The Whipple procedure (pancreatoduodenectomy)
is the most common operation to remove (resect) pancreatic cancers. The Whipple
procedure may also be used to treat some benign pancreatic lesions, pancreatic
cysts and cancers in the bile duct and beginning part of the small intestine
(duodenum).
What is a Whipple operation? Types of Whipple Procedure
Whipple
surgery is often a surgical option when pancreatic cancer is found in the head
of the pancreas. It involves removal of the pancreas head, most of the duodenum
(small intestine), a portion of the bile duct, gallbladder, part of the jejunum
and the lymph nodes located near the pancreas. Sometimes a portion of the
stomach may also be removed.
After
surgical removals, the remaining balance of the pancreas and bile duct is
attached to the small intestine permitting bile from the liver to continue
entering the small intestine. This allows the remaining parts of the pancreas,
stomach and intestines to sustain the digestive process.
Sometimes, your
oncologists will use Intraoperative Radiation Therapy (IORT) in
combination with a Whipple procedure. With IORT, you receive a
single, powerful dose of radiation directly to the tumor site during the
procedure. This helps to minimize side effects, spare healthy
tissues and reduce treatment times.
Some patients may
be eligible for a minimally invasive (laparoscopic) Whipple procedure, which is
performed through several small incisions instead of a single large incision.
Compared to the classic procedure, the laparoscopic procedure may result in
less blood loss, a shorter hospital stay, a quicker recovery, and fewer
complications.
Also, whenever possible, some centers use an
innovative procedure called a mini-Whipple (pylorus preserving). A mini-Whipple
is a type of surgery used to treat pancreatic cancer when the tumor is located
in the head of the pancreas. Unlike the classic Whipple procedure in which the
lower part of the stomach, all of the duodenum and the head of the pancreas are
removed, this modified resection preserves the entire stomach, the pylorus and
several centimeters of the upper duodenum.
Survival rates
The
Whipple operation was first described in the 1930’s by Allan Whipple. In the
1960’s and 1970’s the mortality rate for the Whipple operation was very high.
Up to 25% of patients died from the surgery. This experience of the 1970’s is
still remembered by some physicians who are reluctant to recommend the Whipple
operation.
Today the Whipple operation has become an extremely
safe operation in the USA. At tertiary care centers where a large numbers of
these procedures are performed by a selected few surgeons, the mortality rate
from the operation is less than 4%. Studies have shown that for good outcomes from the Whipple
surgery, the experience of the center and the surgeon is important.
Recent
studies from Johns Hopkins and Memorial Sloan Kettering have shown that outcome
from surgery for a Whipple operation is dependent on the experience of the
hospital and the surgeon performing the surgical operation. In those that
hospitals that perform high volume of these procedures the death rate from the
Whipple operation is now less than 5%. In hospitals that infrequently perform
the Whipple operation a much higher complication rate and the death rate from
the surgery often greater than 15 to 20% has been reported in surgical
literature.
Similar
results were obtained from a study by The New England Journal of Medicine on operative
mortality rates to be four times higher (16.3 percent vs. 3.8 percent) at
low-volume (averaging less than one per year) hospitals versus high-volume (16
or more per year) hospitals.
When is a Whipple operation required?
A
Whipple operation is performed for
- Cancer of the head of
the pancreas
- Cancer of the duodenum
- Cholangiocarcinoma (cancer
of the bottom end of the bile)
- Cancer of the ampulla –
an area where the bile and pancreatic duct enter into the duodenum.
- Whipple operation may also sometimes be performed for patients with benign (non-cancerous) disorders such as chronic pancreatitis and benign tumors of the head of the pancreas.
Note that only
about 20% of pancreatic cancer patients are eligible for the Whipple procedure
and other surgeries. These are usually patients whose tumors are confined to
the head of the pancreas and haven't spread into any nearby major blood
vessels, the liver, lungs, or abdominal
cavity. Intensive testing is usually necessary to identify possible candidates
for the Whipple procedure.
The Whipple
procedure isn't an option for the 40% of newly diagnosed patients whose tumors
have spread (metastasized) beyond the pancreas. Only rarely is it an option for
the 40% of patients with locally advanced disease that has spread to adjacent
areas such as the superior mesenteric vein and artery, or for those whose
tumors have spread to the body or tail of the pancreas.
Expectations
On average, the Whipple procedure takes five to six
hours and can be quite extensive, depending on the size and spread of the
tumor. After surgery, a hospital stay of about 10 days is usually needed, with
another four to six weeks of recovery at home. While the technique is not
widely available, some skilled surgeons perform the Whipple procedure
laparoscopically, using smaller incisions and smaller instruments. In some
cases, laparoscopic surgery may reduce the length of the hospital stay and
reduce recovery time.
Whipple operation improve survival rates
The
overall survival after the Whipple operation for pancreatic adenocarcinoma is
about 20% at five years after surgery. Patients without spread of cancer into
their lymph nodes may have up to a 40% survival. The actuarial survival is less
than 5% at five years for patients with pancreatic adenocarcinoma who are
treated with chemotherapy alone.
The
operation is usually curative in patients with benign or low grade cancers of
the pancreas.
Further treatment after the Whipple operation
In
most cases, it is recommended for all Pancreatic Cancer patients to have chemotherapy
and radiation therapy after the operation. Recent studies from Johns Hopkins
University have shown that the survival rate can be increased by as much as 10%
by adding chemotherapy and radiation therapy to the surgery for patients with
pancreatic adenocarcinoma.
Usually,
there is no need for any further treatment for patients who have benign tumors
of the pancreas and in patients with neuroendocrine tumors of the pancreas.
Diabetes after Whipple operation
During
the Whipple operation part of the pancreas, the head of the pancreas, is removed.
Pancreatic tissue produces insulin that is required for blood sugar control.
When pancreatic tissue is removed the body releases less insulin and the risk
of developing diabetes is present.
Patients
who are diabetic at the time of surgery or who have an abnormal blood sugar
level that is controlled on a diet prior to surgery have a high chance for the
severity of the diabetes becoming worse after the surgery. On the other hand
patients who have completely normal blood sugar prior to surgery with no
history of diabetes and do not have chronic pancreatitis have a low probability
of developing diabetes after the Whipple operation.
Dietary Restrictions
There
are no restrictions of your diet after the operation. Some patients may not
tolerate very sweet foods and may need to avoid this.
Life after Operation
There
is acceptable alteration of lifestyle after the Whipple operation. Most
patients are able to go back to their normal functional levels.
Researchers
at John Hopkins University mailed surveys to Whipple operation survivors who
had been operated on at Hopkins between 1981 and 1997. The questionnaire was
broken down into sections that looked at physical abilities, psychological
issues and social issues; an additional section evaluated functional
capabilities and disabilities. Scores were reported as a percentile, with 100
percent being the highest possible score. The same questionnaire was then sent
to a group of healthy individuals and a group of patients who had laparoscopic
gallbladder removal.
Responses
from this study at Johns Hopkins were tallied from 188 Whipple survivors, 37
laparoscopic gallbladder surgery patients and 31 healthy individuals. Whipple
survivors on average rated their physical quality of life a 79, compared with
an 83 among laparoscopic surgery patients and an 86 among healthy people. For
psychological issues, Whipple survivors rated their quality of life to be a 79,
compared with an 82 for laparoscopic surgery patients and an 83 among healthy
people. Looking at social issues, Whipple survivors ranked their quality of
life at an 81, compared with an 84 among laparoscopic surgery patients and an
83 among healthy individuals. There was no statistical difference amongst these
groups.
Possible Complications
The
Whipple operation is a complex operation with a high chance of developing
complications if the surgeon performing the surgical procedure has limited
experience in this operation. In the hands of surgeons who are experienced with
this surgical operation the complication rate is usually very low.
The
problems and complications that may be seen after this operation include:
- Pancreatic fistula: After the tumor is
removed from the pancreas the cut end of the pancreas is sutured back into
to the intestine so that pancreatic juices can go back into the intestine.
The pancreas is a very soft organ and in some patients this suture line
may not heal very well. If this happens then patients develop leakage of
pancreatic juice. Usually the surgeon leaves behind a drainage catheter in
the abdomen during the surgery. Any leakage of pancreatic juice after the
surgery is usually removed from the body by this drainage catheter. In
almost all patients who develop leakage of pancreatic juice after the
surgery, the leakage heals on its own. It is uncommon for patients to be
re-operated for this complication. At USC this complication has occurred
in about 4% of all the surgeries that we have performed.
- Gastroparesis ( paralysis of the stomach): The first five to six days after the surgery, you will be provided with intravenous fluids until your bowel function returns. After your bowel function have return your surgeon will begin you on a diet of clear liquids and your diet will progress to a regular diet as you tolerate it.
In
up to 25% of patients, the stomach may remain paralyzed after the surgery and
it may take up to 4 to 6 weeks for the stomach to adapt to the changes after
the surgery to function normally. During this period you may not tolerate a
diet very well. If you fall in this category then you will be provided with
nutrition through a small feeding tube that your surgeon has placed into the
intestine at the time of surgery. In almost all patients the stomach function
returns to normal after this 4 to 6 week period after the surgery.
Potential Long-term Complications
Some
of the long-term consequences of the Whipple operation include the following:
- Mal-absorption: The pancreas produces
enzymes required for digestion of food. In some patients removal of part
of the pancreas during the Whipple operation can lead to a diminished
production of these enzymes. Patients complain of bulky diarrhea type of
stool that is very oily. Long-term treatment with oral pancreatic enzyme
supplementation usually provides relief from this problem.
- Alteration in diet: After the Whipple
operation we generally recommend that the patients ingest smaller meals
and snack between meals to allow better absorption of the food and to
minimize symptoms of feeling of being bloated or getting too full.
- Loss of weight: It is common for
patients to lose up to 5 to 10% of their body weight compared to their
weight prior to their illness. The weight loss usually stabilizes very
rapidly and most patients after a small amount of initial weight loss are
able to maintain their weight and do well.
Sources and Additional
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