Purpose of a Whipple Procedure

The Whipple procedure (pancreaticoduodenectomy) is a complex surgery that is usually done to treat non-metastatic pancreatic cancer. Several procedures are performed in one operation. These involve the pancreas, duodenum, common bile duct, gallbladder, adjacent lymph nodes, and (in some instances) part of the stomach known as the pylorus.

The Whipple procedure is considered the only curative treatment for cancer in the pancreatic head or uncinate process. For pancreatic cancer in the body or tail of the pancreas, a distal pancreatectomy may be a curative treatment for pancreatic cancer.

In addition, there are several other conditions of the pancreas, duodenum, and bile ducts that may warrant having a Whipple procedure.

Diagnosis Related to Whipple Procedure

Diagnoses that may warrant a Whipple procedure include:

• Pancreatic cancer: Indicated if the cancer has not metastasized (spread to distant areas of the body)
• Pancreatic cysts: Saclike pockets of fluid on or in the pancreas
• Intraductal papillary mucinous neoplasm (IPMN): A specific type of tumor that may become cancerous; when an IPMN is located in the head of the pancreas, a Whipple procedure may be considered.
• Pancreatic tumors: Including some types of benign pancreatic lesions
• Chronic (long-term) pancreatitis: Can be done for the severe, ongoing pain of chronic small duct inflammation of the head of the pancreas
• Cancer of the ampulla of Vater: Also referred to as ampullary cancer. The ampulla of Vater is the area where the bile duct and the pancreas join, this is where pancreatic enzymes travel into the duodenum.
• Cancer of the bile duct (cholangiocarcinoma)
• Neuroendocrine tumors: Tumors that form in hormone-producing (endocrine) cells as well as in nerve cells. Hormone producing cells are located in the pancreas and are thus, subject to the possibility of becoming neuroendocrine tumors.
• Cancer of the duodenum: The duodenum is the first segment of the small intestine
• Trauma to the pancreas or small intestine
• Other disorders involving the pancreas, duodenum, or bile ducts.

The surgeon will remove the head of the pancreas, most of the first segment of the small intestine, part of the common bile duct, the gallbladder (cholecystectomy), and adjacent lymph nodes (glands that are part of the immune system).

In some instances, part of the stomach will be removed as well. During the second phase of the procedure, reconstructive surgery will be performed to reconnect the digestive organs that remain.

The procedure (including both phases) takes approximately seven hours to complete. The average hospital stay after a Whipple procedure can be around 10 days (depending on the type of surgery you have) but can be up to two weeks in some circumstances.

Criteria

To be considered for a Whipple procedure for pancreatic cancer (the most common condition warranting the procedure) you must have cancer of the head of the pancreas, that has not metastasized (spread) to a distant site.

Often, at the time of diagnosis, pancreatic cancer has already metastasized. Once cancer has spread to other areas of the body, removing the primary tumor will not result in a cure.

A Whipple procedure can only be considered curative for cancer that is contained within the head or neck of the pancreas. The cancer must not have spread to distant lymph nodes, blood vessels or distant organs. Local lymph node involvement (in the adjacent area of the head of the pancreas) does not disqualify a person from being considered for a Whipple procedure.

When tumors are found in the body or tail of the pancreas, a Whipple procedure will not be considered, but rather, a distal pancreatectomy (the removal of the portion of the pancreas extending to the left of the midline, not including the duodenum and distal bile duct).

Other criteria that would exclude a person from being considered for a Whipple procedure may include pancreatic disease that originates outside of the pancreas (such as autoimmune pancreatitis, which is an inflammation of the pancreas caused by a person’s faulty immune system). Involvement of the adjacent arteries, such as the superior mesenteric artery, is also a contraindication for the Whipple procedure.

Age Criteria

In general, any adult (regardless of age) with a pancreatic tumor (located in the head of the pancreas and which has not metastasized) may be eligible for a Whipple procedure, provided the tumor is considered operable. The procedure is indicated for pediatric and geriatric patients as well as adults.

In a 2017 study involving adults over the age of 75, the results of surgery were the same in those who were over 75 years of age as the study participants who were younger.

In children, diagnoses such as pancreatoblastoma, neuroblastoma, and neuroendocrine tumors may require a Whipple procedure if the tumor is in the head of the pancreas.

Tests and Labs

Having a Whipple procedure performed is no small undertaking. Your healthcare provider must determine if the complex operation is the best course of treatment for you. This can involve a lengthy assessment process.

Diagnosing Pancreatic Cancer

Before a Whipple procedure can be considered, a person must undergo testing to diagnose the underlying condition. The most common condition that is treated with a Whipple procedure is pancreatic cancer.

Your cancer must first be diagnosed, next the healthcare provider must perform tests to discover if your cancer is operative. Imaging tests to view the organs and the pancreas are commonly used to diagnose pancreatic cancer and/or to screen for criteria for a Whipple procedure. Examples of these tests include the following.

Endoscopic Ultrasound (EUS) of the Pancreas

Endoscopic ultrasound involves an ultrasound device that makes images of the pancreas from inside the abdomen. The ultrasound device is passed into the abdomen through an endoscope (a flexible tube, put down the esophagus and into the stomach. An EUS can improve the accuracy of predicting whether a pancreatic tumor can be removed.

Computerized Tomography (CT) Scans

A CT scan uses an X-ray machine and a computer to take very detailed images of the inside of the body from various angles to create 3D views of organs and tissues.

A type of dye may be swallowed by the patient or injected into a vein to enable a clear view of tissues and organs. CT is used to evaluate where pancreatic cancer has spread in the body.

Magnetic Resonance Imaging (MRI)

MRI uses a strong magnetic field and radio waves to make images of the body. An MRI produces more detailed images than a CT scan.

Positron Emission Tomography (PET) Scan

A PET scan is an imaging test that helps reveal how well the pancreas (and other organs) are functioning. It may detect the onset of pancreatic disease via biochemical changes before the disease can be seen using CT scans or MRI imaging.

Biopsy

A biopsy is the removal of a tissue sample for microscopic examination in the lab. The tissue is usually collected during the EUS, via a specialized tool that is passed through the endoscope.

Sometimes a tissue sample is collected by inserting a needle through the skin and aspirating pancreatic tissue, but this is not a very common method of obtaining a pancreatic tissue sample.

Blood Test for Tumor Markers

Tumor markers are specific proteins that are shed by pancreatic cancer cells. One such protein is called such as CA19-9. Tumor marker tests are not always accurate enough to diagnose pancreatic cancer; they are used in conjunction with other tests (such as imaging tests) for a more conclusive diagnosis.

This is because sometimes the level of tumor markers is not high in those with pancreatic cancer; at the same time, it’s possible to have high levels of these markers from causes other than from pancreatic cancer.

Routine Tests Performed Prior to a Whipple Procedure

Before your Whipple procedure, your healthcare provider may order some lab and imaging tests, including:

• Blood tests: Performed to identify problems that could complicate surgery, these usually include a complete blood count (CBC), chemistry panel, liver function panel, and coagulation tests.
• Electrocardiogram (ECG): This test measures the electrical activity of the heart to ensure your heart is healthy to withstand surgery.
• Lung function tests: This test ensures your lungs are strong enough for surgery.
• Various types of imaging tests: These are done to locate where the cancer is and to observe for metastasis.

A Word From Verywell

According to the Pancreatic Cancer Action Network nearly 20% of people with pancreatic cancer should qualify for a Whipple procedure. Regardless of these statistics, nearly 50% of those who should be authorized for the surgery are often considered ineligible by their healthcare provider.

Due to this discrepancy in the numbers (regarding who should qualify for a Whipple procedure) along with the complexity of the Whipple procedure itself, the Pancreatic Cancer Action Network advises patients to be sure to consult with an experienced surgeon (with at least 15 years of experience performing pancreatic surgery).