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Surgical Procedure Steps and Key Points: Whipple Procedure, Enucleations, and Management of Complications

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Endocrine Surgery Comprehensive Board Exam Guide

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Abstract

The scope of this chapter will serve to introduce the basic knowledge of pancreatic pathologies that warrant surgical resection of the head of pancreas and enucleation with a focus on neuroendocrine neoplasm. The surgical technique of a Whipple procedure has evolved over the decades since its popularization in the 1930s; routine basic steps dictated by most common anatomical variants are relayed in this chapter with focus on critical steps in surgical technique. The feasibility and role of minimally invasive surgery in pancreaticoduodenectomies (laparoscopic and robotic approaches) is discussed with evidence from most recent peer-reviewed literature. Finally, the most common surgical complications such as delayed gastric emptying (DGE) and post-operative pancreatic fistula (POPF) related to pancreatic head resection as well as methods of prevention and management are discussed with highlights of the most recent advances in the field.

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References

  1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424. https://doi.org/10.3322/caac.21492.

    Article  PubMed  Google Scholar 

  2. Nagtegaal ID, Odze RD, Klimstra D, et al. The 2019 WHO classification of tumours of the digestive system. Histopathology. 2020;76(2):182–8. https://doi.org/10.1111/his.13975.

    Article  PubMed  Google Scholar 

  3. Torphy RJ, Friedman C, Halpern A, et al. Comparing short-term and oncologic outcomes of minimally invasive versus open pancreaticoduodenectomy across low and high volume centers. Ann Surg. 2019;270(6):1147–55. https://doi.org/10.1097/SLA.0000000000002810.

    Article  PubMed  Google Scholar 

  4. Lidsky ME, Sun Z, Nussbaum DP, Adam MA, Speicher PJ, Blazer DG. Going the extra mile. Ann Surg. 2017;266(2):333–8. https://doi.org/10.1097/SLA.0000000000001924.

    Article  PubMed  Google Scholar 

  5. Cui SJ, Tang TY, Zou XW, Su QM, Feng L, Gong XY. Role of imaging biomarkers for prognostic prediction in patients with pancreatic ductal adenocarcinoma. Clin Radiol. 2020;75(6):478.e1–478.e11. https://doi.org/10.1016/j.crad.2019.12.023.

    Article  Google Scholar 

  6. Kitano M, Yoshida T, Itonaga M, Tamura T, Hatamaru K, Yamashita Y. Impact of endoscopic ultrasonography on diagnosis of pancreatic cancer. J Gastroenterol. 2019;54(1):19–32. https://doi.org/10.1007/s00535-018-1519-2.

    Article  PubMed  Google Scholar 

  7. Krishna SG, Rao BB, Ugbarugba E, et al. Diagnostic performance of endoscopic ultrasound for detection of pancreatic malignancy following an indeterminate multidetector CT scan: a systemic review and meta-analysis. Surg Endosc. 2017;31(11):4558–67. https://doi.org/10.1007/s00464-017-5516-y.

    Article  PubMed  Google Scholar 

  8. Wang KX, Ben QW, Jin ZD, et al. Assessment of morbidity and mortality associated with EUS-guided FNA: a systematic review. Gastrointest Endosc. 2011;73(2):283–90. https://doi.org/10.1016/j.gie.2010.10.045.

    Article  PubMed  Google Scholar 

  9. Shen Z, Zhang J, Chen H, et al. Does pre-operative biliary drainage influence Long-term survival in patients with obstructive jaundice with resectable pancreatic head cancer? Front Oncol. 2020;10(September):1–9. https://doi.org/10.3389/fonc.2020.575316.

    Article  CAS  Google Scholar 

  10. Furukawa K, Onda S, Hamura R, et al. Predictive factors and surgical outcomes of stent dysfunction after preoperative endoscopic biliary stenting in patients who underwent pancreaticoduodenectomy. J Laparoendosc Adv Surg Tech. 2020;30(3):256–9. https://doi.org/10.1089/lap.2019.0666.

    Article  Google Scholar 

  11. Manyak K, Kasi A. Octreotide Scan. StatPearls Publishing; 2020.

    Google Scholar 

  12. Bauckneht M, Albano D, Annunziata S, et al. Somatostatin receptor PET/CT imaging for the detection and staging of pancreatic NET: a systematic review and meta-analysis. Diagnostics. 2020;10(8):80–97. https://doi.org/10.3390/diagnostics10080598.

    Article  Google Scholar 

  13. Takadate T, Morikawa T, Ishida M, et al. Staging laparoscopy is mandatory for the treatment of pancreatic cancer to avoid missing radiologically negative metastases. Surg Today. 2020;0123456789 https://doi.org/10.1007/s00595-020-02121-4.

  14. Yamamura K, Yamashita YI, Yamao T, et al. Efficacy of staging laparoscopy for pancreatic cancer. Anticancer Res. 2020;40(2):1023–7. https://doi.org/10.21873/anticanres.14037.

    Article  Google Scholar 

  15. Ta R, O’Connor DB, Sulistijo A, Chung B, Conlon KC. The role of staging laparoscopy in resectable and borderline resectable pancreatic cancer: a systematic review and meta-analysis. Dig Surg. 2019;36(3):251–60. https://doi.org/10.1159/000488372.

    Article  PubMed  Google Scholar 

  16. Cheng Y, Sun Z, Bai C, et al. Serum chromogranin A levels for the diagnosis and follow-up of well-differentiated non-functioning neuroendocrine tumors. Tumor Biol. 2016;37(3):2863–9. https://doi.org/10.1007/s13277-015-4114-7.

    Article  CAS  Google Scholar 

  17. Zhang C, Huang Y, Long J, et al. Serum chromogranin a for the diagnosis of gastroenteropancreatic neuroendocrine neoplasms and its association with tumour expression. Oncol Lett. 2019;17(2):1497–504. https://doi.org/10.3892/ol.2018.9795.

    Article  CAS  PubMed  Google Scholar 

  18. Cameron JL, Cameron AM. Current surgical therapy. 13th ed. Elsevier Inc.; 2020.

    Google Scholar 

  19. Heidsma CM, Tsilimigras DI, van Dieren S, et al. Indications and outcomes of enucleation versus formal pancreatectomy for pancreatic neuroendocrine tumors. HPB. 2020; https://doi.org/10.1016/j.hpb.2020.06.015.

  20. Nickel F, Haney CM, Kowalewski KF, et al. Laparoscopic versus open pancreaticoduodenectomy: a systematic review and meta-analysis of randomized controlled trials. Ann Surg. 2020;271(1):54–66. https://doi.org/10.1097/SLA.0000000000003309.

    Article  PubMed  Google Scholar 

  21. Snyder RA, Ewing JA, Parikh AA. Delayed gastric emptying after pancreaticoduodenectomy: a study of the national surgical quality improvement program: delayed gastric emptying after pancreaticoduodenectomy. Pancreatology. 2020;20(2):205–10. https://doi.org/10.1016/j.pan.2019.12.003.

    Article  PubMed  Google Scholar 

  22. Cai X, Zhang M, Liang C, Xu Y, Yu W. Delayed gastric emptying after Pancreaticoduodenectomy: a propensity score-matched analysis and clinical nomogram study. BMC Surg. 2020;20(1):1–9. https://doi.org/10.1186/s12893-020-00809-5.

    Article  Google Scholar 

  23. El Khoury R, Kabir C, Maker VK, Banulescu M, Wasserman M, Maker AV. Do drains contribute to pancreatic fistulae? Analysis of over 5000 pancreatectomy patients. J Gastrointest Surg. 2018;22(6):1007–15. https://doi.org/10.1007/s11605-018-3702-4.

    Article  PubMed  Google Scholar 

  24. Addison P, Nauka PC, Fatakhova K, Amodu L, Kohn N, Rodriguez Rilo HL. Impact of drain placement and duration on outcomes after pancreaticoduodenectomy: a National Surgical Quality Improvement Program Analysis. J Surg Res. 2019;243:100–7. https://doi.org/10.1016/j.jss.2019.04.071.

    Article  PubMed  Google Scholar 

  25. Triantafyllidis I, Gayet B, Fuks D. Tips and tricks for a safe laparoscopic pancreatoduodenectomy. Wideochirurgia I Inne Tech Maloinwazyjne. 2020;15(3):383–90. https://doi.org/10.5114/wiitm.2020.97977.

    Article  Google Scholar 

  26. Qin R, Kendrick ML, Wolfgang CL, et al. International expert consensus on laparoscopic pancreaticoduodenectomy*. Hepatobil Surg Nutr. 2020;9(4):464–483. https://doi.org/10.21037/hbsn-20-446.

    Article  Google Scholar 

  27. Baimas-George M, Watson M, Murphy KJ, et al. Robotic pancreaticoduodenectomy may offer improved oncologic outcomes over open surgery: a propensity-matched single-institution study. Surg Endosc. 2020;34(8):3644–9. https://doi.org/10.1007/s00464-020-07564-x.

    Article  PubMed  Google Scholar 

  28. Kamarajah SK, Gujjuri R, Bundred JR, Hilal MA, White SA. Long-term survival after minimally invasive resection versus open pancreaticoduodenectomy for periampullary cancers: a systematic review, meta-analysis and meta-regression. HPB. 2020; https://doi.org/10.1016/j.hpb.2020.09.023.

  29. Miyauchi Y, Furukawa K, Suzuki D, et al. Additional effect of perioperative, compared with preoperative, immunonutrition after pancreaticoduodenectomy: a randomized, controlled trial. Int J Surg. 2019;61(November 2018):69–75. https://doi.org/10.1016/j.ijsu.2018.11.028.

    Article  PubMed  Google Scholar 

  30. Lawrence SA, McIntyre CA, Pulvirenti A, et al. Perioperative bundle to reduce surgical site infection after pancreaticoduodenectomy: a prospective cohort study. J Am Coll Surg. 2019;228(4):595–601. https://doi.org/10.1016/j.jamcollsurg.2018.12.018.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Wang XY, Cai JP, Huang CS, Huang XT, Yin XY. Impact of enhanced recovery after surgery protocol on pancreaticoduodenectomy: a meta-analysis of non-randomized and randomized controlled trials. HPB. 2020;22(10):1373–83. https://doi.org/10.1016/j.hpb.2020.07.001.

    Article  PubMed  Google Scholar 

  32. Sun YM, Wang Y, Mao YX, Wang W. The safety and feasibility of enhanced recovery after surgery in patients undergoing pancreaticoduodenectomy: an updated meta-analysis. Biomed Res Int. 2020;2020 https://doi.org/10.1155/2020/7401276.

  33. Brown JA, Zenati MS, Simmons RL, et al. Long-term surgical complications after pancreatoduodenectomy: incidence, outcomes, and risk factors. J Gastrointest Surg. 2020;24(7):1581–9. https://doi.org/10.1007/s11605-020-04641-3.

    Article  PubMed  Google Scholar 

  34. Mentor K, Ratnayake B, Akter N, et al. Meta-analysis and meta-regression of risk factors for surgical site infections in hepatic and pancreatic resection. World J Surg. 2020;44(12):4221–30. https://doi.org/10.1007/s00268-020-05741-6.

    Article  PubMed  Google Scholar 

  35. Ecker BL, McMillan MT, Asbun HJ, et al. Characterization and optimal management of high-risk pancreatic anastomoses during pancreatoduodenectomy. Ann Surg. 2018;267(4):608–16. https://doi.org/10.1097/SLA.0000000000002327.

    Article  PubMed  Google Scholar 

  36. Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery (United States). 2017;161(3):584–91. https://doi.org/10.1016/j.surg.2016.11.014.

    Article  Google Scholar 

  37. Topal B, Fieuws S, Aerts R, Weerts J, Feryn T. Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours: a multicentre randomised trial. Lancet Oncol. 2013;14:655.

    Article  Google Scholar 

  38. Grendar J, Ouellet JF, Sutherland FR, Bathe OF, Ball CG, Dixon E. In search of the best reconstructive technique after pancreaticoduodenectomy: Pancreaticojejunostomy versus pancreaticogastrostomy. Can J Surg. 2015;58(3):154–9. https://doi.org/10.1503/cjs.010014.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Kawaida H, Kono H, Hosomura N, et al. Surgical techniques and postoperative management to prevent postoperative pancreatic fistula after pancreatic surgery. World J Gastroenterol. 2019;25(28):3722–37. https://doi.org/10.3748/wjg.v25.i28.3722.

    Article  PubMed  PubMed Central  Google Scholar 

  40. McMillan MT, Ecker BL, Behrman SW, et al. Externalized stents for pancreatoduodenectomy provide value only in high-risk scenarios. J Gastrointest Surg. 2016;20(12):2052–62. https://doi.org/10.1007/s11605-016-3289-6.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Sami Shoucair

  2. Departments of Surgery, Oncology, and Pathology, The Pancreatic Cancer Precision Medicine Center of Excellence, The Sidney Kimmel Cancer Center at Johns Hopkins, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Christopher Wolfgang

Authors
  1. Sami Shoucair
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  2. Christopher Wolfgang
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Corresponding author

Correspondence to Christopher Wolfgang .

Editor information

Editors and Affiliations

  1. Department of Surgery, Jersey Shore University Medical Center, Neptune, NJ, USA

    Alexander L. Shifrin

  2. Division of Endocrine and Metabolic Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy

    Marco Raffaelli

  3. The Claire and John Bertucci Endowed Chair in Thyroid Surgical Oncology, Harvard Medical School, Boston, MA, USA

    Gregory W. Randolph

  4. Department of Surgery, Linköping University, Linköping, Sweden

    Oliver Gimm

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Shoucair, S., Wolfgang, C. (2021). Surgical Procedure Steps and Key Points: Whipple Procedure, Enucleations, and Management of Complications. In: Shifrin, A.L., Raffaelli, M., Randolph, G.W., Gimm, O. (eds) Endocrine Surgery Comprehensive Board Exam Guide. Springer, Cham. https://doi.org/10.1007/978-3-030-84737-1_31

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  • DOI: https://doi.org/10.1007/978-3-030-84737-1_31

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  • Online ISBN: 978-3-030-84737-1

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