In defense of the whipple: an argument for aggressive surgical management of pancreatic cancer.

INTRODUCTION In 1898, Allesandro Codivilla performed the first pancreaticoduodenectomy; however, it was Kausch who first described the surgical technique in 1912. More than two decades later (1935), Allen O. Whipple performed a twostaged pancreaticoduodenectomy that involved a biliary diversion and gastrojejunostomy followed by resection of the duodenum and head of the pancreas. In 1941, Whipple modified the operation into a one-stage pancreaticoduodenectomy, which would situate his name into the history of pancreatic surgery. Despite this technical achievement, the procedure lacked rapid adoption because of its difficulty, and came to be associated with high hospital morbidity, and mortality rates approaching 30%. More than a century since the first Whipple procedure, pancreatic cancer continues to affect 200,000 people worldwide and claim 34,200 American lives each year, with an additional 37,680 new diagnoses expected in 2008. The lifetime risk for developing pancreatic cancer is now 1 in 79 for both men and women, and it remains the fourth leading cause of cancer death in the U.S. [1]. Whereas death rates for cancers of the stomach, lung, colon, and prostate have decreased over the past 20 years, death rates from pancreatic cancer have remained stable, with a slow increase in those aged 70 years. Although some of this may be a result of an increased overall life expectancy, the natural history of pancreatic cancer, lack of early detection strategies, inability to adequately identify at-risk populations, and aggressive biology play important roles in the disease’s lethality, and remain a challenge to its treatment.