Pancreas Surgery

What is the pancreas?

 

The pancreas is part of the digestive system.  It produces enzymes used in digestion and hormones (such as insulin) that are involved in regulating blood

sugar levels.  It is made up of head, neck, body, tail and uncinate process.  The pancreas is contained within a loop of the first part of the small bowel.  The bile duct passes from the liver, through the pancreas and into the small bowel.  Major blood vessels that take blood to and from the small bowel pass through the pancreas.

 

 

Why do people need pancreas surgery?

 

People usually undergo pancreas surgery to remove tumours of the pancreas.  These tumours usually arise in the pancreas.  Occasionally pancreas surgery is required to treat infections or manage traumatic injuries.

 

 

Who is suitable for pancreas surgery?

 

Patients are suitable for pancreas surgery depending upon the reason for the surgery.  For patients with pancreas cancer, the tumor needs to be confined to the pancreas without involvement of the major blood vessels that take blood to the liver and intestines.  Patients need to be fit enough to tolerate major surgery.

There is no limit to the amount of pancreas that can be safely removed.

 

 

Who is not suitable for pancreas surgery?

 

Patients whose tumors have spread beyond the pancreas or have extensive involvement of blood vessels that supply blood to the intestines or liver are not generally suitable for pancreas surgery.  Patients who are not fit enough to undergo major surgery are not usually suitable for pancreatic surgery.

 

 

What kind of investigations are required prior to pancreatic surgery?

 

Often patients with tumors in their pancreas first become symptomatic when they become jaundiced (yellow coloring of the skin) due to blockage of the bile dct (which takes bile from the liver to the small bowel).  These patients often require an endoscopy (ERCP) to relieve their jaundice. 

 

Most patients usually required imaging of the abdomen such as ultrasound, CT scanning and often MRI scanning to determine the size, location and probable nature of the pancreas tumour.  Other investigations include blood tests to check tumour markers such as CA19.9 and Chromogrannin A are also usually required.  A CT scan of the chest to exclude spread of liver tumours to the lungs. 

 

 

What is neoadjuvant therapy?

 

Patients with pancreas cancers that are in contact with or invading the blood vessels that take blood to the liver and the small bowel sometimes receive chemotherapy and radiotherapy prior to pancreas surgery.  These patients often require a biopsy performed through an endoscope (either ercp or eus) to confirm the diagnosis of cancer prior to receiving chemotherapy or radiotherapy.

 

What kinds of pancreas surgery are commonly performed?

 

There are two operations commonly performed on the pancreas.  The first operation is called a “Whipple’s Procedure” or pancreaticoduodenectomy.  It involves removing the head of the pancreas, along with the gallbladder, bile duct, the first part of the small bowel and part of the stomach.  Anastomoses (joins) are required between the small bowel, pancreas, bile duct and stomach. 

 

Surgery to remove the body and tail of the pancreas is called a Distal Pancreatectomy.  This usually involves removal of the spleen at the same time. 

 

Surgery on the pancreas is usually performed under general anaesthesia using an open technique ie a large incision on the abdomen.  Occasionally small tumours located in favourable locations can be removed with small incisions using the operating telescope (laparoscopic pancreas surgery).

 

 

Are there alternatives to pancreas surgery?

 

Surgery provides the best chance of cure for patients with tumors confined to the pancreas.  Patients with tumors that cannot be removed with surgery can be treated with chemotherapy and radiotherapy.

 

 

What is my experience with pancreas surgery?

 

I have been performing pancreas surgery as a consultant surgeon at the Canberra Hospital since 2005.  Over that time I have performed over 50 pancreas resections.

 

 

What is a multidisciplinary team meeting?

 

Often patients with suspected cancers in their pancreas are discussed in a meeting with other medical specialists such as surgeons, radiologists, pathologists, medical oncologists, radiation oncologists and interventional radiologists to ensure that patients are offered what is thought to be the best care.  At Canberra Hospital we have a Gastrointestinal Multidiciplinary Group that meets weekly.

 

 

What is involved in the surgery?

 

Once the decision for surgery has been made the patient is asked to sign a consent form and a request for admission is lodged with Canberra Hospital along with an expected surgery date.  Patients usually attend a pre-admission meeting with an anaesthetist a few days prior to their surgery.  They are admitted to hospital on the morning of their surgery.

 

In the operating theatre the anaesthetist will insert an iv drip.  Often they will also insert an arterial line and and epidural catheter or spinal anaesthetic.  Once the patient is asleep a catheter is placed in the bladder.  An incision is made in the upper abdomen, usually the rib cage.  The gallbladder is taken off the liver.  The first part of the small bowel (duodenum) is lifted off the abdominal wall.  The bile duct and blood vessels to the liver are identified above the pancreas,  a tunnel is made between the neck of the liver and the blood vessel that takes blood from the small bowel to the liver (portal vein).  Once the decision has been made that the tumor can be removed, the neck of the pancreas is divided (cut).  The bile duct, stomach and small bowel are divided. The remainder of the pancreas is taken off the blood vessels that take blood to and from the small bowel (portal vein and superior mesenteric artery)and the specimen (pancreas and duodenum) is removed.  Usually the cut end of the pancreas and bile duct are  checked by the pathologist to ensure that no tumour is left behind.

 

Once the cancer has been removed a join (anastomosis) is made between the small bowel and the ct end of the pancreas and the small bowel (pancreatico-jejnostomy).  If this join is thought to be at particularly high risk of leakage, then a small tube that comes out through the skin is left in the pancreas (pancreatic stent).  A join is then made between the bile duct and the small bowel.  Finally a join is made between the stomach and the small bowel.  Two drains are left in the abdomen, coming out through the skin, and the wound is sutured closed.

 

At the end of the operation the anaesthetist usually removes the breathing tube and the patient is taken to the intensive care unit for overnight observation.  In the usual course of events patients are then transferred to the regular ward the day after the operation.  All being well, patients are usually ready to be discharged home seven days after their surgery.

 

 

What are the risks of pancreas surgery?

 

There are risks that are part of any major abdominal surgery and those that are specific to pancreas surgery.  General risks include:

1.         Death - whilst pancreas surgery is safe, overall the chance of not making it out of hospital after pancreas surgery is less than five percent.  This risk depends on the age of the patient, the presence of health problems and the type of the resection being contemplated.

2.         Medical risks such as heart attack, stroke, clot in the lungs and pneumonia.  Usually the risks of these complications is very small.

3.         Surgical risks such as bleeding, infection, hernias and injury to the bowel.

 

Risks specific to all pancreas surgery include

1.         Benign diagnosis - rarely a tumour that is thought to be a cancer can be found be a benign tumour when it is looked at by our pathologists

2.         Non-resection - rarely, at the time of surgery, the disease can be more extensive than predicted based on pre-operative imaging making a major pancreas resection futile.

3.         Recurrence - occasionally cancerous tumours can re-occur within the liver or beyond it following liver surgery.  Recurrences within the liver can often be treated with further surgery.

4.         Adjuvant therapy - if the removed tumour in the liver is a cancer patients may be referred to a medical oncologist to discuss the benefit of further treatment in the form of chemotherapy in order to reduce the risk of recurrence.

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Risks specific to the Whipple’s procedure (pancreatico-duodenectomy)

1.         Anastomotic leak – pancreas surgery on the head of the pancreas requires joins between the small bowel, stomach, bile duct and pancreas.  Whilst any of these joins may leak, it is the pancreatic anastomosis that is most likely to leak and the most likely to require more surgery and a prolonged hospital stay. 

2.         Delayed gastric emptying – it may take some time after pancreas surgery for the stomach to be able to empty into the small bowel.  Occasionally patients require feeding through the drip (Tpn) to support them through this period.

3.         Bleeding from the stomach – patients may bleed from the join between the stomach and the small bowel.  This risk is reduced by taking an acid medication (such as losec) after the operation.

4.         Diabetes – about twenty percent of patients will become diabetic as a result of their surgery.

5.         Malabsorption – the pancreas produces enzymes that aid in digestion.  These enzymes are often replaced after the operation with tablets (for example creon)

 

Risks specific to Distal Pancreatectomy

1.         Pancreatic fistula – during distal pancreatectomy, the pancreas is cut in half and the body and tail of the pancreas are removed.  Around twenty percent of the time patients with leak pancreas juice from the cut end of the pancreas.  This can take some time to heal.  Patients can be discharged home with a drainage bag. 

 2.        Post-splenectomy sepsis – often the spleen is removed with the tail of the pancreas during distal pancreatectomy.  The spleen is involved in fighting some specific forms of infection.  For this reason patients are routinely immunised against specific bacterial infections (pneumococcus, meningococcus and haemophillus influenza b) prior to undergoing distal pancreatectomy.  Patients will usually be discharged on long term antibiotics.

 4.        Diabetes – about twenty percent of patients will become diabetic as a result of their surgery.

 

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What are the costs of pancreas surgery?

 

As a public patient in Canberra Hospital there should minimal out of pocket costs.  Occasionally patients are asked to undergoing specialised imaging tests such as MRI which is not rebated by Medicare and may be out of pocket for this investigation.

 

 

What are the results of pancreas surgery?

 

The results of pancreas surgery depend upon the disease being treated.  Patients with pancreatic cancer tend to do poorly without surgery.   The results of surgery have been improving over time.  With the introduction of neoadjuvant therapy and vascular reconstruction the percentage of patients with pancreas cancer that are able to undergo pancreas surgery has been increasing.  A recent large randomised controlled trial (PREPANC ) demonstrated a five year survival of 20% for patients undergoing neoadjuvant therapy followed by surgery.

 

 

Is further treatment required after pancreas surgery?

 

Occasionally further treatment, usually in the form of chemotherapy or radiotherapy is recommended following surgery.

 

 

What follow up is required after pancreas surgery?

 

Patients are seen one to two months after surgery in the general outpatient clinic at Canberra hospital.  Follow-up thereafter depends on the tumour that has been removed.  Usually the recommendations of the NCCN (National Comprehensive Cancer Network) are followed. This often involves regular clinic review, blood tests and CT scanning.