Evolution and current status of the Whipple procedure: an update for gastroenterologists

The Whipple procedure has undergone a remarkable gradual evolution in the last 20 years, of which many gastroenterologists are unaware. Improvements in staging, particularly staging laparoscopy with ultrasonography, have reduced the incidence of negative laparotomies. The forbidding mortality of pancreaticoduodenectomy, approximately 20% just a generation ago, has decreased precipitously in high-volume referral centers. Near zero mortality rates are now common. Morbidity and length of stay have also been reduced. Cardiac and pulmonary complications have been markedly reduced, whereas others such as pancreatic fistula still remain a problem. Modifications of the procedure have been introduced to improve long-term outcome of pancreatic cancer and to lessen digestive sequelae. Total pancreatectomy and large regional excisions did not improve results. However, 5-year survival rates of 20% are now reported by several centers for adenocarcinoma of the pancreas, and long-term survival rates for other periampullary tumors are approximately 40%. Pylorus-sparing procedures can be performed and may lessen postoperative sequelae. The clinical consequences of improved results are that large numbers of procedures are being performed at specialty centers, providing the opportunity to perform clinical trials, and that the procedure is used more widely, for instance, in benign diseases such as chronic pancreatitis.