Ask the Expert: Pancreatic Surgeon Barish H. Edil, MD, FACS
The Whipple Operation is called a pancreaticoduodenectomy in medical terms. It takes the name “Whipple” from the New York surgeon Allen O. Whipple who was the first in the United States to describe the procedure. It is performed very differently today than it was back in the time of Dr. Whipple. There are two general variations of the procedure called the Classic Whipple (standard pancreaticoduodenectomy) or the Pylorus Preserving Whipple (pylorus preserving pancreaticoduodenectomy) also known as the “Mini-Whipple”. Both variations of the Whipple Operation involve the removal of the gallbladder, common bile duct, duodenum and the head of the pancreas. The operation is done for tumors of the pancreas (pancreatic cancer), ampulla of Vater, duodenum and distal bile duct. This operation is complex and requires extensive experience by the surgeons performing the operation. In addition the surgeon must work in an environment with experienced surgical nurses, ICU and anesthesia team, pathologists and ancillary hospital staff. A landmark study conducted in 2002 by John D. Birkmeyer and his co-investigators published in the New England Journal of Medicine shows that the lowest mortality and best outcomes are obtained for the Whipple operation when it is performed at high volume centers. The pancreatic surgeons at Johns Hopkins do more Whipple operations (both Classic Whipples and Pylorus Preserving Whipples aka Mini-Whipple) than any other institution in the United States. Last year the team at Johns Hopkins performed over 240 Whipple operations, of these, approximately 160 were pylorous preserving Whipples (Mini-Whipples).
What is the difference between the Classic Whipple and the Pylorus Preserving Whipple (Mini-Whipple)?
Both operations involve a similar dissection, postoperative stay and recovery. The resection is identical except for the proximal gastrointestinal tract. In the Classic Whipple a 30-40% distal gastrectomy or stomach resection is preformed. In the pylorus preserving Whipple (Mini-Whipple) the stomach is preserved and the GI tract is transected 1 inch past the stomach leaving a small segment of duodenum (the first portion of intestine leaving the stomach).
Why do one over the other?
We are often asked by our patients if they can have a “Mini-Whipple” instead of a Classic Whipple. This question is often prompted by confusing and misleading information on the internet. It should be clear that there is nothing “mini” about either a pylorus preserving or classic Whipple. The operation to remove a tumor from the head of the pancreas is a big one no matter what variation is used. This will likely be the case for all other variations of the Whipple Operation that will be developed in the near future – including the laparoscopic Whipple. The Classic Whipple and Pylorus Preserving Whipple (mini whipple) are similar with regards to potential complications, rate of complications, return to a regular diet, size of incision, postoperative pain control issues, length of hospital stay and recovery time. In fact, from the patient’s perspective no difference would be noted between the two operations. Most importantly, there is no difference in the long-term survival between the two operations. The main advantage of the pylorus preserving Whipple (Mini-Whipple) is that it involves a slightly less complicated operative reconstruction. In certain instances of pancreatic cancer, such as tumors of the proximal neck of the pancreas, the pylorus may be involved with tumor and a classic Whipple must be performed to achieve complete removal. Thus the choice between a Classic Whipple and Pylorus Preserving Whipple is based on the technical aspects of removing the tumor at the time of operation and not a preoperative “choice” made by surgeon and patient to minimize the extent of the operation.
At Johns Hopkins approximately two-thirds of the Whipple Operation’s are the Pylorus Preserving or Mini-Whipple variation and the remaining one third are the Classic Whipple. This distribution results from the need to perform the classic Whipple based on the operative findings and underscores the importance of having an experienced pancreatic surgeon.
If you would to become a patient at Johns Hopkins please call our schedulers at: 410-933-PANC (7262). We would be delighted to assist you.
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Thank you for the kind comments.
Dr. Edil
what is the normal length of hospital stay and recovery time and possible side effects and is there any diet restrictions and for how long
I had the “classic” whipple on Wednesday and was discharged on the following Monday at Johns Hopkins. I think the key to my recovery was JH’s excellent pain management which enabled me to walk every 4 hours, shower 24 hrs after surgery. During my overnight stay in the JH ICU they worked to re-establish my hemodynamic stability, the team worked from 5p-6am. There was no delay when something was needed because the physicians are a 24/7 member of the ICU team.
I now have no diet restrictions, I just take enzyme pills since I have very little pancreas left. Initially, I did not eat hard to digest food such as fiber, red meat or for me milk products because it made me feel full. I drank protein shakes, or boost and had small frequent meals.
They have an EXCELLENT interdiscuplinary team at JH to help you through the Whipple and pancreatic cancer. My last PET scan and CT are negative after my whipple, 4 rounds of Gemcidapine, and radiation since last Feb.
Thanks for the info. I’m preparing for a Whipple or PPPD (Mini-Whipple) at Dongsan Hospital in Daegu Korea. This is pending a biopsy result expected next Tuesday. My problem is a mass blocking the Common Bile Duct. I’m digging up all the information I can and your blog was very helpful. My Korean Doctor here spent some time at Duke earlier and at the Mayo Clinic last year. He actually told me earlier today that Johns Hopkins leads the way on these procedures….
Thanks again!
I had the full Whipple Procedure April 26, 2004 at age 83. The operation was done by Dr. Rebecca Freer who had trained under the Dr. Whipple who first perfected the technique. It was done at Seton Hospital in Austin, TX. The recovery was long and hard. Just about everything that could go wrong did. But by the grace of God, I survived. During the interim six and a half years, I have written and had published two books. I had a 5% chance of getting off the operating table. Dr. Freer in a pre-op meeting with my four children and one granddaughter outlined the poor chances of survival, but asked my family to make the decision. It was, “Go for it!”
I suppose I am writing this out of gratitude and to encourage anyone who is in the unfortunate position of having to make this decision. I have had many health complications as a result of the Whipple, especially as I have grown older, but am thankful to God for life at any cost.
Sincerely,
Aline
I had a successful Pancreas and Duodenum Whipple Procedure done at Mass General in Boston April 2010 for Pancreatic Neuroendocrine Carcinoma. Walter…I went home in 1 week just had a visiting nurse stop by 3 days a week and grown children pop in. For a 73 year old widow I manage very well to live independently. James… I also had a massive tumor that cut off my bile duct causing jaundice, had a temp stent put in to give me a week to find and set up an appointment with a top notch Surgeon.
My sincere best wishes to you. Amazing connection to Dr. Alan Oldfather Whipple! RHH
I found the information here very helpful. I am a RN and even for me, the diagnosis of a mass on your pancrease is scary. Having information like this available helps me to understand what a Whipple is and what to expect.