Twenty-five Consecutive Whipple Procedures in a Community Setting

Twenty-five Consecutive Whipple Procedures
in a Community Setting
by
Joseph N. Michelotti, M.D., M.A., F.A.C.S.

Operative mortality: 0.0% Long term cure rate: 28% Length of stay: 8.5 days

In recent years there has been a thrust among academic 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 surgeons. The presumption, which has also been promulgated by the same academicians, is that surgical quality is proportional to volume and this relationship is not significantly affected by other factors that are known to contribute to quality, such as education, training, experience, judgment, interest, focus, ethics and honesty. Regardless of one's opinion of this assumption's validity, the discussion may prompt diligent surgeons to review their own records and critically evaluate 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

postoperative 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 weight, even after adjuvant chemo-radiation. Coincidentally, one of the patients in this series required the Whipple procedure for a cancer arising in the duodenum 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 revealed that 11 (44%) were pancreatic, 5 (20%) were common bile duct tumors, 5 (20%) were ampullary tumors, 2 (8%) were primary duodenal tumors and the remaining 2 were other unusual tumors. All but one (96%), a hamartoma, were malignant. The 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 5 years. If they are presumed to have died of disease at their last contact, there are 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 survivor had positive lymph nodes at the time of tumor resection. Testifying to the fragility of this patient population, 13 patients were known to have died before five years (52%) but only 7 of them (28%) died with known recurrence.

This author has already admitted that few conclusions can be drawn from such a small cohort of patients. However, the data from this series of 25 consecutive Whipple procedures performed in a low volume community setting presents a more encouraging picture of community practice than has been painted in recent years. Despite the severity of this disease and the difficulty of its surgical treatment, performance was more than acceptable in terms of morbidity, mortality and efficiency. Patient selection and surgical indications were clearly appropriate, surgical outcomes were outstanding, and a long term cure rate approaching 30% with a 5 year disease related mortality under 30% inspires new hope for a malignancy that has frustrated surgical oncologists for a century. This series also demonstrates that unfavorable generalizations about quality from positions of authority, whether well intentioned or selfishly motivated, can unjustly smear interested and focused colleagues who are dedicated to providing safe and effective services in a community setting.

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