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The Whipple procedure (or partial pancreaticoduodenectomy) is considered the definitive surgical operation to resect carcinoma of the head of the pancreas, periampullary carcinoma, or duodenal carcinoma 1.
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In the procedure, the head of the pancreas and adjacent duodenum is resected. The gallbladder is also removed. Three anastomoses are then created between the bowel and the liver, stomach, and pancreas. A nodal resection is also performed. The end result includes:
- resection of pancreatic or duodenal primary
- gastrojejunostomy (or duodenojejunostomy)
The classic Whipple procedure involves resection of the gastric antrum, but in appropriate patients a "pylorus-preserving" Whipple (PPPD) may be performed, which results in improved postoperative functional outcome.
A Whipple procedure can be assumed if the features listed above are present. CT is useful for evaluation of complications:
- gastric outlet obstruction / delayed gastric emptying
- anastomotic leakage (usually occurs within two weeks)
- pancreatic fistula 7
- pancreatitis of the residual gland
- biliary stricture
- wound infection
- abdominal abscess
- intra-abdominal hemorrhage
CT protocols for evaluation of the postoperative Whipple procedure are often customized to the individual center and discussion between surgeon and radiologist. IV contrast is often used. Positive oral contrast is often helpful for evaluation of anastomotic leakage, but may obscure intra-abdominal hemorrhage.
Recurrence of carcinoma after resection can sometimes be difficult to determine on early postoperative studies, due to postoperative change and possible radiation change to the operative bed. A combination of serial CT exams and/or FDG-PET may be necessary to suggest recurrence.
The procedure is considered one of the most invasive in abdominal surgery and the risk of adverse events and recurrence of the primary tumor is high. This can be improved somewhat if the procedure is performed at a high-volume center.
Tumor-specific 10-year actual survival rates post procedure depend on the underlying cancer (1998 data) 3:
- pancreatic: 5%
- ampullary: 25%
- distal bile duct: 21%
- duodenal: 59%
The classic Whipple procedure and the pylorus-preserving Whipple procedure have similar morbidity and mortality 4.
History and etymology
The Whipple procedure (and also the triad of Whipple) were both named after the American surgeon, Allen Oldfather Whipple (1881-1963) 6.
However Whipple disease was named for a different Dr Whipple!
- 1. Ihse I, Anderson H, Andrén-Sandberg. Total pancreatectomy for cancer of the pancreas: is it appropriate?. World J Surg. 1996;20 (3): 288-93. Pubmed citation
- 2. Yamauchi FI, Ortega CD, Blasbalg R et-al. Multidetector CT evaluation of the postoperative pancreas. Radiographics. 2012;32 (3): 743-64. doi:10.1148/rg.323105121 - Pubmed citation
- 3. Yeo CJ. Pancreatic cancer: 1998 update. J. Am. Coll. Surg. 1998;187 (4): 429-42. Pubmed citation
- 4. Belli L, Riolo F, Romani F et-al. Pylorus preserving pancreatoduodenectomy versus Whipple procedure for adenocarcinoma of the head of the pancreas. HPB Surg. 1991;1 (3): 195-200. Free text at pubmed - Pubmed citation
- 5. Raman SP, Horton KM, Cameron JL et-al. CT after pancreaticoduodenectomy: spectrum of normal findings and complications. AJR Am J Roentgenol. 2013;201 (1): 2-13. doi:10.2214/AJR.12.9647 - Pubmed citation
- 6. IN MEMORIAM ALLEN O. WHIPPLE, MD. 1881-1963. (1963) Annals of surgery. 158: 148. Pubmed
- 7. Changazi SH, Ahmed Q, Bhatti S, Siddique S, Abdul Raffay E, Farooka MW, Ayyaz M. Whipple Procedure: A Five-Year Clinical Experience in Tertiary Care Center. (2020) Cureus. 12 (11): e11466. doi:10.7759/cureus.11466 - Pubmed