Whipple

Question 1

Steps of the Whipple – Excisional phase

Answer 1

Question 2

“Classic” vs “Pylorus-preserving” Whipple procedures

Answer 2

“Classic” removes the pylorus and the antrum of the stomach, leaving the proximal stomach.

“Pylorus preserving” removes the duodenum up to a small pre-pyloric region, preserving the entirety of the stomach.

Question 3

Steps of the Whipple – Reconstruction phase

Answer 3

1. Reconnect the remaining pancreas to the jejunum in an end-to-side anastamosis
2. Reconnect the common hepatic duct to the jejunum in an end-to-side anastamosis
3. Reconnect the pylorus (or stomach) to the jejunum downstream of the bile duct anastamosis

Question 4

Vessels at risk of invasion in pancreatic head malignancy

Answer 4

• Superior mesenteric artery
• Superior mesenteric vein
• Portal vein

Question 5

Islet density is highest in the __ of the pancreas

Answer 5

Islet density is highest in the tail of the pancreas

Question 6

Pre-operative biliary decompression in obstructive jaundice

Answer 6

• Mixed evidence in the medical literature.
• Most surgeons reserve this for:
  
  • When bilirubin exceeds 20 mg/dL
  • When surgery must be delayed for two weeks or more
  • When there is debilitating pruritis or cholangitis

Question 7

Indications for Whipple

Answer 7

• Pancreatic adenocarcinoma
• Cholangiocarcinoma
• Ampullary carcinoma
• Obstructive Ampullary adenoma
• Duodenal malignancy
• Rarely for large neuroendocrine tumors of the pancreas
• Combined pancreatic-duodenal injury in trauma
• Chronic pancreatitis (Chronic pain, non-dilated duct, failed endoscopic therapy)

Question 8

Pre-operative biliary stenting for patients with obstructive jaundice scheduled to undergo Whipple

Answer 8

• Plastic stents are preferable, as metal stents tend to induce an inflammatory response and become incorporated into the bile duct wall (making them hard to remove intraoperatively)
• Care should be taken not to place the stent too high in the common bile duct, as this may complicate the surgery.

Question 9

Resectability of pancreatic adenocarcinoma

Answer 9

Question 10

Anatomy of pancreatic adenocarcinoma

Answer 10

Question 11

Preferred method to stage pancreatic cancer

Answer 11

Three-phase CT

Question 12

Main vascular contraindications to Whipple

Answer 12

• Envasement of a vessel (SMV, portal vein, > 180 degrees SMA)
• Occlusion or thrombosis of the SMV
• SMV-portal vein confluence

Question 13

Role of biopsies in pancreatic malignancy

Answer 13

• A diagnostic biopsy of a suspected pancreatic malignancy may be indicated if:
  
  • There is evidence of systemic spread of disease
  • There is local evidence of unresectability on staging studies
  • The patient is unfit for major surgery
  • Neoadjuvant treatment is being contemplated
• However, a preoperative diagnostic biopsy may not be needed in a fit patient with a potentially resectable pancreatic lesion that is highly suspected of malignancy
• Biopsies are highly specific, but not entirely sensitive

Question 14

Preparation for the Whipple

Answer 14

• NPO from midnight
• Prophylactic antibiotics (probably cefazolin + metronidazole)
• Subcutaneous lovenox and pneumoboots for thromboprophylaxis

Question 15

Some surgeons begin the Whipple procedure as. . .

Answer 15

. . . staging laparoscopy

To ensure that the disease is resectable – as imaging may miss liver or peritoneal metastasis.

However, these laparoscopies are poorly sensitive for vascular invasion, which can also be a contraindication to resection.

Question 16

If you go in for a Whipple, but disease is found to be unresectable, what should you do?

Answer 16

Typically the opportunity will be taken to preform an appropriate palliative surgery instead – such as gastrojejunostomy or biliary bypass

Question 17

Lymph nodes in pancreatic head malignancy

Answer 17

The standard regional lymph node basin for tumors located in the head and neck of the pancreas includes those along the common bile duct; common hepatic artery; portal vein; pyloric, posterior, and anterior pancreaticoduodenal arcades; and along the superior mesenteric vein and right lateral wall of the superior mesenteric artery

Evaluation of a minimum of 12 lymph nodes is recommended to accurately stage N0 tumors. (1-3 positive nodes is N1, >4 is N2)

Nodes outside of this area are considered distant metastases. If one is found to be positive, the operation is aborted.

Question 18

Rationale of placing a drain after Whipple

Answer 18

To provide controlled external drainage of a pancreatic leak.

Inadequate drainage of a leak can lead to an intra-abdominal abscess.

Question 19

Enucleation of small pancreatic head lesions

Answer 19

• < 1 cm benign pancreatic head lesions may be enucleated to avoid unnecessary pancreaticoduodenectomies
• This should not be performed for any lesion greater than 2 cm or any lesion suspicious for malignancy
• Most commonly performed for neuroendocrine tumors, like insulinomas and gastrinomas
• Generally well tolerated, but suprisingly the rate of pancreatic fistulas is higher after enucleation than after Whipple

Question 20

Postoperative management following a Whipple

Answer 20

• Most stay 7-10 days
• Oral feeding is preferred, if possible (if not, jejunostomy), starting with a clear liquid diet on POD 1 or 2, then normal diet on POD 3-5
• Drain management (see separate card)
• Most patients will not need enzyme supplementation, but if steatorrhea develops then Creon and PPI may be perscribed
• Conflicting data over whether or not somatostatin analogues reduce the post-operative rate of pancreatic fistula formation

Question 21

Drain management following Whipple

Answer 21

• Should be straw-colored or clear
• If green, there is a bile leak
• If cloudy/turbulent, pancreatic leak should be suspected.
  
  • On this fluid, obtain an amylase
  • Fluid amylase > 3x the ULN serum amylase on or after POD#3 defines a pancreatic leak
  • High amylase also suggests high probability of later fistula formation
• If no evidence of bile or pancreatic leak, drain can be removed once the patient is tolerating a normal oral diet

Question 22

Most post-operative biliary and pancreatic fistulas. . .

Answer 22

. . . close spontaneously in 4-6 weeks

If there is a leak but the patient is otherwise ready for discharge, they may be discharged with the drain in place and can be removed at a later date once the fistula has resolved.

Question 23

Patient is POD#3 following a Whipple. The procedure was uncomplicated and they are generally recovering well. However, they have persistent vomiting when taking food PO. Patient history includes prior cholecystectomy and type II diabetes mellitus. What are the next steps? What is the likely diagnosis?

Answer 23

• Likely diagnosis: Delayed gastric emptying following Whipple. Occurs in ~25% of patients following this procedure.
• Next steps:
  
  • CT to rule out gastric obstruction due to fluid collection
  • Conservative therapy
• Exact etiology is unclear. Fluid collections or pancreatic anastamosis may mimic this condition, and alkaline reflux gastritis may contribute to the pathophysiology.

Question 24

Rates of relevant post-operative complications in Whipple patients

Answer 24

• Pancreatic leak/fistula: 5-10%
• Bile leak: 1-3%
• Delayed gastric emptying: ~25%
• New onset diabetes (Type 3c): ~16%
• Pancreaticojejunal anastamotic stricture: 1 - 11%
• Abscess: ~1%
• GI hemorrhage: ~3%

Question 25

Pancreatic leak or fistula following Whipple

Answer 25

• Dx: Cloudy drainage with lipase > 3x ULN for serum lipase on or after POD#3
• Risks: High BMI, narrow pancreatic duct, preoperative jaundice, >4,000 lipase in drain fluid on POD#1, prolonged operative time, and soft pancreatic texture
• Early studies suggest that neoadjuvant approach reduces the risk of pancreatic fistula
• May lead to hemorrhage or sepsis if not adequately externally drained

Question 26

Bile leak following Whipple

Answer 26

• Uncommon
• Presents as bile in the drain
• If this happens, just leave the drain in until the drainage is no longer bilious – even if you have to discharge the patient with the drain
• If it persists long enough, surgical ablation may be warranted (>6 weeks or so)

Question 27

Risk for new onset diabetes following Whipple

Answer 27

Preoperative A1c > 5.4% increases the baseline risk by 3 fold

Question 28

Pancreaticojejunal anastamotic stricture following Whipple

Answer 28

• Rare, late complication of a Whipple
• Onsets at a median of 34 months post-op
• Postprandial abdominal pain, recurrent acute pancreatitis, impaired pancreatic function
• Dx with secretin-enhanced MRCP
• Tx: Only for symptomatic patients. Endocscopic dilation, surgical repair, or (in severe cases) total pancreatectomy

Question 29

Porta hepatis

Answer 29

Question 30

Note on biopsying suspected pancreatic cancer

Answer 30

Never biopsy a pancreatic mass through anything other than the duodenum!

These lesions like to seed. But, if we biopsy through the duodenum and it is cancer, the duodenum is coming out anyway, so it doesn’t matter.

Question 31

Cutoff for pancreatic head neuroendocrine tumor size as Whipple indication

Answer 31

2 cm

Question 32

Which functional neuroendocrine tumors tend to be malignant vs benign?

Answer 32

• Gatrinoma: Malignant
• Insulinoma: Benign