Whipple procedure

Formally called the pancreaticoduodenectomy, the Whipple procedure is named for the surgeon, Allen Oldfather Whipple, who refined it in the mid-1930s. It’s frequently recommended if the cancer is located in the head of the pancreas, the widest part of the fish-shaped gland in the center of your abdomen.

The Whipple procedure removes the head and possibly other parts of the pancreas, as well as the gallbladder, lymph nodes, part or all of the duodenum (small intestine), and part of the bile duct. On occasion, a portion of the stomach may also be excised.

In addition to pancreatic cancer, the procedure may be used to remove:

• Benign pancreatic lesions
• Cysts
• Cancers in the bile duct
• Cancers in the small intestine

Before the procedure

In preparing for a Whipple procedure, you need to consider certain factors, including:

• Weight loss—If you have pancreatic cancer or another tumor in the digestive tract, you may find you’re losing a lot of weight because the cancer makes it difficult to digest food properly.
• Digestion issues—Ask your care team whether pancreatic enzyme supplement therapy may help you better digest food.
• Nutrition support—You may consider working with a dietitian.
• Strength—If you’re able to exercise, stick to your routine as much as possible. Set small targets to help build strength before surgery. Your care team will encourage you to walk as much as possible before surgery

Additionally, you may need to:

• Stop smoking before surgery.
• Stop taking certain medications, especially blood thinners and pain meds.
• Speak with your care team about your history with anesthesia.
• Complete pre-op tests, which may include blood count, blood sugar, and kidney and liver function, as well as a chest X-ray and electrocardiogram.

What to expect during the procedure

The surgery, which is performed under general anesthesia, usually lasts between three to eight hours, depending on the location and extent of the tumor.

The Whipple procedure involves two phases.

• Phase one of surgery
  • First, the surgeon removes the head and uncinate process (the part that bends backwards and under the pancreas) in order to remove the tumor. Because the pancreas is so closely tied with other organs, the surgeon will remove other nearby organs, including:
    • The first portion of the small intestine (duodenum)
    • Part of the bile duct
    • Gallbladder (which stores bile, a fluid, that helps digestion)
    • Lymph nodes near the pancreas
    • The lower section of the stomach             

• Phase two of surgery
  • The second part of the surgery is reconstruction.
  • The surgeon will first reattach the remaining portion of the pancreas to the small intestine, to allow digestive enzymes to enter the digestive tract.
  • Next, the surgeon will reattach the remaining portion of the bile duct to the small intestine to allow for the flow of bile.
  • Finally, the stomach is reattached to the small intestine so food can pass through the digestive tract.

Whipple procedure method: Open vs. laparoscopic

Typically, the procedure is done through an incision in the stomach, known as an open procedure. The open procedure typically requires you to be hospitalized for a few days.

Another option may be to perform the procedure laparoscopically, also called keyhole surgery, which is a newer approach that is minimally invasive and offers faster recovery.

With the laparoscopic method, your surgeon needs only to make several small cuts in the belly, rather than one large incision. Through these small cuts, the surgeon inserts a tiny camera and uses the images to guide each step. However, the operation is no less difficult.

To determine which method is best for you, discuss both options with your surgeon.

What to expect from Whipple procedure recovery

Recovery depends on the type of surgery and your overall health.

Recommendations are likely to include:

• Eat smaller, more frequent meals and snacks throughout the day.
• Choose foods high in calories and protein (to aid in weight gain).
• Limit how much liquid you drink while eating (think small sips).

You also may need to start or continue pancreatic enzymes to help metabolize your food. Pancreatic enzymes help you absorb fat, carbohydrates and protein in the foods you eat.

Moving may help you feel better after your procedure. It also may help increase your appetite. When you’re ready to resume activity, check with your doctor about which ones are best to pursue, and go slow.

You also may want to work with an occupational therapist and physiotherapist as you recover from surgery.

Possible complications from the Whipple procedure

The Whipple procedure is a major operation, and complications are possible. The most common complication is post-op leaking of pancreatic juices from the site of the incision. A drain may need to be inserted through the skin to allow for the juices to drain, perhaps for several weeks.

A rare but severe complication after surgery is bleeding from the gastroduodenal artery. This will require intervention by a radiologist to stop the bleeding. In very rare instances, some patients go back to the operating room.

Other possible complications include:

• Leaking from connections where the surgeon has joined organs (bile leak or gastric leak)
• Infection at the incision site or inside the abdomen
• Bleeding
• Problems with stomach emptying after eating
• Difficulty digesting certain foods
• Weight loss
• Bowel habit changes

Some people develop diabetes afterward. While it’s a serious concern, it’s a rare one.

On the less-severe side, after the surgery, you may find sores in your mouth. Check for oral thrush, a mouth infection, as well. If you have oral thrush, you may see white spots on the tongue. The sores and thrush may make you lose your appetite, but it’s easy to treat.

As with any surgical procedure, there are risks of pain and infection. It’s important that you ask about how to best control pain post-surgery and follow your team’s instructions to prevent an infection.

Whipple procedure outcomes and survival rates

The Whipple is a complex procedure. The expertise of your care team and hospital is a key factor in your recovery and survival. Patients who underwent the procedure at specialty centers who have performed a higher volume of pancreaticoduodenectomies had a higher chance of five-year survival, according to ongoing research. Survival is also impacted by other factors, such as how far the cancer has spread beyond the pancreas at the time of diagnosis and surgery.

The overall five-year survival estimate for people with all stages of pancreatic cancer is 10 percent, according to CA: A Cancer Journal for Clinicians. The survival rate for each stage includes:

• Localized disease: 39 percent
• Regional disease: 13 percent
• Distant: 3 percent (most people are diagnosed at this stage)

Alternatives to the Whipple procedure

Depending on where the pancreatic tumor is located, your care team may recommend different types of surgery besides the Whipple procedure. These include:

• Distal pancreatectomy and splenectomy—This surgery removes tumors located in the middle and the tail area of the pancreas. The spleen may be removed as well.
• Total pancreatectomy—This surgery is rarely done, as it removes the entire pancreas. It’s only considered if the cancer can’t be treated with partial removal of the gland. The surgeon removes the gallbladder, spleen, part of the duodenum, and any nearby lymph nodes. A portion of the stomach may be removed as well.

Speak with your doctor about which surgery may be right for you and the stage of pancreatic cancer.

Read more about pancreatic cancer.