Whipple Procedure: A case report

Kalpana1, Mercy Ezhil Rani2

1OT staff nurse, Kauvery Hospital, Hosur, India

2Clinical Educator, Kauvery Hospital, Hosur, India

Abstract

The Whipple procedure is an operation to treat tumours and other conditions in the pancreas, small intestine and bile ducts. It involves removing the head of the pancreas, the first part of the small intestine, the gallbladder and the bile duct. The Whipple procedure is also called a pancreaticoduodenectomy. It is often used to treat pancreatic cancer that has not spread beyond the pancreas. The Whipple procedure is a complex operation. It can have serious risks. However, this surgery often saves lives

Indications

The Whipple procedure is a complex surgery that can be used to treat a variety of conditions, including:

  • Pancreatic cancer
  • Bile duct cancer
  • Small intestine cancer
  • Neuroendocrine cancer
  • Cancer of the ampulla of Vater
  • Pancreatic cysts
  • Pancreatitis
  • Trauma to the pancreas or small intestine

Case Presentation

The 64 years male patient admitted with the complaints of abdominal pain, yellowish discoloration of urine, jaundice, polydipsia. Patient was known case of type 2 diabetes mellitus, hypertension, old CVA, hypothyroidism, HbsAg positive for past 6 years.

He was diagnosed to have Periampullary carcinoma. On examination, Patient conscious and oriented, afebrile. Vitals were recorded. BP: 110/70mmHg; PR: 86 beats per minute; RR: 20 breaths per minute; SpO2: 98%; Temp: 98 F; CVS: S1S2 (+); P/A: soft. Non tender (+).

Investigations

InvestigationResults
Hb11.6 g/dl
Total count8980 cells/cum
Platelet266000 lakhs/cum
Na+130mmol/L
K+4.6 mmol/L
Urea17.0 mg/dl
Creatinine0.5 mg/dl
INR1.01
Total bilirubin0.5 mg/dl
SGOT29U/L
SGPT25U/L
TSH0.9916
HbA1C7.8 %
Blood groupO +ve

USG abdomen showed a soft tissue density lesion noted in periampullary region. A large vesicle calculus, diffuse bladder wall thickening. Therefore, Endoscopic Retrograde Cholangiopancreatography and stenting was done and biopsy taken from the lesion. Biopsy showed Choledocholithiasis and Periampullary lesion. Histopathological examination reported as Adenocarcinoma.

Treatment Process

The Whipple procedure done under General anesthesia and epidural anesthesia. 3 units of PRBC and 4 units of FFP transfused. Procedure completed successfully. Sterile dressing was applied. Drains and tubes are secured.

Intra OP findings showed proliferative growth of 2*1 cm present in ampullary region., Multiple nodes present along common hepatic artery and hepatoduodenal ligament, Inflammatory reaction present in common bile duct, common bile duct dilated and filled with sludge. Stent migrated into duodenum

Post operatively patient shifted to ICU and extubated. Respiratory exercises, chest and limb physiotherapy given. Feeding Jejunostomy started. Patient was managed with IV antibiotics, IV fluid and analgesics. Right side drain output was bloody around 100ml and no drop in Hb. Drain amylase level was in acceptable limit. Patient had persistent tachycardia and managed with beta blockers.

Patient shifted to ward. Ryles tube was removed and started on oral feeds. Patient tolerated oral feeds. Drains output was decreased. Left drain was removed. Right drain was cut to short level and stoma bag was applied. Patient discharged in good condition with FJ tube and right stoma bag in situ.

Nursing management

  • Diabetes: Advised the patient to regular monitoring of blood glucose level.
  • Nutritional Follow-Up: High Protein diet, High fibre diet
  • Quality of Life: Long-term care should also focus on improving the patient’s quality of life, addressing issues such as pain, fatigue, and the ability to resume normal activities.
  • Cancer Surveillance: For regular follow-up appointments, imaging, and lab tests (e.g., CA19-9) are necessary to detect recurrence.
  • Physiotherapy: Chest and limb exercise. Spirometry.
  • Advised regarding the Care of tubes and stoma care.
  • Stoma care: Educated to the patient how to manage the stoma, handle emergencies (like stoma pouch leakage or dislodgement), and how to handle common complications (such as infection or skin irritation). Watch for signs of infection around the tube site, such as redness, swelling, or pus.
  • Emotional and Psychological Support: Provided emotional support and counselling to the patient and their family members. It can help them to cope with the changes to their body image and lifestyle.

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