"Whipple Surgery: Procedure, Indication and Complications"

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Whipple surgery or pancreaticoduodenectomy is a surgical management of the cancer of the head of the pancreas. A technique devised in 1935 and named after the American surgeon Dr. Allen Oldfather Whipple.

Whipple surgery is also medically termed as pancreaticoduodenectomy. It is a surgical management of the cancer of the head of the pancreas. However, this entails extensive surgical manipulation. It was a technique devised in 1935 and named after the American surgeon Dr. Allen Oldfather Whipple.

Pancreaticoduodenectomy is indicated for cancer of the head of the pancreas, cancer of the duodenum and cancer of the bottom end of the bile (cholangiocarcinoma). It is also used to surgically treat the cancer of the ampulla of Vater, which serves as the area of entry into the duodenum of the bile and pancreatic duct. This surgery is also sometimes performed on non-cancerous (benign) disorders such as chronic pancreatitis and benign tumors of the head of the pancreas.

In this procedure, the proximal head of the pancreas is removed along with the duodenum (the first portion of the small intestines), a portion of the jejunum (second/middle part of the small intestine), the stomach (partial or total gastrectomy) and the gallbladder with anastomosis ( joining together of two hollow structures) of the pancreatic duct (pancreaticojejunostomy), the common bile duct (choledochojejunostomy), and the stomach (gastrojejunostomy) to the jejunum.

A day prior to the procedure (Pre-operative) you will be in clear liquid diet. You will be told not to take anything after midnight. A laxative will be given hours before the operation. These routine procedures are done to empty your intestines from feces. Because this is an invasive procedure, it is pertinent that a signed consent of the person undergoing the surgery be taken. An anesthetic will be injected by an anesthesiologist before the surgery.

After the surgery (postoperative) you will stay in a recovery room for atleast 4 hours for close monitoring of your status after which you will be sent to your room. Moreover, several tubes will be inserted into your body.

A nasogastric tube (NGT) is inserted through your nose and down to your stomach to help drain secretions out of your stomach. In addition, this will also serve as your feeding access. This is removed when your stomach and intestines have returned to their normal functioning usually within 3 to 5 days.

A folley catheter is inserted into your bladder to help you drain your urine. Removal of this tube depends if you are already allowed to stand and able to go to the comfort room.

A Jackson Pratt Drains are tubes inserted in the right side of your abdomen that are connected to a bulb. It drains excess fluids accumulating in the surgical site.

What are the potential complications of Whipple Surgery?

Cardiovascular Complications:

• Hemorrhage at anastomosis sites with hypovolemia (low blood volume)

• Myocardial infarction (heart attack)

• Heart Failure

• Thrombophlebitis (blood clots in the veins commonly in the lower extremities, that causes inflammation of the veins involved)

Pulmonary Complications:

• Atelectasis (partial or complete collapse of the lungs)

• Pneumonia

• Pulmonary embolism

• Acute respiratory distress syndrome

• Pulmonary edema (accumulation of fluids in the lungs)

Gastrointestinal Complications:

• Adynamic (paralytic ileus) – paralysis of the intestinal muscles causing obstruction of the intestines

• Gastric retention

• Gastric ulceration

• Bowel obstruction from peritonitis (inflammation of the peritoneum that which lines and covers the abdominal organs)

• Pancreatitis (inflammation of the pancrease)

• Hepatic failure (failure of the livers)

• Thrombosis to mesentery (folds of peritoneum that attaches the intestines to the back of the abdominal wall)

Wound Complications:

• Infection

• Dehiscence (partial or complete “bursting open” or splitting open of the surgical wound due to poor wound healing)

• Fistulas: pancreatic, gastric and biliary

Metabolic Complications:

• Unstable diabetes mellitus

• Renal failure

Fistula is the most common and most serious postoperative complication of whipple surgery. It is an abnormal passageway that results from partial or total breakdown of anastomosis site which usually occurs within 7 to 10 days after surgery.

What are the long term effects of Whipple surgery?

Malabsorption: Removal of part of the pancreas leads to decreased or diminished production of enzymes produced by the pancrease that help in digestion of foods. As a result, patients may complain of oily and bulky diarrhea type of stool that can be relieved by pancreatic enzyme supplementation.

Alteration in Diet: Although there is no specific diet modification needed for people who had undergone this surgery, small frequent meals is advised to prevent feelings of being bloated and getting too full. Moreover, consumption of small meals promotes better absorption.

Weight Loss: Weight loss of 5%-10% of your weight is common. Lost weight maybe stable or maybe gained back after 3 months or when your body had already adjusted.

8 to 12 days of stay in the hospital is estimated after the surgery.

A research was conducted by the John Hopkins University comparing the difference in the quality of life amongst the groups of Whipple operation survivors, laparoscopic gallbladder surgery patients and healthy individuals. According to the study, there were no statistical differences amongst these groups. Although there will be slight alterations in your lifestyle, you will be able to go back to your normal activities of daily living.