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Whipple procedure


Medical editor Ivar Gladhaug MD
Specialist in Gastroenterological Surgery
Oslo University Hospital

General

A Whipple procedure is performed when there is suspicion of a malignant tumor in the head of the pancreas or adjacent organs such as the duodenum or bile ducts. The operation is also carried out for some cases of chronic pancreatitis.  

A Whipple procedure is not performed if there is spreading of cancer to other organs or to peripheral lymph nodes. Invasion of blood vessels (especially the mesenteric artery and greater mesenteric vein) is also a contraindication. In some cases of limited vessel invasion, the operation can still be carried out in combination with vascular surgery.

The head of the pancreas is removed. Since the pancreas shares blood supply and lymphatic drainage with adjacent organs, some of the common bile duct is removed along with the entire duodenum and often the distal stomach . Finally, a reconstruction is performed where the small intestine is anastomosed to the remaining bile ducts, stomach, and remaining pancreas. 

Mortality of the procedure is low, but postoperative morbidity is still significant. To reduce postoperative mortality, the patient should be operated at a hospital with a large volume of operations and after critical preoperative assessment of the patients. 

Indications

  • Tumor in the pancreas
  • Tumor in the duodenum
  • Tumor in distal end of the common bile duct 

Goal

  • Cure of the disease

Preparation

  • Antibiotic prophylaxis
  • Thrombosis prophylaxis
  • Urinary bladder catheter 
  • Epidural catheter is installed for postoperative pain relief.
  • The patient lies in the supine position.
  • The operation is performed under general anesthesia.

Implementation

A Whipple procedure consists of three steps:

  • Dissection
  • Resection
  • Reconstruction

Dissection

  • The procedure is performed via an angled, epigastric transverse incision.
  • The abdominal cavity is inspected and palpated thoroughly.
  • Inoperability criteria are:  
    • liver metastasis
    • peritoneal metastasis
    • invasion of the base of the mesentery
    • infiltration of the peritoneal surface
    • growth into adjacent organs (not the duodenum)
  • Kocherization is completed when the duodenum and head of the pancreas are dissected off the underlying structures.
  • The hepatic artery and the base of the gastroduodenal artery are dissected and identified by vessel loops.
  • The common bile duct is dissected and the area of division is identified with a vessel loop.
  • The superior mesenteric vein is dissected at the lower edge of the pancreas.
  • The lesser sac is divided and the omental bursa is opened, and the caudal edge of the pancreas is isolated.
  • The portal vein is bluntly dissected behind the pancreas to isolate the portal vein. The dissected pancreas is identified with a vessel loop.

Resection

  • The gastroduodenal artery is divided at the origin from the hepatic artery.
  • The small intestine is divided 8–10 cm distal to the ligament of Treitz using a GIA stapler. This apparatus inserts two double rows of staples and divdes the tissue between them in one operation.
  • The stomach is divided at the angulus, also with a GIA. The staple suture is inverted manually with sutures.
  • A cholecystectomy is performed.
  • The pancreas is divided with a knife between the head and body.
  • The loop around the common bile duct is removed and the duct is divided.
  • The tissue between the head of the pancreas and the portal vein and superior mesenteric artery is divided by dissection towards the vessels. The specimen is now free to be removed. 

Reconstruction

  • The pancreas is anastomosed end-to-side to the distal small intestine with interrupted sutures. 
  • The common bile duct is anastomosed end-to-side further down on the small intestine. The anastomosis is performed with running sutures posteriorly and interrupted sutures anteriorly.  
  • The stomach is anastomosed side-to-side to the small bowel. The anastomosis is created with a GIA or with sutures. The opening from the GIA is closed with running sutures. 
  • The abdomen is flushed and a drain is placed in the anastomosis area.
  • The abdominal wall is closed by two layers of running sutures. The skin is closed with staples.
  • The surgical specimen is marked by the surgeon and sent to the pathologist.

Follow-up

  • Epidural pain relief is usually given for 3–5 days and helps the mobilization of the patient.
  • The patient often has a naso-gastric tube for the first 24 hours.
  • The patient may drink as soon as he/she would like to.

Possible serious complications are often due to:

  • Failure in one or more anastomoses
  • Abscess and/or sepsis 
  • Bleeding

Less serious complications involve delayed gastric emptying. Thus, long-lasting delay of stomach emptying should raise the suspicion of an underlying intraabdominal complication.

The patient

After a complication-free postoperative stay, the patient is usually transferred to a local hospital after about 1 week and is discharged after 10–14 days.

When histology report from the surgical specimen is available, treatment with chemotherapy will be considered.

The patient is usually followed up by their primary care physician after treatment is completed.

After

  • Patients having stomach resections may develop vitamin B12 and iron deficiencies. Hemoglobin should be checked every 4 months and a B12 injection is recommended.
  • Exocrine insufficiency can occur. This is treated with pancreatic enzymes in tablet form.  
  • After a pancreatic resection, there is an increased risk for developing diabetes and the patient must be informed about the initial symptoms of diabetes mellitus.

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