A Whipple Way Before Whipple

Dr. Whipple, In Fact, Did Not Perform The First Whipple

Alan Oldfather Whipple was obviously a giant in the field of pancreatic surgery, having performed the first successful one-stage pancreaticoduodenectomy in 1940. We covered his life and accomplishments in a previous newsletter. However, Dr. Whipple clearly stood on the shoulders of giants. In the field of pancreatic surgery, there was no giant taller than Alessandro Codivilla.

Who?

Alessandro Codivilla was born on March 21, 1861, in Bologna, Italy. As the youngest of two children, with his father being a pawn broker, he grew up under modest conditions in a family with great interest in music. At school, he differed from his contemporaries by his calm character and affection for study. Early on, he showed a special interest in the studies of sciences. After entering medical school, he distinguished himself with his talent in anatomic dissection. He financed his education through tutoring other students and graduated in 1886 with honors from the University of Bologna. His dissertation addressed the operative treatment of pulmonary empyema. He then performed military service at the School of Military Sanitation in Florence, Italy. In May 1888, he was chosen surgical assistant to Pietro Loreta, later succeeded by Alfonso Poggi, at the surgical clinic of the University of Bologna. In October 1890, after his 2-year apprenticeship, he accepted the position of director at a small hospital in Castiglione Fiorentino, Italy. In June 1894, he changed appointments to another rural hospital in Macerata, Italy. This period was quite difficult for Dr. Codivilla and only 6 months later, in December 1894, he accepted a position in Imola. On January 1, 1895, he opened his practice as surgeon-in-chief at the Ospedale Civile di Imola.

The First Pancreatic Surgeries In Humans

At this time in the late 1890s, major resections of the pancreas were still considered futile by most surgeons, primarily because of limited techniques of hemostasis and the absence of adequate resuscitation. At the turn of century, Benjamin Tilton described pancreatic operations as follows:

The deep location of the organ, its immobility, and its close proximity to very important structures makes such operations most difficult and dangerous. . . . Incision of the gland itself, enucleation of a tumor or partial removal are all difficult and bloody. . . . 

With the technical advances in the evolving field of abdominal surgery of the 1880s, selected cases of pancreatic resections started to emerge. Probably the first reported case of pancreatic head resection originated from Italy. This operation involved an enucleation of a large mass in the head of pancreas and was performed by Giuseppe Ruggi at the surgical hospital of the University of Bologna on September 4, 1889. Interestingly, Codivilla was a surgical trainee at that time in the same hospital, albeit on a different service. It is not known whether Codivilla was aware of or even involved in Ruggi's operation. Five years later, in 1894, Domenico Biondi of Cagliari, Italy, performed the first partial pancreatic head resection with known transection of the pancreatic duct using what might now be referred to as duodenum-preserving pancreatic head resection with reapproximation of the duodenum to the pancreatic remnant.

February 7, 1898

Dr. Codivilla met a 46 year old man from a town near Imola who presented with a mass in the abdomen that was fist sized and noticeable on physical examination in the umbilical region. Plans were made for surgery. Overall, the details about Codivilla's operation are sparse and leave much room for interpretation. It is likely that chloroform inhalational anesthesia was used, as was used by Codivilla for most of his abdominal operations at the time. It is also likely that Codivilla was first assisted by dal Monte, who was the only surgical assistant in the hospital between 1897 and 1901. A large tumor was found in the head of the pancreas at surgical exploration. It appears that Codivilla considered enucleation of the tumor but decided to resect the distal stomach and proximal duodenum en bloc because the neoplasm was adherent to the duodenum.

This was his surgical note from that day.

Admission: February, 7 1898; First and Last Name: [the name of a male patient from a town near Imola was provided]; Age: 46 years; Profession: Peasant; Diagnosis: Carcinoma of the stomach and the pancreas; History: The sickness caused multiple years of suffering from stomach trouble, consisting of difficulties with digestion. Pain that corresponded with the stomach after eating food and a few times vomiting. In essence vomiting for about 20 days before noticing blood. Treatment: Resection of the stomach and duodenum. Resection of the pancreas. Cholecystoenterostomy. Gastroenterostomy; [signature] Codivilla.

Concerning the operative technique used, Codivilla did not mention mobilization of the duodenum to evaluate the pancreatic head, a concept first described in 1895 to establish access to the retroduodenal common bile duct but not popularized until 1903 by Theodor Kocher. The common bile duct and distal duodenal stump were oversewn. Intestinal continuity was reestablished by a Roux-en-Y gastrojejunostomy and cholecystojejunostomy over Murphy buttons. The wound was packed for tamponade. There was no anastomosis of the pancreatic stump. Although Codivilla did not describe how he handled the pancreatic remnant in enough depth, it is likely that he closed it with suture ligatures similar to the usual technique of the time for dealing with the stump after distal pancreatectomies. Formal pancreato-enterostomies were not popularized until 1905. Nevertheless, the “tamponade” described by Codivilla was likely an iodoform gauze exteriorized through the wound, which Codivilla appeared to prefer according to descriptions in his previous article on gastric resection. Later removal of the tamponade may have provided a tract for drainage of any presumed pancreatic fistula.

The histologic evaluation revealed a carcinoma of the pancreas. After the operation, serous drainage was noted from the wound with evacuation of milky clots on day 5 (suggestive of a pancreatic fistula). The patient developed steatorrhea and died of cachexia 18 days after the operation.

The magnitude of Codivilla's surgery cannot be underestimated. Common perception at this time was that removal of the duodenum, especially ". . . the second portion [of duodenum] which is attached with the pancreas and the choledochus, does not seem compatible with life . . . " And yet, this surgery set the stage for exponential growth in pancreatic surgery. The second reported pancreatoduodenectomy was not recognized until the Sauvé publication of 1908. In 1906, while at the hôpital Lariboisière in Paris, France, Paul Michaux resected a large portion of the head of pancreas, the second and third portion of duodenum, and the distal bile duct for a fist-sized “sarcoma” in the head of pancreas; the patient died the same day of hemorrhagic shock. The third reported pancreatoduodenectomy and first survivor of this “new” operation was performed by Oskar Ehrhardt of the Elisabeth-Krankenhaus in Königsberg, Prussia, in 1907. Further pancreatoduodenectomies followed by Walther Kausch of the Augusta-Viktoria-Krankenhaus in Berlin, Germany, in 1909, Georg Hirschel of the Chirurgische Universitätsklinik in Heidelberg, Germany, in 1912, Ottorino Tenani of the Clinica Chirurgica Generale in Florence in 1918, and Gustav Dencks of the Neuköllner Krankenhaus in Berlin in 1923.

All 7 pancreatoduodenectomies were “nonanatomic” resections (by current standards) removing only part of the head of pancreas and duodenum. The operative mortality was about 40%.

And Whatever Happened To Codivilla?

With his reputation as a talented surgeon and clinician spreading rapidly beyond Imola, Codivilla in 1898 received an offer to become the director of the Rizzoli Institute, a privately-funded orthopedic hospital that had opened 18 years earlier in an old monastery at the outskirts of Bologna. Apparently, he was reluctant initially to take the new position in orthopedic surgery, but after visiting other orthopedic surgery institutions in Europe, he resigned from his general surgery practice on January 31, 1899, and moved back to Bologna.

His orthopedics practice grew substantially and rapidly. Throughout his lifetime, Codivilla wrote 124 publications. Throughout his career, he was a member of several national societies and served as president of the Società Italiana di Chirurgia, the Società Italiana di Ortopedia, and several other prestigious organizations. Codivilla provided many advances to the field of orthopedic surgery. In 1901, he published a unique way to repair ankle deformities. The technique developed by Codivilla was immediately internationally recognized and was applied by several surgeons across Europe. One of his most prominent contributions occurred in 1903, when he introduced skeletal traction with a bone nail. His advances in the treatment by external pin fixation and traction for limb lengthening continue to be regarded as foundational. Even today, Codivilla is considered frequently to be the father of orthopedic surgery in Italy.

Under his direction, and furthered by his pupil Vittorio Putti, the Rizzoli Institute grew to ultimately be regarded as one of the finest orthopedics hospitals in the world.

Despite worsening left lower quadrant abdominal pain from presumed recurrent diverticulitis that he had since the age of 25 years, he remained active as the head of the Rizzoli Institute until the end. In November 1908, he underwent an intestinal bypass for colonic obstruction from a presumed inflammatory mass in the sigmoid colon. Shortly after the operation, he returned back to his work. Yet, a colonic obstruction reoccurred in September 1911 requiring emergent intestinal resection in December 1911. On February 28, 1912, Codivilla died at the young age of 50 years.

A monument to this monumental surgeon is in the courtyard of the Rizzoli Institute in Bologna. At its dedication, his pupil, the renowned surgeon Putti published a memorium that can be found here.

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