title: Whipple's pancreaticoduodenectomy: Surgical technique and perioperative clinical outcomes in a single center.
abstract: BACKGROUND
  Pancreatic cancer is the fourth cause of death from cancer in Western countries. The radical surgical resection is the only curative option for this pathology. The prevalence of this disease increases with age in population. The causes of pancreatic cancer are unknown, but we consider risk factors like smoke and tobacco usage, alcohol consumption coffee, history of diabetes or chronic pancreatitis. In this study we report our experience in the treatment of resectable pancreatic cancer and periampullary neoplasms with particular attention to evaluate the evolution of surgical technique and the clinical postoperative outcomes.
  
  
  METHODS
  In our Department between January 2010 and December 2014 we performed a total of 97 pancreaticoduodenectomy. We considered only resectable pancreatic cancer and periampullary neoplasms defined by absence of distant metastases, absence of local tumor extension to the celiac axis and hepatic artery as the lack of involvement of the superior mesenteric vasculature. None of these patients received neoadjuvant chemotherapy.
  
  
  RESULTS
  The mean age of these patients was 64.5 years. Jaundice was the commonest presenting symptom associated to anorexia and weight loss. The mean operative time was 295 min (± 55 min). The mean blood loss was 450 ml and median blood transfusion was 1 units. 12.1% of patients had an intra-abdominal complication. The commonest complication was Delayed Gastric Emptying responsable of increased length of hospital stay and readmission rate. Postoperative pancreatic fistula of grade C occurred in 4 patients. 2 patients developed a postpancreatectomy hemorrhage. Perioperative mortality was 4.1%.
  
  
  CONCLUSIONS
  Pancreaticoduodenectomy is a complex surgical technique and the associated high morbidity and mortality resulted in initial reluctance to adopt this surgery for the management of pancreatic and periampullary tumors. Surgical outcomes of pancreatic surgery are better at high-volume experienced center reporting mortality rates below 5%. We perform an end-to-side duct-to-mucosa pancreaticojejunostomy with routinely use of internal pancreatic stent. However no one technique has been shown to definitely be the solution to the problem of postoperative pancreatic fistula. At our center we have a reasonable volume and our data are comparable to literature data.
authors.affiliation: Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy. Electronic address: giorgio.romano@unipa.it.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Romano
authors.affiliation: Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy. Electronic address: antonino.agrusa@unipa.it.
authors.forename: Antonino
authors.initials: A
authors.lastname: Agrusa
authors.affiliation: Section of Radiology, Di.Bi.Me.F., University of Palermo, Italy. Electronic address: massimo.galia@unipa.it.
authors.forename: Massimo
authors.initials: M
authors.lastname: Galia
authors.affiliation: Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy. Electronic address: g.dibuono@libero.it.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Di Buono
authors.affiliation: Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy. Electronic address: chianetta83@libero.it.
authors.forename: Daniela
authors.initials: D
authors.lastname: Chianetta
authors.affiliation: Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy. Electronic address: vincenzosorce@me.com.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Sorce
authors.affiliation: Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy.
authors.forename: Leonardo
authors.initials: L
authors.lastname: Gulotta
authors.affiliation: Section of Radiology, Di.Bi.Me.F., University of Palermo, Italy. Electronic address: giuseppe.brancatelli@unipa.it.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Brancatelli
authors.affiliation: Department of General Surgery, Urgency and Organ Transplantation, University of Palermo, Via L. Giuffrè, 5, 90127, Palermo, Italy. Electronic address: gaspare.gulotta@unipa.it.
authors.forename: Gaspare
authors.initials: G
authors.lastname: Gulotta
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000379:methods; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy / Q000009:adverse effects; D010185:Pancreatic Fistula / Q000209:etiology; D010190:Pancreatic Neoplasms / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications / Q000209:etiology; D012307:Risk Factors
keywords: Clinical outcomes; Pancreatic cancer; Pancreaticoduodenectomy; Postoperative pancreatic fistula; Whipple procedure