WHIPPLE PROCEDURE (PANCREATICODUODENECTOMY)
The Whipple procedure, also known as pancreaticoduodenectomy, is a complex surgical procedure most commonly used to treat pancreatic cancer. It involves the removal of the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder, and the bile duct. In some cases, a portion of the stomach may also be removed. This surgery is named after Allen Whipple, the American surgeon who first described the procedure in the 1930s.
The Whipple procedure is typically performed in cases where the cancer is confined to the head of the pancreas and has not spread extensively. The primary goal is to remove the cancerous tissue and prevent the spread of the disease.
The steps of the procedure generally include:
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Removal of the head of the pancreas, duodenum, gallbladder, and bile duct.
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Reconnecting the remaining pancreas, bile duct, and stomach (if involved) to the small intestine to maintain digestive functioning.
This procedure is one of the most challenging abdominal operations, primarily due to the complexity of the anatomy in that area and the need for precise reconstruction after removal of the organs.
Patients who undergo the Whipple procedure require lifelong monitoring and care. This includes nutritional support, as the removal of part of the pancreas and other digestive organs can impact the ability to digest food. There's also a need for regular check-ups to monitor for any signs of cancer recurrence or complications arising from the surgery.
Anesthetic Implications for Whipple Procedure (Pancreaticoduodenectomy)
Anesthesia type: General, epidural anesthesia
Airway: ETT
Preoperative:
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Challenging and technically demanding major abdominal procedure (results in a number of pathophysiological alterations)
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Severe electrolyte disturbances may be present with pancreatitis
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Patients with acute pancreatitis are usually hypotensive and hypovolemic
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Patients may have large third-space fluid shifts
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An arterial line is placed, ± central line, ± CVP
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Patients can lose large amounts of blood
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Large-bore IV access and invasive monitoring are normally used for fluid replacement, hemodynamic monitoring, and frequent arterial blood sampling
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Consider epidural
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TAP block can be administered
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Assess for respiratory compromise (pleural effusion, atelectasis)
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Hypocalcemia is often present (decreases myocardial contractility, prolongs QT interval)
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Hypocalcemia from the release of pancreatic lipase (mental fat saponification)
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The presence of ileus or abdominal obstruction requires rapid sequence induction
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Electrolyte abnormalities are common
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Warm fluids
Intraoperative:
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Position: supine, bilateral arms are tucked
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Expect prolonged operative time (4-7 hours)
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EBL 200-1000 mL
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Aggressive volume resuscitation may be required during surgery (crystalloids, colloids, blood products)
Postoperative:
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Epidural may be placed for postoperative pain control
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Assess for hemodynamic and homeostatic stability
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Patients may need to be kept intubated due to large fluid shifts and compromised airway due to edema
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Nasogastric tube for postop
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Intensive respiratory rehabilitation
Complications:
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Significant fluid loss
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Bleeding
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Hypothermia
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Delayed gastric emptying
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Pulmonary complications (pneumonia)
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Pancreatic fistula
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Sepsis
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Myocardial infarction
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Biliary fistula
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Pulmonary aspiration
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Electrolyte imbalance
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Bowel leakage from anastomosis
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VTE
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PONV
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Hyperglycemia
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Pancreatogenic diabetes
Sources:
De Pietri L, Montalti R, Begliomini B. Anaesthetic perioperative management of patients with pancreatic cancer. World J Gastroenterol. 2014 Mar 7;20(9):2304-20. doi: 10.3748/wjg.v20.i9.2304. PMID: 24605028; PMCID: PMC3942834
Elisha, S. (2010). Case Studies in Nurse Anesthesia.
Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice.
Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.).
Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.