A pancreatoduodenectomy (PD) is a major abdominal surgery known for its complexity and specialized expertise. This intricate procedure involves removing several organs to treat serious upper gastrointestinal diseases, primarily cancers. Successful execution offers the only potential cure for many patients with tumors in this delicate region of the body.
Identifying the Eponym
The eponym for the pancreatoduodenectomy is the “Whipple Procedure” or “Whipple Operation.” The procedure involves the surgical removal of the head of the pancreas, the duodenum, the gallbladder, and a portion of the common bile duct.
The need for this complex, multi-organ removal stems from the shared blood supply and lymphatic drainage network in the upper abdomen. Because of this close anatomical relationship, a tumor affecting the head of the pancreas often necessitates removing the adjacent parts of the small intestine and bile drainage system to achieve a complete resection. This operation is named after the surgeon who refined and popularized the technique.
The Surgeon Behind the Name: Allen Oldfather Whipple
The procedure owes its name to Dr. Allen Oldfather Whipple (1881–1963), an American surgeon who pioneered the operation during his career at Columbia University and Columbia-Presbyterian Medical Center in New York. Born in Persia (modern-day Iran) to missionary parents, Dr. Whipple’s career spanned decades. He served as a professor of surgery at Columbia, holding the position until his retirement in 1946.
In 1935, Dr. Whipple published his initial results on a two-stage procedure for treating periampullary tumors. He later refined this into a single-stage operation by 1940, dramatically improving the safety and feasibility of the procedure. This refinement was aided by advancements such as the availability of Vitamin K, which helped control the bleeding issues previously associated with obstructive jaundice. Whipple’s influence extended beyond the operating room, as he also helped establish the American Board of Surgery and shaped the standards for surgical education.
Indications for the Pancreatoduodenectomy
The primary reason for performing a pancreatoduodenectomy is to treat malignant tumors in the upper gastrointestinal tract. The most frequent indication is pancreatic cancer, specifically adenocarcinoma located in the head of the pancreas. Unfortunately, only a small percentage of patients, about 15% to 20%, are candidates for this surgery because the disease is often too advanced or has metastasized by the time of diagnosis.
Other cancers arising from adjacent structures also frequently require a Whipple procedure due to the intertwined anatomy of the region. These include periampullary tumors, which originate in the ampulla of Vater where the bile duct and pancreatic duct join. Distal cholangiocarcinoma, a cancer of the lower bile duct, and duodenal cancer are also common indications. The operation may also be necessary to treat non-malignant conditions, such as chronic pancreatitis that has not responded to other treatments, or certain types of neuroendocrine tumors.
Overview of the Surgical Process
The pancreatoduodenectomy is divided into two major phases: the resection phase and the reconstruction phase. During resection, the surgeon removes the head of the pancreas, the entire duodenum, the gallbladder, and part of the common bile duct, which are taken out as a single unit, or en bloc. In a traditional Whipple procedure, a portion of the stomach’s lower section, the gastric antrum, is also removed.
The reconstruction phase is the most technically demanding part, as it restores the continuity of the digestive tract. To allow bile and digestive enzymes to flow properly, the remaining organs must be reconnected to the jejunum, the middle part of the small intestine. The surgeon creates three new connections, or anastomoses: the remaining pancreas is connected to the jejunum (pancreaticojejunostomy), the bile duct is joined to the jejunum (hepaticojejunostomy), and the stomach or remaining duodenum is connected to the jejunum (gastrojejunostomy or duodenojejunostomy).
A common modification of the classic technique is the Pylorus-Preserving Pancreatoduodenectomy (PPPD), which leaves the stomach’s lower curve and the pylorus valve intact. The PPPD is favored when the tumor is not near the stomach, as it improves the patient’s ability to regain weight and maintain normal stomach function after surgery.