Pylorus preservation pancreatectomy or not

Abstract

Pancreaticoduodenectomy (PD) is the treatment of choice for various benign and malignant tumors of the pancreatic head or the periampullary region, and the only hope for cure in patients with cancer at this side. While it has been associated with high morbidity and mortality rates in the last century, its centralization in specialized institutions together with refinements in the operative technique and better management of postoperative complications have made PD a standardized, safe procedure. Besides the classic Whipple procedure including distal gastrectomy, two variations of PD with or without pylorus resection, but preservation of the entire stomach in either procedure exist today. Pylorus-preserving PD has gained wide acceptance as standard procedure and is being performed by an increasing number of pancreatic surgeons.After its oncological adequacy was questioned initially, pylorus-preserving PD was shown to be equivalent to the classic Whipple procedure regarding tumor recurrence and long-term survival. Moreover, operation time and blood loss were shown to be reduced in the pylorus-preserving procedure and benefits in nutritional status and quality of life were observed. However, preservation of the pylorus has been suggested to result in an increased incidence of postoperative delayed gastric emptying (DGE). In this context, pylorus-resecting PD has become popular especially in Japan with the aim to prevent DGE by removal of the pylorus but preservation of the stomach. In contrast to positive results from early studies, latest high-quality randomized controlled trial (RCT) data show that pylorus resection does not reduce DGE compared to the pyloruspreserving operation. Non-superiority of pylorus resection was also confirmed in current meta-analysis on this topic. This article summarizes the existing evidence on PD with or without pylorus preservation and derives recommendations for daily practice.

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“…Surprisingly in the present cohort of patients with PD, the Whipple procedure was the most frequently used (53% of PDs). The Whipple procedure was the standard approach for PD for many years (2,36). However, pylorus-preserving PD was introduced to prevent post-antrectomy dumping syndrome and to better preserve on the long-term outcome the nutritional status of these patients, and gained wide acceptance today (36).…”

“…The Whipple procedure was the standard approach for PD for many years (2,36). However, pylorus-preserving PD was introduced to prevent post-antrectomy dumping syndrome and to better preserve on the long-term outcome the nutritional status of these patients, and gained wide acceptance today (36). The main drawback of a pyloruspreserving PD is the increased postoperative delayed gastric emptying rates, which is the most frequently reported complication after PD (36).…”

“…However, pylorus-preserving PD was introduced to prevent post-antrectomy dumping syndrome and to better preserve on the long-term outcome the nutritional status of these patients, and gained wide acceptance today (36). The main drawback of a pyloruspreserving PD is the increased postoperative delayed gastric emptying rates, which is the most frequently reported complication after PD (36). The results provided by current literature are inconclusive whether delayed gastric emptying rates are significantly different between the Whipple and pylorus-preserving PD (36).…”

“…The main drawback of a pyloruspreserving PD is the increased postoperative delayed gastric emptying rates, which is the most frequently reported complication after PD (36). The results provided by current literature are inconclusive whether delayed gastric emptying rates are significantly different between the Whipple and pylorus-preserving PD (36). Furthermore, to overcome both drawbacks of antrectomy and pylorus preservation, more recently, the pylorus-resecting PD was proposed (36).…”

“…The results provided by current literature are inconclusive whether delayed gastric emptying rates are significantly different between the Whipple and pylorus-preserving PD (36). Furthermore, to overcome both drawbacks of antrectomy and pylorus preservation, more recently, the pylorus-resecting PD was proposed (36). Initially, the pylorus-resecting PD appears to have significantly reduced delayed gastric emptying rates compared with pyloruspreserving PD; however, more recent data have shown no significant differences between the two surgical techniques (36).…”