Whipple

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The Whipple Procedure

In 1935, O. Whipple described an operation in which portions

of the pancreas, duodenum and bile duct are removed to treat tumors of the

ampulla of Vater. Although this was not the first time an operation such as this

was described, his success with the 3 cases brought national attention to this

operation. Over the years, the Whipple procedure has been modified, but

continues to be used primarily for tumors of the pancreas, ampulla of Vater,

duodenum, and distal bile duct. In the past, the operation had a high mortality

rate, over 20%. Now, at centers where a few surgeons perform many of these each

year (such as MUSC), the risk of dying from the surgery is less than 2%. This,

plus improvements in diagnostic testing has also resulted in increases in long

term survival. Although the actual rate depends on the site of origin of the

tumor and how advanced it is, the 5 year survival rates range from 15% to 50%.

In the Whipple procedure, portions of the upper gastrointestinal

(GI) tract are removed. This includes the " head " of the pancreas, the attached

duodenum, a portion of the common bile duct, the gallbladder, and sometimes a

portion of the stomach. Once this is complete, the remaining portions of the

pancreas, bile duct and stomach are sutured back to the intestine to restore

continuity of the GI tract. Two tubes are then inserted through the skin for

drainage of fluids from the abdomen until the suture lines start to heal.

Another tube goes into the stomach (gastrostomy tube) to prevent postoperative

vomiting. An additional one enters the intestine (jejunostomy tube) for feeding

the patient while he/she recovers from the surgery. The operation takes from 5-8

hours to perform, and the average recovery time in the hospital is about 2 and a

half weeks.

Since this is an extensive procedure, the goal is to only operate on

patients who may have removable tumors. This is facilitated by studying the

patients prior to surgery with a number of different types of xrays and/or

endoscopic procedures. Patients with incurable disease are those with spread of

the cancer to other organs such as the liver. A spiral CT scan is the best

method for evaluating the liver. Another important piece of information is to

rule out extensive involvement of the blood vessels adjacent to the pancreas.

This can be done with either CT scan, endoscopic ultrasound (EUS), or

angiography. EUS involves a special type of endoscope that has an ultrasound

transducer at the end to evaluate the structures adjacent to the pancreas.

Angiography involves injecting dye into the blood vessels around the pancreas to

determine whether the tumor is growing into them. We rarely perform angiography

as much as in the past since CT and EUS have become so accurate.

Once a decision is made to operate, the surgeon must first determine

whether the tumor is removable or not. A number of tools may be used for this.

Laparoscopy is sometimes performed. This is a method of looking at the organs

through a scope placed in the abdomen while the patient is under general

anesthesia. The purpose of this would primarily be to look for spread of the

tumor to the liver or the lining of the abdomen. If this looks free, then the

abdomen is opened with a fairly extensive incision. The belly is explored and

the pancreas mobilized from the surrounding tissues. The main goal at this time

is to determine whether the tumor is free of the underlying major blood vessels.

If it is free of adjacent structures and has not spread, then the Whipple should

be performed. The most common complications from a Whipple procedure include

bleeding, infection, leakage from where the pancreas is sewn to the intestine,

and delay in function of the stomach.

It should also be noted that it is sometimes difficult to obtain a

definitive diagnosis of cancer either before or during the surgery. The pancreas

tends to develop a great deal of scarring or reaction that interferes with

interpreting a needle biopsy. It is common to biopsy a cancer in this region and

only obtain a benign report. Thus, it is up to the surgeon's judgement whether

or not the patient has cancer. At times, a Whipple procedure will be performed

without a definitive diagnosis of cancer. In these instances, cancer will often

be found in the final pathology specimen. It should also be noted that a Whipple

procedure is sometimes performed for benign disease in order to control pain

from pancreatitis or to remove a premalignant tumor that may progress to

invasive cancer with time. These are further reasons why it is important to be

operated on by a surgeon with a great deal of experience with operations for

cancer of the pancreas and periampullary region. His/her judgement will be

valuable in determining whether or not a tumor is present and if it is

removable. This is in addition to the above information that the mortality risk

from the surgery will be much lower.

Long term results for the Whipple procedure have been examined by a

number of authors. Most studies have shown that the five year survival for the

Whipple procedure for pancreatic cancer is about 20%. Even though this

relatively small number shows that few patients are cured, patients that do

undergo a Whipple will have a better long term survival when compared to those

who do not have the tumor removed. Similarly, it should be noted that patients

who have the Whipple procedure for non-pancreatic cancers such as those arising

in the ampulla vater, duodenum or the distal bile duct, will have five year

survivals of about 40-50%. In either instance, patients can have a good quality

of life following a Whipple procedure.

Virtually from Dr. Baron

5/15/98

A Patient's Perspective of the Whipple Procedure

On April 7, 1998 I underwent a Whipple procedure. My diagnosis was

mucinous ductal ectasia of the pancreas (MDE). The gastroenterologists' at MUSC

made the diagnosis. My physicians in Miami, Florida had referred me to MUSC, as

they were not certain what I had. I am a physician myself. MDE is a rare

condition but is recently being diagnosed more frequently. Whether this is due

to better techniques such as endoscopic ultrasound or ERCP or its just becoming

more common is unclear. MDE is a premalignant growth that lines the insides of

the pancreatic ducts like a rug. This abnormal growth of cells produces mucin,

which like mucous, blocks the pancreatic ducts. This in turn causes bouts of

pancreatitis. Eventually, the pancreas becomes seriously damaged (chronic

pancreatitis and atrophy) and this leads to diabetes or malabsorption problems.

Patients can have abdominal pain, bloating, and diarrhea. In my case I only had

one severe bout of pancreatitis occurring just five months prior to my surgery.

I may have had two previous milder episodes of pancreatitis in 1996 and 1987,

but I didn't know it at the time. I just thought I had a bad stomach virus that

lasted about 24-48 hours. It is apparent to me now after the surgery, that my

pancreas was slowly being destroyed by this condition over a 10-15 year period

of time (maybe even longer) and I had no knowledge of this while it was

occurring. In a sense, I had a case of painless chronic pancreatitis.

Apparently, this is a chronic condition that can destroy the pancreas or turn

into a pancreatic malignancy. Most cases of MDE involve only the head and neck

of the pancreas and thus currently the treatment of choice is a Whipple

Procedure. Since the anatomy of the pancreas is so intricately attached to the

blood vessels and structures in its vicinity, one cannot remove the head and

neck of the pancreas without also removing about one half of the stomach, the

entire gallbladder, the duodenum, and a portion of the jejunum.

Post-operatively, the patients are told to eat five small, low fat meals a day.

Since insulin is produced in the tail of the pancreas, and this area is

preserved, diabetes usually does not develop. The above description essentially

describes the Whipple procedure.

After receiving my diagnosis I researched surgeons and centers that

had experience in both the Whipple procedure and my condition. After contacting

the surgeon and also speaking with the pathologist, I made my choice. My surgery

was scheduled five weeks later. The day before surgery I met with the surgeon

and reviewed all the details. He explained to me that I might require a total

pancreatectomy depending on how extensive the tumor was. I also had pre-op labs,

a chest x-ray, and an EKG done the day before surgery. I was admitted on the

same day that I had the surgery. I actually just went right into surgery.

I woke up after surgery in the recovery room. I stayed there for

about two hours because my blood pressure was slightly elevated. I remember

fully waking up there and then waking up again in my room. I did not go to

intensive care. In my room my family was waiting for me and I wanted to know how

everything went including the pathologist's report and how much of the pancreas

was removed. My wife thought I was more alert than she thought I would be. I had

a nasogastric tube in place, a catheter, and four drains coming out of my

abdominal wall a few inches from my incision. One drain came from my pancreas,

and another came from my liver; each draining the fluids the organs produce

(pancreatic juice and bile). The two other drains just drained secretions from

the surgical area inside ( Pratt drains). The first day after surgery

they had me stand up and walk a few times and it was cumbersome. I also had my

IV pole. I felt weak at first, but gradually adapted and actually looked forward

to walking as it was more interesting than lying in bed. The next few days were

full. Each shift I was expected to do my breathing exercises a few times and

walk every few hours and have all my drains emptied. I couldn't wait till I

could wash off and brush my teeth (day 2 and daily thereafter). If I didn't

bathe (sponge bath), I felt very uncomfortable. However bathing took maximal

effort and motivation. When the nasogastric tube came out on day 2 or 3 after

surgery, I was greatly relieved. It was particularly uncomfortable. Shortly

afterward, (day 4), I began sips of water. When I went from clear liquids to

full liquids, I got terribly nauseous after a bowl of Cream of Wheat and they

had to restart my IV (from heparin lock) and put me NPO for twenty-four hours.

That set back was upsetting. Eventually, I was able to restart clear liquids and

then gradually advanced to very small meals over the next four days (day 5 to

day 9). My J-P drains were removed sometime between day 6 and 7 (I'm not sure).

My catheter came out on day 7 and that made it easier to move around and walk. I

depended on the percocet for pain relief and took it around the clock (every 6

to 8 hours). On day 9, they said I was ready to go home. I was discharged with

my pancreatic and bile duct drains still in place, which was a surprise for me.

They were removed six days later when I returned for my one and only follow up

outpatient visit with the surgeon. I stayed locally near the hospital for that

first week and had to walk up three flights of stairs to get to the apartment.

For the next five days as an outpatient, I didn't do very much and I still had a

fair amount of pain. Constipation and nausea were persistent problems during

that time. Finding the right foods to eat wasn't easy. My wife thought I was

getting worse. I called the surgeon once about the constipation (I felt bad

about doing that). After I saw the surgeon on day 15 post-op, I flew home the

next day. It felt great to be home in my own comfortable surroundings. Slowly

things (pain and constipation) began to improve. I thought I'd be 100% in four

weeks post-op, but I wasn't. At two months post-op I was getting pretty close to

feeling normal.

Pain and the Whipple Procedure

Pre-operatively I was offered a choice between having conventional

intravenous narcotic medication and having continuous spinal anesthesia. The

spinal anesthesia involved placing a small tube in my spinal epidural space

prior to surgery and having semi-continuous infusion of numbing medication into

the spinal canal area. This would completely numb the entire abdominal cavity

where the surgery was. Sometimes this spinal tube can become blocked or come

out, hence making it functionless. I elected to do the conventional intravenous

narcotic medication because I wanted the narcotics to make me sleepy so the time

would pass by quicker. I also recently read in a FDA bulletin that spinal

anesthesia and intravenous heparin given at the same time can possibly cause

problems with the spinal cord (e.g. paralysis). The heparin is a blood thinner,

and that, coupled with the numbing medication in the spinal cord, might cause

bleeding around the spinal cord itself. Since I was given low dose heparin

injections for the entire time I was hospitalized, in retrospect, I'm glad I

didn't do the spinal anesthesia.

Post-operative abdominal pain was most intense in the first three to

four days. However narcotic IV medication was administered during this time and

that really controlled the pain fairly well. I received the medication via a PCA

pump that allowed me to pretty much control my pain as well as I liked.

Initially, I received Morphine, but it was switched to Dilaudid when the pump

didn't work (we thought it was the morphine not working at first). The Dilaudid

however, had a tendency to keep me awake (just the opposite of what I wanted)

and thus I tried not to use as much. On day 6, my pain medicine was switched to

p.o. Percocet. Gradually over the next seven weeks, I reduced my need for

medication. My last dose of Percocet was taken two months after surgery. The

pain over that two month period would tend to come and go. I might be pain free

for a day or so and then have one bad day for no clear cut reason. That was a

little frustrating and worrisome. Perhaps my appetite came back too fast and I

overate. In retrospect, perhaps my stomach and intestines were stretching and

adjusting to the new setup. In addition, all the wounds were still healing.

There were however, three occasions where I had a sudden attack of excruciating

mid upper abdominal pain that literally doubled me over. I became short of

breath as my chest seemed to tighten and I even felt faint. Fortunately, it only

lasted one to two minutes and cleared. It was rather frightening. I remember

this occurred on day twelve, day twenty-one, and even as late as day thirty-five

after surgery. The only explanation was that maybe it occurred after a bigger

than usual meal (hamburger). Perhaps it was either severe gastroesophageal

reflux or the stomach was stretching trying to push more food into the smaller

jejunum.

Other Complications Following the Whipple

Constipation was a major problem from day six to day fifteen

post-op. It probably caused much of the pain I experienced during this period of

time. Percocet was a contributing factor and I tried to lower the usage of it by

substituting Extra-Strength Tylenol. It helped a little. However getting back

home to Florida, suppositories, fluids, and time (and a little Milk of Magnesia)

all helped to resolve the problem. There was a decisive drop in my overall

abdominal pain and discomfort once the bowel movements became regular.

Now, three months post-op, I still will have occasional mild

abdominal pain and bloating when I overeat or eat something with too much fat.

Sometimes I can't identify the specific reason for abdominal discomfort, but

it's usually related to eating.

Early on, the foods best tolerated included graham crackers, cottage

cheese and fruit. Breads seemed hard to digest. Caffeine was and continues to be

difficult to tolerate (causing some mild pain). My appetite was minimal in the

first two weeks but gradually improved. Now, my appetite is as strong as it's

always been.

Fatigue and feeling cold were prominent symptoms in the first month.

Surprisingly a One-a-Day vitamin seemed to help. Extreme skin sensitivity around

my incision was quite annoying for the first six weeks but now is completely

gone (three months later).

Sleep problems were initially present. I felt the narcotic Dilaudid

had a side effect of keeping me awake. I thought I slept very little while

taking it. Eventually, a dose of Ativan and getting off the Dilaudid helped (by

day five). My sleep wake cycle was disturbed for about six weeks where I would

wake up frequently at night and fall asleep early at seven to eight in the

evening. This eventually corrected itself.

I have on occasion taken some pancreatic enzymes prior to a large

meal (as in a restaurant). They help but I try not to do this on a routine

basis. Overall if I don't overindulge I do fine. I have one to two bowel

movements per day and I have not had diarrhea. If I overeat or have too much fat

I'll get pain, gas, and bloating.

Conclusion

In conclusion the Whipple procedure was a fairly impressive ordeal.

Knowing that it saved my life made it seem like a piece of cake. I kept my focus

on believing this and it certainly helped. I knew eventually I would feel better

and I do. In fact my energy and capacity for work is better now than it was

before surgery. I am back to running four days per week, 3-4 miles each time. I

resumed my walking and running two months after surgery. However my first couple

of weeks out of the hospital my wife had to force me to go for walks. Initially

I lost about 10% of my weight (20lbs.). I've gained about ten pounds back and I

could gain more but I'm trying not to. I enjoy all the compliments I've been

receiving.

I wish to thank the doctors, nurses, and staff at MUSC. My diagnosis

was not made until I traveled north to MUSC after months of numerous

consultations and third opinions. Drs. Cotton and Hawes seemed to make the

diagnosis with ease. I was treated wonderfully at MUSC and will always be

grateful.

A. , M.D.

Miami, Florida

Reference

1. FDA Medical Bulletin. Summer 1998. Vol.28 No.1 page 7.

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