Saturday, March 24, 2012

Whipple Procedure for Pancreatic Cancer


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.

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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.

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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.

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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 Information:

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