Diehl Martin

The Whipple Procedure Page

This page is for those who are contemplating or scheduled for a Whipple procedure. Mine was performed in October 2004 after a diagnosis of colangiocarcinoma. This is a very major surgery, and the staff at UAB Hospital (Birmingham, Alabama) scheduled eight hours for it. In this case it went as well as could be expected, and took about six hours.

My cancer blog may be found at http://diehlmartin.com/cancer.html

The staff at UAB Hospital were absolutely stellar. Most of them really seemed to care about the patients, and that impressed me. In a situation such as this, it would seem risky to invest this much emotional energy in the patients, since some of us did not survive here. Nevertheless, this was as good an experience as one could rationally expect from a hospital setting.

All of the paperwork was done ahead of time, and a few days before the surgery there was an appointment where all of the preadmission medical tests were done. They performed an EKG, ran blood tests, and asked all of the usual medical questions. On the day of the surgery, I showed up at 4:30 a.m. at UAB Hospital, and from there was escorted to the prep area. I was issued the customary hospital gown, and told that everything I was wearing or brought with me would go in the big plastic bag with my name on it.

After about twenty minutes, they told me to get on the gurney, and was rolled away to the large surgical prep room with a dozen or more working stations, which was where I met the only person involved in the operation that I would meet that day, the anesthesiologist. He asked me if I would prefer to have an epidural, or go with a more potent general anesthetic, and I chose the epidural. He had me lean way over, and inserted the epidural between two vertebrae in my upper back. Then he put a mask on me, and within about three minutes I was out for the duration.

Nearly seven hours later, I woke up while I was being wheeled through an elevated passageway from one building to another. The sun was shining in, and everything looked pretty normal, so I assumed that I must have survived the operation. They wheeled me into what they call the fishbowl, which is a room with extra monitoring equipment, and a big window through which the nurses at the nurses' station could see me. Interestingly enough, I never was in intensive care, in spite of the extensive nature of the surgery. Furthermore, I had needed no blood transfusions. I was amazed. After about 24 hours, I was put in a regular room, about three doors down from the fishbowl, which is where I spent the next six days.

UAB Hospital is sufficiently with-it to allow someone to stay with me while I was in the hospital. My beloved wife Monica stayed in the room with me, sleeping it what had to be the most uncomfortable recliner imaginable. She was a real help throughout the entire event.

Figure 1 is the big picture. This was taken three days after the surgery, and at this point I felt well enough to smile for the camera. The following pictures show that this mugging for the camera was about all I could do, as my energy level at this point was near zero.

As you can see from this picture, there were rather a lot of tubes and machines attached. There is a pain control unit, which was attached through a tiny tube to the epidural entry point in my spine. This was used to numb most everything below my arms. It used an extremely powerful narcotic pain killer, which would be pumped in periodically by the control unit. At first it was putting out so much that it was causing slurred speech, and so I asked them to please turn it down, which they did. There was also a pushbutton for me to push if the pain got to be more than I could bear. The pushbutton didn't do much.

In that hospital bed
Figure 1. The overview

Notice also that there were two visible IVs, one in my left hand, and one in the jugular vein in my right neck. There were multiple drug pumps feeding these. The IV in my neck allowed them to draw blood without having to stick me each time, which made things a little easier on me.

Figure 2 shows the incision and some of the plumbing that was attached to me at this point. The incision went all the way from the sternum down to the bottom of the navel. I was surprised to be stitched back together with staples, but that is apparently common now. I was also surprised that they could do all of what they did without making a longer incision.

The incision
Figure 2. The incision. This is not a pretty picture, but it shows about what to expect.

Also shown in this picture are some of the tubes which were stuck in me to perform certain tasks. The large tube right next to the incision is a combination feeding and drainage tube. It is a fancy thing which provided in one place inside of me a way to feed me a concentrated liquid diet (since at this point I could not eat anything) and in another place inside it provided drainage for the bile which was produced in copious quantities. So there was a feeding pump attached to it, and also a drain bag which filled up with bright green bile, which was frequently drained and measured.

The tube on the lower left of the picture is one of three drainage tubes (the other two are just out of sight on the other side) which was hooked to a pump-up vacuum bottle which drained any liquids which accumulated inside of me after the surgery. These tubes were left in until the drainage stopped, and then were removed one by one as each one soon ran out of liquid to drain.

One of the biggest issues after the surgery was that the digestive tract had been cut up and modified, and so it took some time for it to begin to function normally. There was no "motility" to speak of (motility is the motion of the material through the stomach and intestines). As such, as they pumped in ever more of the concentrated liquid diet, it didn't move much, and as a result the small intestines were forced to stretch - and in an area which had been recently cut upon. The result was predictable - pain. It hurt, and I told them so. The pump feeding continued, and when I was told I could eat again, I really didn't feel like it because my whole system was totally full. The dietician came and gave a a lecture about how I wasn't eating all of my meals, and I needed to before I was sent home. They repeatedly tried to break things loose by applying laxitive suppositories, but they did very little. It took seven days after the surgery for things to even begin to return to normal. When I was sent home, I still had the feeding tube installed, and we had to keep up the pump feeding for a couple of weeks.

The hardest day of all was when they removed the epidural. Oh, the epidural was absolutely painless for me, and worked as well as it possibly could. But the medication was very potent, and quickly made me physically dependent upon it. So after about five days the pain control specialists came in and announced that they were removing the epidural. They did it, and it took all of five minutes. So where there had been a hole in my back there was now just a little bandage. After about two and a half hours, I began to feel ill, and then began to shake. My chest hurt so badly I thought maybe I was having a heart attack. It felt like an elephant was standing on my chest. The nurses were notified, but did nothing, because they knew what this was - these were withdrawal symptoms, and there was noting to be done. After about three hours it began to subside, and then things were much moe normal. What I thought was unusual was that no one told me what was going to happen. At least I would have known what was going on.

All of the above were taken during my hospital stay. The follwing pictures are from afterwards.

Figure 3 shows what an infected incision can look like. Just before I left the hospital, they removed the staples and replaced them with little pieces of special tape. I was supposed to leave the tape there until it fell off of its own accord. What happened was not what they predicted. After about a week there began to be rather a lot of seepage from the incision, and it seemed to be very oily. At first we called the resident on call, and he suggested that this was a case of fat necrosis. It didn't smell as far as I could tell, but it was a mess, and it caused all of the special tape to come off quickly.

The infection
Figure 3. A badly infected incision.

After a few more days we called again, and were told to come in immediately, which we did. The surgeon was not there that day, so this matter was handled by his chief resident. He took one look at it, declared it badly infected, and told us that we should have come in earlier. One of the hard parts about being the patient is that you never really know what is normal, and we certainly didn't. So the resident had me lie down on the examining table, and with his gloved finger pulled the incision back apart. It hurt so badly I nearly passed out. (There is an inner layer of stitches which hold the muscle layer together, and they were left intact.) We were given new instructions on how to deal with the infection, a prescription for a differrent antibiotic, and sent back home. The wound would have to "heal from the bottom up" which is to say that there would be a vee-shaped notch in my tumy until it it healed over. It took about two months to have the skin grow back over, and most of a year for it to fill in some.

Figure 4 is a picture of what the incision looked like nearly two years after the Whipple procedure. It has mostly filled in, but there is still a notch left. The only other obvious scar is from the feeding tube, where there is still an indentation, and the signs of the three holes where it was stitched down.

Scar from Whipple procedure
Figure 4. Scar from Whipple procedure.

Life after a Whipple procedure is different from what it was before. Each case is differrent, and there are variations based on what they find when they open you up, and what actions they take. In my case, they removed the gall bladder, the head of the pancreas, part of the stomach, part of the small intenstines, some lymph nodes and some nerve bundles. They reassembled me by attaching the end of what was left of the small intestines to the bile duct on my liver. A little down from that on the intestines they poked a hole in the side of it and attached the hole to the remaining duct on what was left of the pancreas, adding a stent to keep the duct open. Next, a bit further down on the intestine they poked another hole in it and attached the outlet from the stomach to that hole. As a result, My stomach is smaller, my intestines are shorter, there is no valving on the bile coming out of the liver, and there is only half a pancreas to produce its enzymes..

There are remaining side-effects from the changes listed above. The first is that I cannot eat as much at a time - there is nowhere to put it. The next change is that I now have a strong tendency to develop intestinal ulcers, because of the continuous production and transit of bile. The third change is that digestion is "different." Some  things I simply cannot eat any more, because my digestive tract cannot handle it. On the other hand, I am alive today, and would not have been if they had not performed this Whipple procedure on me. So I accept the fact that I have dietary restrictions, and have to take medications for ulcers and pacnreatic enzyme supplements, as an acceptable tradeoff for still being alive.

I would urge anyone facing a cancer diagnosis to find themselves a top-notch cancer center, and go for treatment as soon as possible. The sooner you start treatment, the higher are the probabilities of surviving the cancer, and going on to live a normal or nearly normal life. I can personally recommend Kirklin Clinic, and the Comprehensive Cancer Center at the University of Alabama, Birmingham. Find a good center near you, and just go. Cancer is a terrible thing, but the sooner you deal with it, the better the likely outcome.

My cancer blog may be found at http://diehlmartin.com/cancer.html

Diehl Martin passed away in October 2007. If you need to contact someone, please contact Monica Martin.

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