The Shipple Procedure

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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.

Mark E. Armstrong

www.top5plus5.com

NW Chapter Rep

Pancreatitis Association, International