Pancreatoduodenectomy with preservation of the pylorus and gastroduodenal artery

Objective The authors evaluated the rationale for and feasibility of gastroduodenal artery preservation in pylorus-preserving pancreatoduodenectomy (PPPD) for periampullary cancer in which the pancreatic remnant maintains a normal function and morphologic characteristics. Summary Background Data Pylorus-preserving pancreatoduodenectomy has become one of the standard treatments used for benign and malignant diseases of the pancreatoduodenal region, surpassing ordinary pancreatoduodenectomy in terms of technical ease, mortality rate, and postoperative nutrition. Pylorus-preserving pancreatoduodenectomy is usually associated with gastroduodenal artery division, which presents potential risks of insufficient duodenal vascularity and lethal postoperative bleeding from the gastroduodenal artery stump. The latter complication particularly occurs after resection of bile duct or ampullary cancer in a patient whose pancreas remains functionally and morphologically normal to have much more pancreatic secretion than the fibrotic pancreas seen in pancreatic cancer. According to the authors' data on the volume of secretion from the residual pancreas via a stent tube after pancreatoduodenectomy, the sclerotic pancreas, as seen in cancer of the pancreatic head, secretes only 20 to 50 mL/day, whereas the secretion from the soft pancreas, as seen in bile duct cancer, amounts to 300 to 600 mL/day, even during the period of nothing by mouth. Methods Retrospectively, we made a histopathologic study of eight specimens of distal bile duct and ampullary cancer resected by pancreatoduodenectomy or PPPD with gastroduodenal artery division. Prospectively, we performed gastroduodenal artery-preserving PPPD for 10 patients with distal bile duct, ampullary, and islet cell cancers. Results The histopathologic study revealed no invasion or metastasis around the gastroduodenal artery. Clinical application of gastroduodenal artery-preserving PPPD showed no technical difficulty, and neither severe complications nor recurrence around the gastroduodenal artery were observed for up to 22 months after surgery. Conclusions Gastroduodenal artery-preserving PPPD might be recommended as a safe procedure for patients who have a functionally and morphologically normal pancreas.