Whipple Procedure

The Whipple procedure, also known as a pancreaticoduodenectomy, is the most common type of surgery to treat pancreatic cancer. It is used to treat tumors in the head or neck of the pancreas where approximately 75% of pancreatic cancer tumors appear.

The procedure involves the surgical removal of the head of the pancreas, the duodenum (the first part of the small intestine), part of the bile duct, the gallbladder, and if needed, lymph nodes and a part of the stomach. The remaining pancreas, bile duct, and stomach are then reconnected to the digestive tract to restore the flow of digestive enzymes, bile, and ingested contents.

Disease Overview

The pancreas is a dual-functioning gland of the digestive system made up of two types of cells: one produces digestive juices and the other releases hormones that help regulate blood sugar levels. The abnormal growth of pancreatic cells can lead to pancreatic cancer.

Most pancreatic cancers are formed in the cells that produce digestive enzymes, causing yellowing of the skin and whites of the eyes (jaundice), upper and middle abdominal pain, back pain, unexplained weight loss, appetite loss, fatigue, dark-colored urine, and light-colored stools. You are at an increased risk of developing pancreatic cancer if you are a smoker, overweight, have diabetes, or a family history of pancreatitis (inflammation of the pancreas) or pancreatic cancer.

Indications

The Whipple procedure is usually indicated for pancreatic cancer patients whose tumors are confined to the head or neck of the pancreas and have not metastasized (spread) to nearby major blood vessels, the lungs, liver, or abdominal cavity. Your physician may also recommend the procedure as a treatment option for individuals whose pancreas, duodenum or bile duct is affected by other disorders, such as:

• Pancreatitis
• Pancreatic cysts
• Bile duct cancer
• Neuroendocrine tumors
• Ampullary cancer
• Trauma to the small intestine or pancreas
• Small intestine cancer
• Other disorders or tumors involving the pancreas, duodenum, or bile ducts

Preparation

Preoperative preparation for the Whipple procedure may involve the following steps:

• A thorough history and physical examination
• Routine blood work and imaging
• Informing your doctor of any medications or supplements you are taking
• Refraining from blood thinners, aspirin, or NSAIDs, if indicated
• Informing your doctor of any allergies to medications, anesthesia, or latex
• Refraining from solids or liquids at least 8 hours prior to the procedure
• Arranging for someone to drive you home after the procedure

Surgical procedure

A Whipple procedure is a complex surgery that typically takes about 6 hours and is usually performed as an open surgery. In general, the procedure involves the following steps:

• You will lie down on the procedure table in a face-up position.
• General anesthesia is administered through an intravenous (IV) line in the arm to keep you asleep throughout the procedure.
• Additional intravenous lines may be placed with other monitoring devices depending on your health condition and the complexity of the procedure.
• A urinary catheter tube will be inserted into your bladder to drain urine during and after surgery. The tube is normally removed a day or two after the procedure.
• Your surgeon will make one large incision down the middle of the abdomen to access the pancreas and other organs.
• The head of the pancreas and nearby structures such as the duodenum, part of the bile duct, the gallbladder, lymph nodes near the pancreas, and sometimes, part of the stomach are also removed.
• Your surgeon then reconnects the remaining segments of your pancreas, intestines, and stomach to enable you to digest food normally.
• Finally, the incision is sutured closed, and a sterile dressing is applied to complete the procedure.

Postoperative care

Post-procedure care and instructions may involve the following:

• You will be transferred to the recovery area where your nurse will monitor your vital signs and watch for any signs of complications as you recover from the effects of anesthesia.
• You may need to spend at least a week in the hospital depending on your overall recovery.
• You will not be able to drink or eat normally for a few days. Your diet will be slowly advanced as tolerated, starting with a liquid diet, and slowly progressing to a soft diet, and then solids.
• Various medications such as antacids, antibiotics, pain relievers, and anti-inflammatories are provided as needed to keep you comfortable.
• Refrain from strenuous activities or lifting weights for a specified period. A gradual increase in activities is recommended.
• You should be able to return to normal activities in about a month’s time with certain activity restrictions. Complete recovery may take 2 to 6 months.

Risks and Complications

As with any surgery risks and complications may occur with the Whipple procedure, including:

• Infection
• Bleeding
• Leakage from various connections
• Diarrhea
• Diabetes
• Weight loss
• Changes in bowel habits

Summary

The Whipple procedure is a common surgical treatment for pancreatic cancer. It can also be used to treat other conditions such as bile duct cancer, cancer of the duodenum, and non-cancerous lesions and cysts. The Whipple procedure is a complex surgery requiring extensive surgical skill and experience and can enhance life expectancy of patients whose pancreas, duodenum, or bile duct is affected by cancer or other disorders.