A MODIFIED WHIPPLE OPERATION FOR CARCINOMA
OF THE HEAD OF THE PANCREAS*

CLARENCE Dennis, M.D., MINNEAPOLIS, MINN.
(From the Department of Surgery, University of Minnesota Hospitals )

SINCE the demonstration by Whipple, Parsons, and Mullins, in 1935,

that ligation of the pancreatie duet could usually be tolerated in the
course of partial pancreatectomy for carcinoma of the ampulla of Vater
in man, renewed interest has been aroused in radical surgical approaches
to the pancreas. This trend was strengthened by Whipple’s report, in
1938, of successful extirpation of carcinoma of the head of the pancreas.
Prior to 1941, procedures designed for extirpation of such lesions were
in general performed in two stages. One such procedure was success-
fully carried out by Dr. John R. Paine at this clinic. The patient
survived for three months after the second stage operation and died else-
where of unknown cause, an autopsy not being obtained.

With the advent of vitamin K and more adequate use of blood and
plasma transfusions, however, the trend is now toward a one-stage
operation. In November, 1941, Trimble, Parsons, and Sherman reported
a successful one-stage procedure, the technique being essentially the
same as that now in use by Whipple. In this procedure, partial
gastrectomy with an anterior Polya gastrojejunostomy was performed,
the common bile duct being implanted into the jejunum just distal to the
gastrie stoma.

Upon review of the pertinent literature, several considerations become
apparent with regard to the performance of a satisfactory operation.
The first of these is the prevention of ascending cholangitis following
anastomosis between the biliary and intestinal tracts, a complication of
considerable frequency in the best of hands. Trautmann, Robbins, and
Stewart showed in experimental studies in dogs that simple side-to-side
anastomosis of bowel to gall bladder uniformly is followed by passage of
intestinal content into the biliary tract. Wangensteen concluded that
even though this occurs, the essential factor in preventing cholangitis
and hepatitis is the prevention of obstruction at the stoma. Bachrach
and Fogelson confirmed this in the case of choledochojejunostomy.

Various authors have deseribed procedures intended to prevent reverse
flow into the biliary tract. Kausch described a Y procedure somewhat
similar to the Roux gastrojejunal anastomosis, and others have offered

 

*This work was siinported by a grant from the research funds of the Graduate
School of the University of Minnesota.

Received for publication, April 20, 1942.
3
modifications, all, however, with short segments separating the biliary
anastomosis from the main enteric stream.

A further consideration is the development of the simplest procedure
possible, one with a minimum of anastomoses, ete., a factor demanded
by the usual poor condition of these patients. Finally, leakage of
pancreatie juice into tissues or suture lines must be prevented. (Verne
C. Hunt has reported successful implantation of the pancreas into the
end of the jejunum, and T. G. Orr has also had two successful cases.)

I have operated upon a case by a variant of these procedures which
seems to overcome the difficulties outlined above. A wide stoma is as-
sured by end-to-end cholecystojejunostomy; regurgitation into the biliary
tract is minimized by use of a long jejunal segment separating the biliary
from the gastric anastomosis. There are but two anastomoses, and
pancreatic digestion is rendered unlikely by adequate use of drainage.

CASE REPORT

History_H. V. J. (U. H. No. 715130), a man of 64, was admitted on the
medical service Dec. 18, 1941, with a one-year history of vague digestive distress
and a two-month history of gradually increasing painless jaundice with dark urine
and acholic stools. He had lost twenty pounds in the preceding three months and
over fifty pounds in the preceding two years. The remainder of the history was
irrelevant, except for a story of dyspnea on exertion.

Examination revealed nothing outside normal limits except for jaundice and
emaciation. The laboratory work showed hemoglobin 12 Gm. per 100 e.c. of blood.
Serum bilirubin was 14.1 mg. per cent. The urine was normal except for bile pig-
ments. Pulse was 60; blood pressure, 109/65; height, 74 inches; weight, 157 pounds
clothed. Quantitative examination of the stool for urobilinogen showed passage of
0.7 mg. daily, indicative of complete biliary obstruction and, therefore, carcinomatous
obstruction (Watson).

He was given a high vitamin, high protein diet including parenteral vitamin K
preoperatively. ,

Operation.—On Jan. 2, 1942, with a weight of 139 pounds, the patient was trans-
ferred to the surgical service and taken to the operating room. The operation was
started under cyclopropane, but the anesthetic was changed to ether and oxygen
shortly because of the development of auricular fibrillation. Through a long trans-
verse incision, one-third of the way from the umbilicus to the xyphoid, the abdomen
was opened. A vertical extension was made upward in the right rectus muscle later
in the procedure.

A small diserete tumor was found in the region of the head of the pancreas.
It was placed rather high (cephalad) in the head of the pancreas. There was no
evidence of spread of the tumor within the peritoneal cavity except for three small
irregularities on the surface of the liver. Inasmuch as these irregularities could not
be definitely considered to be carcinoma, and in any case did not seem to justify
abandonment of all operative procedure, it was decided that radical one-stage resec-
tion of the head of the pancreas and duodenum should be performed. The lower end
of the stomach was dissected free, and the pylorus was cut between clamps. The
lateral avascular ligament of the duodenum was cut down as far as the mesocolon
and the duodenum with the tumor attached to the internal margin was rotated
forward. Dissection was carried down to the uncinate portion of the head of the
pancreas, which was dissected free from the third portion of the duodenum. The

4
superior mesenteric artery and vein were identified and followed upward, and were
found to pass very close to the left lateral margin of the tumor. Nevertheless, it
was possible to cut across the head of the pancreas, sparing these vessels. The
main duct was tied with silk of five-pound test. The common bile duct was tied
with heavy silk and divided near the duodenum. The posterior capsule of the
pancreas was sutured to the anterior with mattress sutures of five-pound test silk.
At this point it became apparent that the circulation to the last part of the duodenum

Whipple & Parsons 1935 Whipple 1938 Moreland & Freeman
2 staqes 2 stages

    
   

    
   
    
 

 
    

  

COT

on +
2 antecolic

Hunt Brunschwig & Clark

retrocolic

retrocolic

Fig. 1.—Outline diagrams of several operative procedures which have been em-
ployed for extirpation of carcinoma of either the ampulla of Vater or of the head of
the pancreas.

and to the lowest third of the stomach was inadequate, and both were, therefore, re-
sected, the lines of section crossing the stomach in the midportion, and the jejunum
about eight inches below the ligament of Treitz. The gall bladder, which had been
found tensely distended, was emptied without spillage by trocar, the remaining end
of the jejunum was brought retrocolically through the channel formerly occupied by
the duodenum, and an end-to-end cholecystojejunostomy was performed by a closed
technique similar to that of Martzloff and Burget, with fine catgut internally
and silk mattress sutures externally, a few grains of sulfathiazole being placed
between the rows of sutures. Leaving a long (40 em.) proximal loop, and implanting

5
a few grains of sulfathiazole between rows of sutures, a retrocolic Polya gastro-
jejunostomy was performed much as described by Wangensteen. It had been planned
to do a Coffey type of anastomosis between the tail of the pancreas and the
jejunum below the gastrojejunostomy, but the patient’s condition was not satisfac-
tory, inasmuch as he had been having fibrillations for some time and the blood pres-
sure had fallen below 100 mm. Hg. A cigarette drain was brought down to the eut
end of the pancreas after all large vessels in the neighborhood and also the ligated
end of the common duct had been covered with omentum. The end of the rubber
drain was sutured anteriorly and posteriorly to the cut end of the pancreas in such
a fashion that any leakage from it would have to escape through the drain, and a
tunnel of omentum was made with catgut sutures to surround the drain to a stab
wound placed about 6 cm. below the midportion of the incision, a precaution to
prevent drainage from reaching the line of closure. Approximately one gram of
sulfathiazole was placed in the region of the cut surface of the pancreas. The in-
cision was closed with interrupted five-pound test silk, with implantation of a few
more grains of sulfathiazole. The patient received 1,500 c.c. of blood and 400 c.c. of
plasma during the seven-hour procedure, and left the operating room in fair condition.

Postoperative Cowrse.—Postoperatively the patient went into acidosis, and the
blood sugar rose to 230 mg. per cent, a result attributed to manipulation of the
pancreas. The daily administered 20 per cent dextrose solution (1,000 c.c. daily)
was, therefore, accompanied by 60 units of insulin per liter the first two days, follow-
ing which the insulin requirement rapidly disappeared. Immediately postoperatively
the patient was digitalized rapidly, but continued to have auricular fibrillation for
several days. On the third day bile stained fluid drained through the cigarette
drain, and this persisted for thirteen days, the daily volume diminishing gradually
from an original 200 ¢.c., and the bile content also decreasing. A small stitch abscess
occurred at fourteen days, but healing occurred quickly on drainage. The cigarette
drain was removed at fourteen days. A trial on pancreatic juice obtained from a
canine pancreatic fistula prior to dismissal resulted in nausea. He was therefore
placed on pancreatin* and polyvitamin capsules on dismissal twenty-one days after
operation.

Following dismissal the patient gained ten pounds in eight weeks, and
improved in general health and strength. On Mareh 28, he had begun
to lose weight and was observed to have bulky, fatty, foamy, strong
smelling stools. He also complained of nausea on ingestion of sweet
foods. For these reasons he was readmitted for study. A gastroin-
testinal roentgen study showed rapid emptying of the gastrie pouch
with no regurgitation of the contrast medium into the proximal jejunal
loop. There has been no evidence of cholangitis and no overt evidence
of recurrence at the present writing, three and one-half months post-
operatively, Preliminary studies indicate absorption of only 65 per
cent of ingested fat; further studies are being performed. The patient
has ceased losing weight at 129 pounds, following institution of a special
diet.t

CONCLUSION

An operative procedure for carcinoma of the head of the pancreas
has proved successful in one case. It encompasses excision, also, of

*Ehi Lilly and Company.

yAfter this paper had been submitted for publication, this patient returned with
recurrence in the line of incision. Roentgen therapy has been employed, but he is
losing ground rapidly at this time (June 24).

G
the lower half of the stomach and of the entire duodenum. To prevent
subsequent cholangitis, internal biliary drainage with a wide stoma
is accomplished by end-to-end cholecystojejunostomy, and regurgitation
into the biliary system is rendered minimal or absent (as shown by
roentgen study) by the use of a long loop between this anastomosis and
the posterior Polya gastroenterostomy.

Panereatic steatorrhea has followed exelusion of pancreatic secretion
from the intestinal tract. Because of this occurrence in this case and
in some cases reported elsewhere, consideration of reimplantion of the
pancreatic duct into the bowel in such cases is being entertained both
here and elsewhere.

ADDENDUM

After this paper had been prepared, an additional case of carcinoma of the head
of the pancreas in a man of 67 has been subjected to resection of the lesion. Diffi-
culties were encountered because of very low choledochocystic junction, which was
involved in the lesion, and because of arterial anomalies consisting of absence of
the celiac axis and origin of the hepatic artery from the superior mesenteric artery,
the anomalous hepatic artery traversing the head of the pancreas. Considerable
blood loss occurred following removal of the lesion, and large transfusions were
necessary before satisfactory repair had been accomplished to the anomalous hepatic
artery, the portal vein, the splenie vein, and an anomalous vessel springing from
the left gastric to the left lobe of the liver. The procedure was completed with
choledocho-enterostomy to the closed end of the jejunum brought through the meso-
colon and Polya gastroenterostomy after hemigastrectomy. The patient, however,
died shortly postoperatively. Autopsy showed a clean, dry operative field and
massive pulmonary edema. Further arterial anomalies were also present.

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. Brunschwig, A., and Clark, D. E.: Careinoma of the Intrahepatic Portion of
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3. Coffey, Robert C.: Pancreato-enterostomy and Pancreatectomy, Ann. Surg.

50: 1238, 1909.

4. Hunt, Verne C.: Surgical Management of Carcinoma of the Ampulla of Vater
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5. Kauseh, W.: Ueber Gallenweg-Darmverbindungen, Arch. f. klin. Chir. 47:
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7. Moreland, Randall B., and Freeman, Bromley S.: Two-Stage Resection of
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8. Trautmann, M., Robbins, H. J., and Stewart, C. C.: An Experimental Study
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9. Trimble, I. R., Parsons, J. W., and Sherman, C. P.: A One-stage Operation for
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nN
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Orr, T. G.: Personal Communication to Owen H. Wangensteen.