Whipple procedure can remove early pancreatic cancers

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Some patients with early stage pancreatic cancers may undergo an operation that can remove the cancer. It's a challenging surgery, and here to tell us about it is Dr. Mashaal Dhir. He's an associate professor of surgery at Upstate and section chief of hepatobiliary and pancreatic surgery. Welcome back to "The Informed Patient," Dr. Dhir.

[00:00:37] Mashaal Dhir, MD: Thank you for having me.

[00:00:38] Host Amber Smith: I understand that you now have robotic assistance for a major surgical procedure nicknamed the Whipple procedure. What is this procedure for?

[00:00:49] Mashaal Dhir, MD: This procedure is named after the surgeon Allen Oldfather Whipple. It's basically removing the head of the pancreas and first part of the intestine called duodenum, and bile duct. It's mainly for cancers arising within the head of the pancreas, the lower part of the bile duct, or first part of the intestine called duodenum.

So, of course, the trick is knowing that there's a cancer there, right? It's difficult to find these cancers when they're small.

Yes.

[00:01:24] Host Amber Smith: But once you do identify it, this Whipple procedure, tell me a little about how it's done because you've named, I think, three organs or structures, but sometimes it involves even more, right?

[00:01:36] Mashaal Dhir, MD: Yeah, traditionally these organs, but sometimes we have to do some work around the blood vessels, reconstruct the blood vessels, which go in this territory. And gallbladder, if present, is also a part of this procedure.

A lot of patients, when they develop a tumor in this area, present with what we say jaundice. You know, they turn yellow because the tumors often block the liver duct, the bile duct. And that's how they come to attention. Some patients cane develop obstruction of their GI (gastrointestinal) tract if the tumor starts obstructing the duodenum. Others may have vague symptoms, for example, unexplained weight loss, some abdominal pain. But jaundice and bowel obstruction are two most common modes of presentation.

[00:02:33] Host Amber Smith: So, for the traditional open surgery, the open Whipple procedure, how long does that typically take?

[00:02:40] Mashaal Dhir, MD: For the traditional open, it can take from 6 to 8 hours in general, but can vary based on certain factors, how difficult it is to remove the tumor, if you have to do additional work on the blood vessels, and other factors.

[00:02:58] Host Amber Smith: And are there risks during the surgery and after the surgery?

[00:03:03] Mashaal Dhir, MD: Yes. It is one of the most challenging procedures that we do because pancreas is in general wrapped around two major blood vessels, SMA (superior mesenteric artery) and SMV, (superior mesenteric vein.) That's why we encourage patients to have surgery in high volume centers, and Upstate is one of the high volume centers. That means we do this a lot. We do it well. And we monitor our outcomes.

The risk in general, as with any major abdominal surgery, a risk of infection, a risk of bleeding. But two particular risks which we talk to patients about are the risks of pancreas leak, where you connect the pancreas to the bowel, and "sleepy stomach." That means the stomach just doesn't pump very well, which is in general a temporary problem and goes away in four to six weeks.

[00:03:54] Host Amber Smith: But if all things go well, you can cure an early pancreatic cancer, right?

[00:04:00] Mashaal Dhir, MD: Yes, that is the potential of this procedure.

We use the term potentially curative. That means that is the intent, but it remains to be determined, and that's why we have to do the surveillance, keep an eye on our patients. We check scans every three months for the first three years, and every six months from years three to five.

[00:04:21] Host Amber Smith: Is recovery, did you say, six to eight weeks? I'm curious about the recovery for the patient. How long does that take?

[00:04:28] Mashaal Dhir, MD: Yes, in general, I would say patients, everyone is variable based on their strength, how strong they are, but in general, patients spend a week in the hospital. Full recovery takes six to eight weeks, but sometimes up to 12 weeks. Depends on if there are any setbacks along the way, how quickly the patients bounce back from the surgery.

[00:04:51] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with surgeon Mashaal Dhir, who's the section chief of hepatobiliary and pancreatic surgery at Upstate. And we're talking about the Whipple procedure, which is used to treat cancers of the pancreas.

What is the overall success rate for being able to remove the cancer?

[00:05:15] Mashaal Dhir, MD: The technical success rate is pretty high nowadays with the good quality CT(computerized tomography imaging) scans. Even before going to the operating room, we know that the likelihood of success would be more than 80 to 90 percent.

In general, in 10 to 20 percent of the cases, we might find unexpected findings. For example, spread of the disease to outside the pancreas or liver, small lesions or masses may not show up on the imaging. Other times, some unexpected findings may be seen at the time of the surgery, but we try our best to avoid a non curative operation, but sometimes that is inherent to what we do.

[00:06:01] Host Amber Smith: Well, let me ask you if you would please to compare the open Whipple procedure with what's being done now using a robot. How does that work?

[00:06:12] Mashaal Dhir, MD: With the open surgery, we work through a large midline incision. But for the robot, we usually make four or five small quarter-sized incisions on the belly and one near the belly button. And once we are done with removing this head of the pancreas and first part of intestine, we put it in a bag and then just slightly enlarge the incision near the belly button, maybe a few, maybe a couple of inches to get the specimen out, and then put the pancreas, bile duct, and stomach back together.

[00:06:48] Host Amber Smith: How long does this take, compared with open (which) I think you said could be six to eight hours, right?

[00:06:53] Mashaal Dhir, MD: Yes, and through small incisions, it could even be longer. Because we have to work under magnification. It's more methodical in a way that we have to make finer movements because we are in a limited space. We have to blow up the belly with the gas, create the space, and work around the blood vessels. So, in general, it takes in our practice about 8 to 12 hours, depending on how extensive the disease is and how easy it is to dissect the tissues.

[00:07:27] Host Amber Smith: So this is a procedure that's one of the most challenging to begin with, but it sounds like it may even be more challenging doing it robotically. Why would you want to do it robotically? What are the benefits?

[00:07:40] Mashaal Dhir, MD: I think it is worth it for the patients. Patients value quicker recovery. If they have smaller incisions, they experience less pain. And I would say patients bounce back quickly. However everybody is different, and the studies haven't shown significant advantage in terms of the survival, but a lot of studies do show that patients start treatments for chemotherapy faster. They do recover faster. So I think there is value to it, not having a big incision and quicker recovery.

[00:08:21] Host Amber Smith: Which patients would be candidates for the robotic procedure?

[00:08:26] Mashaal Dhir, MD: The patients have to have smaller tumors, away from the blood vessels because when we are working on the blood vessels, it's good to be there with your hands in terms of controlling the blood supply as there's potential for bleeding. So smaller tumors around the junction of the bile duct and the pancreatic duct are good for the robotic procedures, tumors which are away from blood vessels. So that's where we are offering robotic surgery in our practice.

[00:09:00] Host Amber Smith: Do patients make the decision if they want open or robotic, or is that something that you tell them what will work?

[00:09:08] Mashaal Dhir, MD: I think it's a collaborative decision, ultimately. We discuss both with the patients, if they are candidates, and I think it is unusual for patients to choose open over robotic. But yeah, most of the times we offer this open based on the challenges posed by the tumor itself. But for patients who are candidates, they are readily agreeable to getting this done robotically.

[00:09:38] Host Amber Smith: Dr. Dhir, thank you so much for making time to tell us about the robotic Whipple procedure.

[00:09:45] Mashaal Dhir, MD: My pleasure. Thank you so much for having me.

[00:09:48] Host Amber Smith: My guest has been Dr. Mashaal Dhir, an associate professor of surgery at Upstate and section chief of hepatobiliary and pancreatic surgery. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.