Whipple Procedure: Long-Term Care

For a person with pancreatic cancer, surgery may be the only option for a cure, and one such type of surgery is a Whipple procedure (pancreaticoduodenectomy). But a Whipple procedure is a very complex operation that often causes major changes to the digestive system.

This can translate into some serious long-term effects, including abdominal discomfort, weight loss, digestive problems, and chronic fatigue.

Benefits of Surgery

There is one large benefit of the Whipple procedure—it may save your life. In fact, according to some studies the expected five-year survival rate is 16.4% of those who undergo a successful Whipple procedure.

Compared to the overall prognosis (outcome) of pancreatic cancer (which is only about 5% who are still alive five years after diagnosis), a Whipple procedure is one of the only known treatment modalities able to give people with pancreatic cancer a chance to survive.

The reason the overall pancreatic cancer survival rate is so low is that often pancreatic cancer begins to grow and spread (metastasize) long before a person even has symptoms. By the time pancreatic cancer is diagnosed, often, it is already too late for surgery to be effective.

So, the primary benefit of having a Whipple procedure is that with early screening and diagnosis, it can give people a chance to live for many years in relatively good health. According to a 2009 report, the highest rate of successful outcomes after a Whipple procedure comes from high volume hospitals where many Whipple procedures are performed.

According to Harvard Health, “The operation [the Whipple procedure] is held up as an example of why steering patients to high-volume centers for complex surgeries and treatments might be one way to improve the quality of health care and treatment outcomes.”

Once a Whipple procedure is complete, most people who have had pancreatic cancer will need to undergo cancer treatment (such as chemotherapy) as well.

The side effects of a Whipple procedure can impact a person’s long-term health and have a major effect on one’s emotional well-being as well. It’s important to learn what can be done to lessen this impact and to cope with the stressors that come with such a multifaceted procedure.

In fact, according to the Pancreatic Cancer Action Network, the Whipple procedure has the potential to cause long-term challenges such as:

• Chronic fatigue
• Digestive problems
• Food intolerance
• Temporary or permanent diabetes
• Diarrhea, gas, stomach discomfort, bloating, abdominal cramping

Possible Future Surgeries

A 2012 study, published by the International Journal of Surgical Oncology, examined the outcome of study participants who had to undergo reoperations following a Whipple procedure. The study involved 520 patients who had a Whipple procedure (pancreaticoduodenectomy) and found that 18.5% (92 patients) required a second procedure (reoperation)

 Of the people in the study who required an additional surgical procedure, 72 needed the surgery early in their recovery process and only 18 required surgery later on; six patients required two subsequent surgeries—including one that was early in recovery and one that was required later on.

The study found several reasons that people who underwent a Whipple procedure needed another operation for various reasons, these included:

• 53 patients experienced hemorrhage (bleeding after surgery)
• 17 patients were found to have had leakage of fluid in various areas where an artificial connection was made (as part of the reconstruction phase of a Whipple procedure)
• 1 patient had an intestinal obstruction
• 7 patients had other causes of reoperation

Lifestyle Adjustments

After a Whipple procedure, there are some common medical complications that may occur, including:

• Vitamin B12 and iron deficiencies (B12 injections and iron supplements may be prescribed)
• Low levels of pancreatic enzymes (pancreatic enzyme supplements may be ordered) These supplemental enzymes can help to break down carbohydrates, fats and proteins in the food you eat, helping to improve digestion after a Whipple procedure.
• Diabetes may occur, either temporarily or permanently (patients must know the symptoms of diabetes and must contact their healthcare provider if symptoms occur; medication and diet regime for diabetes may be ordered).

Digestive Enzymes

After a Whipple procedure, some people have a shortage of digestive enzymes (normally produced by the pancreas) and must take supplements with each meal to properly digest their food.

The body's pancreatic enzymes include:

• Pancreatic proteases (such as trypsin and chymotrypsin): Assist in the digestion of proteins
• Pancreatic amylase: Assists in the digestion of sugars (carbohydrates).
• Pancreatic lipase: Assists in the digestion of fat

Examples of FDA-approved pancreatic enzyme supplements include:

• Creon
• Pancreaze
• Zenpep
• Ultresa
• Viokace
• Pertzye

Diet

Diet is one of the most common lifestyle changes required for people who have undergone a Whipple procedure. If you are having digestive problems, it’s important to consult with a professional; ask your healthcare provider or surgeon to refer you to a dietitian for specific diet recommendations.

Some general long-term post-surgical nutritional guidelines from the Pancreatic Cancer Action Network include:

• Limit fried, greasy, high-fat foods (or eat them in small quantities)
• If you can tolerate healthy sources of fats, those should be substituted for unhealthy saturated and trans fatty foods.
• Attempt to eat at least 2.5 cups of vegetables and fruits each day.
• If you are having digestive problems, ask your healthcare provider about pancreatic enzymes.
• Take medications to reduce stomach acid as ordered by your surgeon or other healthcare provider.
• Get active; plan to engage in physical activity for at least 30 minutes every day.

Exercise

Getting active after a Whipple procedure has always been part of the recovery protocol. But, a 2018 study discovered new evidence on the impact of exercise before and after a Whipple procedure.

"There’s good evidence to suggest exercise should be part of your first line of defense. In fact, research suggests “prehabilitation”—conditioning your body prior to undergoing surgery or cancer treatment—could boost your odds of survival,” says Matthew Katz, M.D., Associate Professor of Surgical Oncology and Chief of Pancreas Surgery at the University of Texas MD Anderson Cancer Center in Houston, Texas.

The study found that exercising before a Whipple procedure enhanced the quality and quantity of life for study participants who realized benefits such as:

• Improvement in blood flow and chemotherapy delivery to cancerous tissues
• Fewer side effects (or less severe side effects) from chemotherapy
• Weight gain (resulting from an increase in appetite as well as an accumulation of lean muscle mass)
• Improvement in energy levels
• Improvement in mental well-being (improved mood and lower levels of anxiety and depression)
• A sense of empowerment is gained (as study participants felt they were participating more in their own treatment and recovery).

Tips for Establishing an Exercise Routine

Tips for establishing a regular workout routine before or after a Whipple procedure include;

• Consult with your healthcare provider. Never start any exercise program without first getting permission from your healthcare provider.
• Begin slowly and gradually work up to more and more physical exertion; starting too fast and doing too much at one time is the biggest mistake that people make when establishing a workout routine.
• Start by walking and doing some simple stretching and muscle strengthening exercises.
• Use wearable fitness trackers (studies show they have the potential for sustained increases in physical activity, particularly in those who have a sedentary lifestyle).
• Be patient with yourself and take the time it needs to establish a solid routine, if something hurts, stop, and keep your healthcare provider updated and informed of your progress.

Although many people are instructed to take it easy during and immediately after cancer treatment (such as a Whipple procedure), the study data shows that getting people to engage in regular exercise for 150 minutes of moderate to vigorous exercise each week and strength training exercises (such as weight lifting) for two days per week, had tremendous benefits for pancreatic cancer patients.