Since the first PD performed by Codivilla [6
], technical modifications have been undertaken in the procedure with an aim to improving outcomes for the patient. Only the most significant of these modifications will be discussed in this section. Despite the high morbidity and the risk of mortality associated with PD, centralization of major pancreatic resectional surgery to high-volume centres [29
] as well as a standardized technique [39
] have been linked to improved outcomes.
No difference in oncological outcomes has been noted between pylorus-preserving PD and the Classic Whipple [41
]. As a result, in patients undergoing PD for periampullary and pancreatic head cancers, the performance of pylorus preservation or classic Whipple remains the prerogative of the surgeon. In contrast, the performance of the classic Whipple should be reserved exclusively for duodenal cancers (part of periampullary tumours) or large pancreatic head tumours invading the gastric antrum and/or the first part of duodenum.
As part of every oncological PD, a standard lymphadenectomy, i.e., removal of lymph nodes of the right side of the hepatoduodenal ligament (12b1, 12b1, 12c), posterior pancreaticoduodenal nodes (13a, 13b), nodes to the right side of the superior mesenteric artery (SMA) from the origin of the SMA at the aorta to the inferior pancreaticoduodenal artery (14a, 14b) and anterior pancreaticoduodenal nodes (17a, 17b), has been shown to be associated with improved outcomes with no additional benefit conferred by the performance of an extended lymphadenectomy [42
]. Additionally, the extended procedure was associated with an increased rate of intractable diarrhoea in the early postoperative phase.
Current literature [44
] does not favour the performance of a pancreaticojejunostomy over a pancreaticogastrostomy, as the outcomes of surgery appear to be the same irrespective of the technique employed.
Antecolic gastro-/duodenojejunostomy has been shown to be associated with a significantly reduced rate of delayed gastric emptying [49
], possibly due to the avoidance of torsion or angulation that may occur with a retrocolic anastomosis.
A review of the literature demonstrated that in order to improve outcomes of the anastomoses following PD, good vascularity, absence of tension, absence of main pancreatic ductal and distal obstruction, use of fine (4–0, 5–0, 6–0) sutures, main pancreatic duct to mucosa approximation and high volume (including high surgeon-volume) were important factors [52