History of pancreatic head resection—the evaluation of surgical technique

The evolution of pancreatoduodenectomy had its origin in the last 2 decades of the 1800s. Retarded by the coagulopathy resulting from obstructive jaundice, the development of palliative biliary bypass was the first step. This era coincided with the confidence gained from resection of the tail of the gland. Next came the 1909 2-stage resection of carcinoma of the ampulla of Vater (bypass first, then resection). One-stage pancreatoduodenectomy gained preference after the 1940 Whipple operation and the 1939 introduction of vitamin K therapy. Whipple’s career included 37 pancreatoduodenectomies—his mortality rate being 33%. The postoperative mortality rate remained 25% to 35% until the evolution of “Centers of Excellence” resulted in a current mortality rate below 5%. Today, using a direct mucosa-to-mucosa anastomosis, the troublesome pancreatojejunal fistula is preventable. After approximately 100 modifications, the Whipple resection can today be performed safely but, to date, the short postoperative survival of patients suggests that the current problems are not technical in nature, but rather are in delayed diagnosis and/or inadequate adjuvant therapy.