Whipple procedure


A surgical operation in which the head of the pancreas, a portion of the bile duct, the gallbladder and the duodenum is removed.

Referred to as a pancreaticoduodenectomy.

Pancreaticoduodenectomy is most often performed as curative treatment for periampullary cancer, which include cancer of the bile duct, duodenum, ampulla or head of the pancreas.

A portion of the stomach may also be removed.

It is a major surgical operation most often performed to remove cancerous tumors from the head of the pancreas.

Other indications for pancreaticoduodenectomy include chronic pancreatitis, benign tumors of the pancreas, cancer metastatic to the pancreas, multiple endocrine neoplasia type 1 and gastrointestinal stromal tumors.

Pancreaticoduodenectomy is the only potentially curative intervention for malignant tumors of the pancreas.

However, the majority of patients with pancreatic cancer present with metastatic or locally advanced un-resectable disease;thus only 15-20% of patients are candidates for the Whipple procedure. 

It is also used for the treatment of pancreatic or duodenal trauma, or chronic pancreatitis.

The shared blood supply of the pancreas, duodenum and common bile duct, necessitates en bloc resection of these multiple structures. 

The remaining pancreas, bile duct and the intestine is sutured back into the intestine to direct the gastrointestinal secretions back into the gut.

Reconstruction consists of attaching the pancreas to the jejunum via a pancreaticojejunostomy, and attaching the hepatic duct to the jejunum via a hepaticojejunostomy, and attaching the stomach to the jejunum via a gastrojejunostomy.

Most common technique consists of the en bloc removal of the distal segment of the stomach,the first and second portions of the duodenum, the head of the pancreas; the common bile duct; and the gallbladder.

The head of the pancreas and the duodenum share the same arterial blood supply, the gastroduodenal artery, so that both organs must be removed if the single blood supply is severed.

Due to the shared blood supply of organs in the proximal gastrointestinal system, surgical removal of the head of the pancreas also necessitates removal of the duodenum, proximal jejunum, gallbladder, and, occasionally, part of the stomach.

The pancreas, stomach, and bowel are joined back together after a pancreaticoduodenectomy

Operative mortality rates to be four times higher, 16.3 percent vs. 3.8 percent at low-volume hospitals than at high-volume hospitals.

The most common technique of a pancreaticoduodenectomy consists of the en bloc removal of the distal segment (antrum) of the stomach, the first and second portions of the duodenum, the head of the pancreas, the common bile duct, and the gallbladder.

Lymph nodes in the area are often removed during the operation.

However, not all lymph nodes are removed in the most common type of pancreaticoduodenectomy because studies showed that patients did not benefit from the more extensive surgery.

Infectious complications have been reported in his many is 30% of patients following open pancreatoduodenectomy.

Biliary colonization that arises from preoperative procedures for biliary drainage closely predicts infectious complications following pancreaticoduodenectomy.

Surgery may follow neoadjuvant chemotherapy, which aims to shrink the tumor and increasing the likelihood of complete resection.

Post-operative death and complications associated with pancreaticoduodenectomy have become less common, with rates of post-operative mortality falling from 10 to 30% in the 1980s to less than 3%.

Perioperative prophylaxis with Piperacillin/tazobactam results in absolute risk reduction of surgical site infections.

At the very beginning of the procedure, the surfaces of the peritoneum and the liver are inspected for disease that has metastasized: the presence of active metastatic disease is a contraindication to performing the operation.

The vascular supply of the pancreas is from the celiac artery via the superior pancreaticoduodenal artery and the superior mesenteric artery from the inferior pancreaticoduodenal artery.

There are additional smaller branches given off by the right gastric artery which is also derived from the celiac artery.

The removal of the duodenum along with the head of the pancreas is that they share the same arterial blood supply.

The blood supply to the liver is left intact.

The common bile duct is removed.

A new connection to drain bile produced in the liver is done at the end of the surgery.

A new attachment between the pancreatic duct and the jejunum or stomach.

During the surgery a cholecystectomy is performed to remove the gallbladder.

Surgery may follow neoadjuvant chemotherapy, which aims to shrink the tumor and increasing the likelihood of complete resection.

Post-operative death and complications associated with pancreaticoduodenectomy have become less common, with rates of post-operative mortality falling from 10 to 30% in the 1980s to less than 3%.

Ampullary cancer arises from the lining of the ampulla of Vater.

Duodenal cancer arises from the lining of the duodenal mucosa. 

Majority of duodenal cancers originate in the second part of the duodenum, where ampulla is located.

Cholangiocarcinoma, or cancer of the bile duct, is an indication for the Whipple procedure when the cancer is present in the distal biliary system, usually the common bile duct that drains into the duodenum. 

Depending on the location and extension of the cholangiocarcinoma, curative surgical resection may require hepatectomy, or removal of part of the liver, with or without pancreaticoduodenectomy.

Treatment of chronic pancreatitis typically includes pain control and management of exocrine insufficiency. Intractable abdominal pain is the main surgical indication for surgical management of chronic pancreatitis.

Removal of the head of the pancreas can relieve pancreatic duct obstruction associated with chronic pancreatitis.

Damage to the pancreas and duodenum from blunt abdominal trauma is uncommon, and is seen as a result of a lap belt in motor vehicle accidents.

Pancreaticoduodenectomy has been performed when abdominal trauma has resulted in bleeding around the pancreas and duodenum, damage to the common bile duct, pancreatic leakage, or transection of the duodenum.

Absolute contraindications for the procedure are metastatic disease in the abdominal cavity or nearby organs: most often on the peritoneum, in the liver, and in the omentum. 

Further contraindications include encasement of major vessels, such as celiac artery, inferior vena cava, or superior mesenteric artery.

The pylorus-preserving pancreaticoduodenectomy’s (also known as Traverso-Longmire procedure/PPPD) main advantage of this technique is that the pylorus, and thus normal gastric emptying, should in theory be preserved.

There is conflicting data as to whether pylorus-preserving pancreaticoduodenectomy is associated with increased likelihood of gastric emptying.

In practice, it shows similar long-term survival as a Whipple’s (pancreaticoduodenectomy + hemigastrectomy), but patients benefit from improved recovery of weight after a PPPD, so this should be performed when the tumor does not involve the stomach and the lymph nodes along the gastric curvatures are not enlarged.

The pylorus preserving pancreaticoduodenectomy technique is associated with shorter operation time and less intraoperative blood loss, requiring less blood transfusion. 

Post-operative complications, hospital mortality and survival do not differ between the two methods.

Pancreaticoduodenectomy is a major surgical procedure.

One study reported actual risk to be 2.4 times greater than the risk reported in the medical literature, with additional variation by type of institution.

Relevant nearby anatomy not removed during the procedure include the major vascular structures in the area: the portal vein, the superior mesenteric vein, and the superior mesenteric artery, the inferior vena cava. 

If the tumor encases around 50% or more of the vessel, the celiac artery, superior mesenteric artery, or inferior vena cava it is considered unresectable due to the lack of patient benefit from the operation while having very high risk.

Postoperative complications:

Three of the most common post-operative complications are: delayed gastric emptying, bile leak, and pancreatic leak. 

Delayed gastric emptying, normally defined as an inability to tolerate a regular diet by the end of the first post-op week and the requirement for nasogastric tube placement, occurs in approximately 17% of operations.

During the surgery, a new biliary connection (choledochal-jejunal anastamosis connecting the common bile duct and jejunum) is made. 

This new connection may leak in 1-2% of operations. 

Surgeon leave a drain in place allowing  for detection of a bile leak via elevated bilirubin in the fluid drained. 

Pancreatic leak or pancreatic fistula, defined as fluid drained after postoperative day 3 that has an amylase content greater than or equal to 3 times the upper limit of normal, occurs in 5-10% of operations.

Immediately after surgery, patients are monitored for return of bowel function and appropriate closed-suction drainage of the abdomen.

Ileus, which refers to functional obstruction or aperistalsis of the intestine, is a physiologic response to abdominal surgery.

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