Pylorus Preserving vs. Pylorus Preserving vs. Classic Whipple:Classic Whipple:

ProPro--ClassicClassicJohn C. Eun, PGYJohn C. Eun, PGY--44

University of Colorado DenverUniversity of Colorado DenverGrand Rounds PresentationGrand Rounds Presentation

12/14/0912/14/09

OutlineOutline

•• BackgroundBackground•• Description of WhippleDescription of Whipple•• SafetySafety•• BenefitsBenefits•• TreatmentTreatment•• ConclusionsConclusions

IncidenceIncidence

Poor PrognosisPoor Prognosis•• The median survival for all stages of pancreatic The median survival for all stages of pancreatic

cancer is less than 3cancer is less than 3--5 months from diagnosis5 months from diagnosis•• 55--year survival of 0.4year survival of 0.4--3% 3%

•• Although there have been some advances in Although there have been some advances in chemotherapy (5chemotherapy (5--FU, gemcitabine), surgery still FU, gemcitabine), surgery still remains the only treatmentremains the only treatment

•• After successful surgery the prognosis is still After successful surgery the prognosis is still poor poor •• Median survival: 13Median survival: 13--15 months15 months•• 55--year survivals: 15year survivals: 15-- 20%20%

Shore et. al. Alimentary Pharmacology & Therapeutics. 2003;18(11)

Two methodsTwo methods

•• ““ClassicClassic”” Whipple: Whipple: PancreaticoduodenectomyPancreaticoduodenectomy•• Developed by Walther Developed by Walther KauschKausch in 1912in 1912•• Modified by Allen Whipple 1935Modified by Allen Whipple 1935•• en bloc resection:en bloc resection:

•• Pancreatic headPancreatic head•• DuodenumDuodenum•• Common bile ductCommon bile duct•• Gall BladderGall Bladder•• Distal portion of stomachDistal portion of stomach•• Adjacent lymph nodesAdjacent lymph nodes

Two MethodsTwo Methods

•• ““PylorusPylorus--preservingpreserving”” WhippleWhipple•• Kenneth Watson 1942Kenneth Watson 1942•• TraversoTraverso and Longmire 1978and Longmire 1978•• en bloc resection:en bloc resection:

•• Pancreatic headPancreatic head•• DuodenumDuodenum•• Common bile ductCommon bile duct•• Gall bladderGall bladder•• Preservation of the stomach and proximal 2Preservation of the stomach and proximal 2--3 cm 3 cm

of the duodenumof the duodenum

Two MethodsTwo Methods

Cameron, JL. Surg Rounds 77-87, 1988

Why Two?Why Two?

cWhipplecWhipple DumpingDumping DiarrheaDiarrhea DyspepsiaDyspepsia Weight lossWeight loss

ppWhippleppWhipple Keep the stomach and Keep the stomach and

(in theory) prevent the (in theory) prevent the side effectsside effects

Less radical operationLess radical operation•• Less time?Less time?•• Less recovery time?Less recovery time?

BUTBUT

•• ppWhipple was initially described for ppWhipple was initially described for periampullaryperiampullary tumors and chronic pancreatitistumors and chronic pancreatitis

•• NOT treatment of cancer at the pancreatic head!NOT treatment of cancer at the pancreatic head!•• Not be performed with patients with:Not be performed with patients with:

•• Bulky tumors of the pancreatic headBulky tumors of the pancreatic head•• Duodenal tumors (1Duodenal tumors (1stst, 2, 2ndnd parts)parts)•• Lesions associated with grossly positive Lesions associated with grossly positive

pyloric/pyloric/peripyloricperipyloric lymph nodeslymph nodesMastery of Surgery, 5th ed-Chapter 113

SoSo……

•• Is the ppWhippleIs the ppWhipple•• Safe?Safe?•• Benefits?Benefits?•• Treatment?Treatment?

Safe?Safe?•• Early and late complications of pylorusEarly and late complications of pylorus--

preserving preserving pancreatoduodenectomypancreatoduodenectomy in Japan in Japan 1998.1998.

•• Yamaguchi K., et al. Yamaguchi K., et al. •• J J HepatobiliaryHepatobiliary PancreatPancreat SurgSurg 19991999•• Retrospective studyRetrospective study•• 74 Institutions74 Institutions•• 1066 patients with ppWhipple1066 patients with ppWhipple•• Analyzed early (within 1 month), and late (after 1 Analyzed early (within 1 month), and late (after 1

month) postoperative complicationsmonth) postoperative complications

Yamaguchi et al. 1999Yamaguchi et al. 1999Early Early complicationscomplications

# patients# patients # evaluated# evaluated Frequency (%)Frequency (%)

Delayed gastric Delayed gastric emptyingemptying 464464 10161016 4646PancreatojejunostomyPancreatojejunostomyleakageleakage 165165 10411041 1616IntraIntra--abdominal abdominal infectioninfection 142142 10551055 1414CholangitisCholangitis 9090 10141014 8.98.9Hepaticojejunostomy Hepaticojejunostomy leakageleakage 4949 10411041 4.74.7IntraIntra--abdominal abdominal hemorrhagehemorrhage 3636 10361036 3.53.5Upper GI hemorrhageUpper GI hemorrhage 3333 10331033 3.23.2Duodenojejunostomy Duodenojejunostomy leakageleakage 2121 10271027 2.02.0Operative mortalityOperative mortality 2323 955955 2.42.4

Yamaguchi et al. 1999Yamaguchi et al. 1999Late Late complicationscomplications

# patients# patients # evaluated# evaluated Frequency (%)Frequency (%)

Delayed gastric Delayed gastric emptyingemptying

215215 913913 2424

Stomal ulcerStomal ulcer 3434 940940 3.63.6

CholangitisCholangitis 6464 962962 6.76.7

Liver abscessLiver abscess 1212 982982 1.21.2

Safe?Safe?

••A literature review on cWhipple vs. ppWhipple in regards to DGEA literature review on cWhipple vs. ppWhipple in regards to DGE

••DGE Definition:DGE Definition:

••Inability to tolerate normal diet by 10Inability to tolerate normal diet by 10--14 days post14 days post--opop

••Inability to tolerate liquid diet by POD #7Inability to tolerate liquid diet by POD #7

••NGT in place for NGT in place for ≥≥ 10 days plus: emesis after NGT removal, 10 days plus: emesis after NGT removal, reinsertion of NGT, use of prokinetic after postreinsertion of NGT, use of prokinetic after post--op day 10, failure to op day 10, failure to progress with dietprogress with diet

ParaskevasParaskevas, et al. 2006, et al. 2006

Benefits?Benefits?

•• Multicenter, prospective RCTMulticenter, prospective RCT•• 170 pts with suspected 170 pts with suspected

pancreatic/pancreatic/periampullaryperiampullary tumortumor•• Randomized to Randomized to cWhipplecWhipple (83) or (83) or

ppWhippleppWhipple (87)(87)

Tran, et al. 2004Tran, et al. 2004cWhipple ppWhipple P-value

Intraop blood loss 2L 2L 0.70

Operative time 300 minutes 300 minutes 0.10

Intraop tranfusion 2 units 2 units 0.70

Hospital stay 20 days 18 days 0.488

Benefits?Benefits?

•• 130 pts randomized to 130 pts randomized to cWhipplecWhipple or or ppWhippleppWhipple

Seiler, et al. 2005Seiler, et al. 2005

Seiler, et al. 2005Seiler, et al. 2005

•No difference in weight gain •No difference in quality of life

Treatment?Treatment?

•• PancreatcoduodenectomyPancreatcoduodenectomy with pyloric with pyloric preservation for carcinoma of the preservation for carcinoma of the pancreas: a cautionary notepancreas: a cautionary note

•• Sharp KW, et al. Sharp KW, et al. Surgery Surgery 19891989•• Case study of 3 patients with Case study of 3 patients with cWhipplecWhipple::

•• 2 2 ww/ proximal, intramural, microscopic spread / proximal, intramural, microscopic spread of pancreatic tumor within the of pancreatic tumor within the duodenum/duodenum/antrumantrum

Sharp, et al.Sharp, et al.

•• ““The use of pylorusThe use of pylorus--sparing sparing pancreatoduodenectomy in resectable pancreatoduodenectomy in resectable pancreatic cancers must be viewed skepticallypancreatic cancers must be viewed skeptically””

Treatment?Treatment?

•• Adequate Adequate lymphadenectomylymphadenectomy•• LN along the lesser gastric curvature and LN along the lesser gastric curvature and

periperi--pyloric region are not removed in the pyloric region are not removed in the ppWhipple.ppWhipple.

Treatment?Treatment?

•• PylorusPylorus--preserving Whipple resection for preserving Whipple resection for pancreatic cancer. Is it any better?pancreatic cancer. Is it any better?

•• Patel A.G., et al. Arch Patel A.G., et al. Arch SurgSurg 19951995•• Retrospective review of 67 pts who had a Retrospective review of 67 pts who had a

WhippleWhipple•• 52 52 cWhipplecWhipple, 15 ppWhipple, 15 ppWhipple•• 5 LN in the ppWhipple group vs. 10 in the 5 LN in the ppWhipple group vs. 10 in the

cWhipplecWhipple groupgroup

ConclusionsConclusions

•• ppWhipple has serious complicationsppWhipple has serious complications•• It is a radical surgeryIt is a radical surgery

•• DGEDGE--still controversystill controversy•• ppWhipple does not have the benefits to ppWhipple does not have the benefits to

allow for aallow for a……•• Less adequate cancer operationLess adequate cancer operation

ReferencesReferences1) Cancer facts & figures 2009. American Cancer Society, Survei1) Cancer facts & figures 2009. American Cancer Society, Surveillance and Health Policy Research, llance and Health Policy Research,

2009.2009.2) Shore S, 2) Shore S, RaratyRaraty M, M, GhanehGhaneh P, P, NeoptolemosNeoptolemos J. Alimentary Pharmacology & J. Alimentary Pharmacology &

Therapeutics.Therapeutics. 2003;18(11).2003;18(11).3) Cameron, JL: Current status of the Whipple operation for 3) Cameron, JL: Current status of the Whipple operation for periampullaryperiampullary carcinoma. carcinoma. SurgSurg Rounds Rounds

7777--87, 1988.87, 1988.4) Fischer JE, et al. Mastery of Surgery 4) Fischer JE, et al. Mastery of Surgery --55thth Edition. Lippincott Williams & Wilkins. December 2006.Edition. Lippincott Williams & Wilkins. December 2006.5) Sharp KW, et al. 5) Sharp KW, et al. PancreatcoduodenectomyPancreatcoduodenectomy with pyloric preservation for carcinoma of the pancreas: with pyloric preservation for carcinoma of the pancreas:

a cautionary note. Surgery. 1989 May;105(5): 645a cautionary note. Surgery. 1989 May;105(5): 645--53.53.6) Seiler C.A., et al. Randomized clinical trial of pylorus6) Seiler C.A., et al. Randomized clinical trial of pylorus--preserving preserving duodenopancreatectomyduodenopancreatectomy versus versus

classical Whipple resectionclassical Whipple resection--long term results. British Journal of Surgery 2005;92:547long term results. British Journal of Surgery 2005;92:547--556.556.7) 7) SrinarmwongSrinarmwong C., et al. Standard WhippleC., et al. Standard Whipple’’s operation versus pylorus preserving s operation versus pylorus preserving

pancreaticoduodenectomypancreaticoduodenectomy: A randomized controlled trial study. J Med Assoc Thai 2008;9: A randomized controlled trial study. J Med Assoc Thai 2008;91:6931:693--698.698.

8) Patel A.G., et al. Pylorus8) Patel A.G., et al. Pylorus--preserving Whipple resection for pancreatic cancer. Is it any bpreserving Whipple resection for pancreatic cancer. Is it any better? etter? Arch Arch SurgSurg 1995 Aug;130(8):8381995 Aug;130(8):838--42.42.

9) Yamaguchi K., et al. Early and late complications of pylorus9) Yamaguchi K., et al. Early and late complications of pylorus--preserving preserving pancreatoduodenectomypancreatoduodenectomy in in Japan 1998. J Japan 1998. J HepatobiliaryHepatobiliary PancreatPancreat SurgSurg 1999;6:3031999;6:303--311.311.