Pancreaticoduodenectomy

Overview
A pancreaticoduodenectomy, Whipple procedure, or Kausch-Whipple procedure, is a major surgical operation involving the pancreas, duodenum, and other organs. This operation is performed to treat cancerous tumours on the head of the pancreas.

History
This procedure was originally described by Alessandro Codivilla in 1898 and Kausch in 1912, and later perfected by Allen Oldfather Whipple in the 1930s.

This technique is often called the Whipple procedure since it was named after American surgeon Dr. Allen Whipple who devised the procedure in 1935 and subsequently came up with multiple refinements to his technique (surgeons in training are often quizzed on the refinement he made that provided the most improvement in outcomes to that date: the use of non-absorbable silk over absorbable catgut suture). The first resection for a periampullary cancer was performed by the German surgeon Kausch in 1909.

Anatomy involving the procedure
The basic concept behind the pancreaticoduodenectomy is that the head of the pancreas and the duodenum share the same arterial blood supply. These arteries run through the head of the pancreas, so that both organs must be removed. If only the head of the pancreas was removed it would compromise blood flow to the duodenum.

The most common technique of a pancreaticoduodenectomy consists of the en bloc removal of the distal segment (antrum) of the stomach; the first and second portions of the duodenum; the head of the pancreas; the common bile duct; and the gallbladder.

Pancreaticoduodenectomy in modern medicine
The Whipple procedure today is very similar to Whipple's original procedure. It consists of removal of the distal half of the stomach (antrectomy), the gall bladder (cholecystectomy), the distal portion of the common bile duct (choledochectomy), the head of the pancreas, duodenum, proximal jejunum, and regional lymph nodes. Reconstruction consists of attaching the pancreas to the jejunum (pancreaticojejunostomy) and attaching the common bile duct to the jejunum (choledochojejunostomy) to allow digestive juices and bile to flow into the gastrointestinal tract and attaching the stomach to the jejunum (gastrojejunostomy) to allow food to pass through.

Originally performed in a two-step process, Whipple refined his technique in 1940 into a one-step operation. Using modern operating techniques, mortality from a Whipple procedure is around 5% nationwide (<2% in high volume academic centers).

Pancreaticoduodenectomy versus total pancreatectomy
Some authors advocate the removal of the whole pancreas (total pancreatectomy) instead of just the head. However, clinical trials have failed to demonstrate significant survival benefits, mostly because patients who submit to this operation tend to develop a particularly severe form of diabetes (so-called brittle diabetes).

Pylorus-sparing pancreaticoduodenectomy
More recently, the pylorus-sparing pancreaticoduodenectomy (a.k.a. Traverso-Longmire procedure) is growing increasingly popular, especially among European surgeons. The main advantage of this technique is that the pylorus, and thus normal gastric emptying, is preserved. However, some doubts remain on whether it is an adequate operation from an oncological point of view.

Another controversial point is whether patients benefit from retroperitoneal lymphadenectomy.

Morbidity and mortality
Pancreaticoduodenectomy is considered, by any standard, a major surgical procedure. In some hospitals, it carries a terrible reputation for high rates of morbidity. Mortality rates are improved in high-volume hospitals, however this procedure still carries a significant degree of risk (~10%).

In popular culture
The early 1970's medical drama television series "Medical Center" had an episode in which Dr Gannon performed a full Whipple's procedure on a young lady, unsuccessfully- as she died of complications shortly thereafter. It was one of the very few of Dr Gannon's fictitious patients to ever die under his knife.