title: Pancreaticoduodenectomy: a comparison of superior approach with classical Whipple's technique.
abstract: BACKGROUND
  Pancreaticoduodenectomy (PD) is the standard procedure for resecting tumors arising from the periampullary area and the pancreatic head. Nevertheless this procedure is inherently difficult and associated with high morbidity and mortality. Besides, the technique applied for exposing the portal and superior mesenteric veins is time-consuming, difficult and associated with the risk of major venous injury. Recently we have introduced a modified approach for making this part of the procedure quick, safe and bloodless, which constitutes the subject of this study.
  
  
  METHODS
  Patients who underwent pylorus preserving pancreaticoduodenectomy (PPPD) either by superior approach technique (group 1) or by classical Whipple's technique (group 2) were retrospectively identified. Age-sex composition, body mass index (BMI), total operative time, operative blood loss, intraoperative blood transfusion requirement, morbidity, mortality and length of hospital stay were compared between the two groups.
  
  
  RESULTS
  Between January 1997 and December 2011, 72 patients underwent PPPD by the superior approach technique (group 1) and 38 underwent PPPD by the classical Whipple's technique (group 2) at our institution. Statistically significant differences were observed in operative time (208.1+/-46.3 minutes in group 1 vs 322.0+/-33.8 minutes in group 2), operative blood loss (601.0+/-250.3 mL in group 1 vs 1371.5+/-471.8 mL in group 2), and intraoperative blood transfusion requirement [10 (13.9%) patients in group 1 and 24 (63.2%) in group 2]. Among 18 (16.4%) obese patients, significant differences in operative time, operative blood loss and intraoperative blood transfusion requirement were observed between groups 1 and 2. There was no significant inter-group difference in complication rate among obese patients, but comparing obese patients with normal weight patients revealed higher rates of complications like pancreatic fistula (27.8% vs 6.5%), delayed gastric emptying (16.7% vs 5.4%), and infective complications like wound infection and intra abdominal collection (44.4% vs 5.4%).
  
  
  CONCLUSIONS
  On the basis of analytical data, we conclude that the superior approach technique is effective for PD compared with the classical Whipple's technique. It allows fast, safe and virtually bloodless dissection for exposure of the superior mesenteric and portal veins during early steps of PD. PD is normally a difficult and tedious procedure carrying a remote risk of major venous injury leading to substantial blood loss.
authors.affiliation: Department of Surgical Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India. omarjshah@yahoo.com
authors.forename: Omar Javed
authors.initials: OJ
authors.lastname: Shah
authors.forename: Mushtaq A
authors.initials: MA
authors.lastname: Gagloo
authors.forename: Irfan Jan
authors.initials: IJ
authors.lastname: Khan
authors.forename: Rayees
authors.initials: R
authors.lastname: Ahmad
authors.forename: Saleema
authors.initials: S
authors.lastname: Bano
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical / Q000517:prevention & control; D001803:Blood Transfusion; D015992:Body Mass Index; D016009:Chi-Square Distribution; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008642:Mesenteric Veins / Q000601:surgery; D008875:Middle Aged; D009765:Obesity / Q000150:complications / Q000175:diagnosis; D010190:Pancreatic Neoplasms / Q000150:complications / Q000473:pathology / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D011169:Portal Vein / Q000601:surgery; D011183:Postoperative Complications / Q000209:etiology; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome