International Journal of Surgery 52 (2018) 383–387

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International Journal of Surgery

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Original Research

The outcomes and complications of pancreaticoduodenectomy (Whipple T

procedure): Cross sectional study
Sherko Abdullah Molah Karima,∗, Karzan Seerwan Abdullab, Qalandar Hussein Abdulkarima,
Fattah Hama Rahimc
a
Department of Digestive Surgery, Kurdistan Center for Gastroenterology & Hepatology, Sulaimanyah Governorate, Kurdistan Region, Iraq
b
Department of Surgery, Lecturer in School of Medicine, Faculty of Medical Science, University of Sulaimani, Kurdistan Region, Iraq
c
Department of Community Medicine, Lecturer in School of Medicine, Faculty of Medical Science, University of Sulaimani, Manager of Health Awareness and Education
Center, Sulaimanyah, Iraq

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Pancreaticoduodenectomy (PD) is one of the most difficult and complex surgery that carries a high
Outcomes rate of major complications, including delayed gastric emptying (DGE), pancreatic fistula, bleeding, intra-ab-
Complications dominal collection, and pulmonary complications. In this study, we have tried to demonstrate the outcomes, and
Pancreaticoduodenectomy rates of complications from patients who had undergone this procedure by our surgical team.
Whipple procedure
Materials and Methods: This retrospective study has been constructed on 98 patients who underwent pancrea-
ticoduodenectomy from May 2010 to November 2017 in three different hospitals of the Sulaimanyah gover-
norate in the Kurdistan region of Iraq by the same surgical team. Data was collected from the medical records of
patients. A preoperative work up had done for all patients, including those who are necessary for anesthesia
fitness and those for staging assessment. None of the operated patients received any types of neoadjuvant
therapy.
Result: Out of all 98 patients who underwent PD, the most common complication was wound infection (23.5%),
followed by pancreatic leak (21.4%). The pulmonary complication rate was 17.3%, while the intra-abdominal
collection rate was 12.2%. In 12.2% of our patients we faced postoperative bleeding, with five patients having to
be reopened for this reason. About 77.3% of patients that underwent preoperative ERCP had difficult bile duct
dissection. There was an association between preoperative ERCP and difficult bile duct dissection (P
Value < 0.001).
Conclusion: Outcomes of our surgical team compared to the published data of some other centers. Preoperative
ERCP seems to make difficulty in bile duct dissection during PD.

1. Introduction progress of surgical techniques and improvements in perioperative and

Pancreaticoduodenectomy (PD) is a complex surgery, commonly
performed for malignant tumors of pancreatic head, ampulla, distal bile
duct, and may be performed for benign tumors, and trauma of pan-
creatic head and duodenum, while rarely perform for chronic pan-
creatitis [1,2]. This procedure is associated with significant post-
operative morbidity, rates of which range from 30% to 60% [3–6].
Major postoperative complications from this procedure include: pan-
creatic leak or fistula, intra-abdominal abscess, bile leak, postoperative
hemorrhage requiring blood transfusion or reopening, delayed gastric
emptying, and complications related to the surgical site:- such as in-
fection and wound dehiscence [3,7]. With moves forward and the
critical cares, the mortality and morbidity rates have fallen [4]. Un-
fortunately, in the Kurdistan region and Iraq there is limited statistical
data published internationally regarding the complications rates of PD.
The studies are usually based on the knowledge of other centers of
western countries, where there is a substantial difference between our
center and western centers with respect to perioperative care, which
may affect the complications rate and their management. Our surgical
team was doing pancreaticoduodenectomies for a long period and it is
necessary to find the outcomes of this procedure in our patients.
However, there is no published data by our team regarding this subject.
The purpose of this article is to estimate the rates of major complica-
tions from PDs that had been done by our surgical team, as well as,

∗
Corresponding author.
E-mail addresses: sherkoabdullah@yahoo.com (S.A.M. Karim), karzans1977@yahoo.com (K.S. Abdulla), qalandaar@gmail.com (Q.H. Abdulkarim),
fattah.fattah@univsul.edu.iq (F.H. Rahim).

https://doi.org/10.1016/j.ijsu.2018.01.041
Received 28 November 2017; Received in revised form 15 January 2018; Accepted 27 January 2018
Available online 10 February 2018
1743-9191/ © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
S.A.M. Karim et al. International Journal of Surgery 52 (2018) 383–387

comparing the outcomes with other western literatures in spite of the

significant differences of perioperative and critical care management. In
addition, we explain some of our impressions of this issue.

2. Materials and Methods

This work has been reported in line with the STROCSS criteria [8].
This retrospective study has been performed on 98 patients who un-
derwent a classic Whipple pancreaticoduodenectomy or pylorus pre-
serving pancreaticoduodenectomy (PPPD) for both benign and malig-
nant tumors by the same surgical team in three different hospitals in the
Sulaimanyah governorate in Iraq, from May 2010 to November 2017.

2.1. Data collection

Patients' data were collected using patients' records focusing on

demographic characteristics, intraoperative findings and postoperative
complications. The impress of the surgical team on the consistency of
pancreas according to the non-standardized measure, such as (soft, Fig. 1. A distribution of patients' age groups.
firm), and pancreatic duct dilatation was extracted from the operative
notes, which was observed by the surgical team. In this study, all pa- readmission. Imaging techniques, such as ultrasonography and CT scan
tients were included who underwent (PD) by this surgical team after were used for detecting any intra-abdominal collections.
exclusion of patients with missing information from their data re-
gistries. Some data were gathered through telephone calls with the
patients or accompanies, where ever it was possible. 2.4. Data analysis

2.2. Preoperative workup Data analysis was performed using SPSS (version 22) program. The
qualitative variables were expressed by number and percentage,
All patients who were candidates for (PD), submitted to complete whereas, the continuous data were expressed by mean, median, and
blood count, liver function test, renal function test, thyroid function standard deviation (SD). Chi square test was used to find associations
test, serum electrolytes, coagulation profile, electrocardiography, and between variables. P-value of < 0.05 was considered as a statistically
chest x-ray as a preoperative workup for anesthesia fitness. Regarding significant value.
the staging of the tumor, all patients were assessed preoperatively by
computed tomography scanning, magnetic resonance imaging, and
endoscopic ultrasonography for some patients, accordingly. 3. Result
Preoperative ERCP with biliary stent insertion was carried out for some
cases as a therapeutic biliary drainage measure for jaundice or cho- During 2010–2017 we managed 98 patients who underwent
langitis. All patients who underwent ERCP, underwent biliary stent Whipple procedure. The mean age was 55.9 ± 14.7 years, ranging
insertion as well. from 13 to 83 years. Sixty six patients were males and 32 patients were
females with male: female ratio (2:1). The most common age groups in
2.3. Surgical technique our patients were between 51 and 60 years (Fig. 1). The most common
symptoms that made the patients seek medical help was jaundice
All patients received prophylactic antibiotics (82.7%), followed by anorexia with weight loss (77.6%), while the least
(Ceftriaxone + Metronidazole) 30–60 min before the skin incision. presenting symptoms were gastrointestinal bleeding (6.1%) (Table 1).
Usually, we used an upper midline incision for their exploration. The
peritoneum and liver were assessed for the presence of metastasis and
the tumor for the respectability. The surgical team observed the pan- 3.1. Preoperative factors
creatic paraechymal texture, pancreatic duct size, and any difficulties of
bile duct dissection during the procedure. Regarding the reconstruc- The median of preoperative serum bilirubin was 9.9 mg/dl and
tions, we used pancreaticojejunostomy in the form of end-to-side ana- about 22.4% of patients underwent preoperative ERCP as a temporary
stomosis over an internal drain (NG tube 6Fr.). A duct to mucosa modality for biliary drainage (Table 2).
anastomosis was carried out by interrupted non-absorbable (Prolene 5/
0) sutures, while the second layer was performed by interrupted non- Table 1
absorbable (Prolene 4/0) between the anterolateral edges of pancreatic Showing patients' demography and symptoms.
parenchyma with seromuscular layer of the jejunum without suturing
Variables Values
the posterior edge of the pancreatic parenchyma. In cases, of small
pancreatic ducts we used 4 sutures, while in dilated ducts; 6–8 sutures Age 55.9 ± 14.7(13–83)
were used. Then we performed a loop gastrojejunostomy and Roux-en-Y Sex (%)
hepaticojejunostomy end-to-side anastomosis fashion. In all patients, Male 66 (67.3)
Female 32 (32.7)
either a Penrose drain or a corrugated drain was employed in hepa- Smoker (%) 30 (30.6)
torenal recess (Morrison's pouch). All patients had no NG tube, neither Symptoms (%)
intraoperative nor postoperative. None of the operated patients re- Jaundice 81 (82.7)
ceived any types of neoadjuvant therapy. The samples were sent for Anorexia & Weight loss 76 (77.6)
Abdominal pain 48 (48.9)
histopathological examination to confirm the type and pathological
Gastric Outlet Obstruction 7 (7.1)
characteristics of the tumor. Mortality and morbidity were estimated GI bleeding 6 (6.1)
within 30 days postoperatively either during hospital stay or

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S.A.M. Karim et al. International Journal of Surgery 52 (2018) 383–387

Table 2 Table 3
The preoperative and intraoperative factors. Showing the complications and their percentages.

Values Variables Complications Total (%)

Laboratory readings: Median (range) Wound infection 23 (23.5)

Hemoglobin level(gm/dl) 11.2(8.9–13.2) Pancreatic leak & Fistula 21 (21.4)
Total white blood cells count 8400(3500–13200) Pulmonary Complications 17 (17.3)
Serum Albumin(gm/dl) 3.8(2–4.6) Intra-abdominal Collections 12 (12.2)
Total serum bilirubin(mg/dl) 9.9(0.6–31) Postoperative Hemorrhage 12 (12.2)
Serum creatinine(mg/dl) 0.8(0.2–1.6) Reoperation 5 (5.1)
Preoperative ERCP (%) 22 (22.4%) Perioperative Death 4 (4.0)
Intraoperative factors
Pancreatic texture (%)
Firm pancreas 55 (56.1)
Table 4
Soft pancreas 43 (43.9)
Association between ERCP & difficult bile duct dissection.
Pancreatic duct status (%)
Dilated caliber 61 (62.2)
Preoperative ERCP Bile Duct Dissection
Normal caliber 37 (37.8)
Difficult Easy P-Value

3.2. Intraoperative factors Performed 17 (77.3%) 5(22.7%) < 0.001

Not performed 7 (9.2%) 69 (90.8%)
Out of 98 patients, 55 of them were observed to have firm pancreas,
while 43 patients had a soft and bulky pancreas. Intraoperatively, we
4. Discussion
did not measure the pancreatic ducts caliber accurately, but the impress
of our surgical team was used as a non-standard measure for assessing
Pancreaticoduodenectomy is a complex and demanding surgical
the pancreatic duct diameter and we found dilated ducts in (62.2%) of
procedure with high complication rates [9]. Although, morbidity and
patients (Table 2). Concerning the indications behind this procedure for
mortality have improved recently and after an improvement in in-
our patients, 16.33% of patients had benign tumors, whereas, the
tensive care management and surgical techniques, the postoperative
commonest malignant tumors were periampullary (43.88%), followed
mortalities have dramatically reduced, but the prevalence of post-
by pancreatic cancer (16.33%), and the least indications were ampul-
operative complications is still high [10,11].
lary carcinoma (9.18%) (Fig. 2). The resections extended for 6 patients;
In our district, some of the surgeons had a concept that this pro-
four of them underwent portal veins resections and the others, colon
cedure is better not be performed, because it is complex, demanding,
resections.
and time-consuming procedure with poor long-term outcomes and ne-
cessitating the presence of an advanced critical care for its success.
3.3. Postoperative complications
Previously, most of our patients used to travel to neighboring countries
for this surgical intervention. At the beginning, we had difficulties in
The most frequent complications were wound infections (23.5%),
some aspects of this operation, but later on, we observed a progressive
followed by pancreatic leak (21.4%) (Table 3). The postoperative
improvement in the surgical technique, fewer complication rates, and
bleeding happened in 12 patients. Four of them had gastrointestinal
desirable short-term outcomes in spite of our underdeveloped critical
bleeding; were treated conservatively, while eight of them had intra-
care units.
abdominal hemorrhage. In three patients we noted bleeding through
In this study, the ages of patients ranged from 13 to 83 years with
the abdominal drain with falling serial hemoglobin levels, those pa-
the mean age of patients being 55.9 years, which is lower than other
tients were treated conservatively. Five cases had severe bleeding and
studies [1–3,5,9,12–17], because the presented study has included both
were reopened: - two from the site of the portal veins resections, an-
benign and malignant tumors. In addition, one of our patients (13 year
other two from the cut edges of the mesentery of the Roux-en-Y, and the
olds boy) was a complex injury to the pancreas and duodenum. Pan-
last patient from the slipped ligature on gastroduodenal artery (GDA).
creaticoduodenectomy is sometimes used to treat a stable patient with a
Four patients died perioperatively; two from sudden cardiac arrest, one
complex injury to pancreatic head [18].
from pulmonary embolism, and one as a result of pancreatic leak.
Unfortunately, we have no data to estimate the rate of delayed
Twenty-two patients underwent preoperative ERCP, 17 of them had
gastric emptying in our patients, because of poor data registry system in
a difficulty of bile duct dissection during the surgery, while 5 of them
our region. The findings of this paper show that the most common
had easy dissection. About 77.3% of patients who underwent pre-
complications were wound infections, including superficial, deep in-
operative ERCP had difficult bile duct dissection and there was a strong
fections, and dehiscence with the rate of 23.5%. This result is higher
association between ERCP and difficulty of bile duct dissections (P
than the results of published data of other countries, e.g. studies in the
value < 0.001) (Table 4).
USA have reported the wound infection rates as 7–13.3% [2,17,19,20],
while a study in Germany has reported 7.2% [13]. However, due to a
relative lack of data we couldn't evaluate the risk factors of wound
infection in our patients; this high rate of wound infection might be
partly explained by improper techniques of sterilizations and theater
design of our hospitals.
In our patients, the rate of pancreatic leak was 21.4% when using
monofilament, non-absorbable (Prolene 5/0) for the pancreatic duct
reconstructions in the manner of duct-to-mucosa pancreaticojeju-
nostomy by putting a routine internal pancreatic duct stent (infant
feeding tube 6Fr.). Although, the rate of pancreatic leak is considerably
variable among the centers that ranging from 13 to 35%
Fig. 2. Shows the final histopathological diagnosis. [3,5,13,14,16,19–23], our result is acceptable. There are multiple fac-
Ca. = Carcinoma. tors that may have effect on the pancreatic leak rate including age,

385
S.A.M. Karim et al.
pathology of the tumor (malignant or benign), malnutrition, pancreatic
duct size, soft or bulky pancreas, operative time, and type of surgical
technique [2,11,24]. Several methods have been advocated to prevent
the pancreatic anastomotic leak, but none are perfect [25], however,
the use of surgical microscope results in a significant reduction in
pancreatic leak [26]. On all our patients we used a surgical loupe, due
to the lack of a surgical microscope in our center. The rate of pancreatic
leak by using a loupe was 23%, whereas, the rate was only 4.2% when
using a microscope [26]. On the other hand, with elderly patients
(> 65 years) with soft and bulky pancreas, closure of the pancreatic
stump, can be a useful tool to decrease morbidity rates related to de-
rivative techniques [27]. None of our patients underwent the pancreatic
duct stump closure technique.
In our analysis, we found that pulmonary complications, such as
pneumonia, pleural effusion, pulmonary embolism, and reintubation
occurred in 17.3% of patients. This result is not in accordance with the
findings of other studies, which reported rates of 6.3–15.1% [2,3,17].
Unfortunately, there is no data to find the exact cause of this phe-
nomenon, but this is might be due to inadequate postoperative chest
physiotherapy and poor pain control in our hospitals.
In this study, we observed that 12.2% of patients had intra-ab-
dominal collections; they were treated by employing percutaneous ca-
theter under ultrasonography guidance. Some studies have reported
collections rates of 8–12% [20,22,23].
During this analysis, we noted that eight patients (8.16%) suffered
from intra-abdominal bleeding postoperatively, which is higher than
that have been reported from some other centers, which ranged from
0.7% to 25% [5,13,20,22,23]. There is no registered data to define the
real cause or contributing factors for this higher rate of bleeding, but
might be related to our techniques of hemostasis, as we always use
surgical electrocautery and ligature for hemostasis, since we have no
other advanced modalities for hemostasis, such as the harmonic scalpel,
ligasure device …. e.t.c.
The overall perioperative mortality rate was 4% in our patients,
which is close to < 5% rate reported by other centers [5,9,14,19,23].
From the scope of this study, we intended to explain our experiences
concerning the impact of preoperative ERCP on patients undergoing PD
operation. We have observed that preoperative ERCP makes the bile
duct dissection and its separation from the portal vein and hepatic ar-
tery difficult and logically the procedure takes a longer time. The longer
operative time has proved to influence perioperative outcomes [15].
After further analysis, we found that 77.3%% of patients who un-
derwent preoperative ERCP had difficulties in bile ducts dissection and
there was a strong association between preoperative ERCP and difficult
bile duct dissection, because of excessive adhesions around the bile
ducts, which might be due to the body's response to the contrast during
cholangiography; or more logically due to the biliary stent, which can
act as a foreign body leading to the production of an inflammatory
process of the area. In fact, the term of difficult bile duct dissection was
an observation of our surgical team and has not been measured by any
standard measure, which is regarded as a limitation in this study. To
our knowledge, this point has not been mentioned in other literature on
the PDs.
5. Conclusion
Pancreaticoduodenectomy has a high rate of complications. Our
surgical team has a reasonable volume of patients and desirable out-
comes. For the first time, we published our data in comparison to the
results of some other centers of the western countries. We have higher
rates of wound infection and postoperative bleeding, which is necessary
to assess carefully and improve upon in order to obtain better outcomes.
Preoperative ERCP seems to be associated with difficulty of bile duct
dissection and the operative time might be longer.
386
International Journal of Surgery 52 (2018) 383–387
Conflicts of interest
All authors declare that there is no any conflict of interest.
Sources of funding
No funding source.
Ethical approval
Permission has given by Ethic and Scientific Committee of Kurdistan
Board for Medical Specialties.
Reference number: 2079 on 12th October, 2017.
Research Registration Unique Identifying Number (UIN)
Registered, the UIN is 3343.
Author contribution
Dr. Sherko Abdullah Molah Karim: Study design, Writing, Data
collection, and Data interpretation.
Dr. Karzan Seerwan Abdulla: Study design, writing.
Dr. Qalandar Hussein Abdulkarim: Study design, writing.
Dr. Fattah Hama Rahim: study design, Statistical analysis, and Data
interpretation.
Guarantor
Dr. Sherko Abdullah Molah Karim.
Acknowledgement
The authors would like to thank Dr. Altun Mahmud Saleh, and Dr.
Ajeen Hashim Ali for their participation in this study who supported our
work through collecting part of the patients' data and helped us for
getting the better quality of results.
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