Caring for pancreatic cancer: Post operative complications of the Whipple operation

20 years ago, doing a Whipple's resection was like climbing Mount Everest for the surgeon. When I was a medical student in 1992, my assistant professor described in glowing terms the whole surgical procedure in the class. Now, how do I look upon this procedure as a pancreatic surgeon? Do I still look at it with awe and admiration like a medical student or like a mounatineer as he sees the "eight thousands". I must say that I am more concerned that the patient passes through the treatment process safely, while the effective treatment is delivered.

The Whipple's resection is undoubtedly one of the most complex surgical procedures known to a surgeon. Probably the equivalent surgery in liver is the left trisectionectomy. The complexity of the surgical procedure combined with the pancreatic - intestinal anastomosis integrity makes it a tall calling indeed.

Every team that has performed the Whipple operation has known that the devil is in the details. From the placement of stitches in the pancreatic jejunal anastomsosis to the way the reconstruction is performed, the wPD is all about doing "all the right things" "all the time", which should be true about every surgery performed.

One of my surgical mentors used to remark that for oncological success, the surgeon has to do a radical surgery and for immediate survival, the surgery has to be safe. It is very true in the Whipple operation. While the Whipple operation complications do include routine surgical complications, like pneumonia, blood clotting in the legs

The first day complications in a Whipple's operation is all about bleeding. The bleeding can be from within the intestine, where it is usually due to bleeding from the places of surgical connections - we call them anastomosis or from the adjoining blood vessels of the pancreas. Each surgeon has evolved a method to solve these issues. I use hand sewn anastomosis in most of my patients as it allows me to control the tissue approximation during the stitching process. This has helped me eliminate the risk of intestinal anastomotic bleeding. The bleeding from the portomesenteric vesssels required meticulous attention to detail during the dissection process. My own method is to tie every small portal venous branch with a prolene stitch and fix a small staple to it. I also make sure that there is no bleeding by giving a 30 minute period after the resection to make sure that there is no bleeding.

The second place from which bleeding occurs is from within the intestine. Suture lines in the intestinal connections can miss certain vessels that can open up after the surgery. Again, technical details go a long way in preventing the complication. As a policy, we have reduced the use of staplers in reconstructing the anastomosis as we did see some bleeding in the initial experience which was eliminated by the use of a sutured anastomosis.

The next complication to worry is the presence of a pancreatic leak. The manifestation of this complication is usually on the post operative day 3. We evaluate for this complication proactively by measuring the amount of amylase in the drain fluid. (Amylase is an enzyme that is produced by the pancreas to help in digestion of protein). A large quantity of amylase in the drain indicates that the connection between the pancreas and the intestine is leaking. It does indicate a serious complication, one that can lead to digestion of the nearby blood vessels. In 2010, we used a series of interventions to handle an actual leak and convert a potentially dangerous complication to a safe one. While technical expertise has improved over the years, we have still a long way to go to make this complication go away. Leaks will mean prolonged hospital stay, nutritional supplements and medications like octreotide. It will also mean CT scans to look for collections and percutaneous CT guided drainage procedures. At times, it may need a laparotomy or removal of the remnant pancreas to handle the complication.

The next complication is usually at the time of discharge - 10 days post operatively - namely delayed gastric emptying. The motor function of the stomach gets disturbed in WPD and a small percentage of patients actually remain unable to eat oral diet till 14 days after surgery. It may not be life threatening but invariably delays the initiation of adjuvant therapies. But we have no issues at present, with the routine use of feeding tubes, this problem looks less awful than it was originally. Small gains may be made by the use of pro kinetic agents.

Like every major surgery, attention to detail in every aspect of patient care allows us to avoid the complications, and also to successfully treat the complication once it has occurred.