A pancreaticoduodenectomy, also known as a Whipple procedure, is a major surgical operation most often performed to remove
cancerous
Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumors, which do not spread. Possible signs and symptoms include a lump, abnormal bl ...
tumours from the head of the
pancreas
The pancreas is an organ of the digestive system and endocrine system of vertebrates. In humans, it is located in the abdomen behind the stomach and functions as a gland. The pancreas is a mixed or heterocrine gland, i.e. it has both an en ...
.
It is also used for the treatment of pancreatic or
duodenal
The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear, and the terms anterior intestine or proximal intestine ...
trauma, or chronic
pancreatitis
Pancreatitis is a condition characterized by inflammation of the pancreas. The pancreas is a large organ behind the stomach that produces digestive enzymes and a number of hormones. There are two main types: acute pancreatitis, and chronic pancr ...
.
Due to the shared blood supply of organs in the proximal gastrointestinal system, surgical removal of the head of the pancreas also necessitates removal of the
duodenum, proximal
jejunum
The jejunum is the second part of the small intestine in humans and most higher vertebrates, including mammals, reptiles, and birds. Its lining is specialised for the absorption by enterocytes of small nutrient molecules which have been previou ...
,
gallbladder
In vertebrates, the gallbladder, also known as the cholecyst, is a small hollow organ where bile is stored and concentrated before it is released into the small intestine. In humans, the pear-shaped gallbladder lies beneath the liver, although ...
, and, occasionally, part of the
stomach
The stomach is a muscular, hollow organ in the gastrointestinal tract of humans and many other animals, including several invertebrates. The stomach has a dilated structure and functions as a vital organ in the digestive system. The stomach i ...
.
Anatomy involved in the procedure
The most common technique of a pancreaticoduodenectomy consists of the
en bloc removal of the distal segment (antrum) of the stomach, the first and second portions of the duodenum, the head of the
pancreas
The pancreas is an organ of the digestive system and endocrine system of vertebrates. In humans, it is located in the abdomen behind the stomach and functions as a gland. The pancreas is a mixed or heterocrine gland, i.e. it has both an en ...
, the
common bile duct
The common bile duct, sometimes abbreviated as CBD, is a duct in the gastrointestinal tract of organisms that have a gallbladder. It is formed by the confluence of the common hepatic duct and cystic duct and terminates by uniting with pancrea ...
, and the
gallbladder
In vertebrates, the gallbladder, also known as the cholecyst, is a small hollow organ where bile is stored and concentrated before it is released into the small intestine. In humans, the pear-shaped gallbladder lies beneath the liver, although ...
.
Lymph nodes in the area are often removed during the operation as well (lymphadenectomy). However, not all lymph nodes are removed in the most common type of pancreaticoduodenectomy because studies showed that patients did not benefit from the more extensive surgery.
At the very beginning of the procedure, after the surgeons have gained access to the abdomen, the surfaces of the
peritoneum
The peritoneum is the serous membrane forming the lining of the abdominal cavity or coelom in amniotes and some invertebrates, such as annelids. It covers most of the intra-abdominal (or coelomic) organs, and is composed of a layer of meso ...
and the liver are inspected for disease that has metastasized. This is an important first step as the presence of active metastatic disease is a contraindication to performing the operation.
The vascular supply of the pancreas is from the
celiac artery
The celiac () artery (also spelled ''coeliac''), also known as the celiac trunk or truncus coeliacus, is the first major branch of the abdominal aorta. It is about 1.25 cm in length. Branching from the aorta at thoracic vertebra 12 (T12) in ...
via the
superior pancreaticoduodenal artery
The superior pancreaticoduodenal artery is an artery that supplies blood to the duodenum and pancreas.
Structure
It is a branch of the gastroduodenal artery, which most commonly arises from the common hepatic artery of the celiac trunk, althou ...
and the
superior mesenteric artery
In human anatomy, the superior mesenteric artery (SMA) is an artery which arises from the anterior surface of the abdominal aorta, just inferior to the origin of the celiac trunk, and supplies blood to the intestine from the lower part of the du ...
from the
inferior pancreaticoduodenal artery
The inferior pancreaticoduodenal artery (the IPDA) is a branch of the superior mesenteric artery. It supplies the head of the pancreas, and the ascending and inferior parts of the duodenum. Rarely, it may have an aneurysm.
Structure
The inferio ...
. There are additional smaller branches given off by the
right gastric artery
The right gastric artery arises, in most cases (53% of cases), from the proper hepatic artery, descends to the pyloric end of the stomach, and passes from right to left along its lesser curvature, supplying it with branches, and anastomosing with ...
which is also derived from the
celiac artery
The celiac () artery (also spelled ''coeliac''), also known as the celiac trunk or truncus coeliacus, is the first major branch of the abdominal aorta. It is about 1.25 cm in length. Branching from the aorta at thoracic vertebra 12 (T12) in ...
. The reason for the removal of the duodenum along with the head of the pancreas is that they share the same arterial blood supply (the superior pancreaticoduodenal artery and inferior pancreaticoduodenal artery). These arteries run through the head of the pancreas, so that both organs must be removed if the single blood supply is severed. If only the head of the pancreas were removed it would compromise blood flow to the duodenum, resulting in tissue
necrosis.
While blood supply to the liver is left intact, the
common bile duct
The common bile duct, sometimes abbreviated as CBD, is a duct in the gastrointestinal tract of organisms that have a gallbladder. It is formed by the confluence of the common hepatic duct and cystic duct and terminates by uniting with pancrea ...
is removed. This means that while the liver remains with a good blood supply the surgeon must make a new connection to drain bile produced in the liver. This is done at the end of the surgery. The surgeon will make a new attachment between the pancreatic duct and the jejunum or stomach. During the surgery a
cholecystectomy is performed to remove the
gallbladder
In vertebrates, the gallbladder, also known as the cholecyst, is a small hollow organ where bile is stored and concentrated before it is released into the small intestine. In humans, the pear-shaped gallbladder lies beneath the liver, although ...
. This portion is not done en bloc, as the gallbladder is removed separately.
Relevant nearby anatomy not removed during the procedure include the major vascular structures in the area: the
portal vein, the
superior mesenteric vein, and the
superior mesenteric artery
In human anatomy, the superior mesenteric artery (SMA) is an artery which arises from the anterior surface of the abdominal aorta, just inferior to the origin of the celiac trunk, and supplies blood to the intestine from the lower part of the du ...
, the
inferior vena cava
The inferior vena cava is a large vein that carries the deoxygenated blood from the lower and middle body into the right atrium of the heart. It is formed by the joining of the right and the left common iliac veins, usually at the level of th ...
. These structures are important to consider in this operation especially if done for resection of a tumor located in the head of the pancreas. If the tumor encases (wraps around 50% or more of the vessel) the celiac artery, superior mesenteric artery, or inferior vena cava it is considered unresectable due to the lack of patient benefit from the operation while having very high risk. Occasionally a portion of the superior mesenteric vein or portal vein is attached or inseparable from the tumor. In this setting
vascular surgeons
Vascular surgery is a surgical subspecialty in which diseases of the vascular system, or arteries, veins and lymphatic circulation, are managed by medical therapy, minimally-invasive catheter procedures and surgical reconstruction. The specialty ...
resect the involved portion of the vessel, and the vessel is repaired either via end-to-end anastomosis, repair of the side wall of the vein, or a
vein graft.
Medical indications
Pancreaticoduodenectomy is most often performed as curative treatment for
periampullary cancer
Periampullary cancer is a cancer that forms near the ampulla of Vater, an enlargement of the ducts from the liver and pancreas where they join and enter the small intestine. Quoted material is in the public domain. It consists of:
# ampullary ...
, which include cancer of the bile duct, duodenum, ampulla or head of the pancreas.
The shared blood supply of the pancreas, duodenum and common bile duct, necessitates en bloc resection of these multiple structures. Other indications for pancreaticoduodenectomy include
chronic pancreatitis,
benign tumors of the pancreas, cancer
metastatic
Metastasis is a pathogenic agent's spread from an initial or primary site to a different or secondary site within the host's body; the term is typically used when referring to metastasis by a cancerous tumor. The newly pathological sites, then, ...
to the pancreas, multiple endocrine neoplasia type 1 and
gastrointestinal stromal tumor
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract. GISTs arise in the smooth muscle pacemaker interstitial cell of Cajal, or similar cells. They are defined as tumors whose behavior ...
s.
Pancreatic cancer
Pancreaticoduodenectomy is the only potentially curative intervention for
malignant tumors of the pancreas. However, the majority of patients with pancreatic cancer present with
metastatic
Metastasis is a pathogenic agent's spread from an initial or primary site to a different or secondary site within the host's body; the term is typically used when referring to metastasis by a cancerous tumor. The newly pathological sites, then, ...
or locally advanced un-resectable disease; thus only 15-20% of patients are candidates for the Whipple procedure. Surgery may follow
neoadjuvant chemotherapy, which aims to shrink the tumor and increasing the likelihood of complete resection. Post-operative death and complications associated with pancreaticoduodenectomy have become less common, with rates of post-operative mortality falling from 10 to 30% in the 1980s to less than 5% in the 2000s.
Ampullary Cancer
Ampullary cancer arises from the lining of the ampulla of Vater.
Cholangiocarcinoma
Cholangiocarcinoma, or cancer of the
bile duct
A bile duct is any of a number of long tube-like structures that carry bile, and is present in most vertebrates.
Bile is required for the digestion of food and is secreted by the liver into passages that carry bile toward the hepatic duct. It ...
, is an indication for the Whipple procedure when the cancer is present in the distal biliary system, usually the common bile duct that drains into the duodenum. Depending on the location and extension of the cholangiocarcinoma, curative surgical resection may require
hepatectomy, or removal of part of the liver, with or without pancreaticoduodenectomy.
Chronic pancreatitis
Treatment of
chronic pancreatitis typically includes pain control and management of
exocrine insufficiency. Intractable abdominal pain is the main surgical indication for surgical management of chronic pancreatitis. Removal of the head of the pancreas can relieve pancreatic duct obstruction associated with chronic pancreatitis.
Trauma
Damage to the pancreas and duodenum from
blunt abdominal trauma is uncommon. In rare cases when this pattern of trauma has been reported, it has been seen as a result of a lap belt in motor vehicle accidents. Pancreaticoduodenectomy has been performed when abdominal trauma has resulted in bleeding around the pancreas and duodenum, damage to the common bile duct, pancreatic leakage, or transection of the duodenum. Due to the rarity of this procedure in the setting of trauma, there is not robust evidence regarding post-operative outcomes.
Contraindications
Absolute contraindications for the procedure are metastatic disease in the abdominal cavity or nearby organs. These are found most often on the peritoneum, in the liver, and in the omentum. In order to determine if there are metastases, surgeons will inspect the abdomen at the beginning of the procedure after gaining access. Alternatively, they may perform a separate procedure called a diagnostic
laparoscopy
Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medlin ...
which involves insertion of a small camera through a small incision to look inside the abdomen. This may spare the patient the large abdominal incision that would occur if they were to undergo the initial part of a pancreaticoduodenectomy that was cancelled due to metastatic disease.
Further contraindications include encasement of major vessels (such as celiac artery, inferior vena cava, or superior mesenteric artery) as mentioned above.
Surgical considerations
Pylorus-sparing pancreaticoduodenectomy
Clinical trials have failed to demonstrate significant survival benefits of
total pancreatectomy, mostly because patients who submit to this operation tend to develop a particularly severe form of
diabetes mellitus
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...
called
brittle diabetes. Sometimes the pancreaticojejunostomy may not hold properly after the completion of the operation and infection may spread inside the patient. This may lead to another operation shortly thereafter in which the remainder of the pancreas (and sometimes the
spleen
The spleen is an organ found in almost all vertebrates. Similar in structure to a large lymph node, it acts primarily as a blood filter. The word spleen comes . ) is removed to prevent further spread of infection and possible
morbidity
A disease is a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury. Diseases are often known to be medical conditions that a ...
. In recent years the pylorus-preserving pancreaticoduodenectomy (also known as Traverso-Longmire procedure/PPPD) has been gaining popularity, especially among European surgeons. The main advantage of this technique is that the
pylorus
The pylorus ( or ), or pyloric part, connects the stomach to the duodenum. The pylorus is considered as having two parts, the ''pyloric antrum'' (opening to the body of the stomach) and the ''pyloric canal'' (opening to the duodenum). The ''pylori ...
, and thus normal gastric emptying, should in theory be preserved.
There is conflicting data as to whether pylorus-preserving pancreaticoduodenectomy is associated with increased likelihood of gastric emptying.
In practice, it shows similar long-term survival as a Whipple's (pancreaticoduodenectomy + hemigastrectomy), but patients benefit from improved recovery of weight after a PPPD, so this should be performed when the tumour does not involve the stomach and the lymph nodes along the gastric curvatures are not enlarged.
Compared to the standard Whipple procedure, the pylorus preserving pancreaticoduodenectomy technique is associated with shorter operation time and less intraoperative blood loss, requiring less blood transfusion. Post-operative complications, hospital mortality and survival do not differ between the two methods.
Morbidity and mortality
Pancreaticoduodenectomy is considered, by any standard, to be a major surgical procedure.
Many studies have shown that hospitals where a given operation is performed more frequently have better overall results (especially in the case of more complex procedures, such as pancreaticoduodenectomy). A frequently cited study published in ''
The New England Journal of Medicine
''The New England Journal of Medicine'' (''NEJM'') is a weekly medical journal published by the Massachusetts Medical Society. It is among the most prestigious peer-reviewed medical journals as well as the oldest continuously published one.
Hi ...
'' found operative
mortality rate
Mortality rate, or death rate, is a measure of the number of deaths (in general, or due to a specific cause) in a particular population, scaled to the size of that population, per unit of time. Mortality rate is typically expressed in units of d ...
s to be four times higher (16.3 v. 3.8%) at low-volume (averaging less than one pancreaticoduodenectomy per year) hospitals than at high-volume (16 or more per year) hospitals. Even at high-volume hospitals, morbidity has been found to vary by a factor of almost four depending on the number of times the surgeon has previously performed the procedure.
de Wilde et al. have reported statistically significant mortality reductions concurrent with centralization of the procedure in the Netherlands.
One study reported actual risk to be 2.4 times greater than the risk reported in the medical literature, with additional variation by type of institution.
Postoperative complications
Three of the most common post-operative complications are: delayed gastric emptying, bile leak, and pancreatic leak. Delayed gastric emptying, normally defined as an inability to tolerate a regular diet by the end of the first post-op week and the requirement for nasogastric tube placement, occurs in approximately 17% of operations. During the surgery, a new biliary connection (normally a choledochal-jejunal anastamosis connecting the common bile duct and jejunum) is made. This new connection may leak in 1-2% of operations. As this complication is fairly common, it is normal in this procedure for the surgeon to leave a drain in place at the end. This allows for detection of a bile leak via elevated bilirubin in the fluid drained. Pancreatic leak or pancreatic fistula, defined as fluid drained after postoperative day 3 that has an
amylase
An amylase () is an enzyme that catalyses the hydrolysis of starch (Latin ') into sugars. Amylase is present in the saliva of humans and some other mammals, where it begins the chemical process of digestion. Foods that contain large amounts of ...
content greater than or equal to 3 times the upper limit of normal, occurs in 5-10% of operations, although changes in the definition of fistula may now include a much larger proportion of patients (upwards of 40%).
Recovery after surgery
Immediately after surgery, patients are monitored for return of bowel function and appropriate closed-suction drainage of the abdomen.
Return of bowel function
Ileus
Ileus is a disruption of the normal propulsive ability of the intestine. It can be caused by lack of peristalsis or by mechanical obstruction.
The word 'ileus' is from Ancient Greek ''eileós'' (, "intestinal obstruction"). The term 'subileus' ref ...
, which refers to functional obstruction or
aperistalsis of the intestine, is a physiologic response to abdominal surgery, including the Whipple procedure. While post-operative ileus is typically self-limited, prolonged post-operative ileus occurs when patients develop nausea, abdominal distention, pain or intolerance of food by mouth. Various measures are taken in the immediate post-operative period to minimize prolonged post-operative ileus. A
nasogastric tube
Nasogastric intubation is a medical process involving the insertion of a plastic tube (nasogastric tube or NG tube) through the nose, down the oesophagus, and down into the stomach. Orogastric intubation is a similar process involving the inserti ...
is typically maintained to suction, to drain gastric and intestinal contents. Ambulation is encouraged to stimulate return of bowel function. Use of
opioid medications, which interfere with intestinal motility, is limited.
History
This procedure was originally described by
Alessandro Codivilla
Alessandro Codivilla (21 March 1861 – 28 February 1912) was an Italian surgeon from Bologna and head of the surgical department of the hospital of Castiglion Fiorentino, known for his work in orthopaedics and first describing the pancreaticoduo ...
, an Italian surgeon, in 1898. The first resection for a
periampullary cancer was performed by the German surgeon
Walther Kausch in 1909 and described by him in 1912. It is often called ''Whipple's procedure'' or the ''Whipple procedure'', after the American surgeon
Allen Whipple
Allen Oldfather Whipple (September 2, 1881 – April 6, 1963) was an American surgeon who is known for the pancreatic cancer operation which bears his name (the Whipple procedure) as well as Whipple's triad.
Whipple was born to missionary paren ...
who devised an improved version of the surgery in 1935 while at
Columbia-Presbyterian Medical Center
NewYork-Presbyterian/Columbia University Irving Medical Center (NYP/CUIMC), also known as the Columbia University Irving Medical Center (CUIMC), is an academic medical center and the largest campus of NewYork-Presbyterian Hospital. It includes Co ...
in New York
and subsequently came up with multiple refinements to his technique.
Nomenclature
Fingerhut et al. argue that while the terms ''pancreatoduodenectomy'' and ''pancreaticoduodenectomy'' are often used interchangeably in the medical literature, scrutinizing their etymology yields different definitions for the two terms.
As a result, the authors prefer ''pancreatoduodenectomy'' over ''pancreaticoduodenectomy'' for the name of this procedure, as strictly speaking ''pancreaticoduodenectomy'' should refer to the resection of the duodenum and pancreatic duct rather than the pancreas itself.
See also
*
List of surgeries by type
Many surgical procedure names can be broken into parts to indicate the meaning. For example, in gastrectomy, "ectomy" is a suffix meaning the removal of a part of the body. "Gastro-" means stomach. Thus, ''gastrectomy'' refers to the surgical remo ...
References
External links
Toronto Whipple Clinical Pathway Education App - Open access App for patient and caregiver education* [http://pie.med.utoronto.ca/tvasurg_pe/TVASurg_PE_content/pancreas_whipple.html The Toronto Video Atlas of Liver, Pancreas and Transplant Surgery Patient Education Module – Patient and Family Education video for the Whipple procedure]
" Whipple pancreaticoduodenectomy: a historical comment Adrian O'Sullivan – The original description of Whipple's operation together with a modern commentary
{{Digestive system surgical procedures
Surgical oncology
Accessory digestive gland surgery
Pancreatic cancer