Resection of the Pancreatic Head

Abstract

Resection of the head of the pancreas is one of the most challenging operations in abdominal surgery; an often difficult dissection is followed by a complex reconstruction. Proximal pancreatectomy, as first described by Whipple et al. (1935), was a conservative operation removing only a limited portion of the pancreas and a short segment of the duodenum. The problem of the pancreatic duct was solved by ligation and reimplantation was not attempted. When the procedure had been proved feasible, it entered a radical phase and within two years Brunschwig (1937) developed an operation involving resection of the entire duodenum and a Polya-type gastric anastomosis. The subsequent high incidence of anastomotic ulceration (17%) that followed this procedure led to more extensive gastric resections, and hemigastrectomy became an integral part of any pancreatoduodenectomy (Warren et al. 1962). Although a wide clearance may be important in the treatment of pancreatic cancer, it is unnecessary if the resection is performed for localised neoplasia or benign disease. Watson (1944) performed the first pylorus-preserving pancreatoduodenectomy but this option was ignored, although the patient survived for 15 years. The procedure was revived in 1978 by Traverso and Longmire for benign disease and is now also widely used in the treatment of localised malignancy (Braasch et al. 1984; Cooper and Williamson 1985). More recently, newer procedures have been described which aim to remove the head of the pancreas without the loss of the duodenum and hence maintain gastrointestinal continuity (Beger et al. 1985; Frey and Smith 1987; Lambert et al. 1987).