Preservation of the Duodenum in Total Pancreatectomy for Chronic Pancreatitis

Abstract

The surgical options in the management of pancreatic disease are limited by the macroscopic disease which the surgeon faces as he assesses the pancreas during the initial laparotomy in conjunction with the pre-operative investigations. There is no procedure suitable for all patients and there are only a few patients suitable for duodenal preservation either as part of a resection of the head or as part of total ablation of the pancreas. The interest shown in preservation procedures such as the Beger operation (Büchler, this volume), the Frey procedure (Frey, this volume), the pylorus-preserving operations (Traverso, this volume) is indicative of the importance of preserving pancreatic function. The need to preserve as much duodenum as possible has arisen because the technical challenges of pancreatic surgery have largely been overcome with a very low morbidity and mortality [14], with the result that surgeons are now becoming more aware of the long-term implications of the ablation of the pancreas. On purely physiological grounds many feel that preserving the pylorus and if possible, as much duodenum as possible will give a better long-term result [13]. Preserving the duodenum should preserve gastric emptying, duodenal and small intestinal motility and bile mixing by preserving the hormonal release from the antrum and duodenum, and maintaining the antropyloric emptying mechanism as well as the duodenal pacemaker with coordinate duodenal and jejunal contractions as a result of the undisturbed myenteric plexus.