| In recent
years there has been a thrust
surgeons to centralize surgical procedures; that is to say, create an
environment in which they are performed only at institutions where a
given procedure is performed in large numbers by a small number of
presumption, which has also been promulgated by the same academicians,
is that surgical
quality is proportional to volume and this relationship is not
affected by other factors that are known to contribute to quality, such
education, training, experience, judgment, interest, focus, ethics and
Regardless of one's opinion of this assumption's validity, the
prompt diligent surgeons to review their own records and critically
the acceptability of their outcomes.
Perhaps the first general surgical operation that is being moved out of the community and toward regional centers is the Whipple procedure to remove the head of the pancreas and its associated structures. The Whipple procedure, named in honor of Allen Oldfather Whipple MD who transformed a universally fatal turn of the century procedure into a dangerous but survivable operation, has benefited from advances in anesthesia and critical care but remains today a complex and hazardous operation fraught with short term complications and long term disabilities. It is usually reserved for attempted cures of pancreatic and periampullary malignancies, tumors that are notoriously resistant to all forms of treatment. Because of the operation's drawbacks, patient selection is limited, and during the course of a career a general surgeon may see only a handful of patients who truly stand to benefit from the procedure more than they stand to risk. This is a series of consecutive Whipple procedures performed in community hospitals by surgeons that some academic authorities would describe a “low volume” and therefore ill-suited to perform these complex operations. Because of the rarity of patients that are candidates for the Whipple procedure, this series includes only 25 patients and cannot be compared to published series from high volume centers containing hundreds of cases over long time periods. It is impossible to draw meaningful conclusions from such a small sample of patients. Nevertheless, this review is of some value and there are a number of interesting observations that can be made.
There were 16 men and 7 women. The mean age of patients was 67 years. The most frequent presenting symptoms were jaundice (68%), weight loss (44%) and pain (36%). Eight patients (32%) had jaundice only and 4 patients (16%) complained of only pain. Preoperatively, cancer was confirmed by biopsy or strongly suspected from imaging studies in 17 (68%) of patients, but preoperative biopsies were performed and returned falsely negative in 6 (24%) patients. Most of the operations were performed by this surgeon (92%) but the average frequency by surgeon was still less than one procedure per year, confirming this to be a “low volume” and therefore ill-advised series, as frequently defined by “high volume” providers. Four patients (16%) required total pancreatectomy and 19 patients (76%) had the so called Traverso-Longmire or pylorus sparing modification to the standard Whipple procedure in which an otherwise standard hemigastrectomy is not performed but rather the distal stomach and the pylorus, along with their blood supplies and nerve innervations, are dissected away from the tumor and preserved. Leaving the patient with an intact and functional stomach eliminates the long term sequealae of gastrectomy such as weight loss, early satiety, “dumping syndrome” and marginal ulceration. The purported disadvantage of the pylorus sparing modification is postoperative pylorospasm that can temporarily prevent gastric emptying and prolong the patient's postoperative recovery time. However in this series, only 3 of 19 patients who had the pylorus sparing modification experienced this complication (16%) and the mean
length of hospital stay for the entire series
was still only 8.5 days. Patients
who had the pylorus sparing modification were
better able to resume their normal eating habits and maintain their
even after adjuvant chemo-radiation. Coincidentally, one of the
this series required the Whipple procedure for a cancer arising in the
many years after a Billroth II hemigastrectomy.
Operative times were not reliably recorded in available records, but were usually noted in the operative report when they were over 8 hours. Thirteen operative reports had noted long operative times that averaged 10.6 hours. Data on estimated blood loss was somewhat more reliable with a mean of 800 ml. There were no operative or postoperative (30 day) deaths (0%). There were 8 patients whose hospital stays were prolonged by predominantly minor and manageable complications. Three patients with temporary postoperative pylorospasm have already been mentioned. Two patients developed bilomas that were self limiting and treated non-operatively. One patient had a low output fistula at a drain site that closed spontaneously, and 1 patient who had a total pancreatectomy for a large tumor requiring an in continuity resection of the right transverse mesocolon, sacrificing the marginal arterial arcade, experienced a brief episode of ischemic colitis. Finally, 1 patient contracted hospital acquired pneumonia and 1 patient had a serious stroke during the postoperative period which was not immediately fatal but contributed to his eventual demise from related problems. No patterns are exhibited in these anecdotal complications, but noteworthy of this series is that 17 of 25 patients (68%) experienced a rapid and completely problem free recovery from an operation notorious for its morbidity and mortality.
Pathologic examination of the resected tumors
that 11 (44%) were pancreatic, 5 (20%) were common bile duct tumors, 5
were ampullary tumors, 2 (8%) were primary duodenal tumors and the
were other unusual tumors. All but one (96%),
a hamartoma, were malignant.
average tumor size was 3.2 cm
and, 11 specimens (46%) had lymph node metastases
identified. Fortunately, only 6 patients were lost to follow up before
If they are presumed to have died of disease at their last contact,
still 7 known survivors at 5 years
(28%), 4 survivors at 10 years and 1 survivor
at 17 years. All long term survivors
in this series had no evidence of tumor
recurrence at their last contact. Interestingly, 1 long term
positive lymph nodes at the time of tumor resection. Testifying to the
of this patient population, 13 patients were known to have died before
years (52%) but only 7 of them (28%) died with known recurrence.