Whipple Procedure

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates

Definition

A Whipple procedure, or pancreaticoduodenectomy, is a surgical procedure which is most often performed to treat pancreatic cancer. The operation may also be performed for cancer of the duodenum, cholangiocarcinoma (cancer of the bile duct), cancer of the ampulla (the area where the bile and pancreatic ducts enter the small intestine), and for chronic pancreatitis and benign (noncancerous) tumors involving the pancreatic head.

During the course of a Whipple procedure, the surgeon removes the head of the pancreas, the majority of the first part of the small intestine (the duodenum), part of the bile duct, and in some cases part of the stomach. Variations on the operation may include removal of the body of the pancreas and/or the entire gall bladder.

Purpose

The Whipple procedure is the most common operation performed for treatment of cancer of the pancreas. The pancreas is an organ located near the liver on the right side of the body. It produces both digestive juices and hormones that are involved in regulation of blood sugar. Pancreatic cancer most often affects what is called the exocrine pancreas, which is the portion of the pancreas involved in producing digestive juices.

Because it initially causes only vague symptoms, pancreatic cancer is often not diagnosed until later stages of the disease. Additionally, it spreads very quickly, so when the disease is often quite widespread by the time it is finally diagnosed. Symptoms of pancreatic cancer can include pain in the upper abdomen, often radiating to the back; jaundice (yellow eyes and skin); decreased appetite; weight loss; and depression.

Demographics

The American Cancer Society estimates that approximately 37,680 people will be diagnosed with pancreatic cancer in the United States in 2008. About 34,290 people will die of pancreatic cancer in 2008, making pancreatic cancer the fourth leading cause of cancer death in the United States. Most people who are diagnosed with pancreatic cancer are over age 60. Men and women are about equally at risk. Risk fac-tors for the development of pancreatic cancer include smoking, history of diabetes, family history, and a personal history of chronic pancreatitis. Researchers

are still examining the possibility that other factors, such as certain workplace exposures or a high fat diet, may also increase an individual’s risk of pancreatic cancer.

Description

A Whipple procedure is a lengthy operation, taking about four to six hours. General anesthesia is required. A classic operation requires a large abdominal incision through which the operation occurs. There are some centers that offer laparoscopic Whipple procedure performed with or without robotic assistance. This minimally invasive method of surgery is performed through four small incisions with the use of a fiberoptic scope and miniaturized surgical instruments.

After the head of the pancreas has been removed during the operation, three important connections (anastamoses) must be performed. The intestine must be connected to the remains of the pancreas, to the bile duct, and to the stomach. These anastamoses must be very carefully achieved, since any leak may allow pancreatic juices to enter the abdomen, risking severe complications.

Diagnosis/Preparation

The patient meets with the operating physician prior to surgery to discuss the details of the surgery and receive instructions on preoperative and postoperative care. Blood tests to evaluate bleeding time and an EKG to evaluate cardiac function may be performed several days prior to the operation. Directly preceding surgery, an intravenous (IV) line is placed to administer fluid and medications, and the patient is given a bowel prep to cleanse the bowel and prepare it for surgery.

Aftercare

Recuperation from Whipple procedure may be slow and difficult. Depending on the type of surgery (traditional open incision or minimally invasive), inpatient stay will range from five to 14 days. Because of the high likeilhood of gastroparesis (slow gastric emptying), patients will remain on intravenous feeding

for five or six days following the operation. A naso-gastric tube may be required to remove excess stomach acid and juices that accumulate. Advancement of diet through clear liquids, full liquids, soft foods, to regular diet will be slow and the timeframe will depend on the patient’s tolerance of each new step. Some patients take as long as 4-6 weeks to have normal stomach emptying return. A feeding tube that delivers a nutritional formula directly into the jejunum may be used if recovery is overly slow.

Risks

Risks associated with the Whipple procedure include excessive bleeding, infection, and complications due to general anesthesia. Delayed gastric emptying after eating affects about 19% of patients. Leakage of pancreatic juices into the abdomen is a serious problem, since these digestive juices are strong enough to actually begin to digest the internal organs themselves. This can result in perforations (holes) in the intestine, stomach, or other nearby organs; abnormal communication between organs (fistulas); or necrosis (cell death) within an affected organ. Some patients may develop diabetes following Whipple procedure. Weight loss of 5-10% of original body weight is common after the operation, as is the need to take oral enzyme supplements to aid digestion.

Normal results

Although the recuperative time may be long, most patients return to their usual level of functioning and their usual quality of life after a Whipple procedure. However, the risk for further advancement of pancreatic cancer is very high. Many patients receive

KEY TERMS

Anastomosis— A surgically created joining or opening between two organs or body spaces.

Fistula— An abnormal connection between two organs, or between an organ and the outside of the body.

Jaundice— A yellowish cast to the whites of the eyes and/or the skin, caused by excess bilirubin circulating in the bloodstreatm.

chemotherapy and radiation for further treatment of the cancer.

Morbidity and mortality rates

The Whipple procedure has a high morbidity and mortality rate. It requires the expertise of a surgeon who has performed a large number of these types of procedures. Even when highly skilled surgeons in cancer centers operate, 2-5% of patients die due to surgical complications. When less skilled surgeons perform this procedure, or when it is undertaken at smaller hospitals rather than major medial centers, the death rate from surgical complications may be as high as 15%. The complication rate is very high as well, between 30-50%. Possible complications include leakage from the anastomoses (connections) between organs, infection, bleeding, and slow gastric (stomach) emptying following meals. Risk of death from advancement of the original pancreatic cancer also is quite high, with only about 20% of all Whipple procedure patients surviving for five years after their initial diagnosis. Patients with no lymph node involvement at the time of surgery may have a higher five-year survival rate (about 40%). However, patients who receive chemotherapy but no surgery have only a 5% survival rate at five years.

Resources

BOOKS

Abeloff, M. D., et al. Clinical Oncology. 3rd ed. Philadelphia: Elsevier, 2004.

Feldman, M., et al. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. 8th ed. St. Louis: Mosby, 2005.

Khatri, V. P., and J. A. Asensio. Operative Surgery Manual. 1st ed. Philadelphia: Saunders, 2003.

Townsend, C. M., et al. Sabiston Textbook of Surgery. 17th ed. Philadelphia: Saunders, 2004.

Rosalyn Carson-DeWitt, MD

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

A Whipple procedure is performed in a hospital operating room. It is considered one of the most technically difficult operations, and should be performed by a very experienced, skilled surgeon who has successfully performed many of these same procedures. Some of the doctors who perform these operations include general surgeons, surgical gastroenterologists, and surgical oncologists.

QUESTIONS TO ASK THE DOCTOR

• Why is a Whipple procedure being recommended?
• What type of Whipple procedure would work best for me?
• What are the risks and complications associated with the recommended procedure?
• Are any nonsurgical treatment alternatives available?
• How soon after surgery may I resume my normal diet and activities?
• If the Whipple procedure is being done to treat pancreatic cancer, will I require any other treatment?