Whipple procedure

The Whipple procedure or pancreaticoduodenectomy is the surgical treatment of pancreatic cancer - cancer that occurs in the head of the pancreas (a gland behind the stomach). During the surgery, the surgeon removes the head of the pancreas, the gallbladder (a small organ under the liver), a major portion of the duodenum (a section of the small intestine), a part of the bile duct (tubes from the liver to the intestine), and the associated lymph nodes (small structures that filter harmful substances). Sometimes, the entire duodenum and a part of the stomach may be removed too.

The enzymes produced by the pancreas flow into the duodenum and help in the digestion of food. The pancreas also releases the hormones insulin and glucagon that help in regulating sugar levels in the blood. A pancreatic tumour interferes with both of these functions. The blockage of enzymes by the tumour can lead to pancreatitis (inflammation of the pancreas) and digestive problems like diarrhoea. The blockage of hormones also causes a spike in blood sugar levels, leading to diabetes.

The Whipple procedure is recommended for the treatment of the following conditions:

• Pancreatic cancer
• Bile duct cancer (cholangiocarcinoma)
• Cancer in the small intestine
• Chronic pancreatitis

Some common symptoms of the above conditions are as follows:

• Jaundice (yellowing of the skin and eyes)
• Nausea and vomiting
• Abdominal pain or back pain
• Poor appetite
• Unintentional weight loss
• Liver or gallbladder enlargement

Additionally, pancreatic cancer also causes dark urine, itching of skin, greasy or pale-coloured stools, blood clots or diabetes whereas cholangiocarcinoma may have similar symptoms along with fever.

Cancer in the small intestine could have additional symptoms like fatigue, weakness, dark-coloured stools and anaemia (due to the bleeding in the bowels) while those with chronic pancreatitis could have fat in stools.

The Whipple procedure is also done as an emergency, life-saving surgery in patients with serious injuries of the duodenum and the head of the pancreas when other surgeries to preserve these organs cannot be done.

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The surgery is contraindicated in the following conditions:

• When the cancer has spread outside the organ extensively
• Locally advanced cancer (cancer that has invaded the adjacent tissues)

A cancer in the head of the pancreas can be operated on; however, if it spreads into the body or tail of the pancreas, surgery may not be possible.

The surgery requires the following preparation:

• If you have high blood pressure, diabetes, and any lung problems or heart diseases, visit the doctor to ensure that the conditions are well-controlled.
• Your doctor may order the following tests before the procedure: 
  • Blood tests for electrolytes, liver function test, kidney function test, and complete blood count
  • Imaging tests such as ultrasound, CT scan, and endoscopic retrograde cholangiopancreatography (bile and pancreatic ducts)
• Your doctor may ask you to stop taking blood thinners like ibuprofen, aspirin, and warfarin
• Avoid smoking as it may slow down the healing after surgery.
• If you have lost weight, you will need to regain it before the surgery.
• You may require pancreatic enzyme supplements to help in digesting food.
• You will need to maintain fasting several hours prior to the procedure. 
• You will need to sign a consent form, allowing the doctor to perform the surgery.

Once you are admitted in the hospital, you will be given a hospital gown to change and then taken to the operation room. The doctor will administer general anaesthesia with a sleep-inducing medicine.

Your doctor will insert an intravenous (IV) line in your arm and administer a dose of antibiotics before and after the surgery.

The surgery may be performed by the following methods:

• Open surgery: In this, the surgeon makes a large incision, depending on the tumour’s position and if other surrounding tissues are involved. The incision may be vertical, in the middle of the abdomen or horizontal, below the ribs.
• Laparoscopic surgery: During this technique, multiple small incisions are made, and a tube containing a light and a camera (laparoscope) is inserted through one. This gives a two-dimensional view of the tumour and the nearby structures. Through the other incisions, surgical instruments to perform the surgery are inserted.

The procedure involves the following steps:

• Once the incision is made, the surgeon will examine the region surrounding the tumour for suspicious lesions or enlarged lymph nodes. He/she may also do a biopsy of the area. If these samples are positive for cancer, the surgery will be aborted. 
• If the samples are negative for cancer, the following procedure is done:
  • The surgeon will move away the major blood vessels from the surgery area.
  • He/she will separate the head of the pancreas and duodenum from the surrounding tissue and remove the gallbladder, a part of the bile duct, and adjacent lymph nodes. 
  • The lower end of the stomach (if required), the head of the pancreas, and the duodenum will also be removed.
  • The surgeon will then connect the remaining part of the pancreas, stomach, and bile duct to the small intestine with sutures and place drainage tubes to remove any collected fluids.
  • Finally, he/she will close your abdominal wall with sutures.

The surgery takes four to seven hours to complete. You can expect the following after the surgery:

• After the surgery, you will be in the intensive care unit for one night and then transferred to the hospital ward. You will be monitored for any complications.
• A nurse will give you pain medication through IV.
• A doctor will also give you an injection each day to prevent blood clots.
• You will have a catheter placed in your bladder to drain urine. The catheter, IV line and drainage tube will be removed when they are not required.
• The day after the surgery, you will be asked to take short walks, which will be increased gradually.
• For the first few days, you cannot eat anything to allow the healing of the reconstructed digestive tract.
• You can start food in the form of liquids like water, juices, milk, tea, or coffee. Slowly, you can have soft foods and then progress to more normal food. If there is a leak where the stomach, pancreas, or bile duct joins the small intestine, you may have IV nutrition for some days. 
• Your nurse will change your dressings. The stitches on your abdomen will be removed 10 to 14 days after the surgery.
• A pathologist will observe your tissues in the laboratory to determine the presence of cancer cells in the edges of the tissue removed.
• You will be discharged from the hospital in one to two weeks, depending on your recovery.
• You may also be administered chemotherapy or radiotherapy as needed.

When you come home after the surgery, you will need to keep the following things in mind:

• Avoid removing your bandages for one or two weeks. 
• Only take showers (do not soak the wound) and use a mild soap and water. Gently wash the area around the incision. 
• Always cover your incision and keep it out of the sunlight. 
• Finding the foods and pattern that suit you will take some time. Follow these instructions:
  • Drink a lot of fluids
  • Avoid fatty foods
  • Have frequent small meals initially
  • Try food supplements
  • Try different foods to see what suits you
• You may be prescribed pancreatic enzyme replacements to take with meals. Use them as directed.
• Avoid lifting anything heavy for six weeks after the surgery.
• Typically, you will be able to resume work in three months; however, it also depends on the type of your work and if you have to have chemotherapy.
• Starting with mild activities such as walking regularly and increasing it gradually will help in the recovery process. 
• It may help to talk to people with pancreatic cancer.

The benefits of the surgery are:

• Treats pancreatic cancer and increases your lifespan
• Symptoms like jaundice, digestion problems, and pain will improve

When to see the doctor?

Immediately talk to your doctor if you see the following symptoms:

• Worsening pain
• Fever
• Drainage from the operation site
• Swelling and redness near the incision
• The incision feels warm to the touch
• No bowel movements for three days
• Frequent bowel movements, oily stools, and severe diarrhoea

The complications associated with Whipple procedure are:

• Bleeding
• Postoperative diabetes
• Infection
• Bile and pancreatic leakage
• Fatty stools

You will have to visit the hospital 2 weeks after discharge from the hospital for the results of the laboratory tests performed after the surgery. You may have follow-appointments with the surgeon every 3 or 6 months during the initial 2 years after the surgery. After 2 years, the frequency of the visits may reduce to once per year.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.