A total of 50 Whipple’s procedures were completed in a 10-year period, an average of 5 cases per year, a number less than the 9 procedures a year considered the low volume cut off (18). Literature exhibits that low volume centres are associated with greater mortality and morbidity compared to higher volume centres where more than 36 procedures are performed a year (6, 11, 18). Most procedures were conducted open (74%) with the remaining procedures being performed in-part laparoscopically. The open approach is still most performed in other centres (4, 9). Although a laparoscopic approach to this procedure is available, it has not yet gained popularity as it is technically challenging and requires proficiency in both laparoscopic and pancreatic surgeries (19).
The median age of patients presenting for a Whipple’s procedure was 53.5 years, this was in line with other studies (4, 8). The procedure was performed almost equally between males and females. The most common indication for Whipple’s procedure was pancreatic mass, in keeping with other centres (9). Whereas other research reflected the similar comorbidities of hypertension and diabetes, our study was unique in that 20% of the patients presenting for Whipple’s procedure were infected with HIV.
Intra-operative
Regional anaesthesia was used in 92% of the Whipple’s procedures, with an epidural being used 78.3% of the times regional anaesthesia was employed. Previously, epidurals were considered the standard, with De Petri et al., recommending a thoracic epidural as the core intra- and post-operative analgesic for Whipple’s procedures (13). More recent literature has highlighted the benefits of morphine spinals over epidurals, with less chance of failure and reduced fluid administration due to intra-operative hypotension (20). Our study showed no significant difference between patients who received a morphine spinal or epidural regarding rates of complications or death.
The average duration of a Whipple’s procedure conducted at CMJAH was 552 minutes, considerably longer than other centres in high income countries, Massachusetts General Hospital reported mean operative time of 347 minutes (5). The duration was also longer than in lower income centres, one study conducted by the Indian Armed Forces reported a mean operative time of 309 +/- 59 minutes (9) while in Pakistan, Changazi et al reported mean surgical times of 315 minutes (4). The average blood loss in our study was 818mL, this was similar to other studies with blood loss varying between studies with volumes of 764mL and 500mL (4, 5).
Post-Operative Findings
In our study, the average ICU stay was 5 days, this was similar 5.24 days reported by a Caribbean centre (21). The overall hospital stay was 17 days which was longer than the 9.5 days reported at Massachusetts General hospital but similar to another lower income centre that reported an average hospital stay of 15.1 days.
While the mortality rates at CMJAH were higher than those reported in other countries, the rates of complications were comparable to current literature (4, 10, 13). Our study showed patients had a post-operative complication rate of 68%, while other studies reported rates between 50 and 60% (4, 10, 13) The most common complication was intra-abdominal collection, occurring in 20% of patients, followed by wound sepsis (16%) and haemorrhage (14%). Another South African study reported found that wound sepsis (24.6%) surpassed pancreatic fistulae (16.9%) as the most common complication (10). Higher income countries reported pancreatic fistula as the more frequent complication, Mass General Hospital reporting a rate of between 9% and 13% (5).
Pulmonary complications occurred at a rate of 14% following Whipple’s procedure at CMJAH, lower than those reported in one Iraqi study, pulmonary complications occurred in 17.3% of patients and 17.6% in an Indian study (12, 22).
Patients who received red packed cells blood transfusions intra-operatively during a Whipple’s procedure were found to be more likely to develop wound sepsis post-operatively. This is in keeping with current literature, Dosch et al. (23) found that patients receiving a blood transfusion had a higher rate of infection and blood transfusion was independently associated with postoperative infection. A single-centre study conducted in Korea showed that patients receiving a blood transfusion in the perioperative period were six times more likely to develop surgical site infections, intra-abdominal abscesses and bacteraemia (15).
The 30-day mortality of patients after a Whipple’s procedure was found to be 26% at CMJAH over the 10-year period. This number is greater than other regions with a South African study conducted at Groote Schuur Hospital in the Western Cape reporting a mortality of 5% (10). In Pakistan, another lower income country, one study reported a mortality rate of 15.8% while Indian literature reported, mortality rates that ranged from 2.9-8% (4, 9, 22). Higher income countries, have reported rates as low as 0.8% in America (5) while a Netherlands study reported a 1% mortality rate (6). The higher mortality rates and surgical times of Whipple’s procedures at our institution could be related to the significantly lower volume of procedures done at our centre compared to others.
Patients in this research who received a greater volume of crystalloids had a longer duration of ICU stay and were more likely to develop bile leakage following their Whipple’s procedure, in line with current literature (13). Current Enhanced Recovery After Surgery (ERAS) society guidelines recommend zero fluid balance with balanced crystalloids being used to replace losses (14).
Limitations
Our study was limited by incomplete anaesthetic charts and in some cases missing patient data. Starting in 2020, the Covid pandemic resulted in the closure of elective theatres and thus a reduction in the number of Whipple’s procedures. CMJAH was also affected by a fire in 2021 which initially resulted in a closure of theatre while the hospital was being repaired and thereafter only limited surgeries being performed, again resulting in lower Whipple’s procedures than normal.