Whipple Procedure: Overview

What You Should Know About a Pancreaticoduodenectomy

A Whipple procedure (pancreaticoduodenectomy) may be necessary to treat cancer of the pancreas, chronic (long-term) pancreatitis, cholangiocarcinoma (a cancer in the bile duct), and more. A Whipple procedure is the most common surgery for tumors of the pancreas.

The surgery involves several procedures in one operation to remove various parts of the gastrointestinal tract commonly involved in the spread of pancreatic cancer (such as the small intestine, gallbladder, and sometimes the stomach).

Recovery from Whipple surgery can be challenging. It usually takes two or more months to recover from such an operation, to reestablish one’s ability to digest food, regain the weight that is commonly lost, and overcome the fatigue and stress that often occurs after this type of surgery.

Surgeons perform Whipple procedure
John Fedele / Getty Images

What Is a Whipple Procedure?

The Whipple procedure is actually several procedures in one operation, involving the removal of various organs involved in digestion and the function of the gastrointestinal tract.

Organs Involved in a Whipple Procedure

The following organs (or portions of them) are removed during a Whipple procedure, and then reconstruction is done to connect the portions of the digestive system to allow function after recovery.

Head of the Pancreas

The pancreas is a 6-inch-long, flattened organ, located in the upper right side of the abdomen (behind the stomach). It secretes enzymes needed to break down ingested fats, proteins, and carbohydrates during digestion.

The head of the pancreas—where pancreatic tumors are commonly formed— is one of three parts, including the head, tail, and body of the pancreas. The head of the pancreas attaches to the first part of the small intestine (called the duodenum).

Although the head of the pancreas is removed during a Whipple procedure, there is normally enough of the organ remaining (the two other portions) to produce the necessary digestive enzymes (such as lipase and amylase) and hormones (insulin and glucagon) that regulate blood sugar.

Duodenum

Most of the duodenum is removed in the Whipple procedure. The duodenum is the first segment of the small intestine is responsible for accepting the food you eat (from the stomach) and moving nutrients into the lower segments of the small intestine. It also accepts bile from the liver via the common bile duct (to be used to break down and digest fats).

Gallbladder and Common Bile Duct

The gallbladder and part of the common bile duct are removed in the Whipple procedure. The bile ducts are a system of thin tubes that carry bile from the liver and gallbladder into the small intestine, to help breakdown fat from food.

Part of the stomach (in some instances) is also removed in a Whipple procedure.

Reconstruction

The reconstruction phase of the Whipple procedure involves reconnecting the involved portions of the gastrointestinal tract, including:

  • Reattaching the stomach to the small intestine
  • Attaching the tail of the pancreas to the end of the small intestine
  • Attaching the shortened remainder of the common bile duct to the small intestine

Various Surgery Techniques

The standard Whipple procedure is an open surgery done under general anesthesia. There are a couple of variations that may be done.

Pylorus-Preserving Whipple Procedure

In some instances, a person may undergo a type of modified Whipple procedure, preserving the pyloric valve. The pyloric valve is also called the pyloric sphincter. It is a part of the stomach that functions to allow food to empty from the stomach into the duodenum. This modified procedure is called a “pylorus-preserving Whipple procedure.”

Note, when the pyloric sphincter is removed, this can increase the incidence of a condition called dumping syndrome, when food moves too quickly into the small intestine from the stomach, causing nausea, abdominal cramps, and diarrhea.

Both the standard Whipple procedure and the pylorus-preserving Whipple surgery normally take approximately five to seven hours to complete.

Laparoscopic Whipple Procedure

A few select people may qualify for a laparoscopic Whipple procedure, which involves very small incisions in the abdomen and introduction of a laparoscope (a small thin tube with a camera on the end).

The surgeon performs this type of procedure with the use of special instruments placed through one or more of small incision, using the laparoscopic images (shown on a monitor) as a guide. Compared to conventional surgery techniques, laparoscopic surgery offers many benefits, including:

  • Smaller incisions
  • Shorter hospitalization stays
  • Faster healing time
  • Less risk of infection
  • Less overall pain
  • Less loss of blood loss

Contraindications

Contraindications are specific situations in which a surgery (or a drug or a procedure) should not be performed/given because it could result in harm to a patient.

The contraindications for a Whipple procedure include:

  • Metastasis (spread) of cancer to a distant site
  • Cancer which has spread to other organs
  • Cancer which has spread to peripheral lymph nodes (glands which are part of a person’s immune system) located deep in the subcutaneous (the deepest layer of skin located below the dermis and epidermis) tissue. 
  • Invasion of blood vessels when cancer cells break into the blood vessels (especially the mesenteric artery and greater mesenteric vein)
  • Extrapancreatic disease (a disease originating outside of the pancreas)

Determining if a person is eligible for a Whipple procedure is not an easy undertaking, regardless of imaging testing using very advanced technology and sophisticated equipment

In some instances, the surgeon may attempt to perform a Whipple procedure, only to begin the surgery and find out the cancer has spread and cannot be removed. At that point in time, the planned Whipple procedure will not be performed.

The Whipple procedure is not contraindicated in adults over the age of 75. In fact, a 2017 study found that the outcome of the surgery was similar in older and younger patients.

The study authors wrote, “The selection of patients is of utmost importance to obtain the best surgical and oncological results. Our analysis demonstrated that post-operative results are similar in patients aged below and over 75 years of age.”

Potential Risks

There are several potential risks of having a Whipple surgery. The most common complication after surgery is leakage of pancreatic fluid from the surgical incision. When this occurs, a drain is usually inserted through the skin to allow for drainage of the fluid for several weeks after the procedure.

Other risks of Whipple surgery include:

  • Weight loss
  • Diabetes (which can be temporary or permanent)
  • Bleeding at the surgical site
  • Infection
  • Dumping syndrome
  • Delayed emptying of the stomach
  • Difficulty keeping food down
  • Diarrhea, nausea, and vomiting
  • Leakage of bile from the common bile duct connection

Purpose of a Whipple Procedure

There are several reasons for a Whipple procedure, these include:

  • Pancreatic cancer
  • Pancreatic cysts
  • Pancreatic tumors
  • Pancreatitis (inflammation of the pancreas)
  • Cancer of the ampulla of Vater (the area where the bile duct and the pancreas come together; the function of the ampulla of Vater is to empty pancreatic enzymes into the duodenum).
  • Cancer of the bile duct
  • Neuroendocrine tumors (tumors formed in cells that are similar to nerve cells and hormone-producing cells, such as those found in the pancreas)
  • Cancer of the small intestine (duodenum)
  • Trauma to the pancreas or small intestine
  • Other disorders involving the pancreas, duodenum, or bile ducts

Call your doctor or 911 if you are experiencing a medical emergency.

How to Prepare

There are many things that a person can do to prepare for Whipple surgery. These include:

  • Consulting with your surgeon regarding medications you are taking (and getting direction on which ones to stop taking (such as blood thinners) before surgery
  • Eating a healthy diet (prepare for impending weight loss after your surgery)
  • Maintaining a healthy lifestyle (such as engaging in a regular workout routine)
  • Quitting smoking
  • Abstaining for drinking alcohol
  • Following the guidelines established by your healthcare provider (you should be scheduled for a preoperative exam that includes getting specific instructions on how to prepare for surgery)

What to Expect on the Day of Surgery

On the day of surgery, you can expect to:

  • Follow your preoperative instructions given to you at the preoperative appointment (including showering the night before, abstaining from eating and drinking fluids, showering the morning of surgery, taking only the medications ordered, and more)
  • Meet with the admissions nurse who will start your IV (a needle placed in the arm for administering medication and intravenous fluids)
  • Meet with the anesthesiologist to go over the safety, risks, and benefits of your anesthesia (and answer any questions you may have about anesthesia)
  • Move to the operating room where the anesthesiologist will administer medication to put you to sleep
  • Wake up after the five- to seven-hour (approximately) procedure in the post-anesthesia care unit (PACU)
  • Receive pain medication as needed
  • Receive close supervision for at least 24 hours before being moved to a regular hospital room the next day

Recovery

It often takes two to three months to recover from a Whipple procedure, In rare cases, the recovery period can take up to six months.

After surgery, you won’t be able to eat or drink, and the process of getting back to being able to digest food normally is often very slow and steady. The gastrointestinal system will need time to recover before it can start to normally digest food again.  You will receive specific instructions from your surgical team on exactly what and when to eat.

The most important thing to keep in mind is that everyone is different, there is no way to gauge for certain, exactly when a person will be able to begin to eat and digest food. Things to expect during post-surgery recovery are:

  • You will not be able to eat or drink anything for the first few days after surgery.
  • You will be encouraged to take a short walk the first day following your surgery, and to increase the length of your walk each day after that.
  • You will most likely not have a bowel movement for several days after your Whipple procedure.
  • You will have several drainage tubes located at the site of your surgical incision that will remove fluid from the site; you will probably be discharged with the drains in place and your discharge nurse will give you instructions on specific wound care at home.
  • Pain management will begin with the use of a pain pump, designed so that you can self-administer pain medication; when you begin eating solid food, you will be given oral (by mouth) pain medication.
  • You will be discharged with a prescription for oral pain medication.

When to Call Your Doctor

After you are discharged from the hospital from having Whipple surgery, be sure to contact your healthcare provider if you have:

  • A fever, higher than 100 degrees Fahrenheit
  • Pain or redness of the incision that worsens (instead of lessening) with time
  • Redness of the incision site that spreads
  • Pain that does not respond to taking prescribed pain medications
  • Constipation (specifically, an absence of having a bowel movement for more than three days)
  • Frequent bowel movements, severe diarrhea or oily stools
  • A sudden increase in blood or fluid from your drainage tube

Long-Term Care

Long-term care after a Whipple procedure may include:

  • A special diet, limiting foods such as fried, greasy, highly processed, and sugary foods (depending on a person’s personal food tolerances)
  • Daily medication to help lower stomach acid
  • A daily vitamin with iron
  • Medication to lower blood sugar (if you require long-term blood sugar control)

A Word From Verywell

Anyone with a tumor (located in the head of the pancreas) that has not spread to another area of the body, and is capable of being surgically removed, is a potential candidate for a Whipple procedure.

In spite of the fact that 20% of those with pancreatic cancer should be eligible for a Whipple procedure, nearly half of those who should be deemed eligible are informed that surgery is contraindicated for them. Therefore, it’s very important to seek out a healthcare professional who specializes in performing pancreatic surgery.

In fact, according to the Pancreatic Cancer Action Network, any surgeon who is making a recommendation for a Whipple procedure should have over 15 years of specific experience performing pancreatic surgery.

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Article Sources
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