The Whipple's operation - History

Whipple's operation in progress - Bared portal vein after the specimen removal
by the surgeons at the Institute of Digestive diseases

The Whipple specimen

The name, Allen Oldfather Whipple will be remembered in surgical circles till the existence of time associated with pancreaticoduodenectomy for pancreatic cancer. The pancreas is a hidden organ and the ability to meet the needs of  a highly demanding procedure, at such a early date speaks of the boldness and resourcefulness of this man, who changed the face of pancreatic surgery forever.

Even as late as the 1990s, I have heard my teachers remark "the pancreas is a sleeping tiger, do not disturb it". Such was the fear among surgeons and it is indeed remarkable that the challenge was met successfully in the 1935. Even today, as I perform the Whipple operation, I am amazed at the boldness of this surgeon to operate on these coagulopathic patients and bring to them, a hope for life.

Whipple's initial series was presented in 1935 and reported 3 cases. The original procedure was a two stage operation. He had a single post operative death and the maximal survival was for 28 months. Even though Vit K was discovered in 1929, it was not available in clinical use till 1939. This made the two stage mandatory.
The paper which changed the face of pancreatic surgery‘‘Pancreaticoduodenectomy for islet carcinoma – a five year follow-up’’was presented by A O Whipple at the New York Surgical Society and the Philadelphia academy of Surgery in February 14, 1945. This was the first reported case of a one stage pancreaticoduodenectomy for pancreatic head cancer. Though the surgery originally planned was a distal gastrectomy for a presumed distal gastric cancer, upon opening the abdomen, Whipple changed the procedure to match the pathology seen. The patient had no jaundice and could be operated upon with success. The Achilles heel of pancreatic resection namely, the pancreatic enteric anastomosis was not addressed at this operation. Whipple simply chose to ligate the pancreatic duct. I looked for whether his patient had any problems in the digestive function or in the endocrine dysfunction in the post operative period. But Whipple did not seem to have seen them in this particular patient (which is surprising!!)

Whipple had already performed a further 19 one stage procedures with a mortality rate of 31% (One in three patients died). This was a challenge in those days and seemed to be so till the 1990s, when improvements in the surgical process had brought down the mortality to low levels. Now Whipple's pancreaticoduodenectomy should be performed in specialist centres where mortality rates can be in the region of 5% or less with 5 year survival rates approaching 40% for node negative and margin free disease.

There remains many more challenges in the management of pancreatic cancer. Even as I write this, it is sad to note that a person with pancreatic cancer has no prospect of cure. They still die of pancreatic cancer at 7 years. Much more work remains to be done in pancreatic cancer.