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Operating on the “Rattlesnake of the Abdomen”

How performing more than 1,600 Whipple procedures has advanced the fight against pancreatic cancer.

Some people may approach Friday the 13th by treading a bit more carefully on a day commonly associated with bad luck. But for Chair of Surgery Charles J. Yeo, it happens to be the day he’s performing his 1,000th Whipple procedure at Thomas Jefferson University Hospitals. The potentially lifesaving pancreas surgery is the most effective way to fight localized pancreatic cancer, which is the third leading cause of cancer death in the United States, affecting an estimated 56,000 Americans per year.

As Dr. Yeo moved toward the millennial milestone (which is Whipple No. 1,640 for him overall, including his time at Johns Hopkins), he discussed why and how the Whipple procedure is performed and why he has focused his career on “the rattlesnake of the abdomen.” Dr. Yeo helps patients with pancreatic tumors and provides a path to potential cure of this often-silent cancer.

A posed photo of Dr. Charles Yeo in a white coat

Chair of Surgery Charles J. Yeo

How has the procedure evolved, or stayed the same, from your training at Johns Hopkins, to your 500th in 2012, to the precipice of one thousand today?
Dr. Allen Oldfather Whipple’s name is eponymously credited with the Whipple operation. His report of this operation included three patients in the first half of the 1930s. In his whole career, Dr. Whipple performed 37 of these operations. At that time, performing a “Whipple” was a major ordeal. Patients were less well-prepared. Hospitals did not have high-level ICU care, nor did they have modern anesthetic techniques. Blood transfusions were uncommon or not possible. The surgical landscape has changed dramatically since the 1930s and ’40s.

We have created a clinical pathway whereby the postoperative hospital time is reduced from a month many decades ago, to two weeks when I was in training, then down to seven or eight days. Our latest clinical pathway, just published and called the Whipple Accelerated Recovery Pathway (WARP), targets a five-day postoperative length of stay after this major operation. So a lot has changed.

The other very critical element I want to underscore is the importance of having a team that focuses on these patients and procedures, starting with the pre-op setting. We carefully assess our patients, their comorbidities, nutrition level and frailty. We have a very talented team of anesthesiologists. We have skilled and experienced OR nurses who are familiar with these procedures. We have amazing nursing and critical care provided to these patients in the ICU setting. And I would be remiss if I didn’t laud the incredible care given to these patients in the location that they all go to postoperatively, the Star Pavilion (Pavilion 13). We have incredible confidence in the talented Jefferson nurses who take care of these patients day in and day out.

What type of team, and how large is it, with you in the OR?
I operate in one of the smallest operating rooms at Jefferson, on purpose. There’s usually one anesthesia resident and one experienced and quite talented anesthesia attending. There’s typically one surgical chief resident. There’s usually either a surgical intern or a medical student, and then, importantly, a scrub nurse or scrub technician, and a circulating nurse. We’ve had visitors come from China and Japan and other places to watch the operation in person and on a video screen. We are very proud of the OR teams we have had over the years. I’m especially thankful to the almost 80 Jefferson surgical chief residents I have worked with these past 14-plus years. They are an incredible group of chief residents.

Surgeon Charles Yeo standing with colleagues

How about customs or rituals during this?
There are many customs and rituals. Many of them are part of the culture of safety at Jefferson. The patient check-in process includes making sure that all of the appropriate preoperative medications are given. We verify which scientific and clinical studies each patient has consented for. We always do a “timeout” in the operating room with the entire team, verifying name and procedure and expected outcomes. During every case we play different music. Usually it’s rock and roll at a low volume, sometimes it is country music at a low volume. This time of the year, we typically play a few Christmas carols.

What’s the general trajectory of a patient’s recovery?
Based upon our latest randomized controlled trial (the WARP trial, led by Dr. Harish Lavu), our expectations are that most patients will leave the hospital on the fifth postoperative day. Most patients are ready to do that. We follow up with them during the first week of their recovery at home. We often do this via a telehealth visit. I did a scheduled visit just this week with one of last week’s Whipple patients, to make sure they’re doing well and to review their pathology with them.

It’s important to remember that most of these patients are having this operation because they have a malignant diagnosis, a cancer diagnosis. They and their families recognize the serious nature of this diagnosis. The majority of patients do have pancreatic cancer. A minority will have bile-duct cancer or ampullary cancer or duodenal cancer, and some will have pre-malignant lesions. For those patients who have a cancer diagnosis, some of them will have had preoperative chemotherapy. Others may have chosen a surgery-first approach and will be candidates for postoperative chemotherapy.

For many of these patients, it’s not true that surgery is the only element of their treatment. Their treatment often involves a combination of surgery, chemotherapy and, in some cases, radiation therapy. Our job is to remove their tumor safely, provide them a path to a prompt recovery, and enable them to move forward with chemotherapy or chemoradiotherapy promptly, if indicated.

An operation such as the Whipple, which can take five hours or more to perform, requires a degree of physical strength. In addition to the mental energy and fortitude, how do you stay fit?
It is important that surgeons and staff who embark upon operations such as this maintain a high level of physical fitness. Although it’s tiring to stand at an OR table for five to eight hours, three days a week, it is not great exercise per se. You have to be sure that you’re doing your best to maintain a level of physical conditioning with running, swimming, using the ergometer and biking, all things that I try to do. I try to do one of those things every day. Physical fitness has both somatic and mental benefits.

A cake with the writing "Way to Go! 1,000 Dr. Yeo"

A cake celebrating Dr. Yeo’s 1,000th Whipple procedure at Jefferson

Why have you made this procedure your career?
Number one, it was considered by some, back in the 1980s, an operation too dangerous for people to do. The pancreas was referred to as “the rattlesnake of the abdomen.” People who know me consider me to be competitive. I don’t consider myself to be all that competitive, but I’ve been told that I’m hypercompetitive. So in that sense, it seemed like something that should be attacked. It was a challenge that merited attention.

Number two, I was fortunate to train with very talented surgeons led by Dr. John Cameron, who was the chair of surgery at Johns Hopkins and my most important professional mentor. This operation was something that he was working on trying to perfect. I was in the right place at the right time.

The third reason was that I was fortunate, back around 1990, to receive our first NIH grant to study pancreas cancer. I was blessed to be able to nucleate a multidisciplinary team of young, talented people in pathology, medical oncology and gastroenterology to work on pancreatic cancer. It just all came together. I was not a high school student who said, “I want to be a pancreas surgeon and do the Whipple operation.” I didn’t know anything about either the pancreas or the Whipple operation in high school, college or really for my first couple of years of medical school.

What is on the horizon?
I’m hoping to keep working and operating for many more years, trying to help more and more patients. Recently, we had our 14th annual Jefferson Pancreatic Cancer Patient Symposium. There were over one hundred survivors of pancreatic cancer in that room, and that’s just a small percentage of the people we’ve helped. It is an incredibly moving experience, being around that many people who have put their trust in us, who have given my colleagues and me the opportunity to help them in their fight against pancreatic cancer.

Anything to add?
Part of the reason to continue doing this is we are constantly looking to make a big impact in the field of pancreatic cancer, and I think the next generation of advances is going to come from experimental work. That’s why we’re very fortunate to have several basic science laboratories here at Jefferson and many very smart scientists who are working on some elements of pancreatic or related cancers, understanding the genetics, and looking for therapeutic opportunities.

I am extraordinarily grateful that I have been given the opportunity to see and assess hundreds and hundreds of patients with pancreas cancer and related diseases. I am very much indebted to the scores of gastroenterologists, oncologists, nurses, other healthcare professionals, and past patients who have referred patients to us here at Jefferson and who have believed in our caring, our efforts, and our team.

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