No Long-Term Effect on Pancreatic Function in Children Who Undergo the Whipple Procedure

A new study from Korea indicates that children who undergo pylorus-preserving pancreaticoduodenectomy (PPPD, aka the Whipple Procedure) generally avoid problems such as exocrine pancreatic insufficiency and lead relatively normal lives.

Researchers recruited 10 of the 15 patients who underwent PPPD at Seoul National University’s Children’s Hospital between 1992 and 2013 and then performed both a retrospective analysis of their medical records and a thorough check-up. The study team evaluated nutritional status by measuring patient height, weight, weight-for-age Z-score, body mass index (BMI), serum protein, and albumin levels. It estimated endocrine and exocrine functions using the Bristol stool chart and checking for diabetes mellitus and steatorrhea. And it evaluated gastrointestinal function and quality of life via questionnaires.

Although all of the patients experienced mild gastrointestinal symptoms, all of them had grown to normal heights and maintained normal weights. A total of 6 patients suffered mild steatorrhea and 3 scored above category 6 in the Bristol stool chart. All but 1 of the patients reported no problems that significantly hurt their quality of life.

“Almost all the study subjects, who underwent PPPD in their childhood, did not present significant problems except for one patient with diabetes mellitus,” the study authors wrote in the Journal of Pediatric Surgery.

Previous studies of (mostly adult) patients who have undergone PPPD have often found a significant risk of exocrine pancreatic insufficiency and other serious damage to pancreatic function. A 1998 article in Digestive Diseases and Sciences reported that 33 of 44 patients who underwent pancreatic surgery to remove cancer were then diagnosed with exocrine pancreatic insufficiency . Of those patients, 11 underwent a full pancreaticoduodenectomy (PD) but the other 29 underwent the less radical PPPD. A 2007 paper in the Scandinavian Journal of Gastroenterology, moreover, detected exocrine pancreatic insufficiency after a median follow-up of 52 weeks in all 15 patients who had undergone PPPD for pancreatic cancer.

That said, other studies have found that many PPPD patients maintain their pancreatic function and that those who lose it are far more likely to recover over time than patients who undergo PD. A 2001 paper in Digestive Diseases and Sciences found that exocrine function fell about as much immediately after PPPD as it did after PD but that it rebounded to pre-operative levels in PPPD patients and remained low in PD patients.

“In summary,” wrote the authors of a review article that appeared in Digestive and Liver Disease, “the available data indicate that exocrine pancreatic insufficiency occurs in 46—100% of patients with resectable pancreatic cancer. Following PD and PPPD prevalence of exocrine pancreatic insufficiency remains high at a rate of 70–100%, irrespective of whether patients undergo PD or PPPD and whether a pancreaticogastrostomy or pancreaticojejunostomy is performed.”

Another study, this from the British Journal of Surgery, noted that the appropriate treatment for exocrine pancreatic surgery could depend upon the type of surgery that caused the problem.

“In cases of exocrine pancreatic insufficiency after Whipple's procedure, 2-mm ECPM [enteric-coated pancreatin microspheres] treatment adequately restores pancreatic enzyme activity. Following PPPD, however, ECPM treatment is often ineffective because the microspheres are retained in the stomach,” the study authors wrote. “In these patients, use of conventional powdered pancreatin enzyme preparations may improve the efficacy of treatment.”