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The aborted Whipple: Why, and what happens next?

Mihir M Shah¹, Pranay S Ajay², Rebecca S Meltzer³

¹Department of Surgery, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA.

Journal of Surgical Oncology

|January 11, 2022

Summary

Most pancreatoduodenectomies for periampullary adenocarcinoma are completed. The most frequent reason for aborting this surgery is liver metastases, suggesting preoperative MRI may improve detection.

Keywords:

metastasis pancreatic ductal adenocarcinoma pancreatoduodenectomy periampullary adenocarcinoma

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Area of Science:

Oncology
Surgical Oncology
Gastroenterology

Background:

Periampullary adenocarcinoma (PAC) is best treated with pancreatoduodenectomy (PD).
A subset of patients undergoing PD for PAC experience surgical abortion.
This study analyzes patients whose PD was aborted intraoperatively.

Purpose of the Study:

To analyze the characteristics and outcomes of patients with PAC whose PD was aborted.
To identify reasons for surgical abortion during PD for PAC.
To evaluate the effectiveness of preoperative imaging in detecting metastatic disease.

Main Methods:

Retrospective analysis of patients undergoing laparotomy for planned PD for PAC (2006-2019).
Identification of patients with intraoperative decision to abort PD from operative notes.
Analysis of patient demographics, treatment, and outcomes, with a focus on pancreatic ductal adenocarcinoma (PDAC) survival.

Main Results:

6.7% of PD procedures for PAC were aborted, primarily due to distant metastases (65.5%) or local invasion (34.5%).
Liver metastases were the most common metastatic site (75%).
Preoperative CT scans were associated with a higher rate of missed metastatic disease compared to MRI (79.2% vs. 54.8%).

Conclusions:

The majority of PD procedures for PAC are completed successfully.
Distant metastases, particularly liver metastases, are the main reasons for aborting PD.
Preoperative MRI may be superior to CT in identifying hepatic metastases before PD.