From the Guidelines
A Whipple procedure, also known as a pancreaticoduodenectomy, is a complex surgical operation that involves the removal of the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder, and the bile duct, and is primarily performed to treat cancerous tumors in the pancreas, particularly those located in the head of the pancreas. This procedure is typically recommended for patients with tumors in the head of the pancreas, as stated in the ESMO clinical practice guideline for diagnosis, treatment, and follow-up of pancreatic cancer 1. The goal of the Whipple procedure is to completely remove the tumor and restore digestive function by reconnecting the remaining pancreas, bile duct, and stomach to the small intestine.
The surgical approach for a Whipple procedure involves dissection of the right hemi-circumference of the superior mesenteric artery (SMA) to the right of the coeliac trunk, as recommended by the International Study Group of Pancreatic Surgery (ISGPS) 1. This approach helps to obtain a good medial clearance and improve the rate of R0 resection. In cases where vein involvement is present, complete venous resection (PV or SMV) followed by reconstruction may be necessary to achieve R0 resection. However, it is essential to note that PV or SMV resection is associated with a lower rate of R0 resection and poorer survival, likely due to the inherent aggressiveness of the tumor.
Some key points to consider when performing a Whipple procedure include:
- The importance of achieving R0 resection, which is defined as a margin of at least 1 mm between the tumor and the resection margin 1
- The need to identify and dissect specific margins, including the anterior, posterior, medial or superior mesenteric groove, SMA, pancreatic transection, bile duct, and enteric margins 1
- The potential benefits and limitations of minimally invasive techniques, which may reduce morbidity but have insufficient data on oncological results 1
Overall, the Whipple procedure is a complex and major operation that requires careful consideration of the patient's overall health, tumor location and size, and potential risks and benefits. The Whipple procedure offers the best chance for long-term survival for patients with pancreatic cancer when the tumor can be completely removed, and therefore, it is essential to prioritize this procedure for patients who meet the criteria for resection 1.
From the Research
Overview of the Whipple Procedure
- The Whipple procedure, also known as pancreaticoduodenectomy, is a complex surgical technique used to treat resectable pancreatic cancer and periampullary neoplasms 2.
- It involves the radical surgical resection of the tumor and is currently the only curative option for pancreatic cancer 2.
Surgical Technique and Outcomes
- The procedure involves the removal of the head of the pancreas, the duodenum, the gallbladder, and a portion of the bile duct 2.
- The study reports a mean operative time of 295 minutes and a mean blood loss of 450 ml, with a median blood transfusion of 1 unit 2.
- Postoperative complications include delayed gastric emptying, postoperative pancreatic fistula, and postpancreatectomy hemorrhage, with a perioperative mortality rate of 4.1% 2.
Clinical Considerations
- The procedure is typically performed on patients with resectable pancreatic cancer and periampullary neoplasms, defined by the absence of distant metastases and local tumor extension 2.
- The study highlights the importance of high-volume experienced centers in performing the Whipple procedure, with mortality rates below 5% 2.
- The use of internal pancreatic stent and end-to-side duct-to-mucosa pancreaticojejunostomy is reported, but no single technique has been shown to definitively prevent postoperative pancreatic fistula 2.