Whipple procedure
Pancreaticoduodenectomy

The Pancreas

The pancreas is a gland, nestled between the loop of the duodenum. The thin tube carrying bile from the liver (bile duct) joins thetube bringing pancreatic juice (pancreatic duct) in the head of the pancreas and opens into the duodenum. The pancreas has three parts, head body and tail.

Surgery for pancreatic and periampullary cancers

Periampullary cancers includes cancer of the head of the pancreas, distal bile duct (cholangiocarcinoma), duodenum and ampulla. Pancreatic cancer or periampullary cancer if detected before it has spread to other organs, is treated by surgery. Surgical removal of these tumours offers the best chances of cure.

The type of surgery to treat tumour depends on the location of the tumour in the pancreas. The cancers in the pancreatic head are treated by Whipple procedure or pancreaticoduodenectomy and cancers in the body and tail is removed by distal pancreatectomy or distal pancreaticosplenectomy. Some tumours in the body of the pancreas can be removed by central pancreatectomy.

The surgical procedure

Whipple procedure or pancreaticoduodenectomy is a complex surgical procedure. This operation is named after Allen Whipple, who was the first surgeon to perform this operation in 1935.

Whipple procedure is performed to treat following conditions:

• Pancreatic cancer
• Tumours and cysts of the head of the pancreas
• Neuroendocrine tumours of the head of the pancreas
• Periampullary cancers
  • Distal bile duct cancer (cholangiocarcinoma)
  • Duodenal cancer
  • Ampullary cancer

Preoperative Evaluation and Preparation

Before undergoing the Whipple procedure, patients will undergo a comprehensive evaluation, including imaging studies, blood tests, and a thorough medical check up. This evaluation aims to determine the extent of the disease, assess the patient's overall health status, and identify any contraindications to surgery. If the tumour is advanced, patients may also receive neoadjuvant therapies such as chemotherapy or radiation to shrink tumors before surgery.

Surgical Technique

In this operation, head of the pancreas, bile duct, gall bladder, first part of the small intestine and a portion of the stomach is removed.

Intestinal continuity is then restored by joining the cut end of the pancreas to small intestine or stomach, cut end of the bile duct is joined to small intestine and stomach is joined with the small intestine.

It is a complex operation that takes several hours to complete and demands great skill and expertise. The anatomy of the area is complex and there are variations in the arrangement of blood vessels around. Moreover, sometimes these cancers are stuck to vital blood vessels, which need to be cut and joined to achieve complete removal of the tumour.

Who can undergo surgery?

Not all patients with pancreatic or periampullary cancer will undergo this operation. Only about 20 per cent of patients suffering from pancreatic cancer are eligible for surgical removal. For periampullary cancers this number is much higher.

In these patients, cancer has not spread to nearby blood vessels, liver, lungs and abdominal cavity. In patients whose tumour is attached to the adjacent blood vessels, called borderline resectable cancers, this operation is done after giving chemotherapy in an attempt to downsize the tumour and achieve better control.

Besides, the patient has to be fit to undergo major surgery. Some patients have high levels of jaundice, and it need to be brought down by doing an endoscopic procedure called ERCP.

Who should be doing this operation?

Since it is a complex operation, your surgeon should have done enough of them. A high volume pancreatic surgeon performs more than 15 to 20 such surgeries per year. A high volume surgeon at a high volume centre will have the best outcome. For the success of a surgical procedure, it is not only important for the surgeon to be skilled, but also for the rest of the medical team and the hospital infrastructure to be well-equipped.

After surgery

The patient would stay in the hospital until he recovers. Initially, the patient is monitored in the ICU and is then shifted to the ward once the condition is more stable. Once the movement of the intestine returns oral feeding will be started. During this surgery, tubes are placed in the abdomen to monitor for bleeding or leakage and they will be removed once the secretions dry up.

The recovery generally takes 8-10 days but can be prolonged if there are complications. There can be many complications following this surgery but the most common ones are pancreatic fistula and delayed gastric emptying. Other complications can be bleeding and infection.

Earlier this operation was fraught with a very high complication rate and risk of death. With the advancement of medical science including diagnosis, staging, surgical technique, anaesthesia, intensive care and postoperative care, the risk of mortality has now been reduced to less than 3% in experienced hands.

At the time of discharge, most patients are eating a normal diet and can carry out activities of daily living.

Those who undergo a successful Whipple operation can have a five-year survival of 15-70%, depending upon the primary location of the tumour and stage of the disease. Depending on the stage of the tumour, you might be advised further chemotherapy or chemoradiotherapy called adjuvant treatment.

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Wish you a speedy recovery!