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Journal of Indian Association of Pediatric Surgeons
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ORIGINAL ARTICLE
Year : 2018  |  Volume : 23  |  Issue : 4  |  Page : 212-215
 

Whipple's pancreaticoduodenectomy in pediatric patients: An experience from a tertiary care center


Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication4-Oct-2018

Correspondence Address:
Dr. Anjan Kumar Dhua
Department of Pediatric Surgery, Teaching Block, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.JIAPS_35_18

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   Abstract 


Purpose: Whipple's pancreaticoduodenectomy (WPD) is rarely required in children. However, WPD is the only option with pathologies involving the head of the pancreas requiring surgical excision. The objective of our study was to review our experience with WPD performed on children.
Materials and Methods: A retrospective analysis of case records was conducted on all patients <18 years of age, who underwent WPD at our center over the last 20 years. Data regarding demographics, signs, and symptoms at presentation, diagnostic imaging and procedures, pathologic reports, surgical and medical treatment, and follow-up were collected to study the indications and safety and outcomes of WPD in children.
Results: Five patients had been planned for a WPD during the study (1995–2015); but in one patient, the procedure was abandoned, the rest four patients formed the study group. Male to female ratio was 3:1. Median age at the time of surgery was 9 years (11 months–12 years). The most common presentation was obstructive jaundice (50%, 2/4). Radiological imaging was able to accurately predict the surgical procedure required in all except one case. The mean operating time was 205 min (180–240 min). There were no intraoperative complications. The mean intraoperative blood loss was 85 mL (20–150 mL). The youngest patient requiring WPD was an 11-month-old child. Oral feeding was established by the 7th postoperative day (range 5–7 days) in all cases. There were no cases of anastomotic leak or pancreatic or jejunal fistulae. One patient developed features of subacute intestinal obstruction after discharge and required re-exploration. There was no intra- or post-operative mortality.
Conclusion: WPD is safe and efficacious procedure in a selected group of children. The overall efficacy of surgical treatment combined with the relatively low severity of complications leads us to recommend WPD in children when indicated.


Keywords: Pancreatoblastoma, solid pseudopapillary epithelial neoplasm, Whipple's pancreatoduodenectomy


How to cite this article:
Varshney A, Dhua AK, Jain V, Agarwala S, Bhatnagar V. Whipple's pancreaticoduodenectomy in pediatric patients: An experience from a tertiary care center. J Indian Assoc Pediatr Surg 2018;23:212-5

How to cite this URL:
Varshney A, Dhua AK, Jain V, Agarwala S, Bhatnagar V. Whipple's pancreaticoduodenectomy in pediatric patients: An experience from a tertiary care center. J Indian Assoc Pediatr Surg [serial online] 2018 [cited 2018 Dec 14];23:212-5. Available from: http://www.jiaps.com/text.asp?2018/23/4/212/242715





   Introduction Top


Whipple's pancreaticoduodenectomy (WPD) has been described as one of the most complex and technically demanding surgical procedures of the abdomen, with a perioperative complication rate of up to 60%.[1] It is primarily indicated for pathological processes involving the head of the pancreas. The procedure involves the surgical removal of the pancreatic head and the C-loop of duodenum followed by anastomosis of the distal pancreatic stump with the jejunum or the stomach, a choledochojejunostomy, and a gastrojejunostomy. Common postoperative complications include anastomotic leak, adhesive intestinal obstruction, pancreatic, gastric or jejunal fistulae, anastomotic strictures, and delayed gastric emptying.

There is ample literature available describing the outcomes of WPD in adult patients.[2],[3],[4],[5] Pancreatic and biliary pathologies requiring WPD are very rare among children; and therefore, relevant literature describing the safety of WPD for the pediatric patient population is lacking. In this article, we report our experience with the Whipple's procedure in children and discuss the relevant literature.


   Materials and Methods Top


A retrospective review of the case record was conducted on all patients <18 years of age who underwent WPD at our center from 1995 to 2015 years. The clinical records of the patients were reviewed, and the data regarding demographics, the signs and symptoms at presentation, the diagnostic imaging and procedures, the pathologic reports, the surgical and the medical treatment, and the follow-up were collected. Ethical clearance for the study was obtained from the Institutional Ethical Committee.


   Results Top


Five patients were planned to undergo required a WPD during the study (1995–2015), but in one patient, the procedure was abandoned; the rest four patients formed the study group [Table 1]. Of these, three were male and one was female (M:F - 3:1). The median age at the time of surgery was 9 years (11 months–12 years). The most common presenting symptom was obstructive jaundice (50%, 2/4), followed by abdominal pain in one child (25%, 1/4). One patient presented with recurrent vomiting and gastric outlet obstruction. Preoperative biliary drainage was not required in any case. The clinical and radiological features of individual cases are described in [Table 1]. Radiological imaging was able to accurately predict the surgical procedure required all these patients except one (Case #1). This child was explored with a diagnosis of gastric outlet obstruction and intraoperatively found to have a mass in the head of the pancreas and underwent WPD.
Table 1: Clinical and operative details

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In one case, the procedure was abandoned as the tumor was found to be metastatic at the time of exploration with multiple liver secondaries. Rest of the four patients underwent WPD with triple reconstruction (pancreaticojejunostomy, gastrojejunostomy, and choledochojejunostomy). The mean intraoperative blood loss was 85 mL (20–150 mL), and blood transfusion was required in two of the four cases. The mean operating time was 205 min (180–240 min). There were no intraoperative complications. The youngest patient for whom successful WPD could be performed was 11 months of age (case#2). One or more abdominal drains were placed in all patients.

Postoperatively, patients spent a median of 10 days in the hospital (range: 8–12 days). Blood sugar levels were monitored postoperatively in all patients. One patient (case#3) developed hyperglycemia with ketoacidosis postoperatively. He was managed with injection insulin and dietary restriction and recovered well. Feeds through the feeding jejunostomy could be started as early as the 4th postoperative day (range 4–6 days) and oral feeding was established by the 7th postoperative day (range 5–7 days) in all cases. There were no cases of anastomotic leak or pancreatic or jejunal fistulae in our patients. The procedure-related complication rate was thus 25%. One patient developed features of subacute intestinal obstruction after 2 days of discharge (Case #4) and was re-admitted and re-explored and was subsequently discharged on full oral feeds after adhesiolysis. There was no postoperative mortality, and all patients were discharged in stable condition. All were healthy at first follow-up. The postoperative complications in individual cases are described in [Table 2].
Table 2: Postoperative outcome

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The patient who was excluded from the study was referred for palliative care. Chemotherapy could not be administered, and the patient expired after 6 months. The median follow-up period in the study group was 108 months. After censoring out a patient who was lost to follow-up (case#1), the 5-year overall survival considered from the point of diagnosis till the last follow-up was 100%, among those with neoplasm (case#2 and #4). The patient with chronic pancreatitis was symptom-free and without pancreatic dysfunction at the last follow-up after 120 months after the procedure.


   Discussion Top


Published retrospective reviews of pancreatic tumors report the incidence of pediatric pancreatic tumors at 0.018 cases per 100,000 people.[6] The most common pancreatic tumors are pancreatoblastoma in younger patients and solid pseudopapillary tumor in adolescents.[6],[7],[8],[9] In the surgical management of these patients, WPD is usually not required, and most patients can be managed with distal pancreatic resection or tumor enucleation. Pancreaticoduodenectomy is indicated in only a handful of patients. Many of these cases were deemed unresectable in the past, but in recent years reports have shown that WPD is feasible and leads to cure in pediatric patients with pancreatic head tumors.[6],[7],[8],[9],[10],[11],[12],[13],[14] Shorter et al.[11] published a case series of 17 patients with pancreatic tumors of which seven required pancreaticoduodenectomy. Wang et al.[15] reported three cases of papillary cystic neoplasm of the pancreas out of which two required pancreaticoduodenectomy. Choi et al. reported 23 cases of solid pseudopapillary tumor of the pancreas in children;[8] of these six were managed with pylorus-preserving pancreaticoduodenectomy. To the best of our knowledge, there have been no reports of WPD in pediatric patients from the Indian subcontinent. The fact that only four patients underwent WPD over a period of two decades in a tertiary care setup further endorses the rarity of these tumors in this age group.

Despite the infrequency of the operation, the outcome of WPD in the hands of pediatric surgeons has been comparable to that in the adult population. In a retrospective review of pancreatic tumors from Children's Hospital Los Angeles, Speer et al.[16] reported their 20-year history with 11 cases and included data on surgical outcomes for all pancreatic resections. Four of their 11 patients required a WPD. The median length of stay for all patients was 8 days (range 5–19 days), and complications occurred in 36% of patients. Complications were a pancreatic leak, delayed gastric emptying, and fat malabsorption requiring medical management. We observed a relatively low rate of complications in our patient population, with an overall rate of 50% (two of four patients). Of the complications, only one required an additional procedure in the operating room, while others could be managed by medical management alone. Furthermore, a successful WPD could be performed in a child as young as 11 months. There was no incidence of postoperative biliary or pancreatic leak and no perioperative mortality. There was no recurrence of symptoms post-procedure till the last follow-up.

Dasgupta and Kim[7] found that the presenting symptoms in children were commonly abdominal pain unlike obstructive jaundice in the adults.[2],[3],[4],[5] In our series, two patients had obstructive jaundice at presentation while another child had abdominal pain as the presenting feature as in the adult series.[2],[3],[4],[5] One patient had a gastric outlet obstruction. The pathological characteristics of pediatric patients requiring WPD differ significantly from their adult counterparts. In adults, the usual indication is a ductal adenocarcinoma,[2] while the spectrum of pathologies that may require a WPD in children is quite broad. There are cases of ductal adenocarcinoma, acinar cell carcinoma, pancreatoblastoma, solid pseudopapillary tumor, and pancreatic endocrine neoplasms (benign and malignant). Furthermore, teratoma, rhabdomyosarcoma, primitive neuroectodermal tumor, and lymphoma have all been reported. The pathology in our series also reflects this pattern. A rare case of yolk sac tumor was also present in our series and was reported separately.[17]

The postoperative course and the outcome of pediatric patients are comparable or possibly better than their adult counterparts. This could probably be attributed to easily visualized surgical planes, the consistency of pediatric pancreatic tissue, better healing, differences in adult and pediatric disease profile as well as the fine tissue handling skills of a pediatric surgeon. Despite having a small study population, our series shows that WPD is safe and technically feasible in children, even in infants. The incidence of complications was low (25%), and the postoperative pancreatic function was preserved in all, except in one patient who had a transient postoperative hyperglycemia.


   Conclusion Top


WPD is a safe and efficacious procedure in selected pediatric patients. The overall efficacy of surgical treatment for patients with pancreatic tumors combined with the relatively low severity of complications leads us to recommend resection wherever complete resection is achievable, even in infants.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Wamser P, Stift A, Passler C, Goetzinger P, Sautner T, Jakesz R, et al. How to pass on expertise: Pancreatoduodenectomy at a teaching hospital. World J Surg 2002;26:1458-62.  Back to cited text no. 1
    
2.
Winter JM, Cameron JL, Campbell KA, Arnold MA, Chang DC, Coleman J, et al. 1423 pancreaticoduodenectomies for pancreatic cancer: A single-institution experience. J Gastrointest Surg 2006;10:1199-210.  Back to cited text no. 2
    
3.
Fernández-del Castillo C, Morales-Oyarvide V, McGrath D, Wargo JA, Ferrone CR, Thayer SP, et al. Evolution of the Whipple procedure at the Massachusetts general hospital. Surgery 2012;152:S56-63.  Back to cited text no. 3
    
4.
Lee MK, Dinorcia J, Reavey PL, Holden MM, Genkinger JM, Lee JA, et al. Pancreaticoduodenectomy can be performed safely in patients aged 80 years and older. J Gastrointest Surg 2010;14:1838-46.  Back to cited text no. 4
    
5.
Lightner AM, Glasgow RE, Jordan TH, Krassner AD, Way LW, Mulvihill SJ, et al. Pancreatic resection in the elderly. J Am Coll Surg 2004;198:697-706.  Back to cited text no. 5
    
6.
Perez EA, Gutierrez JC, Koniaris LG, Neville HL, Thompson WR, Sola JE, et al. Malignant pancreatic tumors: Incidence and outcome in 58 pediatric patients. J Pediatr Surg 2009;44:197-203.  Back to cited text no. 6
    
7.
Dasgupta R, Kim PC. Relationship between surgical volume and clinical outcome: Should pediatric surgeons be doing pancreaticoduodenectomies? J Pediatr Surg 2005;40:793-6.  Back to cited text no. 7
    
8.
Choi SH, Kim SM, Oh JT, Park JY, Seo JM, Lee SK, et al. Solid pseudopapillary tumor of the pancreas: A multicenter study of 23 pediatric cases. J Pediatr Surg 2006;41:1992-5.  Back to cited text no. 8
    
9.
Rojas Y, Warneke CL, Dhamne CA, Tsao K, Nuchtern JG, Lally KP, et al. Primary malignant pancreatic neoplasms in children and adolescents: A 20 year experience. J Pediatr Surg 2012;47:2199-204.  Back to cited text no. 9
    
10.
van den Akker M, Angelini P, Taylor G, Chami R, Gerstle JT, Gupta A, et al. Malignant pancreatic tumors in children: A single-institution series. J Pediatr Surg 2012;47:681-7.  Back to cited text no. 10
    
11.
Shorter NA, Glick RD, Klimstra DS, Brennan MF, Laquaglia MP. Malignant pancreatic tumors in childhood and adolescence: The memorial Sloan-Kettering experience, 1967 to present. J Pediatr Surg 2002;37:887-92.  Back to cited text no. 11
    
12.
Grosfeld JL, Vane DW, Rescorla FJ, McGuire W, West KW. Pancreatic tumors in childhood: Analysis of 13 cases. J Pediatr Surg 1990;25:1057-62.  Back to cited text no. 12
    
13.
Jung SE, Kim DY, Park KW, Lee SC, Jang JJ, Kim WK, et al. Solid and papillary epithelial neoplasm of the pancreas in children. World J Surg 1999;23:233-6.  Back to cited text no. 13
    
14.
d'Ambrosio G, del Prete L, Grimaldi C, Bertocchini A, Lo Zupone C, Monti L, et al. Pancreaticoduodenectomy for malignancies in children. J Pediatr Surg 2014;49:534-8.  Back to cited text no. 14
    
15.
Wang KS, Albanese C, Dada F, Skarsgard ED. Papillary cystic neoplasm of the pancreas: A report of three pediatric cases and literature review. J Pediatr Surg 1998;33:842-5.  Back to cited text no. 15
    
16.
Speer AL, Barthel ER, Patel MM, Grikscheit TC. Solid pseudopapillary tumor of the pancreas: A single-institution 20-year series of pediatric patients. J Pediatr Surg 2012;47:1217-22.  Back to cited text no. 16
    
17.
Munghate GS, Agarwala S, Bhatnagar V. Primary yolk sac tumor of the common bile duct. J Pediatr Surg 2011;46:1271-3.  Back to cited text no. 17
    



 
 
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