From the Guidelines
A pylorus preserving Whipple procedure involves several key steps, including mobilization of the duodenum, division of the gastrocolic ligament, removal of the gallbladder, and division of the common bile duct, while preserving the pylorus and 1-2 cm of proximal duodenum. The procedure begins with opening and exploring the abdomen to confirm resectability, as described in guidelines for pancreatic cancer management 1. The steps involved in the procedure include:
- Mobilization of the duodenum through a Kocher maneuver
- Division of the gastrocolic ligament to access the pancreas
- Removal of the gallbladder
- Division of the common bile duct above the pancreas
- Preservation of the pylorus and 1-2 cm of proximal duodenum by dividing the duodenum 2-3 cm distal to the pylorus
- Transection of the pancreatic neck at the level of the portal vein
- Division of the proximal jejunum about 10-15 cm from the ligament of Treitz
- Removal of the specimen (pancreatic head, duodenum, distal bile duct) en bloc
- Reconstruction involving three anastomoses: pancreaticojejunostomy, hepaticojejunostomy, and duodenojejunostomy, as outlined in guidelines for the management of patients with pancreatic cancer periampullary and ampullary carcinomas 1.
The pylorus-preserving approach aims to improve gastric emptying and nutritional outcomes while maintaining the oncologic principles of the standard Whipple procedure, with potential advantages including a reduction in post-gastrectomy complications, entero-gastric reflux, and improved postoperative nutritional status and weight gain 1. However, the potential drawbacks of the pylorus-preserving operation, such as tumour involvement of the duodenal resection line and incomplete removal of regional lymph nodes, can be obviated by patient selection, as noted in the guidelines for pancreatic cancer management 1. Postoperatively, patients require close monitoring for complications such as pancreatic fistula, delayed gastric emptying, and hemorrhage.
From the Research
Steps of a Pylorus Preserving Whipple
The steps of a pylorus preserving Whipple procedure are not explicitly outlined in the provided studies. However, the following general information about the procedure can be gathered:
- The pylorus preserving Whipple procedure is a type of pancreaticoduodenectomy that preserves the pylorus, a part of the stomach [ 2, 3, 4, 5, 6 ].
- The procedure involves the resection of the pancreatic head, duodenum, and other surrounding tissues, while preserving the pylorus [ 2, 3, 4, 5, 6 ].
- The goal of the procedure is to remove the tumor or diseased tissue while preserving as much of the stomach and digestive function as possible [ 2, 3, 4, 5, 6 ].
Key Considerations
Some key considerations for the pylorus preserving Whipple procedure include:
- The procedure can be performed with a low postoperative mortality rate, provided that the pancreatic and biliary anastomoses are constructed correctly [ 6 ].
- The procedure may be associated with a higher incidence of delayed gastric emptying, although this is not universally agreed upon [ 3, 5 ].
- The procedure can provide satisfactory survival rates and relief of pain for patients with periampullary cancer and chronic pancreatitis [ 6 ].
Comparison to Standard Whipple Procedure
The pylorus preserving Whipple procedure is often compared to the standard Whipple procedure, which involves the removal of the pylorus. Some key differences between the two procedures include:
- Operating time and intraoperative blood loss may be reduced in the pylorus preserving Whipple procedure [ 3, 4 ].
- The incidence of delayed gastric emptying may be higher in the pylorus preserving Whipple procedure, although this is not universally agreed upon [ 3, 5 ].
- The overall survival rates and disease-free survival rates may be comparable between the two procedures [ 2, 3, 5 ].