Whipple Procedure (Pancreaticoduodenectomy)
The Whipple procedure is typically performed on patients with tumors in the head of the pancreas. In this operation, the surgeon removes the tumor with the head of the pancreas and the first portion of the small intestine, called the duodenum. The gallbladder is also removed during the surgery. In a classical Whipple, the lower third of the stomach is also removed. A more recent modification of the Whipple procedure (the pylorus preserving Whipple) preserves the entire stomach. Once the tumor is removed with the surrounding structures, the remnant of the pancreas (the neck, body, and tail of the gland), the bile duct and the stomach are sewn into the remaining small intestine.
A Whipple procedure typically requires between 4 and 6 hours to complete. When patients wake up from the surgery, they will have two temporary tubes coming out of the abdomen. One is a surgical drain that is placed next to all of the new connections. About 5% of patients will leak from one of the new connections. If this occurs, it almost never requires returning to the operating room. However, all of the leaking fluid does need to be aspirated. Patients get sick with infection if the fluid is allowed to pool in the abdomen. The leaking fluid is typically captured by the drain which can be removed in the office about a month after the surgery once the leak has sealed.
The second tube coming out of the abdomen comes directly out of the stomach and is called a gastrostomy tube. The stomach tends to be lazy after a Whipple procedure; it often does not empty well in the early postoperative period. Most patients are eating solid food by about a week after surgery. However, up to 15% of patients will have delayed return of their stomach function. The stomach needs to be well drained until it is functioning. The gastrostomy tube is the most comfortable and safest way to achieve this. Most patients return home with the gastrostomy tube taped to their sides. After two weeks, the surgeon can safely remove the tube in the office with minor if any discomfort.
Risks of Surgery
This operation also carries a 2% risk of bleeding that would require a return to the operating room and about a 5% risk of infection (wound infection, urinary tract infection, abdominal abscess). These infectious complications are aggressively managed until they resolve. There is also a risk of blood clots developing in the leg veins. Both cancer and surgery increase this risk. For this reason patients are kept on low dose blood thinners for their entire hospital stay.
Changes in Diabetic Status
The pancreas has two functions. One is to make insulin to control the blood sugar. The Whipple procedure removes part of the pancreas and thus, some of the insulin producing cells (beta islet cells). Patients with normal preoperative blood sugar who undergo this operation have about a 10% chance of developing diabetes which would require insulin injections to manage. Patients who have diet controlled diabetes before the surgery have a higher chance of needing insulin after the operation, and almost all patients who are taking an oral hypoglycemic agent preoperatively will require insulin to control their blood sugar after the operation.
Hospital Stay and Recovery
Patients can expect to stay in the hospital for 7 to 10 days after the surgery. What keeps patients in the hospital the longest is waiting for their stomach function to return. Once home, the full recovery is expected to take about two months.