For some patients with abnormalities in the right side of the pancreas (known as the head of the pancreas), a complex surgery known as the Whipple procedure may extend life and could be a potential cure.
The classic Whipple procedure is named after Allen Oldfather Whipple, MD, a Columbia University surgeon who was the first American to perform the operation in 1935. Also known as pancreaticoduodenectomy, the Whipple procedure involves removal of the head of the pancreas (approximately 1/3 to ½ of the pancreas), the first foot of the small intestine (duodenum), the bile duct, gallbladder, and sometimes part of the stomach. Afterward, the remaining intestine is used to reconnect the bile duct, pancreas, and stomach to allow for normal digestion.
Who Is a Candidate for the Whipple Procedure?
Only about 20% of pancreatic cancer patients are eligible for the Whipple procedure and other surgeries. These are usually patients whose tumors are confined to the head of the pancreas and haven’t spread into any nearby major blood vessels, the liver, lungs, or abdominal cavity. Intensive testing is usually necessary to identify possible candidates for the Whipple procedure. This testing involves making sure that the tumor has not spread, is not involving organs or blood vessels that cannot be removed, and assuring that the patient is in adequate health to undergo major surgery.
The first step in determining whose cancer is able to be removed is to see if it has spread to other organs. Once pancreatic cancer is found in other organs, the focus of therapy is on treating the entire patient by chemotherapy or offering appropriate palliative care to maintain quality of life. In these situations surgery may be undertaken to reroute the food and/or bile but tumor removal is not undertaken.
Next, using high resolution CT or MRI scans, it is determined if the tumor is growing into nearby blood vessels. Deciding if a tumor is surgically removable or not should be determined by an experienced pancreatic surgeon. Sometimes the tumor may grow into or around a critical blood vessel in the upper abdomen. Removing a tumor in this circumstance adds greater difficulty to an already complex operation. Therefore, chemotherapy and radiation are often used to improve the likelihood of being able to remove the tumor. Studies have shown that these complicated operations are safe and effective when completed by experienced surgeons.
The Whipple procedure is a complex operation that requires great technical skill and experience. Studies have shown that optimal outcomes are obtained only in the hands of high volume surgeons. When undertaken by dedicated pancreatic surgeons, the Whipple procedure carries a risk of death of <5%. Complications are still common after the operation, but the experienced pancreatic surgeon is able to lead a team that can safely manage these complications and lead to a full recovery. Knowledge of the complex anatomy, sound technical skills, and experience with the recovery process allows the Whipple procedure to be safely undertaken on even elderly and high risk patients.
Who Should Perform the Whipple Procedure?
After the Whipple procedure was introduced, many surgeons were reluctant to perform it because it had a high death rate. As recently as the 1970s, up to 25% of patients either died during the surgery or shortly thereafter.
Since then, improvements in diagnosis, staging, surgical techniques, anesthesia, and postoperative care have reduced the short-term death rate to less than 4% in patients whose operation is performed at cancer centers by experienced surgeons. At some major centers, the reported death rate is less than 1%. But the rate may still be above 15% in patients who are treated by less experienced surgeons.
Because the Whipple procedure continues to be one of the most demanding and risky operations for surgeons and patients, the American Cancer Society says it’s best to have the procedure done at a hospital that performs at least 15 to 20 pancreas surgeries per year. The organization also recommends choosing a surgeon who does many such operations.
Prognosis After the Whipple Procedure
When completed for pancreatic cancer, the five-year survival rate after a Whipple procedure is about 20 to 25%. Even if the procedure successfully removes the visible tumor, it is possible that some cancer cells have already spread elsewhere in the body, where they can form new tumors and eventually cause death.
The five-year survival rate is higher in node-negative patients (their cancer has not spread to nearby lymph nodes) than for node-positive patients.
Regardless of node status, most patients receive chemotherapy, radiation, or both after surgery. However, cancer specialists have differing opinions on the best combination and the best drugs to use. Therefore, patients are encouraged to register to participate in clinical trials, when available, to get the most up-to-date and novel therapies for pancreatic cancer to ensure optimal outcomes.