Among common cancers, pancreatic cancer has one of the poorest prognoses. Because pancreatic cancer often grows and spreads long before it causes any symptoms, only about 6% of patients are still alive five years after diagnosis.
For some pancreatic patients, however, a complex surgery known as the Whipple procedure may extend life and could be a potential cure. Those who undergo a successful Whipple procedure may have a five-year survival rate of up to 25%.
The classic Whipple procedure is named after Allen 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" (wide part) of the pancreas next to the first part of the small intestine (duodenum). It also involves removal of the duodenum, a portion of the common bile duct, gallbladder, and sometimes part of the stomach. Afterward, surgeons reconnect the remaining intestine, bile duct, and pancreas.
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.
Some patients may be eligible for a minimally invasive (laparoscopic) Whipple procedure, which is performed through several small incisions instead of a single large incision. Compared to the classic procedure, the laparoscopic procedure may result in less blood loss, a shorter hospital stay, a quicker recovery, and fewer complications.
The Whipple procedure isn't an option for the 40% of newly diagnosed patients whose tumors have spread (metastasized) beyond the pancreas. Only rarely is it an option for the 40% of patients with locally advanced disease that has spread to adjacent areas such as the superior mesenteric vein and artery, or for those whose tumors have spread to the body or tail of the pancreas.
Who Should Perform the Whipple Procedure?
The Whipple procedure can take several hours to perform and requires great surgical skill and experience. The area around the pancreas is complex and surgeons often encounter patients who have a variation in the arrangement of blood vessels and ducts.
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 at small hospitals or 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.
What Are Complications of the Whipple Procedure?
Immediately after the Whipple procedure, serious complications can affect many patients. One of the most common of these include the development of false channels (fistulas) and leakage from the site of the bowel reconnection. Other possible surgical complications include:
- Infections
- Bleeding
- Trouble with the stomach emptying itself after meals
After surgery, patients are usually hospitalized for a week before returning home. Because recovery can be slow and painful, they usually need to take prescription or over-the-counter pain medications.
At first, patients can eat only small amounts of easily digestible food. They may need to take pancreatic enzymes -- either short-term or long-term -- to assist with digestion. Diarrhea is a common problem during the two or three months it usually takes for the rearranged digestive tract to fully recover.
Other possible complications include:
- Weight loss. Most patients can expect to lose weight after the surgery.
- Diabetes.This condition can develop if too many insulin-producing cells are removed from the pancreas. However, patients who have normal blood sugar before surgery are unlikely to develop diabetes, and those who recently developed diabetes before surgery are even likely to improve.
Prognosis After the Whipple Procedure
Overall, the five-year survival rate after a Whipple procedure is about 20 to 25%. Even if the procedure successfully removes the visible tumor, it's 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.
Recent trials have shown improved outcomes with chemotherapy before surgery and with different chemotherapy regimens before and after surgery.