Analysis of Whipple’s resection specimens: A histopathological perspective

  • Shifa Ibrahim Assistant Professor,Department of Pathology,Madurai Medical College,Madurai
  • Meena Kumari G Department of Pathology,Madurai Medical College,Madurai
Keywords: Whipples’ procedure, Ampullary Carcinoma, Periampullary, Pancreas, Carcinoma


Background: Pancreaticoduodenectomy or Whipples’s procedure is done for pancreatic, bile duct carcinoma, duodenal carcinoma and periampullary carcinoma. About 5% of the gastrointestinal malignancy is constituted by the ampullary and periampullary carcinoma. Histopathological studies related to the diagnosis, grade, stage, nodal status, marginal status, prognosis and incidence of these tumors are analyzed from the received Whipple’s specimen in our study. Aim of this study is to analyze the incidence of various tumors we encounter in the Whipple’s specimen, to calculate the sex ratio, to grade and to stage the tumors based on the WHO grading system. And to compare the incidence with other studies.Methods:  Histopathology records of all the patients who had Whipple’s resection during September 2013 - September 2015 were analyzed. The slides were reviewed and the parameters were calculated.Results: Out of thirty cases, on which Whipple’s resection was done, twenty one had ampullary and periampullary carcinoma, The mean age incidence of ampullary carcinoma calculated was 44 years. The sex ratio of ampullary carcinoma was 1:1. Three had pancreatic tumors and six had chronic pancreatitis. Out of the three cases with pancreatic tumor, two had pancreatic endocrine tumors. They both were female. One had a Solid pseudopapillary pancreatic tumor. Literatures were reviewed and the predominance of ampullary carcinoma was noted in our study in contrast to other studies.Conclusion: In the analysis of the Whipple’s specimen we found out that ampullary adenocarcinoma predominates and there were an equal sex incidence. This is in contrast to other published literatures. This variable needs further evaluation.

Author Biographies

Shifa Ibrahim, Assistant Professor,Department of Pathology,Madurai Medical College,Madurai
Assistant Professor, Department of Pathology
Meena Kumari G, Department of Pathology,Madurai Medical College,Madurai
Professor and HOD, Department of Pathology,Madurai Medical College,Madurai


1. Saraee A, Vahedian-Ardakani J, Saraee E, Pakzad R and Wadji M B. Whipple procedure: a review of a 7-year clinical experience in a referral center for hepatobiliary and pancreas diseases. Saraee et al. World Journal of Surgical Oncology 2015; 13:98
2. Crothers JW, Zhao L, Wilcox R .Benign is a Relative Term: the Whipple Resection in Non-Oncologic Cases. Ann Clin Pathol 2014:2:1019.
3. Adsay NV, Basturk O, Saka B, Bagci P, Ozdemir D, Balci S, et al. Whipple Made Simple For Surgical Pathologists. Am J Surg Pathol. 2014; 38(4): 480–493.
4. Gonzalez RS, Bagci P, Kong KT, et al. Distal common bile duct adenocarcinoma: analysis of 47 cases and comparison with pancreatic and ampullary ductal carcinomas Mod Pathol. 2012; 25:109.
5. Saka B, Bagci P, Krasinskas A, et al. Duodenal carcinomas of non-ampullary origin are significantly more aggressive than ampullary carcinomas. Mod Pathol. 2013; 26(2S):176.
6. Landis SH, Murray T, Bolden S, et al. Cancer statistics.CA Cancer J. Clin.1999; 49:8.
7. Duffy JP, Hines OJ, Liu JH, Ko CY, Cortina G, Isacoff WH, et al. Improved survival for adenocarcinoma of the ampulla of vater: fifty-five consecutive resections. Arch Surg. 2003; 138:941-950.
8. Talamini MA, Moesinger RC, Pitt HA, Sohn TA, Hruban RH,Lillemoe KD, et al. Adenocarcinoma of the ampulla of vater. A 28-year experience. Ann Surg. 1997; 225: 590-600.
9. Howe JR, Klimstra DS, Moccia RD, Conlon KC, Brennan MF. Factors predictive of survival in ampullary carcinoma. Ann Surg. 1998; 228(1): 87-94.
10. Roder JD, Schneider PM, Stein HJ, Siewert JR. Number of lymph node metastases is significantly correlated with survival in patients with radically resected carcinoma of the ampulla of Vater. Br J Surg 1995; 82: 1693-1696.
11. Costi R, Caruana P, Sarli L, Violi V, Roncoroni L, Bordi C. Ampullary Adenocarcinoma in Neurofibromatosis Type1. Case Report and Literature Review. Mod Pathol 2001; 14(11):1169–1174.
12. Pauli RM, Pauli ME, Hall JG. Gardner syndrome and periampullary malignancy. Am J Med Genet 1980; 6:205-219.
13. Colarian J, Pietruk T, LaFave L, et al. Adenocarcinoma of the ampulla of Vater associated with neurofibromatosis. J Clin Gastroenterol 1990;12:118-119
14. Howe JR, Klimstra DK, Cordon-Cardo C, et al. K-ras mutations in adenomas and carcinomas of the ampulla of Vater. Clinical Cancer Research 1997; 3: 129-134.
15. Albores-Saavedra J, Henson DE, Klimstra DS. Tumors of the Gallbladder, Extrahepatic Bile Ducts, and Ampulla of Vater. Washington, DC: Armed Forces Institute of Pathology.Atlas of Tumor Pathology2000; 3rd series, fascicle 27.
16. Henson E D, Schwartz M A, Nsouli H, Albores-Saavedra J, Carcinomas of the Pancreas, Gallbladder,Extrahepatic Bile Ducts, and Ampulla of Vater Share a Field for Carcinogenesis. Arch Pathol Lab Med. 2009; 133:67–71.
17. Yeo J C, Sohn A T, Cameron L J, Hruban H R, Uiemoe DK, Pitt A H, Periampullary Adenocarcinoma analysis of 5-Year Survivors. Ann. Surg. 1998; 227(60): 821-831.
18. Westgaard A, Tafjord S, Farstad N I, Cvancarova M, Eide J T, Mathisen O et al. Pancreatobiliary versus intestinal histologic type of differentiation is an independent prognostic factor in resected periampullary adenocarcinoma. BMC Cancer 2008, 8:170
19. Warren KW, Choe DS, Plaza J, Relihan M. Results of radical resection for periampullary cancer. Ann Surg 1975; 181: 534-540.
20. Allema JH, Reinders ME, van Gulik TM, et al. Results of Pancreaticoduodenectomy for ampullary carcinoma and analysis of prognostic factors for survival. Surgery 1995; 117: 247-253.
21. Al Jitawi SA, Hiarat AM, Al-Majali SH. Diffuse myoepithelial hamartoma of the duodenum associated with adenocarcinoma. Clin Oncol 1984; 10: 289-93.
22. Bergdahl L, Andersson A. Benign tumors of the papilla of Vater. Am Surg 1980; 46: 563-6.
23. Sahin P, Pozsar J, Simon K, et al. Autoimmune pancreatitis associated with immune-mediated inflammation of the papilla of Vater: report on two cases. Pancreas 2004; 29: 162-166.
24. Adsay NV, Basturk O, Klimstra DS, et al. Pancreatic pseudotumors: non-neoplastic solid lesions of the pancreas that clinically mimic pancreas cancer. Semin Diagn Pathol 2005; 21: 260-267.
25. Shutze WP, Sack J, Aldrete JS: Long-term follow-up of 24 patients undergoing radical resection for ampullary carcinoma, 1953 to 1988. Cancer 1990; 66:1717-1720.
26. Willett CG, Warshaw AL, Convery K, Compton CC: Patterns of failure after pancreaticoduodenectomy for ampullary carcinoma. Surg Gynecol Obstet 1993; 176:33-38
27. Ohike N, Coban I, Kim GE, Basturk O, Tajiri T, Krasinskas A et al: Tumor budding as a strong prognostic indicator in invasive ampullary adenocarcinomas. Am J Surg Pathol 2010; 34:1417-1424.
28. Sessa F, Furlan D, Zampatti C, Carnevali I, Franzi F, and Capella C: Prognostic factors for ampullary adenocarcinomas: tumor stage, tumor histology, tumor location, immunohistochemistry and microsatellite instability. Virchows Arch 2007; 451:649-657.
29. Shyr Y, Su C, Wu L, Fen-Yau Li A, Chiu J, Wu C et al. Prognostic Value of MIB-1 Index and DNA Ploidy in Resectable Ampulla of Vater Carcinoma. Annals of surgery 1998; 229, (40): 523-527.
30. . Carriaga MT, Henson DE. Liver, gallbladder, extrahepatic bile ducts, and pancreas. Cancer 1995; 75:171–190.
31. Öberg K, Knigge U, Kwekkeboom D, Perren A on behalf of the ESMO Guidelines Working Group. Neuroendocrine gastro-entero-pancreatic tumors: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up Ann Oncol 2012;23 (7): 124-130
32. Halfdanarson TR, Rabe, K, Rubin J, Petersen GM. Pancreatic endocrine tumors (PETs): Incidence and recent trend toward improved survival. Presented at the 2007 Gastrointestinal Cancers Symposium; Orlando, FL. 2007
33. Patil T B, Shrikhande S V, Kanhere H A, Saoji R R, Ramadwar M R, Shukla PJ, Solid pseudopapillary neoplasm of the pancreas: a single institution experience of 14 cases HPB, 2006; 8: 148-150.
34. Martin RC, Klimstra DS, Brennan MF, Conlon KC. Solid-pseudopapillary tumor of the pancreas: A surgical enigma? Ann Surg Oncol. 2002; 9:35-40.
35. Abraham SC, Klimstra DS, Wilentz RE, Yeo CJ, Conlon K, Brennan M, Cameron JL, Wu T-T, Hruban RH: Solid–pseudopapillary tumors of the pancreas are genetically distinct from pancreatic ductal adenocarcinomas and almost always harbor beta-catenin mutations. Am J Pathol 2002; 160:1361-1369.
36. De la Fuente SG, Ceppa EP, Reddy SK, Clary BM, Tyler DS, Pappas TN. Incidence of benign disease in patients that underwent resection for presumed pancreatic cancer diagnosed by endoscopic ultrasonography (EUS) and fine-needle aspiration (FNA). J Gastrointest Surg. 2010; 14: 1139-1142.
37. Asbun HJ, Rossi RL, Munson JL. Local resection for ampullary tumors. Is there a place for it? Arch Surg 1993; 128: 515-20.
38. Chan C, Herrera F M, de la G, Quintanilla-Martinez L, Vargas-Vorackova F, Richaud-Patin Y. Clinical Behavior and Prognostic Factors of Periampullary Adenocarcinoma. Annals of surgery 1995; 222(5): 632-637.
39. Michelassi F, Erroi F, Dawson J P, Pietrabissa A, Noda S, Handcock M et al. Experience with 647 Consecutive Tumors of the Duodenum, Ampulla, Head of the Pancreas, and Distal Common Bile Duct. Ann. Surg. 1989; 210(4): 544-554.
Original Article