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Pancreaticoduodenectomy
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Perhaps one of the most technically challenging abdominal surgeries, pancreatectomy has evolved from a bold innovative intervention to a well-refined lifesaving procedure over the past decades. Pancreatectomy is, however, associated with a long history of high mortality and morbidity. In 1899, William S. Halsted performed the first successful resection of ampullary carcinoma through a transduodenal approach at Johns Hopkins Hospital. In this surgery, he reimplanted the common bile duct and pancreatic duct onto the duodenum, but did not resect the head of pancreas. The first true pancreatectomy did not occur until 1912, when the German surgeon Walther Carl Eduard Kausch performed the first two-stage pancreaticoduodenectomy with an en bloc resection of the head of pancreas for ampullary carcinoma. Mortality was as high as 25%, and mostly resulted from postoperative hemorrhage, peritonitis, and pancreatic fistula.
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The transduodenal approach to pancreatectomy continued to be the approach of choice until 1935. In that year, Allen O. Whipple from Columbia University published his first three cases of the two-stage pancreaticoduodenectomy for ampullary carcinoma (Whipple et al., 1935). Whipple described oversewing the pancreatic stump in order to avoid disruption of the pancreaticojejunostomy. Of the three patients in this report, one died during the immediate postoperative period, one died of anastomotic leak a few months later, and the other suffered from pancreatic fistula but survived. Whipple later modified the pancreaticoduodenectomy into a one-stage procedure. Alexander Brunschwig from the University of Chicago is credited, though, as the first to perform a one-stage procedure to resect a pancreatic head cancer. In 1941, Whipple reported his experience with 41 cases of pancreaticoduodenectomy, emphasizing the importance of one-stage procedure to avoid inflammatory adhesions from a two-stage resection along with an end-to-side choledochojejunostomy and jejunojejunostomy for prevention of reflux cholangitis (Whipple, 1941).
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From the 1940s to the early 1970s, the mortality from pancreaticoduodenectomy remained at least 25% in most series. The one exception was a report by Dr. John M. Howard in 1968, in which 41 cases of pancreaticoduodenectomy were performed without any mortality at the Hahnemann Hospital (Howard, 1968). With the advent of preoperative risk stratification improved imaging, high-volume pancreatic surgery centers, and interventional radiology, the mortality has decreased significantly, to below <2%. In 1990, Dr. Michael Trede from Heidelberg published the experience of 118 consecutive pancreaticoduodenectomies without mortality (Trede et al., 1990). In 1997, Charles Yeo et al. published the experience at Johns Hopkins Hospital with 650 pancreaticoduodenectomies and an overall mortality of 1.4%. Despite these improvements in mortality and the expansion of the indications for a variety of pathologies, the morbidity remains high to this day, ranging from 25% to 45% at most centers. These complications include pancreatic fistula (PF), delayed gastric emptying (DGE), post-pancreatectomy hemorrhage (PPH), biliary leaks, and pancreatic insufficiency. General complications nonspecific to pancreatectomy such as wound infections, sepsis, cardiac and pulmonary events, and renal failure have significantly decreased.