Pancreatic Cancer

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.

It is anatomically divided in 4 parts: the head, the neck, the body and the tail. 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: the superior mesenteric vein ”SMV” superior mesenteric artery “SMA” and the splenic vein and artery.

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.

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.

Pancreatic Cancer

PANCREATIC HEAD MASSES
What is it?
It is important to distinguish between cancers that originate from different structures, which can present in the pancreatic head giving very similar clinical picture. In the pancreatic head or the peri ampullary region (as near to the ampulla of Vater in the second part of the duodenum) cancers can originate from the pancreatic tissue, the distal bile duct, the ampullary tissue or the duodenum itself. Each of these cancers may have different behaviour and prognosis despite the similar presentation. Unfortunately it is sometimes difficult to define the origin of the cancer before taking the whole specimen for histological exam.

Pancreatic Cancer
Is the sixth commonest cancer in the UK. The most common symptoms are jaundice, weight loss, diabetes and back pain. The treatment of choice is surgery, if the tumour presents in an early stage (before invading the adjacent vessels or giving liver metastasis).

Ampullary Cancer
The most common symptom is jaundice. It tends to present earlier which permits a better chance of surgical treatment.

Distal Bile Duct Cancer
These are cancers origination from the lower part of the bile duct. They present early with jaundice are likely to be diagnosed in an early stage.

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.

Other cancers involving the pancreas
Intraductal papillary mucinous tumors (IPMTs). These are newly diagnosed neoplasm, they originate from the pancreatic ducts and secret mucin. They may present with pain or symptoms of acute or chronic pancreatitis. Generally, they are very slow growing cancers, and are not always indicated for surgical treatment; they can be removed with a very good long term outcome.

Surgery for Pancreatic Disease

WHIPPLE'S PROCEDURE
This is the standard procedure for the treatment for pancreatic head (periampullary) cancers. It is a very complex procedure and requires highly technical surgical skills. It should be only performed in specialist centres by expert surgeons, who perform it regularly. It involves a resection part, this involves the 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. This is followed by the reconstruction part, this involves the reconstruction of the pancreatic, biliary and gastric anatomy. The stomach and bile duct are joined to the small bowel and the pancreas can be joined to either the stomach or the small bowel. The reconstruction choices depends on intraoperative findings and surgeon's judgment.
Commonly this procedure is performed with a minimally invasive approach (laparoscopic or robotic) with the exception of special cases.

What is the mortality rate?
In pancreatic centres this should not exceed 3-5%.

What are the surgical risks?

Anastomotic leakage: this procedure involves 4 joins (stomach to small bowel, bile duct to small bowel, pancreas to small bowel, small bowel to small bowel ) . Any of these joins is at risk of leaking after the operation. The highest risk of leak is from the joins involving the pancreas. This risk is around 20% in most centres. However, drains (plastic tubes) are normally positioned near the join to drain any leak out of the abdomen. This permits a conservative management of this complication as the leak would normally heal within 2 weeks.
Bleeding: it is a risk in any surgical procedure especially in major surgery. However, thanks to advances in surgical techniques, in expert hands blood loss is now significantly reduced and the need of intra operative blood transfusion is quite rare.
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 help 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.

These are potential risks and they are usually reversible. Very careful post operative care is needed to ensure their prompt identification and treatment.

DISTAL PANCREATECTOMY
This procedure is approached almost exclusively by a minimally invasive approach (laparoscopic or robotic) and involves removing the left side of the pancreas (body/tail). It is a more simple procedure that Whipple's procedure as less organs will be resected and there is no reconstructive part. The procedure is performed through 4-5 small incisions and the specimen is removed in a bag through a 3-5 cm supra pubic incision (similar to a cesarian section). In some cases the spleen may also need to be removed, this depends on the type of disease , its relation with vessels and its location.

Common Asked Questions

Will I become diabetic?
This is possible in around 40% of patients after pancreatic resections. This depends on the status and the size of the remnant pancreas.
How long will I be in hospital?
Average hospital stay after whipple's resection is 10 days, after distal pancreatectomy, it is 5 days if completed laproscopically and 8-10 days in open cases.
What are surgical drains?
These are plastic tubes positioned in the surgical area to ensure that any blood or fluid is drained out of the abdomen. These will be removed within 5-10 days from surgery unless there are complications such as leak. In these cases the drain is left till the leak heals. However, patients may be discharged home with a drain and reviewed regularly in out patient clinic.
When will I go back to work?
This depends on many factors including the type of surgery performed, the indication for surgery, your fitness and type of work. This will be decided with patients before discharge.
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 and able to perform an emergency stop without discomfort or difficulty.
Will I be in pain after surgery?
After key hole surgery there is less pain as there will be no large incisions. In open surgery, pain will be initially controlled with epidural, oral and intravenous pain killers. You will be discharged on regular pain killers, however at that stage there should be no significant pain but some discomfort which will continue to improve and normally resolves in 3 weeks.
Will I need chemotherapy as well?
This depends on the type of tumour and your state of health. This will be decided after discussing the histological findings in the Multidisciplinary team meeting. In almost all patients with malignant cancers, chemotherapy may offer clear advantages in terms of improving quality of life and prognosis.
Can I drink alcohol?
In the first few weeks after major pancreatic surgery it is wise to be cautious and avoid alcohol. Patients with alcohol related diseases such as chronic and acute pancreatitis alcohol should be completely stopped.
Am I going to be followed up?
Yes you will be regularly seen in outpatient clinic in the first year. Follow up will be continued based on your disease and clinical needs.
Do I need regular medications following major pancreatic surgery?
Yes, in addition to any regular medication you are regularly on, you will need to take; pancreatic enzyme supplements to help with food digestion, calcium and multivitamins for life. Tablets to protect your stomach will be needed for at least 6 months.

To book a visit

Prof. Mohammad Abu Hilal is the Director of the Department of General Surgery and Head of the Hepatobiliopancreatic, Robotic and Minimally Invasive Surgery Unit at Fondazione Poliambulanza.

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