemporary comparisons show that delayed gastric emptying, bile leak, fistula, mortality, and other adverse outcomes vary by operative subtype, patient selection, and institutional practice (Martinez-Cabrera et al. 2024).

Delayed gastric emptying is a common complication after pancreaticoduodenectomy and should be reported using the ISGPS definition and grades A, B, and C. This standardized framework allows comparison across studies and distinguishes mild deviations from clinically significant delayed gastric emptying requiring prolonged decompression, delayed diet tolerance, medications, or prolonged hospitalization (Wente et al. 2007).

PPPD is an accepted operative option for selected periampullary, duodenal, distal bile duct, and pancreatic-head lesions when negative margins, appropriate lymph node evaluation, and safe reconstruction can be achieved. For malignant disease, procedure choice should be integrated with modern staging, oncologic planning, margin assessment, nodal evaluation, and adjuvant-treatment decisions. For benign or low-grade malignant disease, such as solid pseudopapillary neoplasm, operative planning should balance oncologic adequacy with preservation of pancreatic and gastrointestinal function.

For trauma, pancreaticoduodenectomy is not a routine alternative to simpler repair. It is reserved for rare destructive injuries involving the pancreatic head, duodenum, ampulla, or distal bile duct when drainage, repair, diversion, or limited resection is inadequate. Physiologic instability may require abbreviated source-control surgery with delayed reconstruction rather than immediate definitive reconstruction (Coccolini et al. 2019).

Conclusion

These four cases demonstrate that PPPD can be used for a range of selected pancreatic-head and periampullary conditions, including solid pseudopapillary neoplasm, duodenal adenocarcinoma, complex pancreaticoduodenal trauma, and extensive pancreaticoduodenal hemangioma. All four patients survived, and only delayed gastric emptying was emphasized as a postoperative complication.

In contemporary practice, PPPD should be described as one operative variant of pancreaticoduodenectomy rather than a universally preferable alternative to classic Whipple. Its use should be individualized according to diagnosis, anatomy, oncologic requirements, physiologic status, surgeon and center expertise, and expected reconstruction risk. Delayed gastric emptying should be reported with ISGPS criteria, and trauma pancreaticoduodenectomy should be reserved for exceptionally destructive pancreaticoduodenal injuries.

Educational disclaimer

This article is for educational purposes and does not substitute for individualized medical advice or surgical judgment. Patients with pancreatic, periampullary, duodenal, or traumatic pancreaticoduodenal disease should be evaluated by qualified clinicians in an appropriate multidisciplinary setting.

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