THE OBITUARY OF THE PYLORUS-PRESERVING PANCREATODUODENECTOMY

Pancreatoduodenectomy is the treatment of choice for patients with benign and malignant disease of pancreatic head. Classic pancreatoduodenectomy was described by Whipple originally and included distal hemigastrectomy. Pylorus-preserving pancreatoduodenectomy (pylorus-preserving) was popularized in the late 1970s for benign disease and it included full preservation of the pylorus. However, delayed gastric emptying after pylorus-preserving is a frustrating complication. Its incidence varying from 19% to 61% in previous series and it results in discomfort, prolonged length of stay and increases the risk of respiratory complications. Delayed gastric emptying contributes to increased hospital costs and decreased quality of life. There has been no evidence from prospective studies and meta-analyses to indicate the superiority of pylorus preserving in terms of quality of life or delayed gastric emptying^2,4,5,7.

More recently, and mostly in Japan since the late 1990s, subtotal stomach-preserving pancreatoduodenectomy (stomach-preserving) in which the pyloric ring and 2 cm of the distal stomach only is removed with preservation of about 90% of the stomach has been performed for pancreatic head disease. This surgical procedure was associated with fewer postoperative complications. After stomach-preserving, many recent studies have been carried out comparing the two techniques^2,6,8. Subtotal stomach-preserving pancreatoduodenectomy was adopted in 2011 at the Department of Hepato-pancreatobiliary Surgery, Federal University of Maranhão, Brazil.

Delayed gastric emptying is a very important complication and needs to be minimized in patients who undergo pancreatoduodenectomy for malignant disease. Many factors were reported in the pathophysiology of this complication after pylorus-preserving. Pylorospasm caused by operative disruption of the vagal nervous system and vascular supply with antropyloric ischemia may play a main role^2,7,9. As for prophylactic management of pylorospasm due to denervation after pylorus-preserving, some operative technique has been described. The most common are: a) mechanical dilatation of the pylorus ring, b) pyloromyotomy, c) preservation of the right gastric artery, gastroduodenal artery and all innervation along the lesser curvature of the stomach and proximal duodenum, and d) low doses of erythromycin in the unfed period with preservation of the right gastric artery^2,7.