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What is the pancreas?
The pancreas is a gland that lies at the back of the upper abdomen,
behind the stomach. It is shaped like a tadpole; the globular head
lies attached to the duodenum (a part of the intestine that forms
the outlet of the stomach), while the body and tail extend across
to the left side. The pancreas produces digestive juices and aids
digestion of food. Pancreatic juice and bile mix with food in the
intestine and help digestion. The pancreas also produces insulin,
which controls the level of sugar in the blood. Lack of insulin causes
diabetes.
What is Whipple’s operation?
In the Whipple operation the head of the pancreas, a portion of
the bile duct, the gallbladder and the duodenum are removed,
usually with part of the stomach. After removal of these structures,
the remaining pancreas, bile duct and stomach are rejoined to the
intestine. This allows pancreatic juice, bile and food to flow back
into the gut, so that digestion can proceed normally. The operation
normally lasts for 4-7 hours.
When is it done?
The Whipple operation is usually performed for cancers in the
head of the pancreas. The operation is also used to treat cancers
of the bile duct, duodenum or ampulla. It may also be performed
for benign (not cancerous) disorders, such as pancreatitis. The exact
problem in your case may or may not be clear, and you may be
advised to undergo surgery on the suspicion of a cancer.
Most patients who need a Whipple operation have presented to
their doctor with jaundice (when the skin and eyes go yellow). This
is caused by a blockage to the bile duct. Most patients will undergo
an endoscopy (ERCP) to place a plastic tube (or stent) into the bile
duct. This unblocks the bile duct and allows bile to flow normally.
What alternative treatments are available?
Chemotherapy may be able to shrink the cancer or delay its
growth. However, no treatment other than surgery is able to cure
this problem.
What are the benefits of surgery?
Without surgery, the average survival of patients with pancreatic
cancer is less than one year, and very few survive more than 3 years.
A successful Whipple operation can improve your chance of cure to
10%-40%. The operation aims to completely remove the cancerous
growth, and give you the best chance of curing the problem. That is
why a wide area of tissue around the affected part is removed. The
chance of the cancer recurring depends on the type of tumour that
you have. This will only be accurately known after the operation,
when the pathologist examines the removed pancreas. If you wish,
your surgeon can discuss the likely outcomes in your case.
What are the risks and possible complications?
The Whipple operation is a major procedure, with associated risks
and complications. However the operation has become much safer.
At specialised centres like Oxford, where a large number of these
procedures are performed by selected surgeons, at least 19 in 20
patients will survive the operation.
Possible complications include:
• Those related to general anaesthesia and the epidural
• Chest infection and problems with breathing
• Bleeding during or after the operation, which may result in blood
transfusion
• Wound infection
• Blood clots forming in the legs
• Anastomotic leak (1 in 10 patients): After the tumour is removed,
the cut ends of the pancreas, bile duct and stomach are sewn
back to the intestine. In some patients, these stitches may not
heal well. If this happens then pancreatic juice or bile can leak
into the abdomen. Your surgeon will leave a drain tube in the
abdomen, in order to identify and remove any leakage of these
fluids after the surgery. In most patients who develop leakage
after the surgery, the leakage heals on its own. Sometimes
patients need to be re-operated for this complication.
• Delayed emptying of the stomach (1 in 10 patients): After the
surgery, you will be provided with fluids by a drip into your vein,
and liquid food via a feeding tube. You will not be allowed to
eat or drink until your bowel function has returned. This usually
takes 6-7 days. In some patients, the stomach may take a longer
time to recover after surgery. During this period, they may not be
able to tolerate food well, and may need continued tube feeds
for several weeks.
What anaesthetic will I have?
Our normal anaesthetic technique for this procedure is a
combination of general and epidural anaesthesia. During general
anaesthesia you are put completely to sleep, and a tube is put into
your windpipe, so it is not uncommon to get a sore throat after the
operation.
The epidural is a way of blocking the nerves that supply the area
of the operation. An epidural is a fine tube that is the anaesthetist
will place in your back, next to the spinal cord nerves, before you
go to sleep with the general anaesthetic. It remains in place for
3-5 days after the operation. The tube is very fine, so that you can
lie on your back. The epidural helps you to breathe deeply, which
would be very difficult to do if you were in a lot of pain. You will
also be able to sit and walk with the epidural in place. The epidural
is very safe. The chance of any permanent nerve damage from an
epidural is very rare, less than 1 in 10,000.
We will give you a PCEA (patient-controlled epidural analgesia)
button to control the amount of painkiller that you get. You
can press the button whenever you need more pain relief, and a
computerised pump will deliver it from a syringe into the epidural.
The pump is designed to prevent an overdose, so for a few minutes
after one dose, it will not deliver another dose.
Your anaesthetist is also responsible for replacing fluids and blood
during the operation. About one in ten patients will need blood
transfusions during or after the operation.
You will have a chance to meet the anaesthetist and ask any
questions on the day of the operation.
When is surgical removal of the cancer not possible?
The tests that you have had indicate that the cancer is localised and
has not spread. Sometimes, problems are discovered during the
operation that could not be identified before surgery. This includes
spread of the cancer to other organs, or that the cancer is fixed to
important structures. Such findings occur in 1 out of 10 patients.
In these cases, the cancer is not removed. Your surgeon may then
choose to perform a bypass operation, so that future blockage of
the bile duct or stomach is prevented.
How do I prepare for surgery?
Try to stop smoking as soon as you know that you need an
operation. You will also need to plan for any additional help you
may need at home while convalescing, particularly if you live
alone. You will be invited to attend the preassessment clinic before
the operation. Please bring a list of your medication with you to
the hospital. Here our team will give you further instructions and
explain what you can expect during your admission.
What happens after the operation?
You will return to the ward after spending some time in the
recovery area of the operating suite. The nursing staff will monitor
your progress and administer painkillers. You will be on intravenous
drips and will not be allowed to eat for the first 5-6 days.
It is important that you get out of bed and move about as soon
as possible. Our physiotherapist will assist you with breathing
exercises, which are important in order to prevent a chest infection.
How long will I be in hospital after the operation?
Most patients are able to go home 7-14 days after the operation.
The ward nursing staff will give you painkiller medication to take at
home as needed, and arrange a follow up visit at the surgical out-
patient clinic.
When can I return to normal activities?
On your return home, you will find movements and activity difficult
for the first few weeks, and you are likely to require help. Your
ability to eat will also take several months to improve. You may
also feel low in mood, but this will resolve shortly. It is important
to keep as active as possible, but also to rest. You may return to
normal activities after 2-3 months. There are usually no restrictions
on activities after that time.
Will I require any further treatment for my cancer?
In some cases, the survival rate can be improved by adding
chemotherapy to surgery. We will discuss the option of having
chemotherapy with you. Your may be referred to see an oncologist,
a specialist at medical treatment of cancers with chemotherapy.
Will I become diabetic after a Whipple operation?
The pancreas produces insulin that is required for control of blood
sugar. There is a risk of developing diabetes after this operation. In
our experience, patients who are not diabetic before surgery are
unlikely to develop diabetes afterwards. Patients who are diabetic
before surgery are likely to need additional diabetic medication or
insulin after surgery.
What are long-term consequences of the operation?
Some of the long-term consequences of the Whipple operation are:
• Malabsorption: This is the poor digestion and absorption of
food, resulting in loose stools that are greasy, pale and tend to
float. The pancreas produces enzymes required for digestion of
food. Removal of part of the pancreas will decrease production
of these enzymes. They will need long-term treatment with
pancreatic enzyme capsules with meals.
• Alteration in diet: There is no restriction to your diet after the
operation, though you may be able to eat only small amounts at
one time. You may need to have small meals and snack between
meals to minimise symptoms of bloating or discomfort. The
dietician can give you advice about your diet and supplements
that you can have between meals to improve your nutrition. It
will take several months for your digestion and ability to eat to
return to normal.
• Loss of weight: It is common for patients to lose weight
compared to their weight before their illness. We would expect
you to start regaining some of the lost weight by three months
after surgery.
When should I call my doctor after surgery?
Call your doctor if you:
• develop a fever
• develop an unusual degree of pain
• develop nausea, vomiting or diarrhoea, or cannot eat properly
• become jaundiced (yellow eyes, dark urine)
• your scar becomes red and painful, or has a smelly discharge
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