P&S Medical Review: Nov 1993, Vol.1, No.1
The Whipple Procedure - 1935 to 1993

JOHN A. CHABOT, M.D.
Department of Surgery
Columbia University College of Physicians and Surgeons,
New York, NY.

The operation that Dr. Whipple described in 1935 has since been greatly modified. Although others have contributed, Dr. Whipple developed and described many of these modifications.[1],[2] As the procedure has evolved, however, the principles outlined in the original description have remained important.

Dr. Whipple gained confidence operating on the pancreas after successfully operating on patients with insulinomas. This success was attributed to careful technique and the use of fine silk sutures. A severe complication after duodenal adenomectomy was then attributed to the dissolution of catgut sutures by pancreatic juice. Armed with these experiences, Dr. Whipple performed his radical resection of the pancreatic head with silk technique and avoidance of a pancreatic anastomosis. Although an anastomosis to the pancreas is currently incorporated into the Whipple Procedure, it remains the Achilles' Heel of pancreaticoduodenectomy. Even in the best of series, pancreaticoenteric anastomosis leak rates remain 10 - 20%.[3] The principle of careful attention to this aspect of the operation, including the technical details of the anastomosis, remains an actively studied issue.

The second principle elucidated by Dr. Whipple was the performance of this operation in two stages. The first stage relieved jaundice and allowed the patient to be physiologically prepared for the major resection. Dr. Whipple modified this principle in 1940, when he performed the first recorded, successful, one-stage resection of the entire pancreatic head and duodenum. With the availability of Vitamin K, the coagulopathy associated with jaundice could be corrected without operation. The principle of adequate patient preparation remains paramount. In 1993, we rarely need to go to the extreme of operating on patients in order to prepare them; however endoscopy, angiography, percutaneous biliary drainage and parenteral nutrition all play a role in adequately preparing the patient for pancreaticoduodenectomy.

The third principle implied by Dr. Whipple's original description is that not all tumors in this region are amenable to surgery. The incidence of pancreatic adenocarcinoma is far higher than that of ampullary carcinoma and yet Dr. Whipple chose to perform this operation only in cases of ampullary carcinoma. All cases reported in the literature from 1927 to 1935 were attempts at treatment of ampullary and distal common bile duct tumors. Currently, the Whipple Procedure is done far more often for carcinoma of the head of the pancreas than for these other, rare lesions. Although Dr. Whipple's experience in curing pancreatic adenocarcinoma was poor, in 1963 he predicted some improvement by stating: "If the diagnosis of cancer of the pancreas and the ampullary area were made much earlier, and if patients were not studied to death in too many medical services, the results with radical surgery would be much better."[2]

The results published in recent series suggest that Dr. Whipple's prediction may become a reality. Published series of pancreaticoduodenectomy for pancreatic adenocarcinoma from Harvard [4] and Johns Hopkins [5] report 5 year survival rates of 13% and 19% respectively. Multiple series have reported mortality rates under 5%, minimal morbidity and a return to pre-operative activity of 75%. [6] It is this author's belief that adherence to Dr. Whipple's implied principle of careful patient selection and careful staging has resulted in these dramatically improved results.

My personal approach to the application of Whipple's operation to pancreatic adenocarcinoma includes strict adherence to the principles he outlined in 1935. The pancreatic anastomosis is done with great care; currently we are examining a laser welding technique developed in the legacy of Dr. Whipple's laboratory to further decrease the rate of pancreaticojejunal anastomotic leak. Patients are selected very carefully; anyone with significant medical problems is eliminated as a resection candidate. Lastly, patients are staged very carefully. All patients undergo endoscopic pancreatography, angiography and laparoscopy to limit application of this operation to potentially curable patients. The operation remains, as Dr. Whipple described it in 1946, "a long, trying operation;" however, with our advances in both operative and non-operative care it remains an important component of the surgeon's armamentarium.

REFERENCES

1. Whipple AO. Observations on radical surgery for lesions of the pancreas. Surg Gyn Obst 1946;82:62.

2. Whipple AO. A reminiscence: pancreaticoduodenectomy. Rev Surg 1963;20:221.

3. Miedema BW, Sarr MG, van Heerden JA, et al. Complications following pancreaticoduodenectomy. Arch Surg 1992;12:945.

4. Willett CG, Lewandrowski K, Warshaw A, et al. Resection margins in carcinoma of the head of the pancreas. Ann Surg 1993;217:144.

5. Cameron JL, Pitt HA, Yeo CJ, Lillemor KD, Kaufman HS, Coleman JC. One hundred and forty-five consecutive pancreaticoduodenectomies without morbidity. Ann Surg 1993;217:430.

6. Fernandez-del Castillo C, Warshaw AL. Diagnosis and preoperative evaluation of pancreatic cancer, with implications for management. Gastroenterol Clin N Am 1990;19:915.