Pancreatic surgery

Anatomy and function of the pancreas

The pancreas is a small but vitally important organ that lies across the back of the abdomen behind most of the other organs in your tummy. It has two very important functions: firstly it makes enzymes (digestive juices) that are released into your intestines (gut) to enable you to break down and absorb nutrients from your food. Secondly it makes hormones that are released into the blood stream which control the metabolism of sugars in your bloodstream and around your body. If the pancreas is not working properly these two sets of functions often break down. The anatomical relations of the pancreas are quite complex (see below).
In particular it is intimately related to several very large and important blood vessels.

Apart from the vessels shown above the pancreas is also in contact with the inferior vena cava, aorta, renal veins, splenic vein and artery, inferior mesenteric vein, gastroduodenal artery, common hepatic artery and coeliac artery; these are some of the most important blood vessels in the human body. Surgery on the pancreas always has to take into consideration the close proximity of these other organs and vessels. With some pancreatic operations it is often necessary to remove part or all of some adjacent organs in order to safely remove the part of the pancreas that is diseased.

2) Symptoms of pancreatic disease

Many pancreatic disorders have few obvious or specific symptoms. When the pancreas is inflamed (e.g. acute pancreatitis) it often causes pain, this is usually felt in the central or upper part of the abdomen and is often associated with back pain. The pain may be sharp, aching or burning in nature.

If the head of the pancreas is enlarged or abnormal then the bile duct may become blocked as it enters the pancreas, this blockage causes a build up of bile which leads to jaundice (a yellow discolouration of the eyes and skin) which is often associated with dark urine, pale motions and itchy skin.

Steatorrhoea is the medical term for the loose, pale, fatty, floating, offensive bowel motions which occur when the pancreas is not releasing digestive juices into the intestines and there is failure to absorb fats from the gut.

Weight loss is common with most pancreatic disorders because of the interference with digestion and sugar metabolism. Patients also get a loss of appetite with some pancreatic diseases.

Diabetes can be caused by pancreatic failure, it is usually characterised by weight loss, lethargy, thirst, blurred vision, increased volumes of urine and drowsiness.

3) Benign Pancreatic diseases

Acute Pancreatitis.

This is sudden inflammation of the pancreas. In over half the cases it is caused by a gallstone passing from the gallbladder, through the bile duct and temporarily blocking the exit from the bile duct and pancreatic duct.(upper picture)

This causes obstruction of the pancreas, and may allow bile to reflux into the pancreatic duct (lower picture - close up).

About a quarter of cases of acute pancreatitis are caused by drinking too much alcohol and there is a long list of other rare causes including a wide variety of prescription medications, virus infections including mumps, hypothermia and (in the tropics) scorpion stings. Most attacks of pancreatitis (about 80%) are relatively mild and settle spontaneously over a period of 4 or 5 days. The usual symptoms of pancreatitis are severe pain in the upper part of the abdomen, often going into the back, and at least one bout of vomiting.

About 1 in 5 people develop serious complications, either in or around the pancreas, or involving other systems in the body especially the lungs and the kidneys. These systemic complications are due to an excessive inflammatory reaction to the damage in the pancreas. At the moment treatment for this phase of the illness is supportive, and may require transfer to the intensive care unit if the condition is serious. The local complications in the pancreas are caused by severe inflammation leading to death (necrosis) of pancreatic tissue and the surrounding fatty tissue. Patients with necrosis usually have systemic complications as well and often need to stay in intensive care or high dependency unit for several days. The necrosis itself does not require treatment, and if the acute illness settles the patient may need no further treatment. However the necrotic tissue may become infected and when this happens the only solution is to remove the infected necrotic tissue. That usually requires a surgical operation which may be extremely difficult and is always hazardous for the patient. Fortunately it is relatively uncommon, and usually an operation can be avoided.

Later on after the initial pancreatitis has settled the necrotic tissue may lead to accumulation of a fluid collection called a pseudocyst next to the pancreas. Sometimes these resolve spontaneously by gradual absorption of the fluid, but sometimes, especially if there is a communication with the pancreatic duct, the cyst will persist and may cause symptoms by pressure on other organs, or by pain. Such symptomatic pseudocysts need treatment. This is usually done by internal drainage, either by placing a drainage tube or stent, or by a surgical operation.

The vast majority of patients with acute pancreatitis can be treated in their local hospital. However patients with pancreatic necrosis who may require surgery should be treated by a specialist pancreatic team. Such patients may need transfer to a specialist pancreatic centre for surgical treatment.

Preventing another attack. If the cause of acute pancreatitis is known, it should be treated or removed. If this can be done then a further attack of pancreatitis is extremely unlikely. If the pancreatitis is caused by gallstones it is essential to ensure that appropriate treatment to prevent a further attack is completed before the patient leaves hospital, or is planned to be completed within the next 2 weeks. This will usually be either by a laparoscopic cholecystectomy (removal of the gallbladder) with an x-ray (cholangiogram) taken during the operation to check for any stones in the bile duct, or else by an endoscopic procedure (ERCP and sphincterotomy) which opens the lower end of the bile duct and allows any stones in the duct to pass easily without causing obstruction <- link to gallbladder surgery->.

Alcohol and the pancreas.

When acute pancreatitis is associated with a high alcohol intake, and no other obvious cause is found, it is likely that the pancreatitis is due to alcohol. Different people have different levels of sensitivity to alcohol, and in some people with a moderate alcohol consumption, who have no other cause of pancreatitis, the illness may be due to alcohol. Anyone who has alcohol-associated pancreatitis is at risk of further attacks if they drink any alcohol at all; if they continue to drink they are also at risk of developing <-chronic-pancreatitis-> . We therefore advise anyone with alcohol-related acute pancreatitis to abstain from alcohol indefinitely.

Even if your attack of pancreatitis is not due to alcohol, it is wise to avoid alcohol during the 6-12 months immediately after. Pancreatitis causes severe injury to the pancreas, which goes through a prolonged phase of healing and recovery. During this time your pancreas is much more sensitive than usual to any harmful substance, and it seems wise therefore to avoid risking further injury. Once your pancreas has returned to normal after 6-12 months, depending on the severity of the attack, it is safe to return to moderate alcohol consumption.

Chronic pancreatitis.

This is an uncommon condition in which there is recurring inflammation and progressive damage in the pancreas. Symptoms usually include abdominal pain particularly in the upper abdomen, and often going into the back. Other symptoms may be jaundice, weight loss, changes in the bowel motions including frequency, and loose pale stools. In the late stages of the disease, diabetes may occur.

The commonest cause of chronic pancreatitis is long term alcohol consumption. However there are many other rare causes, and in at least a quarter of patients no known cause is found. The rare causes include exposure to industrial toxins, congenital variations in the pancreatic duct system and genetic factors.

Most patients with chronic pancreatitis require appropriate medical treatment. This includes replacement of pancreatic enzymes (enzyme supplements) attention to nutrition with a proper balanced diet, and regular checks to ensure adequate absorption of minerals and vitamins. The most important aspect of treatment for many patients is pain control. This may require a variety of different pain killers including strong analgesics such as morphine. Sometimes pain may be sufficiently severe to require surgical treatment (see below).

Patients who become diabetic will require treatment of the diabetes. In chronic pancreatitis this often means treatment with insulin rather than tablets.

The most important part of medical management is avoidance of any precipitating factors. For this reason any patient with chronic pancreatitis is advised strongly to avoid alcohol completely. Patients with alcohol-related chronic pancreatitis who continue to drink run a serious risk of continuing damage to the pancreas, repeated attacks of pain, and increased difficulty in managing other complications such as diabetes. However once the chronic pancreatitis has developed, attacks of pain may continue even if alcohol is avoided completely. This is because the scarring in the pancreas is sufficient to obstruct parts of the pancreas and lead to continuing damage.

Surgical treatment. There are two main reasons for surgical treatments in chronic pancreatitis. Surgery may be required to deal with pain from the pancreas, or to treat complications such as jaundice or painful pseudocysts.

Pain relief may be achieved by blocking the nerves to the pancreas. These run backwards from the pancreas and close to the spine, to enter the spinal cord high in the chest. In some hospitals they are blocked by a needle injection in the back, a procedure which depends on accurate placement of the needle tip using x-ray or ultrasound guidance. We prefer to use a procedure called thoracoscopic splanchnicectomy. This is a minimally invasive surgical operation done through the back of the chest, in which the nerves that carry the pain are visualised by the surgeon and divided. The surgeon can look for additional nerve branches and can be sure that all have been divided. With this approach the early results are very good, but unfortunately in some patients pain does recur as time goes by. With thoracoscopic splanchnicectomy about half the patients have good pain relief for at least two years.

Surgical treatment of pain may also involve operating on the pancreas itself, either by removing part of the pancreas, or by draining the pancreatic duct and surrounding inflamed tissue. Surgery can also achieve good treatment of complications such as jaundice (caused by blockage of the bile duct by fibrosis around the pancreas, or by drainage of painful pseudocysts). The exact type of operation depends on the main area of inflammation in the pancreas and some operations can correct a structural cause. Some patients benefit from a combination of removing part of the pancreas, and drainage of the remaining part. In operations for chronic pancreatitis we make every effort to avoid removing other organs, especially the stomach and duodenum. This helps to maintain digestive function as much as possible. Patients with painful chronic pancreatitis have a 4 out of 5 chance of good pain relief following surgical treatment. With surgery, pain relief is usually permanent, although some patients may get recurrence of symptoms if the pancreatitis progresses in the remaining pancreatic tissue.

4) Pancreatic cancer and other malignant tumours involving the pancreas

Cancers in organs close to the pancreas often spread into the pancreas and often require pancreatic surgery so they are considered here with pancreatic cancer
a) Pancreatic cancer: this is the sixth commonest cancer in the UK, it is rare under the age of 45 years. The most common symptoms are jaundice, weight loss, diabetes and back pain. In the UK as a whole less than 1:10 patients are treated with surgery, in our experience this can be pushed up to 1:5, by careful case selection.
b) Ampullary cancer: this is usually the easiest of the pancreatic cancers to treat because even very small tumours cause jaundice which means that the cancer is often picked up at an early stage which makes the surgery easier and likely to be more successful.
c) Bile duct cancer: lower bile duct tumours are treated the same as pancreatic cancers because they are hard to tell apart and behave in the same way. This tumour also usually causes jaundice at an early stage. Tumours higher up in the bile duct are considered in the section on<-liver cancer-> .
d) Duodenal cancer: this rare tumour usually causes a blockage to the exit of the stomach so it is common to get bloating and vomiting as the initial symptoms. Some patients also get anaemia because of blood loss into the gut.
e) Sarcomas: these are very rare cancerous tumours that arise from cells in the fat, muscles, nerves or blood vessels in or around the pancreas. The one we see most often is the GIST (Gastro-Intestinal Stromal Tumour) which develops from muscle cells in the wall of the gut. They often grow very slowly pushing other structures out of the way. Due to their slow progression they often do not cause many symptoms, thus by the time patients are aware of them they may be very large and attached to several different organs. However, because of their less aggressive nature it means that surgery to remove even massive tumours is worthwhile because a cure may still be possible. This extensive surgery may involve removal of parts of other adjacent organs (such as liver, kidney, stomach or colon) as well as part of the pancreas.
f) IPMT: this stands for intra ductal papillary mucinous tumour. These are very slow growing cancers that arise in the cells lining the ducts of the pancreas. They often cause chronic pancreatitis (see above) and they are often diffuse or multifocal (arising simultaneously in more than one part of the organ). They are usually surgically resectable, but sometimes require removal of the whole of the pancreas.

If you have one of these difficult tumours you must be assessed by a surgeon with a specialist interest in this disease. Your investigations should then be reviewed by your surgeon with the specialist pancreatic multidisciplinary team including radiologists, oncologists, physicians and surgeons. The ALLPS group is at the core of the Southampton multidisciplinary pancreatic team, which is the largest pancreatic unit on the south coast; we currently manage over 130 new pancreatic cases per year and perform 40 major pancreatic operations. By 2007 we expect to be treating all of the operable pancreatic tumours for Hampshire, The Isle of Wight, Dorset, South Wiltshire and West Sussex.

5) Surgery for pancreatic disease

This section will briefly describe just a few of the commonest operations that we do for pancreatic disorders, it would take a thousand page text book to cover all the many types of pancreatic surgery in detail.

5.1 Whipple’s pancreatico duodenectomy: this is the operation most commonly performed for tumours of the pancreatic head. It involves removal of part of the stomach, the whole of the duodenum, part of the small bowel, the head of the pancreas, the bile duct and the gallbladder, leaving behind the major blood vessels. There are many modifications of this procedure, which vary slightly in the extent of the resection in one direction or another, however there is no proven advantage of one variation over another.

After the head of the pancreas and the tumour have been removed it is necessary to reconstruct the anatomy in a functional form. Again there are seemingly endless variations for the reconstruction all of which have their exponents and their pro’s and con’s, two of the commonest reconstructions which we use are shown below.

1 = hepatico-jejunostomy
2 = gastro-enterostomy
3 = pancreatico-gastrostomy
4 = entero-enterostomy

Reconstructions after pancreatico-duodenectomy

This is very major surgery; there is no other routinely performed abdominal operation which can be considered greater in extent or impact on normal function. However in high volume specialist centres this procedure carries acceptable risks. Twenty five years ago there were centres reporting series of this operation with a twenty to forty per cent mortality risk, this is no longer acceptable. Current national guidelines suggest that mortality should be around 5% in specialist centres.

Since 2001 ALLPS group mortality rate within 28 days of Whipple’s pancreatico-duodenectomy is 1.8%.

Although our mortality rate is low this does not mean that this operation is without complication. There are a large number of possible complications of this surgery.

Risks of anaesthesia these have been minimised by improvements in pre operative evaluation and peri-operative care, however major surgery such as this places a huge strain on the bodies resources; the risks for any individual patient are different and are assessed person by person. If we think the risks are too great then we will advise against surgery.

Anastomotic leakage this is the risk of one of the joins in the reconstruction leaking after the operation. The join which is most likely to leak is that between the pancreas and stomach (number 3 above), this join is most likely to leak because of the caustic nature of the substances passing through it. Pancreatic juice contains very potent digestive enzymes which can break down proteins trying to heal the join and thus disrupt the reconstruction.

Diabetes: around 60% of patients having this operation will be diabetic afterwards, this varies in severity from just having to change your diet all the way up to requiring
Insulin.

Malabsorption of food: almost all patients after a Whipple’s operation require extra supplements of concentrated pancreatic enzymes to digest their food. These are supplied as capsules to take with meals.

Infection: this is a broad term that encompasses everything from a mild chest infection to abscesses inside the abdominal cavity.

Haemorrhage: most patients lose between 500-1500ml of blood during the operation. Patients who lose more than this or who are anaemic to start with usually require blood transfusion. Rarely patients develop a late postoperative haemorrhage and need to go back to theatre to control the problem again.

Despite all of these risks and potential complications, approximately 2/3 of patients will have returned home within 3 weeks of the surgery without significant complication. Fit patients should expect to stay in hospital for 10-15 days after the surgery.

5.2) Distal pancreatectomy: this involves dividing the left side of the pancreas to remove areas of disease in the tail and body of the pancreas. The tail of the pancreas lies directly in front of the blood vessels to the spleen, if these vessels cannot be preserved then we usually have to remove the spleen as well as it cannot survive without a blood supply. This occurs in around 60% of the cases we operate on, usually because there is tumour invading around the vessels. The spleen is an important part of the immune system, if we think there is a risk of having to remove the spleen then we routinely vaccinate you before the operation against a number of serious infections that you may be more prone to without a spleen.

Some patients are diabetic after this surgery because the body and tail of the pancreas contain most of the insulin secreting cells. Diasbetes is more likely to occur if the remaining pancreas is already damaged, for example by chronic pancreatitis. Diabetes is unusual after distal pancreatectomy for tumours.
Average hospital stay is 7-10 days after the surgery.

5.3) Pancreatic bypass: this operation is occasionally performed for patients with blockage of the bile duct or duodenum caused by pancreatic tumours that cannot be removed. In most cases we try and treat the blockages without surgery by placing plastic or metal drainage tubes internally by passing a telescope via the mouth into the stomach and duodenum. If this does not work then we can perform bypass surgery, however this is major surgery for such seriously ill patients to undergo and not something we under take lightly.

5.4) Beger’s resection: this is an operation for chronic pancreatitis that involves removing the head of the pancreas and then draining the pancreas into a separate loop of bowel. The duodenum is not removed, which helps to preserve normal digestive function. The pancreatic head is “cored out” leaving a rim of pancreas attached to the duodenum.
Average hospital stay is approximately 7-10 days.

5.5) Pancreatic necrosectomy: this operation is usually only performed for patients who are extremely ill with severe acute pancreatitis who have dead and infected areas of pancreas that require surgery to literally scoop out the dead tissue (necrosis) and wash out the cavity. This can be a life saving operation, but it carries very high risks and is never undertaken lightly. We always have to assess whether the patient is strong enough to survive the operation, before embarking on this extreme course of action. Sometimes the procedure can be done percutaneously, as a type of keyhole surgery, but not every patient is suitable for this, and a major open operation may be required. In this condition, patients often need several procedures with repeated operations to deal with extensions of the necrosis.

5.6) Drainage of pseudocyst: this operation is performed for patients with collections of inflammatory fluid (pseudocysts) around the pancreas. Sometimes the pseudocyst can be treated by endoscopic or percutaneous drains placed into the cyst. Many cases are not suitable for this approach, or recur after drainage, so surgery may be required. The surgery involves connecting the wall of the cyst to either the wall of the stomach or an adjacent loop of bowel and forming a permanent join that allows the fluid to drain into the stomach or intestine. Average stay in hospital is around 5-10 days after this operation

5.7) Thoracoscopic splanchnicectomy: this operation is a keyhole procedure that involves dividing nerves (splanchnic nerves) within the chest that supply sensation of pain to and from the pancreas. It is a very effective procedure for controlling pain from chronic pancreatitis or untreatable tumours. Unfortunately in some patients the response starts to wear off after a year or two. Most patients go home within 48 hours of the operation.

5.8) Pancreatic bypass: this operation is occasionally performed for patients with blockage of the bile duct or duodenum caused by pancreatic tumours that cannot be removed. In most cases we try and treat the blockages without surgery by placing plastic or metal drainage tubes internally by passing a telescope via the mouth into the stomach and duodenum. If this does not work then we can perform bypass surgery, however this is major surgery for such seriously ill patients to undergo and not something we under take lightly.

6) Common questions before or after pancreatic surgery

Will I need a blood transfusion after the operation? The majority of patients do not require blood transfusion after pancreatic surgery (including Whipple’s procedure). For routine surgery we expect the blood loss to be between 500-1500ml. If you are anaemic before the surgery you are more likely to require transfusion.

How long will I be in hospital? This depends on the nature of your illness, your fitness, social circumstances and the extent of the surgery you require please see the operations section above for some further guidance.

I have gone home with a plastic drainage tube coming out of my tummy, is this ok? We routinely place several plastic tubes into the abdomen during major pancreatic surgery (e.g. Whipple’s procedure), it is common to go home with at least one of these in place as a temporary measure. One tube is a feeding tube that is used in the first few days after surgery to give nutrition into the gut whilst all of the joins heal up, another tube is a safety valve (stent) that we place across the join between the pancreas and the stomach to take pressure off this join as it heals up. Both of these tubes are fixed internally with a dissolving stitch, when we see you in outpatients 4-6 weeks after the surgery the stitch will have dissolved and the tubes can be removed. The final tube is a larger drainage tube, that we usually remove a week after the operation whilst you are still in hospital, if the drainage fluid is excessive or infected or rich in pancreatic juice then the drain stays in until the problem has settled.

When will I go back to work? Every individual and their response to surgery is different but the majority of patients having uncomplicated routine open pancreatic surgery are able to go back to work three months after the operation. Younger, fitter patients may get back sooner as may those who have desk jobs. In general terms it is good advice not to rush back to work as major surgery is often more debilitating than people think and it is unwise to return to a heavy schedule until you are strong enough to face it.

When can I drive a car? It is usually around six weeks after surgery before you can try driving again. You must be moving freely enough to operate the wheel, gears and instruments without restriction and most importantly be able to perform an emergency stop without discomfort or difficulty.

I am still getting some pain after the surgery, is this normal? Every week after the operation you should feel the discomfort improving, however when you first get back to strenuous physical activity it is common to get some twinges of pain in the upper part of the abdomen as the scar and the deep layers of sutures in the muscular wall of the abdomen heal and settle down. You may get the odd twinge even a year or more after the operation on certain awkward movements or activities. If you are getting pain or discomfort that is worse than when you were discharged from hospital you should seek advice from a doctor or qualified nurse familiar with your treatment, this could be your GP or practice nurse or a member of the liver surgery team.

Will I need chemotherapy as well? This is a common question after pancreatic cancer surgery and one that can only be answered for specific individuals; it depends on the type of tumour, the type and results of surgery and your state of health. If we think it might be helpful we will ask one of our oncology doctor (chemotherapy) colleagues to give an opinion. For many pancreatic cancers the answer is not clear and therefore we may suggest going into one of the national studies that we are involved in looking at different combinations of treatments to improve outcome.

The wound looks a bit red, is it infected? Most wounds look quite red and angry a few weeks after the surgery when the clips or sutures have been removed, this is a normal part of the healing process. If the wound has got a wider red patch on it or particularly if it has discharged pus or you feel feverish you need to be seen by a doctor or qualified nurse familiar with your treatment. This could be your own GP or practice nurse or we are happy to arrange review back on the ward or in outpatients if it is more convenient.

Can I drink alcohol? In the first few weeks after major pancreatic surgery it is wise to be cautious and avoid alcohol, (although for those patients who feel the need it is probably safe enough to have one or two units of alcohol to celebrate release from hospital).

Patients who have had alcohol related pancreatitis must stay teetotal for life or risk developing recurrent attacks and life threatening complications.

Am I going to be followed up? In general we carry on seeing most of our patients on whom we do pancreatic surgery. If we have removed a cancer from your pancreas we normally keep you under review for 5-10 years. If you live outside the Southampton area we will discuss your case with your local doctors and usually make an arrangement for follow up so that you see a local surgeon or oncologist and have most of your blood tests and scans done in your local hospital and only come and see us for an annual check up or if there are problems.

Will I need long term treatment after a pancreatic operation? After an operation which has removed part of the pancreas it is very common to need to take pancreatic enzyme supplements to help with digestion of food. Sometimes pancreatic function recovers with time, but this treatment often needs to be life-long. If you become diabetic after surgery, that is also usually a permanent change.
We have found from studying patients after surgery, that removal of the head of the pancreas, and the duodenum (Whipple’s operation) can lead to deficiencies of iron, calcium, and some other minerals and vitamins. We recommend daily vitamin and mineral supplements after this type of surgery (We prescribe Forceval and calcichewD3)

Useful Links

Pancreatic Society of Great Britain and Ireland