Evolution of the Whipple procedure at the Massachusetts General Hospital

Abstract

Background: Since Allen O. Whipple published his seminal paper in 1935, the procedure that bears his name has been performed widely throughout the world and is now a common operation in major medical centers. The goal of this study was to investigate the evolution of pancreatoduodenectomy at the Massachusetts General Hospital (MGH).

Methods: We sought to identify all pancreatoduodenectomies performed at the MGH since 1935. Cases were obtained from a computerized database, hospital medical records, and the MGH historical archive. Demographics, diagnosis, intraoperative variables and short-term surgical outcomes were recorded.

Results: The first pancreatoduodenectomy at the MGH was carried out in 1941; since then, 2,050 Whipple procedures have been performed. Pancreatic ductal adenocarcinoma was the most frequent indication (36%). Pylorus preservation has been the most important variation in technique, accounting for 45% of Whipple procedures in the 1980s; observation of frequent delayed gastric emptying after this procedure led to decline in its use. Pancreatic fistula was the most frequent complication (13%). Operative blood replacement and reoperation rates have decreased markedly over time; the most frequent indication for reoperation was intra-abdominal bleeding. Mortality has decreased from 45% to 0.8%, with sepsis and hypovolemic shock being the most frequent causes of death. Mean duration of hospital stay has decreased from >30 to 9.5 days, along with an increasing readmission rate (currently 19%).

Conclusion: The Whipple procedure in the 21st century is a well-established operation. Improvements in operative technique and perioperative care have contributed in making it a safe operation that continues evolving.

Fig 1

Whipple procedures performed at the Massachusetts General Hospital between 1941 and 2011.

Fig 2

Indications for Whipple procedure (1941–2011). PDAC, Pancreatic ductal adenocarcinoma.

Fig 3

Operative reconstruction involved in the Whipple procedure. Drawn in a chart by house officer J.R. Newstedt, MD, in 1947.

Fig 4

Correlation between the proportion of pylorus-preserving Whipple procedures and the incidence of delayed gastric emptying as a complication.

Fig 5

Intraoperative variables and reoperation rates in 2,050 Whipple procedures. (A) Proportion of patients requiring intraoperative blood replacement. (B) Mean operative time for a Whipple procedure. (C) Operative mortality. (D) Reoperation rates.

Fig 6

Short-term surgical outcomes. (A) Mean duration of hospital stay over time. (B) Readmissions rate for operative complications.