This topic had appeared in Question 25 from the first paper of 2020, where the college asked for "the complications of this procedure that are of relevance to its ICU management". The impetus for this SAQ may well have been the simple fact that this procedure is not without its complications, and many of these complications end up becoming the ICU's problem. Or, perhaps it was the concern, raised by many a surgical staff, that the ICU trainees do not appear to have a solid grasp of what exactly was done during one of these eponymous procedures (Whipples, Ivor-Lewis, Benthal, etc), or what complications to expect. As assessment drives learning, this SAQ would have an intelligent response to that concern.
The time-poor candidate has not time for idle gibberish, and needs one solid reference to read before the test date. The best resource for this purpose is probably the 2020 ERAS society guidelines, which is a manageable 19-page document with a nice summary table.
A Whipple procedures (or Whipple's procedure) is a pancreaticoduodenectomy. It's known as a "Whipples" after Allen Oldfather Whipple, who in the 1930s modified a much older procedure originally described by Alessandro Codivilla (in 1898). Codivilla pioneered the technique of pancreaticoduodenectomy, resecting the head of pancreas distal stomach and proximal duodenum en bloc with the hospital's only surgical assitant (a monsieur Bartolo dal Monte), with the patient under chloroform. He then attached the bile duct to the remaining duodenal stump, and reattached the rest of the duodenum to the stomach in a manner reminscent of a roux-en-Y. What he did with the stump of the pancreatic duct is unclear, but he probably just ligated it, and it ultimately formed some sort of fistula. Walther Kausch was the next to refine the procedure in 1912, but his article is too German for the author to determine how he entfernte das Carcinom; all that can be established is that it was a staged procedure and not all of the duodenum was removed. Whipple basically performed the exact same procedure in 1935 (and the patient died within 30 hours) but in contrast to the others he removed all of the duodenum. Somehow, the procedure ended up being named after him (probably because Kausch was not around to contest it, having died in 1928).
Anyway. None of this would have earned any marks. The college wanted a list of anastomoses:
As one might imagine of a 6-8 hour procedure which ends with three anastomoses in the abdomen, "the complications of this procedure that are of relevance to its ICU management" are numerous, and making a coherent answer to this sort of question really relies on the candidate's abilities to categorise them quickly. What is offered below was constructed mainly from Butturini et al (2006), McEvoy (et al (2014) and Karim et al (2018), of which the latter offer some percentages from their case series of 98 patients. None of them offer any sort of structure, so a simple alphabetic systems-based one has been produced to help non-surgical people.
For a good summary, Aoki et al (2017) have this excellent bar graph based on Japanese data:
Now, to put an ICU spin on this:
Surgical complications
Airway-related concerns
Respiratory complications
Vascular complications
Pain
Electrolyte derangement
Fluid balance
Nutritional problems
Intra-abdominal collections (12.2%)
Thromboembolic disease
Lassen, Kristoffer, et al. "Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations." Clinical nutrition 31.6 (2012): 817-830.
Crippa, Stefano, et al. "Anastomotic leakage in pancreatic surgery." HPB: the official journal of the International Hepato Pancreato Biliary Association 9.1 (2007): 8.
Schnelldorfer, Thomas, and Michael G. Sarr. "Alessandro Codivilla and the first pancreatoduodenectomy." Archives of Surgery 144.12 (2009): 1179-1184.
Kausch, W. "Das Carcinom der Papilla duodeni und seine radikale Entfernung." Beitr Klin Chir. 78 (1912): 439-486.
Are, Chandrakanth, Mashaal Dhir, and Lavanya Ravipati. "History of pancreaticoduodenectomy: early misconceptions, initial milestones and the pioneers." Hpb 13.6 (2011): 377-384.
Whipple, A. O. "Observations on radical surgery for lesions of the pancreas." Surg Gynecol Obstet 82 (1946): 623-631.
Whipple, Allen O., William Barclay Parsons, and Clinton R. Mullins. "Treatment of carcinoma of the ampulla of Vater." Annals of surgery 102.4 (1935): 763.
Butturini, Giovanni, et al. "Complications after pancreaticoduodenectomy: the problem of current definitions." Journal of hepato-biliary-pancreatic surgery 13.3 (2006): 207-211.
Karim, Sherko Abdullah Molah, et al. "The outcomes and complications of pancreaticoduodenectomy (Whipple procedure): Cross sectional study." International Journal of Surgery 52 (2018): 383-387.
McEvoy, S. H., et al. "Pancreaticoduodenectomy: expected post-operative anatomy and complications." The British journal of radiology 87.1041 (2014): 20140050.
Keim, Volker, et al. "Postoperative care following pancreatic surgery: surveillance and treatment." Deutsches Ärzteblatt International 106.48 (2009): 789.
Fuks, David, et al. "Life-threatening postoperative pancreatic fistula (grade C) after pancreaticoduodenectomy: incidence, prognosis, and risk factors." The American journal of surgery 197.6 (2009): 702-709.
Junejo, M. A., et al. "Cardiopulmonary exercise testing for preoperative risk assessment before pancreaticoduodenectomy for cancer." Annals of surgical oncology 21.6 (2014): 1929-1936.
Aoki, Shuichi, et al. "Risk factors of serious postoperative complications after pancreaticoduodenectomy and risk calculators for predicting postoperative complications: a nationwide study of 17,564 patients in Japan." Journal of Hepato‐Biliary‐Pancreatic Sciences 24.5 (2017): 243-251.