Experience with the Whipple procedure (pancreaticoduodenectomy) in a university-affiliated community hospital

The purpose of this report is to review the current standards of the Whipple pancreaticoduodenectomy and show that excellent results are achievable in a low-volume, university-affiliated community hospital.

A case series of consecutive patients operated on during the period November 1981 to June 1996 was evaluated retrospectively. Medical records were abstracted for demographic data, clinical presentation, comorbid factors, pathological diagnosis and staging, operative records, perioperative mortality, morbidity, and length of stay. Postoperative follow-up data were obtained from telephone interviews and from the primary referring physicians.

A total of 29 patients underwent a pancreaticoduodenectomy procedure during this 15-year period. Twenty-eight patients underwent the standard Whipple resection and 1 patient underwent an extended resection owing to the extent of the disease. The average age was 64 years (range 41 to 82). Comorbid diseases were present in 59% of cases. Jaundice was the main presenting complaint (62%), loss of weight and appetite was present in 34%. The most common indication for this procedure was malignant periampullary disease (83% of cases). Of patients with adenocarcinoma of the pancreas, 67% were stage I and 33% were stage III. The operation lasted an average of 5.5 hours (range 3.5 to 8 h). The mean operative blood loss was 1153 mL (range 250 to 4,000). The median length of stay was 11 days (range 7 to 81). There was 1 operative mortality (3%), and the overall major morbidity rate was 28%. Three patients required reoperation (10%), 2 for intraabdominal hemorrhage and 1 for delayed gastric emptying. The major morbidity was hemorrhage at the gastrojejunostomy site (14%); 2 cases were intraabdominal and 2 were intraluminal. Pancreaticojejunostomy leak occurred in 1 patient, resulting in a localized intraabdominal abscess. Delayed gastric emptying, defined as the need for nasogastric suctioning for more than 10 days postoperatively, occurred in only 1 patient. Overall, an oral diet was tolerated after a median of 6 days (range 4 to 61). Seventy-two percent of patients had no major complications at all, 17% had one major complication, and 10% had two or more major complications. Pancreatic insufficiency was the major long-term complication, developing in about 50% of patients. There were no biliary strictures. The median survival for patients with carcinoma of the pancreas was 21 months and the 5-year survival was 15%.

The above study demonstrates that a complicated procedure like the Whipple pancreaticoduodenectomy can be performed with excellent results in a community hospital. The most important prerequisite is that the surgeon be adequately trained in the procedure. In low-volume hospitals, the case load should be restricted to a minimal number of trained surgeons in order to concentrate the experience.