WHIPPLE OPERATION

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WHIPPLE OPERATION
USC Center for Pancreatic and Biliary Diseases

The Whipple operation was first described in the 1930’s by Allan Whipple. In the 1960’s and 1970’s the mortality rate for the Whipple operation was very high. Up to 25% of patients died from the surgery. This experience of the 1970’s is still remembered by some physicians who are reluctant to recommend the Whipple operation.

Today the Whipple operation has become an extremely safe operation in the USA. At tertiary care centers where a large numbers of these procedures are performed by a selected few surgeons, the mortality rate from the operation is less than 4%. Studies have shown that for good outcomes from the Whipple surgery, the experience of the center and the surgeon is important. At USC, Dilip Parekh M.D. has performed more than 100 consecutive Whipple type of procedures over the past 9 years with good outcomes.
What is a Whipple operation?

In the Whipple operation the head of the pancreas, a portion of the bile duct, the gallbladder and the duodenum is removed. Occasionally a portion of the stomach may also be removed. After removal of these structures the remaining pancreas, bile duct and the intestine is sutured back into the intestine to direct the gastrointestinal secretions back into the gut.
Laparoscopic Whipple operation

At USC, Dr Parekh is developing techniques for a laparoscopic Whipple operation. At present this procedure may be offered at USC to selected patients with chronic pancreatitis, cystic tumors and islet cell tumors of the pancreas and patients who have ampullary cancer. We do not offer the laparoscopic Whipple operation for pancreatic adenocarcinoma. The Whipple operation is performed laparoscopically utilizing a laparoscopic hand-access device.
When is a Whipple operation required

A Whipple operation is performed for

* cancer of the head of the pancreas
* cancer of the duodenum
* cholangiocarcinoma (cancer of the the bottom end of the bile)
* cancer of the ampulla – an area where the bile and pancreatic duct enter into the duodenum.
* whipple operation may also sometimes be performed for patients with benign (non-cancerous) disorders such as chronic pancreatitis and benign tumors of the head of the pancreas.

What is the results of the Whipple surgery?

Over the last 15 years major pancreatic centers in the United States have developed excellent results for the Whipple surgery. In almost all the major centers the death rate from this surgery is now less than 5%.

Recent studies from Johns Hopkins and Memorial Sloan Kettering have shown that outcome from surgery for a Whipple operation is dependent on the experience of the hospital and the surgeon performing the surgical operation. In those that hospitals that perform high volume of these procedures the death rate from the Whipple operation is now less than 5%. In hospitals that infrequently perform the Whipple operation a much higher complication rate and the death rate from the surgery often greater than 15 to 20% has been reported in surgical literature.

The American Cancer Society recommends that the Whipple operation should be performed in a center that is experienced and does high volume of these complex surgical procedures to ensure the best outcome.
What is the experience of the Whipple operation at USC?

At USC Dilip Parekh, MD has performed more than a hundred consecutive Whipple operations without any deaths from the surgical procedure.
Will the Whipple operation improve my survival?

The overall survival after the whipple operation for pancreatic adenocarcinoma is about 20% at five years after surgery. Patients without spread of cancer into their lymph nodes may have up to a 40% survival. The actuarial survival is less than 5% at five years for patients patients with pancreatic adenocarcinoma who are treated with chemotherapy alone.

The operation is usually curative in patients with benign or low grade cancers of the pancreas.
Will I require any further treatment for my cancer after the Whipple operation?

We recommend that all patients with pancreatic cancer should have chemotherapy and radiation therapy after the operation. Recent studies from Johns Hopkins University have shown that the survival rate can be increased by as much as 10% by adding chemotherapy and radiation therapy to the surgery for patients with pancreatic adenocarcinoma.

We do not recommend any further treatment for patients who have benign tumors of the pancreas and in patients with neuroendocrine tumors of the pancreas.
Will I become diabetic after a Whipple operation?

During the Whipple operation part of the pancreas, the head of the pancreas, is removed. Pancreatic tissue produces insulin that is required for blood sugar control. When pancreatic tissue is removed the body releases less insulin and the risk of developing diabetes is present.

Our experience has been that patients who are diabetic at the time of surgery or who have an abnormal blood sugar level that is controlled on a diet prior to surgery have a high chance for the severity of the diabetes becoming worse after the surgery. On the other hand patients who have completely normal blood sugar prior to surgery with no history of diabetes and do not have chronic pancreatitis have a low probability of developing diabetes after the Whipple operation.
What can I eat after the surgery?

There is no restriction of your diet after the operation. Some patients may not tolerate very sweet foods and may need to avoid this.
Will my life be altered very much after the Whipple operation? Will I be able to do all the things that I can do now?

There is acceptable alteration of lifestyle after the Whipple operation. Most patients are able to go back to their normal functional levels.

Researchers at John Hopkins University mailed surveys to Whipple operation survivors who had been operated on at Hopkins between 1981 and 1997. The questionnaire was broken down into sections that looked at physical abilities, psychological issues and social issues; an additional section evaluated functional capabilities and disabilities. Scores were reported as a percentile, with 100 percent being the highest possible score. The same questionnaire was then sent to a group of healthy individuals and a group of patients who had laparoscopic gallbladder removal.

Responses from this study at Johns hopkins were tallied from 188 Whipple survivors, 37 laparoscopic gallbladder surgery patients and 31 healthy individuals. Whipple survivors on average rated their physical quality of life a 79, compared with an 83 among laparoscopic surgery patients and an 86 among healthy people. For psychological issues, Whipple survivors rated their quality of life to be a 79, compared with an 82 for laparoscopic surgery patients and an 83 among healthy people. Looking at social issues, Whipple survivors ranked their quality of life at an 81, compared with an 84 among laparoscopic surgery patients and an 83 among healthy individuals. There were no statistical difference amongst these groups.
What are the complications that are likely to happen immediately after surgery for the Whipple operation?

The Whipple operation is a complex operation with a high chance of developing complications if the surgeon performing the surgical procedure has limited experience in this operation. In the hands of surgeons who are experienced with this surgical operation the complication rate is usually very low.

The problems and complications that may be seen after this operation include:

* Pancreatic fistula: After the tumor is removed from the pancreas the cut end of the pancreas is sutured back into to the intestine so that pancreatic juices can go back into the intestine. The pancreas is a very soft organ and in some patients this suture line may not heal very well. If this happens then patients develop leakage of pancreatic juice. Usually the surgeon leaves behind a drainage catheter in the abdomen during the surgery. Any leakage of pancreatic juice after the surgery is usually removed from the body by this drainage catheter. In almost all patients who develop leakage of pancreatic juice after the surgery, the leakage heals on its own. It is uncommon for patients to be re-operated for this complication. At USC this complication has occurred in about 4% of all the surgeries that we have performed.
* Gastroparesis ( paralysis of the stomach): The first five to six days after the surgery, you will be provided with intravenous fluids until your bowel function returns. After your bowel function have return your surgeon will begin you on a diet of clear liquids and your diet will progress to a regular diet as you tolerate it.

In up to 25% of patients, the stomach may remain paralyzed after the surgery and it may take up to 4 to 6 weeks for the stomach to adapt to the changes after the surgery to function normally. During this period you may not a tolerate a diet very well. If you fall in this category then you will be provided with nutrition through a small feeding tube that your surgeon has placed into the intestine at the time of surgery. In almost all patients the stomach function returns to normal after this 4 to 6 week period after the surgery

What are the long-term complications of the Whipple operation?

Some of the long-term consequences of the Whipple operation include the following:

* Mal-absorption: The pancreas produces enzymes required for digestion of food. In some patients removal of part of the pancreas during the Whipple operation can lead to a diminished production of these enzymes. Patients complain of bulky diarrhea type of stool that is very oily. Long-term treatment with oral pancreatic enzyme supplementation usually provides relief from this problem.
* Alteration in diet: After the Whipple operation we generally recommend that the patients ingest smaller meals and snack between meals to allow better absorption of the food and to minimize symptoms of feeling of being bloated or getting too full.
* Loss of weight: It is common for patients to lose up to 5 to 10% of their body weight compared to their weight prior to their illness. The weight loss usually stabilizes very rapidly and most patients after a small amount of initial weight loss are able to maintain their weight and do well.

What questions should I ask my surgeon about a Whipple operation?

The Whipple operation is a very complex operation and staging of the patient and outcome of surgery is very dependant on the experience of the surgeon in treating the pancreatic cancer. Outcome research studies in Maryland, New York and elsewhere has suggested that best outcomes from the Whipple operation is dependant on the experience of the surgeon with this operation.An open and frank discussion with your physician may help you make appropriate choices regarding your therapy. The following are some of the question that may

* How many pancreatic cancers are operated at your hospital on a yearly basis?
* How many Whipple operations have you done?
* How many Whipple operations do you do a year?
* What are the complications in your hands of a Whipple operations?
* What is the death rate of the Whipple operation at your institution and in your hands?
* How many pancreatic cancer patients do you treat per year?
* What is the average length of hospital stay of the patients that you have treated in the past?

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