Definition & Overview

Pancreaticoduodenectomy is a surgical procedure for treating pancreatic cancer and involves removing several parts of the digestive system. More commonly termed Whipple surgery, it was pioneered and developed by surgeon Allen Oldfather Whipple to remove tumours in the head of the pancreas.

Depending on the location of tumour cells, the physician would recommend one of the two types of pancreaticoduodenectomy. The first is the conventional Whipple surgery, which removes the head of the pancreas and nearby lymph nodes, gallbladder, the uppermost part of the small intestine, and the pylorus. The other type, which is referred to as pylorus-sparing Whipple surgery, retains the pylorus.

Who Should Undergo & Expected Results

The procedure was initially developed to treat several malignant conditions of the pancreas, which include:

  • Pancreatic ductal adenocarcinoma
  • Pancreatic islet cell carcinoma
  • Ampullary carcinoma
  • Cholangiocarcinoma
  • Duodenal carcinoma
    It is important to note that this procedure is only recommended if malignant cells have not spread to other parts of the pancreas and the disease has not advanced to nearby blood vessels like the artery and the superior mesenteric vein.

Whipple surgery may also be a treatment option for some benign diseases, such as benign periampullary neoplasms in which the surgeon would be unable to perform a resection of the ampulla and those with duodenal neoplasms. In rare cases, the procedure is also performed when parts of the pancreas have been damaged due to trauma.

Pancreaticoduodenectomy can be performed in young and older patients, who are then advised to undergo chemotherapy radiation after surgery. In some cases, the connection between the small intestine and the pancreas breaks down after surgery and would require emergency care.

Studies have indicated that patients experience near-normal quality of life after a successful Whipple surgery. Hospitalisation is required for several weeks to monitor patient condition depending on several factors like age and extent of disease. Patients would expect weight loss and pancreatic insufficiency as common outcomes of this procedure.

How Does the Procedure Work?

Pancreaticoduodenectomy usually takes five to eight hours and starts with sedating the patient. The surgeon then makes one large incision in the abdominal area. Since several parts of the digestive system are affected, the procedure progresses in several stages or sections and major blood vessels are located and carefully evaluated. Care and precision are crucial to segregate and protect unaffected vessels. Those that need to be cut off are carefully ligated to prevent internal bleeding. The head of the pancreas, the gallbladder, the uppermost part of the small intestine, and the surrounding lymph nodes are then located and removed in stages. For the conventional Whipple procedure, the pylorus is removed as well. The remaining parts of the pancreas are then reconnected to the remaining bile duct and small intestine. If necessary, abdominal drains are used to prevent pancreatic leak. Sutures are then used to close the abdomen.

Possible Complications and Risks

Classified as a major surgical procedure, pancreaticoduodenectomy is linked to the following risks and complications:

  • Delayed gastric emptying that might require intravenous feeding
  • Gastroduodenal artery complications such as bleeding from abdominal drains and gastrointestinal bleeding
  • Accumulation of pancreatic fluid
  • Formation of pancreatic fistula
  • Bacterial infection of the wound or in the blood
  • Compromised functions of the digestive system, such as bowel movement and the production of digestive enzymes. Other bodily functions might also be affected, as respiratory and renal failure can occur. There is a small possibility of multisystem organ failure and even death. As the digestive organs are regaining their functions, diarrhea is a common occurrence.
    There are also several long-term associated risks such as the development of pancreatic insufficiency, as well recurring pancreatitis and chronic pancreatic pain, which may necessitate the long-term intake of pain medications. The pancreas also produce insulin and removing some part of it might lead to the development of diabetes, especially for people who have abnormal blood levels long before surgery.

    References

  • Claudius C, Lillemoe KD. Palliative Therapy for Pancreatic Cancer. In: Cameron JL, Cameron AM, eds. Current Surgical Therapy. 11th ed. Philadelphia, PA: Elsevier Saunders; 2014: 481-487.

  • Jensen EH, Borja-Cacho D, Al-Refaie WB, Vickers SM. Exocrine Pancreas. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Elsevier Saunders; 2012:chap 56.

  • Mauro LA, Herman JM, Jaffee EM, Laheru DA. Carcinoma of the Pancreas. In: Niederhuber JE, Armitage JO, Doroshow JH, Kastan MB, Tepper JE, eds. Abeloff's Clinical Oncology. 5th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2014:chap 81.

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