Pylorus-Preserving Pancreaticoduodenectomy for Pancreatic Cancer: How I Do It

  • Norbert HüserEmail author
  • Volker Aßfalg
  • Matthias Maak
  • Helmut Friess


Pylorus-preserving partial pancreaticoduodenectomy is considered to be one of the most demanding and comprehensive operative procedures in visceral surgery and is usually performed for malignant lesions of the pancreatic head, the distal bile duct, or the duodenum. Numerous modalities of this procedure, which can be structurally divided into exploration, resection, and reconstruction, have been defined. The particularly determining relevance of postoperative pancreatic fistulas probably causes the outstanding key role of the pancreatic (duct) anastomosis during the procedure, which led to multitudinous clinical and experimental studies aiming for the best anastomotic technique. This chapter describes the procedure of the pylorus-preserving pancreaticoduodenectomy as performed at our center, illustrates the distinct operative phases with detailed pictures, and puts special emphasis on both the pancreatic and the biliodigestive anastomoses with clear drawings.



Biliodigestive anastomosis


Intraductal papillary mucinous neoplasm


Polydioxanone suture




Pylorus-preserving pancreaticoduodenectomy


Superior mesenteric artery


Superior mesenteric vein


  1. 1.
    Huttner FJ, Fitzmaurice C, Schwarzer G, Seiler CM, Antes G, Buchler MW, et al. Pylorus-preserving pancreaticoduodenectomy (pp Whipple) versus pancreaticoduodenectomy (classic Whipple) for surgical treatment of periampullary and pancreatic carcinoma. Cochrane Database Syst Rev. 2016;2:CD006053.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Seiler CA, Wagner M, Bachmann T, Redaelli CA, Schmied B, Uhl W, et al. Randomized clinical trial of pylorus-preserving duodenopancreatectomy versus classical Whipple resection-long term results. Br J Surg. 2005;92(5):547–56.CrossRefPubMedCentralPubMedGoogle Scholar
  3. 3.
    Sutton CD, Garcea G, White SA, O'Leary E, Marshall LJ, Berry DP, et al. Isolated Roux-loop pancreaticojejunostomy: a series of 61 patients with zero postoperative pancreaticoenteric leaks. J Gastrointest Surg. 2004;8(6):701–5.CrossRefPubMedCentralPubMedGoogle Scholar
  4. 4.
    Bassi C, Falconi M, Molinari E, Mantovani W, Butturini G, Gumbs AA, et al. Duct-to-mucosa versus end-to-side pancreaticojejunostomy reconstruction after pancreaticoduodenectomy: results of a prospective randomized trial. Surgery. 2003;134(5):766–71.CrossRefPubMedCentralPubMedGoogle Scholar
  5. 5.
    Wente MN, Shrikhande SV, Muller MW, Diener MK, Seiler CM, Friess H, et al. Pancreaticojejunostomy versus pancreaticogastrostomy: systematic review and meta-analysis. Am J Surg. 2007;193(2):171–83.CrossRefPubMedCentralPubMedGoogle Scholar
  6. 6.
    Bassi C, Falconi M, Molinari E, Salvia R, Butturini G, Sartori N, et al. Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: results of a comparative study. Ann Surg. 2005;242(6):767–71; discussion 71-3.CrossRefPubMedCentralPubMedGoogle Scholar
  7. 7.
    Jacob DA, Bahra M, Langrehr JM. Jejunal loop drainage versus direct pancreatic duct drainage after pancreatic head resection. Surg Today. 2006;36(10):898–907.CrossRefPubMedCentralPubMedGoogle Scholar
  8. 8.
    Tani M, Kawai M, Hirono S, Ina S, Miyazawa M, Shimizu A, et al. A prospective randomized controlled trial of internal versus external drainage with pancreaticojejunostomy for pancreaticoduodenectomy. Am J Surg. 2010;199(6):759–64.CrossRefPubMedCentralPubMedGoogle Scholar
  9. 9.
    Pessaux P, Sauvanet A, Mariette C, Paye F, Muscari F, Cunha AS, et al. External pancreatic duct stent decreases pancreatic fistula rate after pancreaticoduodenectomy: prospective multicenter randomized trial. Ann Surg. 2011;253(5):879–85.CrossRefPubMedCentralPubMedGoogle Scholar
  10. 10.
    Su AP, Cao SS, Zhang Y, Fu L, Zhang ZD, Hu WM, et al. Does internal stenting for pancreaticojejunostomy decrease the rate of pancreatic fistula following pancreatic resections? A meta-analysis. Hepatogastroenterology. 2013;60(121):191–6.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Zhou Y, Zhou Q, Li Z, Chen R. Internal pancreatic duct stent does not decrease pancreatic fistula rate after pancreatic resection: a meta-analysis. Am J Surg. 2013;205(6):718–25.CrossRefPubMedCentralPubMedGoogle Scholar
  12. 12.
    Traverso LW, Longmire WP Jr. Preservation of the pylorus in pancreaticoduodenectomy. Surg Gynecol Obstet. 1978;146(6):959–62.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Carcinoma WK. of ampulla of vater successful radical resection. Br J Surg. 1944;31:368–73.CrossRefGoogle Scholar
  14. 14.
    Assfalg V, Huser N, Michalski C, Gillen S, Kleeff J, Friess H. Palliative interventional and surgical therapy for unresectable pancreatic cancer. Cancers (Basel). 2011;3(1):652–61.CrossRefGoogle Scholar
  15. 15.
    Huser N, Michalski CW, Schuster T, Friess H, Kleeff J. Systematic review and meta-analysis of prophylactic gastroenterostomy for unresectable advanced pancreatic cancer. Br J Surg. 2009;96(7):711–9.CrossRefPubMedCentralPubMedGoogle Scholar
  16. 16.
    Mihaljevic AL, Schirren R, Ozer M, Ottl S, Grun S, Michalski CW, et al. Multicenter double-blinded randomized controlled trial of standard abdominal wound edge protection with surgical dressings versus coverage with a sterile circular polyethylene drape for prevention of surgical site infections: a CHIR-Net trial (BaFO; NCT01181206). Ann Surg. 2014;260(5):730–7; discussion 7–9.CrossRefPubMedCentralPubMedGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2018

Authors and Affiliations

  • Norbert Hüser
    • 1
    Email author
  • Volker Aßfalg
    • 1
  • Matthias Maak
    • 2
  • Helmut Friess
    • 1
  1. 1.Department of SurgeryKlinikum rechts der Isar, Technische Universität MünchenMunichGermany
  2. 2.Department of SurgeryUniversitätsklinikum ErlangenErlangenGermany

Personalised recommendations