Overview of Pancreaticoduodenectomy (Whipple Procedure)
The Whipple procedure, also known as a Pancreaticoduodenectomy, is a complex surgery primarily used to treat cancers in certain parts of the pancreas and near the small intestine. During this surgery, several parts are usually removed: the head of the pancreas, a part of the small intestine called the duodenum, the beginning of another part of the small intestine (jejunum), the end of the bile duct, the gallbladder, and often a part of the stomach. Then, the surgeon reconnects the digestive system.
Though the Whipple procedure is mainly done to treat cancer, it can also be used for non-cancerous conditions like chronic pancreatitis (a long-lasting inflammation of the pancreas), large symptomatic cysts (fluid-filled sacs that can cause symptoms), or premalignant lesions such as growths inside the pancreas that might turn into cancer.
The procedure was first performed by Walter Kausch in Germany, then improved by Allen Whipple in the United States. It has now become a common way to treat cancers in the pancreas and nearby areas. Surgical techniques have improved over time, including less invasive approaches like laparoscopy (using a thin tube with a camera to perform the surgery) with or without assistance from a robot. However, the Whipple procedure still has significant risks and potential complications. The success of the procedure depends on careful selection of suitable patients, thorough preparation before the surgery, highly skilled surgeons and anesthetists, and coordinated care after the surgery.
Anatomy and Physiology of Pancreaticoduodenectomy (Whipple Procedure)
The pancreas is a body organ located behind the stomach. It can be divided into several parts including: the head, the uncinate process (a protraction from the head), the neck, body, and tail. The head of the pancreas is usually cradled in a curve of the small intestine called the duodenum (see Image. Pancreas and Duodenum, Anterior View).
The pancreas receives blood from two main sources: the superior mesenteric artery (SMA), and the celiac trunk (see Image. Celiac Trunk). These arteries provide blood to different parts of the pancreas through smaller arteries, creating a complex network of blood vessels. After the blood vessels have supplied the pancreas with nutrients and oxygen, the blood is told to leave through veins. Some parts of the pancreas drain into the splenic vein, and others into the superior mesenteric vein (SMV) or portal vein (PV).
The pancreas’ position in our body is quite fascinating; it lies in front of the inferior vena cava (a large vein carrying deoxygenated blood from the lower half of the body back to the heart) and the left renal vein (a vein transporting blood depleted in oxygen away from the left kidney), while the PV is situated behind the pancreas. The splenic artery hangs out on top of the pancreas, while the splenic vein resides behind it. Another feature of the pancreas is that it has its own lymphatic system similar to the blood supply.
The pancreas also has ducts that drain its secretions into the duodenum. The main duct begins from its tail and merges with the common bile duct at a location known as the Ampulla of Vater, while a minor duct drains the lower part of the pancreas to the duodenum.
Before a surgeon attempts an operation involving the pancreas, they must consider several things. The pancreas shares its blood supply with the duodenum, so during surgery, the pancreas and duodenum are often removed together. The surgeon must carefully navigate around the web of blood vessels near the pancreas. In some cases, they may need to separate the pancreas from the union of the SMV and PV, which may require a removal of a section of vein. Additionally, lymph nodes that may be affected by the surgery are also essential.
Before surgery, the surgeon must also be aware of the unique vascular anatomy each patient might have. For instance, in roughly 12% of individuals, a replaced right hepatic artery arises from the SMA, which presents an additional challenge during surgery. This vessel often runs behind the pancreatic head and bile duct. Understanding these variations is key to minimizing possible complications during surgery.
Why do People Need Pancreaticoduodenectomy (Whipple Procedure)
A pancreaticoduodenectomy, also known as a “Whipple’s procedure,” is a surgery done to remove parts of the pancreas and the small intestine, specifically the top section (duodenum). It’s a treatment used to address specific health conditions and there are several reasons why a doctor might decide to perform one. The procedure might be carried out if a person has:
- Tumors in the head of the pancreas or a part of it called the uncinate process: These tumors might be a variety of things, including pancreatic ductal adenocarcinoma, pancreatic neuroendocrine tumors, duodenal gastrointestinal stromal tumor, intraductal papillary mucinous neoplasms, periampullary cancer, adenocarcinoma of the ampulla of Vater, or duodenal adenocarcinoma and other duodenal tumors
- Chronic pancreatitis, which is long-term inflammation of the pancreas
- Severe pancreatic trauma, which is a serious injury to the pancreas
The decision to remove a tumor in the pancreas is largely based on detailed scans, which can tell the doctor if a tumor can be removed (resectable), is difficult to remove but might still be possible (borderline resectable), or if it can’t be removed (unresectable). Here’s what those terms mean in more detail:
- Resectable Disease means there is no distant spread (metastasis) of the disease, no imaging results that show the veins, such as PV or SMV, are distorted, and there are clear areas around the celiac trunk, hepatic artery, and SMA where the surgeon can safely cut
- Borderline Resectable Disease means the SMV/PV veins are involved and are distorted, narrowed, or blocked, but there are still good veins above and below for reconstruction. The tumor encases the artery that supplies the stomach and first part of the duodenum up to the hepatic artery, and it’s either hugging or encasing the SMA less than half (180°) way around
- Unresectable disease is when there are distant metastases, the tumor encases over half of the SMA or affects the celiac trunk, the IVC vein and/or aorta are involved, or if there’s a blockage in the SMV or PV veins that can’t be fixed.
So the decision to carry out a pancreaticoduodenectomy depends on the type of health condition a person has and how much it has affected the pancreas and the surrounding vessels.
When a Person Should Avoid Pancreaticoduodenectomy (Whipple Procedure)
There are certain conditions where a pancreaticoduodenectomy (which is a complex surgery that removes parts of the pancreas and small intestine) cannot be done. These conditions include when the disease cannot be cut out (resected) or has spread to other parts of the body (metastatic disease).
It’s important to note that this type of surgery comes with significant risks and can be associated with severe illness or even death. Because of these risks, doctors must carefully consider a patient’s overall health and their ability to handle this surgery. The surgery might not be suitable for those with serious health problems or who are dealing with other life-threatening illnesses.
Equipment used for Pancreaticoduodenectomy (Whipple Procedure)
When doctors perform an open pancreaticoduodenectomy, or surgery on the pancreas and duodenum (the first part of the small intestine), they use a series of tools and equipment, including:
Tools that are used for viewing the inside of the body and taking small tissue samples before the major surgery is performed. This procedure is called a diagnostic laparoscopy and biopsy.
A self-retaining retractor, a device that holds open the body part being operated on, giving the surgeon better visibility and access to the surgical area.
A laparotomy instrument set, a collection of tools specifically designed for opening up the abdomen during an operation.
Surgical clips, which are used to hold body tissues together or to stop the flow of blood during surgery.
Different types of suture materials, which are special threads that hold together the portions of a patient’s body that are cut open during surgery. For instance, fine monofilament sutures might be used if a blood vessel is damaged during the procedure.
A scalpel, a small and sharp knife that is used in surgeries to make incisions, or cuts into the body.
Electrocautery, a procedure that uses an electric current to cut through tissue or stop bleeding.
Intestinal staplers, special surgical devices that are used to close off sections of the small or large intestines.
Surgical drains, tubes that remove blood or other fluid from a wound or operation site to help healing.
A vessel-sealing device, a special tool that is used to close off blood vessels to prevent bleeding.
Vascular surgical instruments are used when the surgeon needs to repair or replace a blood vessel.
Intraoperative ultrasound, a type of imaging that uses sound waves to create pictures of the inside of the body during surgery. This helps guide the surgeon during the procedure.
Who is needed to perform Pancreaticoduodenectomy (Whipple Procedure)?
A pancreaticoduodenectomy, also known as Whipple procedure, is a complex surgery that needs a team of healthcare professionals. The team includes:
The main surgeon, who directs and carries out the surgery. They have special training and experience in performing complicated surgeries like a pancreaticoduodenectomy.
A surgical assistant or sometimes even a second surgeon, who helps the main surgeon during the surgery. They work together to ensure the surgery goes smoothly and safely.
An anesthesiologist or anesthesia personnel, who is responsible for giving you the medicine that makes you sleep and not feel any pain during the surgery. They also continue to monitor you throughout the surgery to ensure you’re safe and comfortable.
A surgical technician or operating room nurse, who helps to prepare the operation room, arrange the surgical instruments and assist the surgeon and assistant during the surgery.
A circulating or operating room nurse, who helps in coordinating the activities in the operating room, managing the equipment and supporting the surgical team.
Each person in this team has an important role in making sure your surgery is successful and that your recovery goes well.
Preparing for Pancreaticoduodenectomy (Whipple Procedure)
Before surgery, there are several important steps that must be taken in preparation. These include:
* Examining images from detailed body scans, such as a CT scan or an MRI. These scans will help identify specific details of the area where surgery will take place, including the size and exact location of the problem area and its relationship to blood vessels nearby.
* Making sure that the patient has good nutrition before the surgery. This can be done through a balanced diet or through nutritional supplements, depending on the patient’s individual needs.
* For patients whose bile flow is blocked – a condition called hyperbilirubinemia – this blockage needs to be corrected before surgery. One way to do this is by using a procedure known as endoscopic biliary stenting.
* Discussing in detail with the patient about the risks and benefits of the surgery. This helps in making an informed decision about going forward with the procedure.
* Making arrangements for managing pain after the surgery, which can be done with the help of an anesthesiologist. They may recommend different ways to control pain, such as epidural or intrathecal analgesia (pain relief that’s given into the spinal cord area), nerve blocks (which “turn off” pain signals), and other medications that don’t contain opioids.
Additionally, for those who are more likely to have complications after surgery, a process known as prehabilitation might be recommended. This involves steps taken before surgery to help improve the patient’s condition and help them recover more quickly afterwards.
During surgery, even more steps are taken to ensure safety. This includes:
* Giving antibiotics within 30 minutes of making the first skin incision, to prevent infection.
* Taking steps to prevent deep vein thrombosis, which is a blood clot that forms in a deep vein, usually in the leg.
* If needed, closely monitoring vitals through invasive methods like central venous access (inserting a tube into a large vein) and arterial line (a thin catheter inserted into an artery).
* Having grafts or other potential conduits ready for vascular resections, which involves removing a part of a blood vessel.
* Making sure that the body temperature and blood sugar levels are kept within their normal ranges to aid in healing and prevent complications.
How is Pancreaticoduodenectomy (Whipple Procedure) performed
This section will explain a procedure known as a open pancreaticoduodenectomy, commonly called the ‘Whipple procedure’. This is a major operation performed to remove the head of the pancreas, most of the duodenum and a part of your bile duct. The way it is performed can vary, based on the anatomy of the patient and the preference of the surgeon.
Before we start the actual operation, there’s a preliminary step called “staging laparoscopy”. This is a procedure where we make small cuts and insert a camera to look inside your abdomen. It’s done to make sure there are no other cancer cells hiding outside of the pancreas before we begin the main operation. We pay special attention to harder to see areas like the root of the mesentery which is the tissue that holds the different parts of your intestines, the place where the falciform ligament attaches, and the diaphragm and pelvis which are the top and bottom parts of your abdominal cavity.
Once we’ve determined that the cancer hasn’t spread, we begin removing the pancreas. We make an incision along the middle line of your abdomen or under the ribs on either side and insert a special retractor to help us see better. We then separate the head of your pancreas and a part of your intestine, called the duodenum, by performing a maneuver named after a doctor called Kocher. We proceed to loosen and remove fat-like tissues around the pancreas and vessels until we reach the left renal vein, a major vein that comes from your left kidney. If it’s needed, we also identify and tie off the gonadal vein, the directly connects your gonads to your vein system.
The next step is to detach the mesocolonic attachments that hold your colon to your pancreas, making it easier to see your pancreas. After making sure the anterior (the front part) of your pancreas is visible, we separate the stomach from the pancreas and then remove the tissue connecting the pancreas to the large intestine.
After that, we dissect the hepatoduodenal ligament, which is a structure that connects your liver to the first part of your small intestine (the duodenum) and houses your portal vein. We use the common hepatic artery lymph node as our guide. We identify, free, and encircle an artery called the gastroduodenal artery which we then ligate (tie off) once we see that blood still flows to other arteries. This exposes the portal vein which we separate from an artery on the right and the common bile duct on the left. If the gallbladder is still present, we perform a cholecystectomy, which is a gallbladder removal, and send it separately for examination. The bile duct is cut where the tumor is located, the margin we cut is sent to be examined, and the bile duct is temporarily sewn up to stop bile from leaking.
The next step is to create a tunnel behind your pancreas and separate your pancreas and a vein called the superior mesenteric vein (SMV), which is done carefully to avoid damaging adjacent structures, especially if the tumor involves these veins.
Next, your jejunum (a part of your small intestine) and stomach are cut, and the pancreas is separated from surrounding arteries/veins while it’s being held with stitches. The parts of the pancreas that need to be removed are separated from the small bowel and the surrounding veins and arteries, and we send it for examination.
Now we’re ready to start reconstructing. This involves creating new connections between different parts of your digestive tract. The pancreaticojejunostomy is where we create a new connection between your pancreas and your jejunum, which varies on duct size, pancreatic consistency, and surgeon’s experience. If necessary, we place a tube in your pancreas. The Hepaticojejunostomy is where we connect your liver and jejunum with either interrupted or continuous sutures, typically in a single layer. Lastly, a gastrojejunostomy is performed where we connect your stomach and jejunum.
Before we close, a suction drain is placed near the new pancreas and bile connections to drain any fluid that accumulates after the surgery. Closing the incision is done in layers depending on the surgeon’s preference. Some might leave in a nasogastric tube, which is a tube that’s inserted through your nose and into your stomach to remove air and fluid and help with digestion. If it is used, it’s usually removed the following morning. After the operation, we check the drain contents to detect any leaks from the pancreatic connections. Depending on the result and other factors like your general condition, we decide the next steps, which usually involves gradually removing drains once we see minimal output and no signs of a leak.
Possible Complications of Pancreaticoduodenectomy (Whipple Procedure)
Having a pancreaticoduodenectomy, or surgery to remove parts of your pancreas, is a serious procedure and can sometimes have complications, even though the risk has gone down over time. Today, the risk of dying from this surgery varies from 2% to 10%, with up to 60% of people experiencing other complications. This passage will focus on the complications specific to pancreaticoduodenectomy, but remember that there are also general risks typical of any major belly surgery.
Sometimes after a pancreaticoduodenectomy, a patient has trouble digesting solid food or needs a tube in their nose (nasogastric tube) to help with feeding several days after the surgery. This is known as delayed gastric emptying. Usually, doctors will manage this by using the nasogastric tube to remove excess air and fluids from your stomach, feeding you through a tube beyond your stomach, giving you nutrition through an IV, and giving you medication to help your stomach digest faster. This problem often gets better once the cause, like a pancreatic leak, is improved.
A pancreatic fistula, or a hole in the tube-like organ called the pancreas, is another possible complication after surgery. This is diagnosed by a test that measures levels of a substance called amylase. The seriousness of the fistula is graded as A, B, or C. Grade A leaks usually get better with proper drainage and nutrition, and in some cases may need a new drain or antibiotics. Grade B and C leaks may need continued nutrition and repeated drainage or treatment through a scope.
Visceral artery pseudoaneurysm, a bulging blood vessel near your stomach or pancreas, is common and can often be connected to a pancreatic leak. Here, pancreatic substances eat away at the blood vessel over time, causing a bulge. If this bulge bursts, it could cause major bleeding, which is a medical emergency. This condition is usually managed by blocking or placing a stent in the bulge, with surgery considered as a final option due to the high risk of failure.
Exocrine insufficiency, or reduced function of the pancreas to digest food, can cause symptoms like diarrhea, bloating, and oily stools that often get worse after high-fat meals. Doctors can give you pancreatic enzyme pills to help with symptoms and improve nutrient absorption.
Endocrine insufficiency, or reduced function of glands to create hormones, can lead to diabetes in about 20% of patients after surgery. The risk is higher for those who already have trouble with managing sugar levels before the surgery.
Bile leaks, or leakage of fluid made by your liver to help digest fats, and biliary strictures, or scarring and narrowing of tubes that carry bile from your liver, are other potential complications. Small bile leaks often get better on their own, but more significant ones may need you to undergo surgery again. Biliary strictures can happen later after surgery due to a narrow connection made during surgery, loss of blood supply, or cancer coming back.
What Else Should I Know About Pancreaticoduodenectomy (Whipple Procedure)?
Pancreaticoduodenectomy, also known as the Whipple procedure, is the only treatment that can potentially cure tumors in certain parts of the pancreas, near the bile duct, and in the area surrounding both. This is a complex surgery, but proper understanding of the body’s internal structures, the use of diagnostic images, surgical steps, and care before, during, and after the operation can improve the patient’s prospects.
Educating doctors, nurses, and the whole healthcare team is vital to ensure the best results. This highlights the importance of a team approach where everyone works together, each contributing their expertise to the patient’s care.
