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Whipple Procedure

A Whipple procedure (also called pancreaticoduodenectomy) is a complex, yet lifesaving surgical procedure used to treat pancreatic cancer, and other disease and disorders of the pancreas, bile duct, duodenum etc. The procedure involves the removal of the part of the pancreas(head of the pancreas), duodenum, bile duct, and sometimes portions of the stomach may be removed. The pancreas is an organ surrounded by the stomach, liver, spleen, small intestine, gallbladder, major blood vessels, etc. It is divided anatomically into the head (wide portion), neck or body (middle portion), and tail (thin portion). The pancreas releases digestive enzymes to digest food and hormones (insulin and glucagon) to regulate blood sugar levels. A variety of cancerous and non-cancerous tumours can be found in the pancreas, mostly confined to the head or the widest portion of the organ and is treated using the Whipple procedure.  

Surgery for tumours or disorders in the body and tail of the pancreas

The benign or malignant tumours found in the body and tail of the pancreas is treated using distal pancreatectomy. This is a surgical procedure that involves the removal of the affected body and the tail portion of the pancreas and does not include the duodenum and the bile duct. Splenectomy (removal of the spleen) may or may not be performed. Splenectomy is generally performed in the case of malignant pancreatic tumours, whereas for a benign tumour, the spleen is preserved. The procedure involves a larger incision (open distal pancreatectomy) or multiple smaller incisions using a minimally invasive approach called laparoscopic distal pancreatectomy, resulting in fewer complications, shortened hospital stay and recovery time. A laparoscopy is inserted through one of the incisions to get a detailed view of the pancreas and the surrounding areas. The affected part of the body and tail of the pancreas along with the spleen (if required) are removed. The process is performed under general anaesthesia and the procedure lasts for about 3 - 4 hours. 

Surgery for tumours affecting nearby blood vessels

The pancreas is located near the two major blood vessels called the Superior mesenteric artery and the superior mesenteric vein. When cancer from the pancreas spreads to these major blood vessels, it is referred to as borderline resectable pancreatic cancer. At this stage, depending on the blood vessel affected and the spread of cancer, the treatment may include chemotherapy, or surgery, or both. If the pancreatic cancer is too close to or around a major artery or vein, chemotherapy along with radiotherapy (chemoradiotherapy) is given to shrink cancerous growth, and then it is surgically removed. However, sometimes during the surgery, when the surgeon realizes that cancer has spread too far and that it may not be possible to remove cancer, a different procedure called palliative surgery or bypass surgery, that involves removing and reconstructing certain parts of blood vessels, are performed to help control symptoms. Post-operatively, chemotherapy may be given to reduce the chances of cancer recurrence.  

Why is a Whipple procedure done? 

A Whipple procedure (also called pancreaticoduodenectomy) is a major surgical procedure used to treat pancreatic cancer, and other disease and disorders of the pancreas, bile duct, duodenum, etc. The pancreas is located in between the stomach, liver, spleen, small intestine, gallbladder, major blood vessels, etc., and releases digestive enzymes to digest food and hormones (insulin and glucagon) to regulate blood sugar levels. A Whipple procedure may be indicated to treat:

  • Cancer of the pancreas, bile ducts, duodenum, etc.

  • Tumour growth in the pancreas, neuroendocrine glands, small intestine, etc.

  • Pancreatic cysts

  • Chronic pancreatitis

  • Ampullary cancer

  • Trauma to the pancreas or duodenum

Cancers of the pancreas have poor long-term survival if not operated on, and surgical resection is the best modality of treatment. 

Risks

The Whipple procedure is a complex operation and results in fewer complications when performed by highly skilled and experienced surgeons. Some risks during and after surgery include:

  • Bleeding at the incision site or intra-abdominal site

  • Infection of the incision site and inside the abdominal cavity.

  • Difficulty in eating due to delayed gastric emptying. 

  • Discharge or leakage from the pancreas or bile duct connection

  • Post-operative penumonia

  • Diabetes

  • Recurrence of cancer

How do you prepare? 

Before the procedure, several factors are reviewed to determine the best approach that suits your situation. Maintenance of your health problems and some tests and scans may be carried out to stage cancer and see if it has spread beyond the pancreas. Your surgeon will explain what to expect during the procedure and will provide instruction of care before and after the producer. You might be asked to begin chest physiotherapy before the surgery which mitigates post-operative chest complications. A Whipple procedure can be performed using open surgery or minimally invasive techniques like laparoscopic or robotic surgery. Minimally invasive surgeries offer fewer complications, shorter hospital stay, speedy recovery, less blood loss, etc. 

  • Open surgery is performed through a midline incision on the abdomen. The abdominal cavity is carefully explored to confirm that the tumour has not spread to the nearby structures before removing the tumour.  

  • Laparoscopic surgery, which is a minimally invasive procedure, is performed using multiple (4 - 5) smaller incisions in your abdomen. Laparoscopy and other special instruments are inserted through these incisions to remove the tumour growth. 

  • Robotic surgery, which is a minimally invasive procedure, is performed using sophisticated surgical instruments that are attached to a robotic arm. The robotic arm can mimic a human hand while performing the surgery. The surgeon operates by controlling and manipulating the robotic arm from a console nearby and uses hand controls to direct the robot. 

If you are looking for a Whipple procedure in Delhi then book an appointment with Manipal Hospital, Dwarka Delhi to get the personalized and the best care you need.

Food and Medications

Discuss your concerns with your doctor. Notify about all the medication and supplements you are taking, and if you are allergic to any medications, anaesthesia, etc., You can ask your doctor about your diet and food restrictions and if you can take medications before and after the procedure. However, you may be asked to stop taking blood thinner medication a week before the procedure and not to eat or drink anything for about 8 hours before the procedure. 

What to expect?

Before the procedure

On the day of the procedure, you will be asked to change into a surgical gown and your abdomen is prepped with an antiseptic and draped appropriately. Fluid and medications are delivered through the intravenous (IV) line that is put in your arm. These medications will prevent infection and help you relax. A urinary catheter will be inserted into your bladder to drain and collect urine during and after surgery. An epidural catheter or a spinal injection is administered to reduce pain and discomfort after surgery and to reduce the dose of narcotic pain medication post-surgery. 

During the procedure

A team of highly skilled and experienced pancreatic surgeon, nurses, technicians, anaesthetists, etc., perform this complex operation and may take about 4 - 12 hours. General anaesthesia is administered, and your vitals are monitored regularly throughout the procedure. Based on the selected approach a midline incision (open surgery) on the abdomen or multiple small incision (laparoscopic or robotic surgery) on the abdomen is made to access the pancreas and other organs. The internal organs are carefully explored to confirm the tumour has not spread to the nearby organs and structures. The head of the pancreas, duodenum, gallbladder, and bile duct are removed. In some cases, a pylorus-preserving Whipple procedure or a classic Whipple procedure (a part of the stomach or the surrounding lymph nodes are removed) is performed. Once the portion of the pancreas containing the tumour and the surrounding structures are removed, the process of reconstruction is initiated. The remaining part of the healthy pancreas is reconnected or anastomosed to the bile duct, intestine and stomach. 

After the procedure

After the procedure, you will be placed in an ICU unit for a few days for observation. The nursing staff will monitor your progress regularly and watch for signs of infection or complications. The next day following the surgery, the nasogastric tube is removed and after a couple of days, the urinary catheter is also removed. Slowly you will be made to walk with assistance. You will be allowed a few sips of water, and your diet will be slowly changed from liquids to soft foods to a normal tolerable diet. Depending on the wound healing and post-operative complications, you may spend a week in the hospital. Routinely about 1-2 days in ICU and 5-6 days in the ward is required before the patient is ready for discharge. After a few weeks of the recovery period, you will be able to lead a normal life. The final staging of the tumor happens after the surgery when the resected specimen is sent for histopathology(biopsy) examination. The specimen is examined under the microscope by the pathologist who assigns a clinical stage to the tumor. The pathological staging of the tumor determines the long-term prognosis of the patient. It also determines if the patient requires further chemotherapy or radiotherapy to avoid cancer reoccurrence.  If chemo-radiotherapy is required then it is planned after a few weeks, when the patient has completely recovered from the surgery. 

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