Pancreatic tumors are the most common periampullary tumors. In advanced-stage patients with extremely poor prognosis and inoperable patients, the mean survival is between 6 and 12 months [1]. In patients with resection, the 5-year average survival rate is reported to be 10-30% [2].

The only curative treatment of pancreatic tumors was the Whipple's operation and was first described in 1935 [3]. Whipple's operation is a very complex operation, with a mortality rate of 1-5%, regardless of the disease [4].

The aim of this retrospective study is to evaluate patients who underwent a standard Whipple's operation for a pancreatic tumor.

Patients

In this study, twenty patients who underwent a Whipple's operation for a pancreatic tumor in the Hepatopancreatobiliary Surgery Department of Istanbul Medipol University Medical Faculty Hospital between March 2015 and March 2018 were retrospectively analyzed. The demographic characteristics, clinical characteristics, surgical results and disease stages of these patients were evaluated using age, gender, liver function tests (alanine aminotransferase, aspartate aminotransferase, bilirubin and gamma-glutamyl transferase) among the factors that may affect mortality.

The technical content of the research protocol was reviewed and approved by the ethical committee of the Istanbul Medipol University (Ethical Committee Approved Number: 10840098-772.02) and the protocols were performed in accordance with the Declaration of Helsinki.

Statistical Analysis

SPSS 22.0 (SPSS for Windows, 2007, Chicago) was used for statistical analysis. Normally distributed continuous variables were given as mean ± Standard deviation. Statistical analysis for parametric variables was performed by Student's T-test. Qualitative variables were given as percentages and the correlation between categorical variables was investigated using the chi-square test and Fisher's exact test. Statistical significance level was defined as p 0.05.

The mean age of the patients was 61.6±12.5 years. Twelve (60%) of these patients were male and 8 (40%) were female. Twelve (60%) of the patients were early stage (Stage1-2), 8 (40%) were advanced (Stage 3-4). Standard Whipple's operation was performed for all patients. Postoperatively, 2 (10%) patients had spontaneous regression of pancreatic fistula, 1 (5%) patient had bleeding from jejunogenostomy anastomosis controlled with relaparotomy + anastomosis revision, 1 (5%) patient had bleeding from the gastroduodenal artery controlled by relaparotomy + hemostasis and 1 (5%). 5%), leakage was detected from the gastrojejunostomy anastomosis controlled by relaparotomy + anastomosis revision.

Table 1 shows the demographic-clinical characteristics and surgical results of patients who underwent Whipple's operation for pancreatic tumors.

The mean follow-up time was 10.8±10.3 (1-36) months. During the follow-up period, the overall mortality rate was 40%. Age, gender and liver function tests (alanine aminotransferase, aspartate aminotransferase, bilirubin and gamma-glutamyl transferase) were not found to be associated with mortality, among the factors that may increase the risk for mortality. It was found that only the disease stage was associated with mortality and mortality was more common in advanced-stage patients.

Table 2 shows the risk factors for postoperative mortality are compared. 

Figure 1 shows the effect of stage on cumulative overall survival.

Pancreatic tumors are the most common of all periampullary tumors and have the worst prognosis [5]. The most common pathological type is pancreatic ductal adenocarcinoma [6]. Predisposing factors for the development of pancreatic cancer include advanced age, obesity, smoking, alcohol use, diabetes mellitus and previous chronic pancreatitis [7].

Table 1: Demographic and Clinical Characteristics of the Patients

Table 2: Comparison of Risk Factors for Post-Surgical Mortality

ALT: Alanine Aminotransferase, AST: Aspartate Aminotransferase, GGT: Gamma Glutamyl Transferase

Figure 1: Effect of Stage on Cumulative Overall Survival

The only curative treatment option in its treatment is Whipple's operation and it is combined with neoadjuvant and adjuvant chemo-radiotherapy [8].

Whipple's operation was first described in 1935 and its modified form of pylorus-sparing Whipple's operation was described in 1944 [3,9]. Whipple's operation, which has been performed as open surgery for many years, can now be performed by laparoscopic technique [10,11]. In our study, standard Whipple's operation with the open surgical technique was performed for a pancreatic tumor in 20 patients.

Whipple's operation is an extremely complex surgery. Complications and mortality due to surgery are common. The most common complication after Whipple's operation is a pancreatic fistula, with a reported incidence of 2–30% [12]. Other common complications are leaks from other anastomoses, bleeding and infection [13,14].

In our study, the postoperative complication rate was 25%. Spontaneously regressing pancreatic fistula in 2 (10%) patients, bleeding from jejunogenostomy anastomosis controlled with relaparotomy + anastomosis revision in 1 (5%) patient, bleeding from the gastroduodenal artery controlled by relaparotomy + hemostasis in 1 (5%) patient and 1 (5%)), leakage was detected from the gastrojejunostomy anastomosis controlled by relaparotomy + anastomosis revision.

Despite all technical improvements, the operative mortality rate is between 1 and 5% on average [4]. In our study, no perioperative mortality due to Whipple's operation was observed.

Predisposing factors that increase postoperative mortality of patients include advanced age (over 65 years of age), male gender, advanced stage of the tumor and the presence of additional diseases (liver, kidney, heart) [15,16]. In our study, age, gender and liver function tests (alanine aminotransferase, aspartate aminotransferase, bilirubin and gamma-glutamyl transferase) were not found to be associated with mortality. It was found that only the disease stage was associated with mortality and the mortality rate was higher in patients with advanced-stage tumors. The 5-year average survival rate in patients with resection is reported to be between 10 and 30% [2].

The mean follow-up time in our study was 10.8±10.3 (1-36) months. During the follow-up period, the overall mortality rate was 40% (8 patients).

There are some limitations in our study. These are retrospective studies and a small number of cases.

In conclusion, mortality was more common among patients who underwent Whipple's operation for pancreatic tumors, especially those with advanced-stage tumors. Despite the limitations stated in the discussion section, we think that attention should be paid especially in terms of mortality in this patient group.

Informed Consent

Written informed consent was obtained from the patients who participated in this study.

Conflict of Interest

The authors have no conflict of interest to declare.

Funding

The authors declared that this study has received no financial support.

Author Contributions

Gokhan Ertugrul and Mahmut Zenciroglu: Concept; Gokhan Ertugrul and Mahmut Zenciroglu: Design; Gokhan Ertugrul and Mahmut Zenciroglu: Supervision; Gokhan Ertugrul, Mahmut Zenciroglu and Atıf Tekin: Resource; Gokhan Ertugrul, Mahmut Zenciroglu and Atıf Tekin: Materials; Gokhan Ertugrul, Mahmut Zenciroglu and Atıf Tekin: Data Collection and/or Processing; Gokhan Ertugrul, Mahmut Zenciroglu and Hande Gungor: Analysis and/or Interpretation; Literature Search; Gokhan Ertugrul: Writing; Gokhan Ertugrul, Mahmut Zenciroglu, Atıf Tekin and Hande Gungor : Critical Reviews.

Ethical Approval

Ethics committee approval was received for this study from the Istanbul Medipol University Hospital (Decision date: 27.01.2021). 

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