Pancreaticoduodenectomy (Whipple procedure)

28 Mar, 2023

When is pancreaticoduodenectomy (Whipple procedure) needed?

Pancreaticoduodenectomy, also known as the Whipple procedure, is a surgical procedure used to treat certain conditions (mostly cancers or precancerous conditions) affecting the pancreas, bile ducts, or the initial part of small intestine called duodenum in the upper abdomen. Surgery is the mainstay of treatment of cancers at these locations especially in early stages. Other modalities like chemotherapy and occasionally radiotherapy maybe given to patients whose tumours are inoperable or borderline operable to make these operable.

What is removed in pancreaticoduodenectomy or Whipple procedure?

During the Whipple procedure, the surgeon removes certain structures surrounding the tumourto ensure complete removal of the tumour with a margin of healthy surrounding tissue which helps reduce the risk of tumour coming back. During the procedure, the following are typically removed:

• The head of the pancreas: This is the part of the pancreas which lies on right side and is closest to the duodenum.
• The duodenum: This is the first part of the small intestine, which is attached to the stomach.
• The gallbladder: This is the small organ that stores bile, which is produced by the liver and helps with digestion.
• The common bile duct: This is the duct that carries bile from the liver and gallbladder to the small intestine.
• Nearby lymph nodes
• Sometimes a portion of the stomach depending on the reason for the

Classic Whipple’s

PPPD or stomach preservation In Whipple

How is the digestive system restored?

After a pancreaticoduodenectomy, also known as the Whipple procedure, reconstruction is necessary to restore the digestive function of the patient. After the abovementioned organs and parts are removed, the remaining parts of the pancreas, stomach, and small intestine are reconnected to allow for digestion. This is a complex surgical procedure that requires significant skill and experience.

The reconstruction process typically involves several steps:

• Reconnecting the remaining pancreas: The surgeon will reconnect the remaining part of the pancreas to the small intestine or the stomach to allow for the release of pancreatic enzymes into the digestive system.
• Reconnecting the bile duct: The common bile duct is reconnected to the small intestine or the stomach to allow for the release of bile into the digestive system.
• Reconnecting the stomach and small intestine: The remaining parts of the stomach and small intestine are connected to each other to allow for the passage of food through the digestive system.
• Placement of an intestinal feeding tube at surgery is helpful in maintaining nutrition and maybe opted for by the surgical team.

Pre-surgery preparation

Preparing for a Whipple procedure involves several steps to ensure that the patient is in the best possible condition for the surgery and to reduce the risk of complications. Here are some pre-surgery preparations for a Whipple procedure:

• Medical evaluation: Before the surgery, your doctor will conduct a thorough medical evaluation to assess your overall health, including your heart and lung function, blood pressure, and any existing medical conditions.Careful attention needs to be given to co-existing illnesses including but not limited to diabetes, hypertension, cardiac or pulmonary diseases and ensure that these are optimally attended to.
• Blood tests: Blood tests are done to check your blood count, electrolyte levels, and liver and kidney function. Certain tumour markers, most commonly CA 19-9, and sometimes CEA and serum chromogranin levels may be needed.
• Imaging tests: Imaging tests such as an endoscopy, CT scans, MRI, and sometimes an ultrasound done at endoscopy (called endoscopic ultrasound) will be performed to get a better look at the organs that will be removed during the surgery.
• Medication management: You may need to stop taking certain medications, such as blood thinners, for a period before the surgery. Your doctor will advise you on which medications to avoid and when to stop taking them.
• Nutritional support: You may be advised to add proteins in diet to improve your nutrition and optimize your overall health before the surgery.
• Smoking and alcohol cessation: Smoking and alcohol intake can increase the risk of complications during and after surgery. Your doctor would advise you to quit smoking and alcohol intake before the surgery.
• Chest exercises: Deep breathing exercises, spirometry and brisk walking help keep the chest in good condition and prevent respiratory complications in postoperative period.
• Mental preparation: A Whipple procedure is a major surgery that can be emotionally and physically challenging. It is important to talk to your doctor about any concerns or fears you may have and to seek support from family and friends.
• Preoperative stenting: Patients undergoing pancreaticoduodenectomy are usually jaundiced and it is the symptom which most commonly brings the disease to attention. Routine preoperative biliary stenting increases the risk of complications after the procedure and hence must be avoided. The decision is bet taken by the treating team clearly in consultation with the surgical team. It may be needed only in certain selected situations such as very deep jaundice (>15-20 mg/dL); cholangitis (association of jaundice with fever), poor nutritional condition, or an expected delay in surgery due to logistic reasons or need for stabilization of coexisting illnesses. It may sometimes be also needed when it is felt that giving some chemotherapy prior to surgery would help make an inoperable tumour operable. Once stenting has been done, surgery should be done 2-6 weeks from time of stenting as this helps reduce risk associated with surgery.

It is essential to follow your doctor's instructions closely to ensure that you are well-prepared for the surgery and to achieve the best possible outcome.

Risks

Pancreaticoduodenectomy, or the Whipple procedure, is a major surgical procedure with risks and potential complications. Some of the possible risks associated withpancreaticoduodenectomy include:

• Bleeding: Bleeding during or after the surgery is a possible complication, and it may require blood transfusions or additional procedures including interventional radiology or rarely surgery to correct the issue.
• Infection: There is a risk of infection at the surgical site or elsewhere in the body after the surgery.
• Pancreatic fistula: A pancreatic fistula is a leakage of pancreatic juice from the pancreas after the surgery. This can cause pain, infection, and other complications necessitating corrective minor or major procedures.
• Delayed gastric emptying: After the surgery, the stomach may take longer than usual to empty, which can cause nausea, vomiting, and abdominal pain. In this time, having a feeding tube placed at the time of primary surgery is quite helpful tide over this period.
• Diabetes: After the surgery, the remaining part of the pancreas may not produce enough insulin, leading to diabetes in about 15-20% patients
• Complications related to anaesthesia: There is a risk of complications related to anaesthesia, such as allergic reactions or breathing problems.

In centres like ours, where this surgery is done regularly, most patients recover in 7-10 days’ time with an uneventful postoperative period. Some patients with complications, may need additional hospital, ICU stay or additional procedures. Despite advances in care, worldwide, these complications may lead to risk to life in a small subset of patients, which as per scientific evidence, can be reduced further at better equipped centres.

Recovery after pancreaticoduodenectomy

Recovery after pancreaticoduodenectomy (Whipple procedure), can be a lengthy and challenging process.Most patients would be nursed in post operative recovery or ICU for observation for a day or sometimes more time depending on their recovery. Patients are encouraged to walk and do deep breathing exercises starting from first day onwards which helps hasten recovery. There would besome tubes placed in abdomen which would be removed over the next few days.Patients are usually allowed gradually increasing amounts orally depending on the patient’s tolerance of oral intake. Most patients would also have a feeding access through which liquid feeds would be started from day 1-day 3 onwards depending on protocol of the treating institution. Importantly, the liquid feeds must be given slowly, about 200-300 ml over about 1-2 hours, at 3–4-hour interval as needed. The tube must be flushed with water about 50 ml slowly after each field to ensure that the particulate matter in the feed does not deposit in the tube and block it. Most patients would be taking oral diet (with feeds supplementation) and be able to comfortably walk around and able to do activities of self-care at discharge.

Home care after pancreaticoduodenectomy

After pancreaticoduodenectomy, also known as the Whipple procedure, the patient will likely need significant support and care at home during the recovery period. Here are some things to consider for home care:

• Wound care: The incision site will need to be kept clean and dry to prevent infection. The healthcare team will provide instructions on how to care for the wound and when it's safe to remove the dressing.
• Pain management: Pain management will likely be necessary at home, as the patient may continue to experience pain and discomfort after leaving the hospital. The healthcare team will provide instructions on pain medication dosage and timing.
• Dietary changes: The patient will need to follow a strict diet to allow the digestive system to heal. This may involve consuming small, frequent meals throughout the day and avoiding foods that are difficult to digest. Tube feeding, which was being given during hospital stay may need to be continued at home for some time.
• Physical activity: The patient will need to gradually increase physical activity levels as they recover. The healthcare team will provide instructions on when it's safe to start light exercise and how to gradually increase activity levels.
• Emotional support: Recovery from pancreaticoduodenectomy can be emotionally challenging. The patient may benefit from emotional support from family members, friends, or a mental health professional.

It's important to closely follow all post-operative instructions from the healthcare team, including medication schedules, dietary restrictions, and activity restrictions. In some cases, a home healthcare provider or visiting nurse may be necessary to assist with wound care, medication administration, and other tasks.

Diet after pancreaticoduodenectomy

Smaller more frequent meals, dietary vitamin supplements,high protein low carbohydrate diet, Avoiding water at mealtime helps ensure small residual stomach does not get filled up with water and patient is able to get adequate calories and protein in the diet.