Purpose: Current literature supports centralization of the Whipple procedure. Centralization assumes that high volume correlates with good outcomes. We believe training, preparation, technique and postoperative care leads to superior outcomes. We are a low to moderate volume Whipple service with results similar to high volume centers.
Methods: A retrospective review of patients undergoing Whipple from 1/03-8/06 was performed. Data of demographics, pathology, operative details, and complications were collected. The hospital is a 600 bed tertiary center. Workup included combinations of computed tomography, ultrasound, endoscopic retrograde cholangiopancreatography, endoscopic ultrasound and laparoscopic staging.
Results: 37 patients underwent Whipple. Average age was 58 years (27-80) with 18 females and 19 males. American Society of Anesthesiologist score averaged 3 (1-4). Indications were for malignancies (22) and benign processes (15). Pathology demonstrated 21 malignancies, 5 benign tumors and 11 chronic pancreatitis specimens. The portal vein was resected in 6 cases. The pylorus was spared in 30 cases. The microscope was used for the pancreaticojejunal anastomosis in 12 cases. The gastrointestinal anastomosis was antecolic in 19 and retrocolic in 18 cases. Operative time averaged 8:14 (5:04-13:04). Blood loss averaged 505cc (200-1800). Average hospital stay was 15 days (8-32). Perioperative mortality was 0%. 18 (48.6%) patients had no perioperative complications. Complications were: 10 (27%) delayed gastric emptying (DGE); 6 (16.2%) wound infection (WI); 5 (13.5%) fistula; 3 (8.1%) deep venous thromobosis (DVT); 3 (8.1%) arrhythmia; 1 (2.7%) dehiscence; 1 (2.7%) reoperation for suspected leak, no leak found; 1 (2.7%) line sepsis. DGE was managed with time and medication. WI were managed with drainage and wound care. The four grade A fistulas healed without issue. The one patient with grade B fistula required readmission, antibiotics and healed 4 weeks after discharge. DVT were treated with anticoagulation. All arrhythmias were known cardiac patients controlled medically. The patient with dehiscence was repaired with mesh and recovered well. The patient with negative exploration recovered without issue. Line sepsis was treated with catheter removal and antibiotics.
Conclusions: A low volume center can provide care for patients requiring Whipple just as well as high volume centers. Our results suggest that centralization is not the sole determinant for good surgical outcomes. We believe that adherence to sound surgical principles to evaluate, diagnose, plan, operate and postoperative follow up are the key determinants of superior results.