Whipple Procedure (Pancreaticoduodenectomy) for Pancreatic Cancer

The Whipple procedure is the most common pancreatic cancer surgery. Pancreatic cancer has a poor prognosis because the cancer often grows and spreads long before symptoms develop. While only 6% of all pancreatic cancer patients are still alive five years after diagnosis, that number goes up to 25% for those who have a successful Whipple procedure. A Whipple procedure is not just pancreas surgery, but a complex surgery involving other organs in the digestive system. For patients whose pancreatic cancer fits the right criteria, Whipple surgery offers a chance to extend life and potentially cure pancreatic cancer.

Whipple procedure – pancreaticoduodenectomy

The Whipple procedure is named after the surgeon who was the first American to perform the operation, Dr. Allen Whipple. He perfected this operation, which is also known as a pancreaticoduodenectomy. A standard Whipple procedure, or pancreaticoduodenectomy, is an operation that removes the head of the pancreas, where the tumor is located, and the first part of the small intestine, called the duodenum. The digestive organs are then reconnected so that digestion can occur properly.

Modified Whipple procedure – pylorus-preserving pancreatoduodenectomy

A modified Whipple procedure, also called pylorus-preserving pancreatoduodenectomy, is when only part of the duodenum is removed and the pylorus, the part connecting the stomach to the duodenum is kept. Since the pylorus functions to control the release of stomach contents into the intestine the modified Whipple procedure is thought to better preserve the normal movement of stomach contents into the intestine.

Pancreas anatomy and function

Whipple surgery is used for patients whose pancreatic cancer is confined to the head of the tadpole-shaped pancreas. The pancreas is an organ about the size of a banana that is shaped like a tadpole with regions referred to as the head, body, and tail. In addition to producing insulin which converts sugar to energy that the body needs, the pancreas is important for digestion. In digestion, food is partially broken down in the stomach and pushed into the duodenum. The pancreas produces digestive enzymes which it sends to the duodenum through a pipe system called the pancreatic duct.

The liver produces the digestive juice, bile, which is stored in the gallbladder between meals. Bile from the liver and gallbladder is transported through the common bile duct, a pipe that passes through part of the head of the pancreas. In most people, the common bile duct joins with the pancreatic duct to supply bile to the duodenum. In a minority of people, the bile duct and pancreatic duct remain as separate passageways to the duodenum. Because surgeons may encounter different arrangements of ducts and blood vessels in each patient, performing a Whipple procedure requires a high level of skill and experience.

Pancreatic cancer

The Whipple procedure is used to treat the two main types of pancreatic cancer: adenocarcinoma and neuroendocrine tumors of the pancreas. Approximately 90 percent of pancreatic cancers are adenocarcinomas. Pancreatic adenocarcinomas begin as abnormal growth of the cells lining the pancreatic ducts, whose job is to produce digestive enzymes. Consequently, the pancreas may not make enough digestive juices to process nutrients from food. This can lead to weight loss. Less than 5 percent of pancreatic cancers are pancreatic neuroendocrine tumors, which develop from the endocrine gland of the pancreas that secretes the hormones insulin and glucagon.

Pancreatic cancer patients can experience weight loss because their cancer consumes energy. Also, they may find it hard to eat due to nausea which can happen when the tumor presses on the stomach. Because the bile duct passes through the pancreas, pancreatic cancer patients often develop blockage of the bile duct. This causes bile to get backed up, which causes jaundice, or yellowing of the skin, dark-colored urine, and pale-colored stools. Further complications of pancreatic cancer include pain and bowel obstruction.

Undergoing Whipple surgery

Whipple surgery may begin with laparoscopy, to examine the internal organs surrounding the pancreas. Biopsies may be taken of areas where pancreatic cancer may have spread. If open abdominal surgery is performed, it will still begin with the surgeon inspecting the areas around the pancreas for the spread of cancer.

As the surgeon carefully moves and separates tissues in the abdomen, he or she will examine the pancreatic tumor by sight and palpation and determine if the tumor is resectable. Resectable means that the tumor can be removed with surgery. Patients should know that it is possible for the surgeon to decide after beginning surgery that the planned operation cannot be completed.

Patients undergoing Whipple surgery can expect to undergo about five hours of operative time and to stay in the hospital for one to two weeks. Whipple operations may be performed using less invasive laparoscopic surgery for some patients who are eligible. Laparoscopic surgery can result in less blood loss, shorter hospital stays, quicker recovery, and fewer complications.

A surgeon performing a Whipple procedure removes the head of the pancreas, the duodenum, part of the common bile duct, the gallbladder, and sometimes part of the stomach as well. The remaining intestine, bile duct, and pancreas are reconnected.

In the reconstruction, the intestine is connected to the remaining portion of the pancreas, allowing the intestine to receive pancreatic digestive enzymes. The bile duct from the liver is connected to the intestine to allow bile to enter the intestine. The stomach is attached to the intestine in a location a little further down. This allows the stomach to empty its contents into the intestine where it is joined by bile and digestive enzymes which enter the intestine above. This arrangement allows proper food digestion.

Complications after Whipple surgery

Whipple surgeries are complicated, high-risk procedures that are best performed by surgeons with lots of experience. Patients should know that the lowest mortality rates and best long-term cancer outcomes are at centers that perform large volumes of Whipple procedures. The American Cancer Society recommends that patients have the Whipple procedure done at a hospital that performs at least 15 to 20 pancreas surgeries per year.

The short-term death rate in patients having a Whipple procedure is less than 4 percent when the operation is done at a cancer center with experienced surgeons. At some major centers, the death rate is reported to be even lower than 1 percent. Compare this to a short-term death rate above 15 percent for patients treated at smaller hospitals with less experienced surgeons. Overall short-term death rates have decreased since Dr. Alan Whipple first performed the procedure in 1940, thanks to improvements in diagnosis, staging, surgical techniques, anesthesia, and postoperative care.

Compared with standard pancreaticoduodenectomy (Whipple), pylorus-preserving pancreaticoduodenectomy (modified Whipple) may decrease the incidence of certain complications. One of these complications is postoperative dumping, when undigested food enters the intestine too quickly, causing symptoms like diarrhea, bloating, nausea, and heart palpitations. In addition, the modified Whipple procedure may decrease the incidence of ulcers at surgical sites and the reflux of bile into the stomach, irritating the stomach lining.

Delayed gastric emptying, is a condition where food stays in the stomach longer, which occurs in about 15 percent of patients that have undergone a Whipple procedure or modified Whipple procedure. Delayed gastric emptying is usually temporary, causing nausea, vomiting, and a feeling of fullness. Some patients may need a temporary feeding tube to help them get enough nutrition.

A conventional Whipple procedure performed for cancer is similar to a modified Whipple procedure in terms of long-term survival and outcomes. However, the modified Whipple procedure is associated with shorter operative times and less blood loss.

Immediately after a Whipple procedure, patients may develop leakage at the sites of reconnection. Digestive juices from the pancreas, bile, or stomach acid can leak out and damage surrounding tissues. Leakage from the sites of reconnection can also cause infection, a dangerous complication that the patient’s healthcare team will watch out for.

Diabetes occurs in 20 percent of cases where the head of the pancreas is removed, due to inadequate insulin production. This is because the remaining pancreas may not be able to make enough insulin to control the patient’s blood sugar. Patients may need insulin injections while the pancreas recovers from surgery. Patients who have normal blood sugar levels before surgery are not likely to develop diabetes after Whipple surgery. Patients who only recently developed diabetes before surgery are likely to have improvements in blood sugar levels after Whipple surgery.

Some patients may need to take oral digestive enzymes to make up for their pancreas not producing enough after surgery so that they can break down food and absorb nutrients. This and the other previously mentioned postoperative digestive issues may cause patients to lose weight after Whipple surgery.

Pain after Whipple surgery is usually managed with over-the-counter pain medications. Due to digestive issues post-surgery patients may at first only be able to eat a small amount of food at a time. Diarrhea is another common problem that may last for two to three months. This is to be expected because the digestive tract has been rearranged and needs time to recover. It may take a few months to a year for patients to feel normal again.

The Whipple procedure offers a chance to successfully remove the pancreatic tumor. New tumors may grow later on if cancer cells, not visible at the time of surgery, are left behind. This is the reason that most patients receive other treatments like chemotherapy and/or radiation to try to kill remaining cancer cells and decrease the chance of cancer recurrence.

Who is eligible for a Whipple procedure?

Imaging tests will help determine if the pancreatic tumor can be removed with Whipple surgery. The overall health of the patient also determines their eligibility for the Whipple procedure because they need to be strong enough to fully recover from this complex operation.

Approximately 20 percent of patients with pancreatic cancer are eligible for the Whipple procedure. Eligible patients usually have pancreatic tumors confined to the head of the pancreas and their cancer has not spread into nearby blood vessels, liver, lungs, and abdominal cavity. Patients whose tumor has spread to the duodenum, pylorus, or the part of the stomach called the gastric antrum should have a conventional Whipple procedure, rather than a pylorus-preserving pancreatoduodendectomy (modified Whipple procedure).

Most patients with pancreatic cancer that has metastasized beyond the pancreas cannot have a Whipple procedure. In rare cases, a Whipple procedure may be performed on locally advanced pancreatic cancer. Locally advanced pancreatic cancer is when the tumor has spread to nearby veins and arteries or to the body or tail of the pancreas.

The potential benefits of the Whipple procedure are to extend life, provide a chance for a cure, and relieve pain and digestive symptoms of pancreatic cancer. Because the Whipple operation is complicated, with a long recovery and many potential complications, patients need to weigh the risks and benefits. When performed at the ideal stage of disease by an experienced surgeon it is possible for pancreatic cancer patients to fully recover and return to the quality of life they had before.

myTomorrows is dedicated to helping patients with pancreatic cancer find pancreatic cancer clinical trials.