The Pancreaticoduodenectomy is the most commonly known surgery for pancreatic cancer. It is performed when the cancer is in the head of the pancreas. Dr. Alan O. Whipple of New York Memorial Hospital (now called Memorial Sloan-Kettering) first described the procedure in 1935. The procedure removes the head of the pancreas, the duodenum, the gallbladder, the bottom section of the stomach, and the upper part of the small intestine. The remaining tail of the pancreas and bile duct from the liver are re-sewn to the small intestine and the small intestine is sewn directly to the remaining stomach. Bile from the liver and pancreatic juices from the remaining pancreas will be secreted into the small intestine to digest food, rather than into the duodenum. (A diagram showing how the organs are removed is in our FAQ section.) The original operation actually took two separate procedures, and had a high mortality and complication rate. A lot of progress has been made since then, so that in the hands of a surgeon specializing in pancreatic cancer, the mortality rate is very low (about 1-2%). The procedure takes approximately 6 to 8 hours in the operating room.

Most surgeons cannot perform the Whipple procedure if the major blood vessels have been invaded by tumor. The largest blood vessels near the pancreas are the superior mesenteric artery (SMA), the superior mesenteric vein (SMV) and the hepatic portal vein. The SMV and the portal vein converge near the pancreas in a structure called the superior mesenteric vein-portal vein confluence (SM/PV). However, in recent years, a new technique has been developed and perfected at M. D. Anderson that allows experienced surgeons to completely remove the tumor, even if it invades the SMV or the SM/PV. This procedure is performed at the same time as the Whipple and is called a vein resection. If a tiny section of the SMV is involved with tumor, the surgeon will simply remove the small section of vein and sew the remaining vein closed. If a larger section of SMV is involved, the surgeon will take a graft to replace it. The graft is usually taken from the internal jugular vein in the patient's neck. This graft removal is very similar to the removal of a leg vein for heart bypass surgery. The neck vein is used instead of a leg vein because it is much thicker and stronger than leg veins. The jugular vein graft is inserted into the section where the SMV or SM/PV was removed during the Whipple. A vein resection adds about 2 hours to a Whipple operation. This resection and graft can only be performed on the vein. If the artery is involved, the surgery can not be performed.

Historical Notes: Dr Alan Whipple was consulted on the design and construction of the first M. D. Anderson buildings on its current campus. This picture of one of those meetings was taken in 1948. From left to right: Dr Nesselrode, Univ of Kansas; Dr R. Lee Clark, first full-time president of M. D. Anderson; Dr Ernst Bertner, outgoing acting director of M. D. Anderson; and Dr. Whipple. From the M. D. Anderson Cancer Center Historical Archives.

The Distal Pancreatectomy is performed when the tumor is growing in the tail of the pancreas. This procedure is simpler than the Whipple is; it is not the same as the Whipple. In this procedure, the tail of the pancreas is removed, along with the spleen, which lies right next to the pancreas. The stomach, duodenum, and small intestine do not have to be removed. This procedure takes much less time than a Whipple to perform, and patients in general recover more quickly.

The Total Pancreatectomy is similar to (but not the same as) a Whipple, except the entire pancreas is removed. This is performed if the surgeon feels that the tumor has spread throughout the pancreas and the entire organ must be removed to ensure that the entire tumor is taken out. The duodenum, stomach, and other organs removed in the Whipple are also removed in the Total; the difference is that the tail of the pancreas is not sewn back into the small intestine. It is possible for a patient to live without their pancreas. These patients are absolutely required to use insulin to control their blood sugar and pancreatic enzyme supplements to digest food. The Total pancreatectomy takes about the same amount of time as the Whipple.

If the tumor cannot be removed by surgery, and grows large enough to block the bile duct and/or the duodenum, a surgeon may decide it is best to bypass the small intestine or bile duct. Without removing the tumor, the surgeon will take a loop of small intestine and sew it directly to the stomach. This allows food to move into the small intestine without getting stuck in the area blocked by tumor. This is called a gastrojejunostomy, or "gastric bypass". In a similar manner, a section of bile duct leading from the liver can be routed to the small intestine, thereby allowing bile to drain into the small intestine without getting backed up in the liver and causing jaundice. This is called a hepaticodochojejunostomy, or "biliary bypass". These 2 procedures are often done at the same time when they are performed and together take about 4 to 5 hours. Bypasses are done when it is not possible to remove the tumor in order to prevent pain and other symptoms and to allow the patient to keep taking food orally.

Only your doctor can decide which (if any) operation is appropriate for your particular situation. Your doctor is the best person to ask about the particular risks you may face, what the expected benefits are for you, and how to recover afterwards.

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