**13. Morbidity**

introduced in 1941 by Trimble [81]. No major variations occurred in technique until preser‐ vation of the pylorus was introduced by Warshaw in 1981 [85]. These changes in operative technique were not as radical as the introduction of the minimally invasive approach. The laparoscopic pancreaticoduodenectomy was introduced by Gagner and Pomp in 1994 [88]. Almost 100 years later, the first human robotic surgery was described by Himpens in 1997 [92] and the first robotic pancreaticoduodenectomy is credited to Giulianotti in 2000 [93]. While several limitations still exist, robotic surgery is the most innovative technology brought to the

A recent systematic review of the robotic approach demonstrated that up to date, 203 patients have had an intention to treat approach to a pancreaticoduodenectomy [94]. While the technical approach is wide and not clearly defined, the number of reported cases appears to be increasing over the past few years. In Cirocchi's review, the conversion rate was 14%, overall morbidity 58% and reoperation occurred in 7.3% of the cases [94]. Totally robotic technique has been reported by several surgeons [93;95-98]. While oncologic operations (R0) have been performed with similar morbidity and mortality to the open Whipple, the innovative nature of this approach makes it highly experimental and should only be undertaken in specialized

In the United States, there has been a substantial increase in the number of pancreaticoduo‐ denectomies performed. The average age of patients undergoing surgical intervention has also increased from 1991 to 2005. Similarly, more patients with a higher index of comorbidities underwent Whipples during this time. In spite of this, perioperative morbidity remained unchanged (53%) and 30-day mortality decreased from 6% to 3% in this cohort of patients [1].

The mortality rate in high volume centers performing pancreaticoduodenectomies is 2-4% [99]. However, perioperative morbidity remains substantially high (15% to 50%) even at high volume centers [100]. In patients undergoing resection for cure and treated with neoadjuvant chemoradiation, the 5-year survival is still disappointingly low (10% to 20%) [101-106]. In a study using the Surveillance, Epidemiology, and End Results-Medicare data inclusive of 2,461 patients investigating outcomes and use of adjuvant therapy between 1991 and 2005 in the USA, the median survival of patients treated for cure was 14 months, the 1-, 3-, and 5- year survival was 53.2%, 19.7%, and 12.6%, respectively. This study, demonstrated that the use of adjuvant chemoradiotherapy led to a 2 month increase in overall survival [1]. A study from Johns Hopkins examining temporal variation in morbid‐ ity and mortality following pancreaticoduodenectomy found a magnificent decrease in mortality to 4% (1981-1986) from 24% (1969-1980) with an accompanying decrease in morbidity from 59% to 36% during the same periods. The 5-year survival in patients with pancreatic cancer was 18% [107]. Thus, while the number of patients undergoing pancrea‐ ticoduodenectomy has increased with a variable decrease in complications, the overall

centers. Similarly, cost analysis must be addressed in subsequent studies.

mortality has not improved in most high volume centers [108].

operating room in the last century.

240 Updates on Cancer Treatment

**12. Outcomes**

Postoperative complications occur in 25-50% of patients following this operation. Delayed gastric emptying, even with standard definitions by the International Study Group of Pancre‐ atic Surgery, occurs in a wide range of 14% to 45% and constitutes the most common compli‐ cation following pancreaticoduodenectomy [109-111]. Erythromycin or metoclopramide may reduce the incidence of gastric emptying by only 37% [112]. Thus, a jejunostomy tube for prolonged postoperative feeding as well as a gastrostomy tube for postoperative decompres‐ sion should be routinely employed during pancreaticoduodenectomy.

Pancreatic fistula (defined as the output of more than 50 cc of amylase-rich fluid) accompanies 5%-30% of cases [113-117] and is directly responsible for up to 20% of postoperative deaths [115;117], which constitutes the most serious complication of pancreaticoduodenectomy. Pancreatic fistula indicates disruption of the pancreatic-enteric anastomosis and occurs at the same rate regardless of anastomosis (i.e. pancreaticogastrostomy *vs.* pancreaticojejunostomy), modified drainage strategies, or somatostatin administration [118].

Disruption of biliary and gastric anastomoses are rare and less serious. Patients with pancreatic fistula may be completely asymptomatic if it is a controlled fistula and the output is well captured by the drain. These patients do well with a clear liquid diet, enteral nutrition through a jejunostomy tube, or parenteral nutrition. A CT scan should be performed to exclude abdominal fluid collections. The benefits of somatostatin in this setting are unclear. Diet may be progressively advanced as output decreases. Eighty percent of patients can be managed conservatively. An additional 10%-15% of patients with this complication respond well to percutaneous drainage.

Patients with sepsis or hemorrhage related to pancreaticoenteric anastomotic disruption necessitate immediate and aggressive intervention. Septic patients who do not respond to aggressive medical management within 48 hours should be explored. Hemorrhage associated with pancreatic fistulas can be managed with angiographic embolization. Patients who require operative exploration and have diffuse retroperitoneal hemorrhage and necrosis require completion pancreatectomy. The rare cases of hemobilia and hemopancreaticus are best diagnosed and treated angiographically.

Endocrine pancreatic function is rarely impaired and diabetes is unusual following pancrea‐ ticoduodenectomy. Exocrine pancreatic function, on the other hand, is affected to various degrees and in severe cases may require lifelong exogenous enzyme supplementation.
