The Whipple operation was first described in the 1941 by Allan Whipple. In the past the mortality rate for the Whipple operation was very high. Whipple operation has become a safe operation. The mortality rate from the operation is less than 4%.
In the Whipple operation the head of the pancreas, a portion of the bile duct, the gallbladder and the duodenum and the distal part of the stomach is removed. After removal of these structures the remaining pancreas, bile duct and the stomach is joined back to direct the gastrointestinal secretions and food back into the gut.
Indications for Whipple’s operation
A Whipple operation is performed for
- Cancer of the head of the pancreas
- Cancer of the duodenum
- Cancer of the distal part of the bile duct (cholangiocarcinoma)
- Ampullary cancer an area where the bile and pancreatic duct join and enter the duodenum.
- Whipple operation is also sometimes indicated for patients with benign conditions such as neuroendocrine tumors, chronic pancreatitis and precancerous cystic lesions.
Survival after Whipple operation:
The overall survival after the Whipple operation for pancreatic cancer is about 20% at five years after surgery. if the cancer is detected early when the lesion is less than 2cm with no spread of cancer to lymph nodes may have up to a 40% five years survival. Survival is less than 5% at five years for patients with pancreatic cancer treated with chemotherapy alone or palliative measures.
The operation is usually curative in patients with benign and precancerous lesions of the pancreas.
Further treatment after surgery:
it is generally recommended that the patient get what is called adjuvant chemotherapy and sometimes radiation therapy, there is a bout 10% survival improvement from such added treatment. Patients who have benign tumors of the pancreas and in patients with neuroendocrine tumors of the pancreas will require no further treatment.
Diabetes after a Whipple operation
During the Whipple operation the head of the pancreas, is removed. Pancreatic tissue produces the hormone insulin, which is required for blood sugar control. When pancreatic tissue is removed there is always a risk of becoming diabetic; the estimated risk is 20%. Patients who are diabetic prior to surgery or who have an altered glucose tolerance that is controlled by diet prior to surgery have a higher risk for the diabetes becoming worse after surgery. Patients who have normal blood sugar prior to surgery and do not have chronic pancreatitis have a low risk of developing diabetes after the Whipple operation.
Diet after Whipple’s operation:
There is no dietary restriction after the operation. Usually the patient is seen by a dietician and instructed to have several small meals during the day and avoid drinking liquids at the time of the meals .Due to the nature of the operation some patients may not tolerate very sweet foods and may need to avoid this due to the dumping phenomenon that follow the operation.
Recovery and quality of life
There is acceptable alteration of lifestyle after the Whipple operation. Most patients are able to go back to their normal functional levels. But that will take several weeks and can be prolonged due to postoperative complications. Fatigue is very common after such surgery also the appetite will take a few weeks to recover.
The Whipple operation is a complex operation with a high risk of developing complications. The problems and complications that may be seen after this operation include:
- Pancreatic fistula: the cut end of the pancreas is sutured back into to the intestine so that pancreatic secretions flow back into the intestine. The pancreas is a soft organ often with a small duct and in some patients this suture line may not heal that well. If this happens then patients develop leakage of pancreatic juice. Usually the surgeon leaves a drain in the abdomen close to that anastomosis. Usually the leakage heals on its own, but the drain needs to be left in for a while. It is uncommon for patients to be re-operated for this complication.
- Delayed gastric emptying: Patients will be given intravenous fluids until bowel function returns. After that the patient is allowed clear liquids and diet will progress to a regular diet as tolerated. Poor emptying of the stomach may take up to 4 to 6 weeks to recover. The patient may need alternative method to provide feeding
Long-term complications of the Whipple operation:
- Steatorrhoea (malabsorption): The pancreas produces enzymes required for digestion of dietary fat and proteins. reduced production of enzymes leads the patient to have bulky diarrhea , the stool is very greasy and difficult to flush. Long-term treatment with pancreatic enzyme supplementation usually provides relief given as tablets with each meal and snacks.
- Alteration in diet: After the Whipple operation the patients is instructed to have smaller meals and snack between meals to allow better absorption of the food and to minimize symptom.
- Loss of weight: patients usually lose up to 10% of their body weight compared to their weight prior to surgery. Most patients will eventually be able to maintain their weight.