Melissa Maskal

An Overview of the Whipple Procedure and the Associated Nutritional Implications

I. Diagnosis

The Whipple Procedure, otherwise known as a pancreaticoduodenectomy, have been carried out
by surgeons around the world since the 1930s. This complex surgery removes the head of the
pancreas, gallbladder, common bile duct, duodenum, pylorus, and surrounding lymph nodes. A
once very dangerous surgical procedure that yielded a mortality rate of as high as twenty-five
percent, the Whipple Procedure is now the most commonly performed surgical treatment to
remove pancreatic tumors with a mortality rate of less than 5 percent (University of Southern
California, 2002). Other indications for this procedure include the removal of tumors in the
duodenum or lower part of the bile duct and as a treatment option for some cases of chronic
pancreatitis. Symptoms of pancreatic cancer include unintended weight loss, abdominal pain, and
jaundice (Livstone, 2017). Symptoms of chronic pancreatitis include abdominal pain and
pancreatic insufficiency. Pancreatic insufficiency often presents as symptoms related to
malabsorption, including flatulence, a bloated abdomen, steatorrhea, weight loss, and generalized
fatigue (Bansal, 2017).

The gastrointestinal tract is comprised of many organs that act in accordance with one another in
an effort to properly digest and absorb nutrients found in food. It is important to understand the
roles of the gastrointestinal organs that are interrupted with a Whipple Procedure. The pancreas
dually functions as both an endocrine and exocrine organ. The pancreas’ endocrine role includes
monitoring blood glucose levels through the production of both insulin and glucagon. The
pancreas additionally has exocrine roles, as it is a producer of digestive enzymes such as lipase.
The gallbladder is the storage site for bile, a secretory product that emulsifies fats. The
gallbladder receives this bile from the liver via the common bile duct. The small intestine,
including the duodenum, is the main site of nutrient absorption in the body.

II. Surgical Procedure

The ultimate goal of a Whipple Procedure would be to prolong life expectancy in the case of
abnormal growths or treatment of chronic pancreatitis. Cancer treatments such as chemotherapy
or radiation therapy often precede or
follow the procedure. The Whipple
Procedure can be conducted with the
assistance of laparoscopic or robotic
technology, but is more commonly
performed as a traditional surgery
with an abdominal incision. In a
traditional Whipple Procedure, the
pancreatic head, gallbladder, common
bile duct, duodenum, and pylorus are
removed. After these organs are
removed, the pancreatic tail and other
digestive organs are connected to the small intestine to allow for proper digestion and absorption.
There is a variation of a traditional Whipple Procedure called a pylorus-preserving Whipple
procedure that leaves the pylorus intact (University of Southern California, 2002). One study
reported no differences in quality of life, loss of appetite, nausea and vomiting, newly-diagnosed
diabetes, or pancreatic insufficiency between the two surgical variations; however, the study did
report that the pylorus-preserving variant resulted in better outcomes in terms of gastric
emptying and earlier removal of the nasogastric tube (Niedergethmann et al. 2006). The surgery
generally takes between five and eight hours to complete. It is a procedure that requires
postoperative hospitalization lasting about one week, but can increase in time if any
complications arise.

III. Nutritional Implications

The Whipple Procedure has complex nutritional implications that must be properly treated to
prevent nutrient deficiencies and unpleasant eating experiences. The most common complication
of this procedure is delayed gastric emptying, occurring in up to 35.5% of patients (Lytral et al.,
2006). Symptoms to monitor include nausea, vomiting, bloating, early satiety and abdominal
pain (Marcason, 2015). Although delayed gastric emptying is not a life-threatening complication,
it prolongs hospitalization and increases the prevalence of postoperative morbidity and mortality,
resulting in increased healthcare costs. In order to avoid gastric peristalsis disturbances, it is
crucial that the surgeons preserve the duodenal pacemaker, which is located about one centimeter
from the pylorus. Delayed gastric emptying can be managed pharmaceutically with the initiation
of promotility agents such as motilin or metoclopramide; the use of erythromycin, and Cisapride
are being investigated. Enteral nutrition should also be carefully considered before initiation, as
enteral nutrition is a predisposing factor for the development of delayed gastric emptying (Lytras,
2006).

It is no surprise that absorption is altered postoperatively, leading to malnutrition and weight

loss. One study reported a weight loss of eight to ten percent of preoperative weight (Carey et al.
2013). Another study determined that the patients reached their preoperative weight after four to
six months (Niedergethmann et al. 2006). This weight loss may be due to altered eating habits
prior to and immediately after surgery. The removal of the duodenum results in the loss of a great
deal of absorptive surface area, causing diminished absorptive capabilities. The chyme that
enters the stomach to aid in digestion is often altered because of the pancreatic insufficiency. The
doctor should monitor and evaluate the patient to determine if the patient needs pancreatic
enzyme replacement therapy; one study determined that 55-63% of patients required pancreatic
enzymes in the long-term (Pappas et al., 2010). Exogenous lipase such as Creon can be
prescribed and taken with each meal to aid in the digestion of fats and to prevent malabsorption
symptoms such as steatorrhea. The most common nutritional deficiencies that occur secondary to
a pancreaticoduodenectomy include the fat-soluble vitamins (A, D, E, and K), Vitamin B12, iron,
calcium, zinc, copper, and selenium (Armstrong et al., 2007) These micronutrients should be
monitored and supplemented as needed to prevent any clinical manifestations of deficiencies. A
multivitamin and mineral supplement is frequently recommended to all patients after a Whipple
Procedure is performed. If lactose intolerance is suspected, patients are advised to avoid foods
containing lactose.
Because of the pancreas’ role in the endocrine regulation of blood glucose levels, patients are at
an increased risk for hyperglycemia and diabetes. Following surgery, there is a decreased insulin
production, resulting in a new diagnosis of diabetes in twenty to fifty percent of patients
(Marcason, 2015). The diabetes may be temporal or permanent, but it is still crucial to educate
patients on the signs and symptoms of both hyperglycemia and hypoglycemia and evaluate the
need for nutrition education.

The role of the RDN after a pancreaticoduodenectomy is to provide appropriate medical nutrition
therapy to the patient to manage and prevent gastrointestinal and nutritional complications. The
RDN should advise the patient to consume small, frequent meals consisting of a moderate fat
restriction of less than thirty percent of kilocalories from fat. This aids with problems of early
satiety and fat intolerance. Additionally, the patient should be advised to consume a maximum of
five ounces of fluid at meals and to avoid fluids forty minutes after a meal. A multivitamin
supplement should be encouraged to prevent and treat any subclinical micronutrient deficiencies.
The patient should avoid simple sugars to prevent dumping syndrome and lactose-containing
products if they are lactose intolerant. Lastly, the RDN should encourage the patient to consume
protein at every meal (Academy of Nutrition and Dietetics, 2017).

IV. Prognosis

In terms of pancreatic cancer, the life expectancy postoperatively is around twenty percent when
the cancer has metastasized to the surrounding lymph nodes. For those who do not have
metastasis, the five-year survival rate is forty percent. A pancreaticoduodenectomy is curative in
cases of benign neoplasms or low-grade pancreatic cancers (University of Southern California,
2002).

References

Armstrong, T., Strommer, L., Ruiz-Jasbon, F., Shek, F., Harris, S., Permert, J., & Johnson, C.

(2007). Pancreaticoduodenectomy for peri-ampullary neoplasia leads to specific

micronutrient deficiencies. Pancreatology, 7(1), 37-44. Available at:

http://ezproxy.montclair.edu:2048/login?url=https://search-proquest-

com.ezproxy.montclair.edu/docview/222779433?accountid=12536

Bansal, R. (2017). Chronic Pancreatitis. [online] The Merck Manual. Available at:

http://www.merckmanuals.com/professional/gastrointestinal-

disorders/pancreatitis/chronic-pancreatitis [Accessed 20 Nov. 2017].

Livstone, E. (2017). Pancreatic Cancer. [online] The Merck Manual. Available at:

http://www.merckmanuals.com/professional/gastrointestinal-disorders/tumors-of-the-gi-

tract/pancreatic-cancer [Accessed 20 Nov. 2017].

Lytras, D., Paraskevas, K., Avgerinos, C., Manes, C., Touloumis, Z., Paraskeva, K. and

Dervenis, C. (2006). Therapeutic strategies for the management of delayed gastric

emptying after pancreatic resection. Langenbeck's Archives of Surgery, 392(1), pp.1-12.

Marcason, W. (2015). What Is the Whipple Procedure and What Is the Appropriate Nutrition

Therapy for It?. Journal of the Academy of Nutrition and Dietetics, 115(1), p.168.

Nutritioncaremanual.org. (2017). Whipple Surgery Nutrition Therapy. [online] Available at:

https://www.nutritioncaremanual.org/client_ed.cfm?ncm_client_ed_id=354 [Accessed 14

Nov. 2017].

Pappas, S., Krzywda, E. and Mcdowell, N. (2010). Nutrition and

Pancreaticoduodenectomy. Nutrition in Clinical Practice, 25(3), pp.234-243.

University of Southern California (2002). Whipple operation/surgery. [online] Available at:

http://www.surgery.usc.edu/divisions/tumor/pancreasdiseases/web

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