What Is the Whipple Procedure?

What is the Whipple procedure?

The Whipple procedure is an extensive surgery named after Dr. Allen Whipple, the surgeon who performed the first modernized version in 1940. It’s the most common surgery used to remove pancreatic cancer.

The Whipple procedure has two variations, the classical Whipple and pylorus sparing pancreatoduodenectomy (PSD). In the classical procedure, part of the stomach is removed. In the PSD, the stomach is spared.

Both procedures involve the removal of:

• the head of the pancreas
• the duodenum, part of your small intestine
• common bile duct
• gallbladder

Once these organs are removed, the remaining parts of the digestive tract are reconnected.

Why is the Whipple procedure done?

The Whipple procedure is most often used to treat cancer at the head of the pancreas that’s considered resectable or borderline resectable. Resectable means that it can be removed with surgery, while borderline resectable means it may be possible to remove the tumor but there’s a risk that not all the cancer cells will be removed.

Less commonly, the Whipple procedure is used to treat:

• chronic pancreatitis
• severe pancreatic trauma
• bile duct cancer
• duodenal cancer

What is pancreatic cancer?

Pancreatic cancer is cancer of your pancreas, an organ that produces the hormone insulin and digestive enzymes. It’s difficult to treat because it often doesn’t respond to treatment and isn’t found until it’s spread to other tissues. It has one of the poorest prognoses of any cancer with a 5-year survival rate of about 12 percent.

The most common type of pancreatic cancer is adenocarcinoma, which starts in cells that produce digestive enzymes called exocrine cells.

Symptoms

By the time pancreatic cancer causes signs or symptoms, it has usually already grown very large or has spread beyond the pancreas. According to the American Cancer Society (ACS), signs and symptoms of pancreatic cancer can include:

• jaundice
• belly or back pain
• weight loss or poor appetite
• nausea and vomiting
• Gallbladder or liver enlargement
• blood clot
• diabetes

Why the Whipple procedure is performed

The goal of the Whipple procedure is to cure the cancer or to increase the time of survival. Your surgeon can leave enough of your pancreas to preserve digestive enzyme and insulin production.

How to prepare for a Whipple procedure

Many people lose a significant amount of weight after a Whipple procedure, so it’s often recommended to gain weight before the operation.

Strengthening the muscles in your abdominal wall and hip flexors can help you become mobile faster after surgery.

Before your procedure, it’s important to follow your surgeon’s recommendations to minimize your risk of complications. Discuss with your surgeon:

• how physically active you are
• chronic health issues such as asthma or diabetes
• allergies
• any other medical conditions
• whether you snore or have sleep apnea
• any medications or supplements you’re taking
• your alcohol and smoking habits
• whether you use recreational drugs
• whether you’ve had a prior reaction to anesthesia
• any other questions or concerns

On the day of your surgery:

• wear comfortable and loose-fitting clothing
• wear glasses instead of contacts
• use a sanitary pad instead of a tampon if menstruating
• avoid lotions, creams, deodorants, or other substances that can leave residue on your skin
• don’t wear any metal, including piercings

Your surgeon will likely give you instructions on when to stop eating, drinking, smoking, and consuming alcohol before your procedure. You may be told to consume a special drink to clear your bowels or to shower with a special antiseptic soap called Hibiclens.

When in doubt, it’s always best to follow your healthcare professional’s instructions.

What to expect during the Whipple procedure

On the day of your surgery, your surgeon and anesthesiology team will answer any last-minute questions in the preoperative area. You’ll then be taken to the operating room where you’ll be given an intravenous (IV) line into your arm. You may also receive a spinal injection and local nerve block injections around your abdomen to minimize pain.

You’ll be put to sleep with medications administered through the IV. A urinary catheter will be inserted into your bladder to drain urine.

The surgery usually takes about 5 to 7 hours to complete. During the procedure,

1. The surgeon will make a central incision or several small incisions in your abdomen.
2. They will then remove part of your pancreas, duodenum, bile duct, gall bladder, and possibly part of your stomach depending on the technique being used.
3. The remainder of your pancreas will be attached to your small intestines and your small intestines will be reattached to your stomach.

What to expect after the Whipple procedure

You’ll likely stay in a hospital for about 8 to 10 days after the procedure so your healthcare team can monitor you for complications. They’ll also run tests to see if they removed all of the cancer.

You may experience pain from the surgical incisions. Pain is usually initially controlled with medications administered through a spinal catheter or IV. Once you can resume eating, you’ll likely be given oral pain medications.

You’ll slowly be able to start drinking and eating again several days after the procedure. If you develop delayed stomach emptying, you may need to feed through tubes for several weeks.

Many people undergo chemotherapy or radiation therapy after recovering from surgery.

It can take anywhere from a few months to a year to feel relatively normal again. Many people take pancreatic enzymes to help digest food. You may have to make permanent dietary changes.

You can expect to lose a significant amount of weight after the procedure. You’ll doctor will likely want to perform a checkup within 3 weeks, and then in regular intervals.

What are the risks of having the Whipple procedure?

The Whipple procedure is an extensive surgery that has a high risk of complications. About 50 percent of people have complications. The most common are:

• pancreatic fistula (leakage of pancreatic secretions)
• delayed stomach emptying
• bleeding
• leakage of small intestine or liver secretions
• wound infection
• intraabdominal abscess (pus in abdomen)

The most serious complication is an infection due to leakage of pancreatic secretions, which can lead to death. About 10 percent of people develop an infection, which is controlled with draining tubes and antibiotics.

In a 2020 study, researchers found the following rates of complications in a group of 57 people who received treatment between 2014 and 2018:

Ascending cholangitis, or inflammation of the bile duct, is considered the most frequent long-term complication.

Some people develop postoperative diabetes if too many cells that produce insulin are removed.

What’s the outlook for people who have had a Whipple procedure?

Despite its risks, the Whipple procedure can be lifesaving for people with pancreatic cancer. The mortality rate has been declining in recent years, but still, about 5 percent of people die due to surgical complications. In the same 2020 study as above, researchers found that the top cause of death was septic shock, which is when blood pressure drops to a dangerously low level due to an infection.

According to the ACS, as many as 15 percent of people die due to surgical complications when performed in small hospitals or by doctors with little experience performing the procedures. Fewer than 5 percent of people die when the surgery is performed in cancer centers by experienced surgeons. People do best at hospitals that perform at least 15 to 20 surgeries per year.

In a 2019 study, researchers found that the 30-day and 1-year survival rates of 29 people who underwent a Whipple procedure with vascular reconstruction were 92.4 and 52.7 percent respectively.

The takeaway

The Whipple procedure is a type of surgery most often used to treat pancreatic cancer. It involves removing the head of the pancreas, part of the small intestine, common bile duct, gallbladder, and sometimes part of the stomach.

Although the Whipple procedure has a high risk of complications, it can be lifesaving. The rate of complications and mortality is lowest when performed by an experienced surgeon. If possible, try to have your surgery at a cancer center that performs at least 15 to 20 Whipple procedures per year.