Pancreas

Pancreas

File:1820 The Pancreas.jpg

 

The pancreas is a complex organ that lies right at the posterior part of the abdomen across the vertebral column. In short there are two major functions that the pancreas provide. One of them is what we call the exocrine part of the pancreas which secretes enzymes and the enzymes are delivered to the small intestine in order to meet with the food and they will help along with the bile to digest and absorb fats and proteins in the diet.

Another part of the pancreas is the endocrine and that means that there are certain cells in groups called the Langerhans islets. One of the major functions of these cells is the production of insulin. The insulin is the hormone that regulates glucose in the blood and hence the pancreas is connected to diabetes.

Cancer of the pancreas, when we mention that term, it is a neoplastic malignant growth that arises from the exocrine part of the pancreas which mainly affects the pancreatic duct. Alternatively it is called ductal adenocarcinoma of the pancreas. Basically the cancer arises from a mutation in a single cell that will gradually acquire more and more DNA changes which are called mutations which lead to the pancreatic cancer growth and its spread.

The endocrine part of the pancreas also does have tumours however they only constitute about 15% of all of the tumours that arise from the pancreas compared with the adenocarcinoma of the pancreatic duct.

Risks for pancreatic cancer in general are the following:

  1. Smoking is a major preventable risk factor which increases the risk of having pancreatic cancer to about three to four times more than a non smoker
  2. Obesity and a fatty diet
  3. Pancreatitis
  4. Family history of pancreatic cancer and also inherited recurrent pancreatitis. Also cancer family syndromes in people who are predisposed to have bowel cancer, breast cancer and ovarian cancer.

Having said that most pancreatic cancers are called sporadic and they happen in a sporadic manner or just randomly, usually as a result of interaction between genetic factors and environmental exposure to a variety of carcinogens.

Condition, Treatment & Procedure

It is important to be aware particularly for the Doctors and patients relatives of the warning signs of pancreatic cancer. Unfortunately despite all the advances in medicine pancreatic cancer is very difficult to detect at its early stages where it theoretically should be curable. However, only a minority of patients will present at a stage where the cancer can be removed and cured. The warning signs and symptoms of pancreatic cancer are generally well known. Some of the cancers that are present in the head of the pancreas can include the bile duct at early stages because the bile duct traverses the pancreas. The patient will become jaundiced with itching, pale stools and dark urine and some of these patients do present early to medical attention where they can be treated effectively. If someone suddenly turns jaundiced, particularly when there is no pain associated with it the major concern will be pancreatic cancer. They are advised to speak to their Doctor to be investigated for the possibility of pancreatic cancer as jaundice tends to be a bad sign in general and an alarm for the diagnosis of cancer. However, there are other causes for jaundice other than pancreatic cancer which could be a stone disease or other benign problem such as troubles with chronic pancreatitis. The other possible symptoms of pancreatic cancer are similar to cancers that effect the other organs and they will be mainly in the form of a new onset of pain in the top part of the abdomen just below where the heart is, particularly if that pain is radiating to the back. That should be an alarming sign to anyone to get investigated for pancreatic cancer. A new onset of dyspepsia or lack of appetite, weight loss and excessive fatigue is an important warning sign where patients will feel they are really exhausted after minor tasks and they need to have some rest after doing anything. A fever, night sweats and itching in addition to the fatigue and lack of appetite should prompt your Doctor to investigate you for the possibility of cancer which can be pancreatic cancer.

Whenever there is suspicion of pancreatic cancer there will be certain tests that will need to be done and these tests will include some blood tests. We check for what we call tumour markers for cancer of the pancreas and once the blood test has been done your Doctor will order a series of imaging. They might start with an ultrasound scan. Ultrasound is good to look at the biliary tree, the gallbladder and the bile duct to ensure there are no stones in these organs. However, it is not a good morality to investigate pancreatic cancer and we advise every patient to have a CT scan of the abdomen in that situation. The CT scan or what generally is known as CAT scan is a comprised form of abdominal x-ray that will be able to detect any mass bigger than about five to seven millimetres in the pancreas. There are some difficulties to find the mass sometimes, it depends on the type of the tumour and the CAT scan can miss about 15% of masses in the pancreas. In that situation your Doctor might organise an MRI to also look for lesions in the pancreas as well as in the bile duct that could be responsible for the jaundice. If there is a mass in the head of the pancreas or elsewhere and your Doctor is concerned about cancer of the pancreas there are other tests that might need to be done in order to confirm the diagnosis. Such as endoscopic ultrasound and fine needle aspiration. Or to ensure the disease has not spread elsewhere you will need a CT scan of the chest, abdomen and pelvis in addition to what is called a PET scan to look for cancer spread in other organs. Staging of the disease is of prime importance and if the disease is localised to the pancreas it can be potentially resectable. Your surgeon will decide on what the next step is going to be in order to ensure you get the appropriate form of treatment and advice. Because the pancreas lies close to the major vessels that provide blood to the gastrointestinal tract which are vital to life if the cancer has invaded or are in very close proximity or encased one of the major vessels in the abdominal cavity then it might become non resectable

Some patients would ask why there is no screening test for pancreatic cancer. True, there is no screening test for pancreatic cancer due to the fact that most of the cases are sporadic. However, there is a small group of patients who make up about 10% of all cases of pancreatic cancer where the disease can be inherited as a faulty gene or an unidentified genetic element in familiarly pancreatic cancer with more than one first degree relative effected by the cancer. There are certain blood tests and images that can be done but the screening process would only target a small amount of the population and there is no available screening test for the rest of the population for pancreatic cancer.

If a suspicion arises on blood tests or symptoms then it is advised to have at least a CT scan and this could be followed by what we call an endoscopic ultrasound scan which is ultrasound examination to the pancreas via endoscopy where the ultrasound prop gets close to the pancreas while the endoscope is inserted into the stomach and the duodenum. Samples can be taken from suspicious lesions in the pancreas.

Cystic lesions of the pancreas. Cystic lesions of the pancreas are very common. A majority of these cysts have no consequences. Your Doctor will probably order either a CT scan or a MRI to investigate them. Most of these lesions are found incidentally when a patient gets a scan for another reason usually. Once the cyst has been diagnosed your Doctor will probably refer you to a pancreatic specialist and you would have a discussion about whether you need ongoing surveillance or surgery or no further treatment. About 50% of these cysts that are found in the pancreas are what we call a pseudocyst as a result of previous inflammation of the pancreas. The rest of them are neoplastic and most of the neoplastic are called branch duct Intraductal papillary mucinous neoplasm (IPMN). These lesions are inconsequential however your Doctor might ask for a follow up scan every six months for two years to ensure stability of the lesions. However, there are two categories. One of them is called mucinous cyst adenoma and it is proven to be premalignant. This lesion happens in middle aged females and if it is diagnosed it is usually removed surgically to prevent its progression to cancer. Another form is called intraductal papillary mucinous neoplasm with involvement of the main duct and they are premalignant and you need to have a discussion with your Doctor about surgical removal of these lesions prior their progress to an invasive cancer.

Surgery of the Pancreas

Pancreatic Surgery

pancreas, stomach, duodenum, gallbladder

Surgery for cancer of the head of the pancreas which is called pancreatico-duodenectomy or Whipple’s operation. The Whipple’s operation is a super major undertaking and it is the only curative form of treatment for cancers of the head of the pancreas. It is also being utilised for cancers of the distal part of the bile duct or the region of the ampulla in which both the pancreatic secretions and the biliary secretions enter into the small intestine to help in the digestion absorption process. Commonly patients who develop cancer in this area, they become jaundiced. The operation is quite involved and it takes about six to seven hours where the head of the pancreas, usually the distal part of the stomach, the distal part of the bile duct, the gallbladder and the duodenum are removed. After the operation the gastrointestinal tract will need to be reconstructed and there will be at least three anastomosis that will be made. The achilles heal of these anastomosis and the operation is the anastomosis between the pancreas and the intestine. It can leak pancreatic enzymes which leads to further complications such as bleeding, infective collections and ongoing leak. Usually the patient will stay a few days in the intensive care unit and there will be drains and catheters and vascular lines inserted and they will stay in for a few days until the patient has passed the critical stage of the operation. Usually in about four to five days the patient will start having clear fluids and gradually they get upgraded to a normal diet. The immediate complication that can arise from the operation is bleeding, which can happen at the time of the operation or a few days later which might necessitate a blood transfusion and further forms of intervention and even could mean a return back to theatre. After this operation some people might have a problem with their blood sugar control, they can become diabetic and also due to a reduction in the amount of the pancreatic enzymes that get secreted they could develop ongoing diarrhoea. These complications will be watched for and if they happen they are generally treatable. Infections such as wound infection or deep infection and collections are mainly related to leak from the pancreatic enzymes or leak from the bile duct anastomosis or from the stomach anastomosis. They can lead to various forms of infections that might need antibiotics and interventions. Usually your Doctor will prescribe to you some form of medication to prevent ulceration in the new gastrointestinal anastomosis. In addition to that you might need lifelong attention to treatment of diabetes and deficiency of pancreatic enzymes which is easily rectified with some tablets. The patient after the surgery will be advised to eat small meals with a few snacks. Usually about six times a day and they are advised not to have any liquids with their meals and they also need to avoid high concentration sugar drinks such as milkshakes. Recovery from the operation is significantly long. It will take about six weeks to get everything to heal and for full recovery, particularly from the tiredness and the lack of appetite it might take up to three months to settle down.

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Whipple’s operation

 

The Whipple operation was first described in the 1941 by Allan Whipple. In the past the mortality rate for the Whipple operation was very high. Whipple operation has become a safe operation. The mortality rate from the operation is less than 4%.

In the Whipple operation the head of the pancreas, a portion of the bile duct, the gallbladder and the duodenum  and the distal part of the stomach is removed. After removal of these structures the remaining pancreas, bile duct and the stomach is joined back to direct the gastrointestinal secretions  and food back into the gut.

Indications for Whipple’s operation

A Whipple operation is performed for

  • Cancer of the head of the pancreas
  • Cancer of the duodenum
  • Cancer of the distal part of the bile duct (cholangiocarcinoma)
  • Ampullary cancer an area where the bile and pancreatic duct join and enter the duodenum.
  • Whipple operation is also sometimes indicated for patients with benign conditions such as neuroendocrine tumors, chronic pancreatitis and precancerous  cystic lesions.

Survival after Whipple operation:

The overall survival after the Whipple operation for pancreatic cancer  is about 20% at five years after surgery. if the cancer is detected early when the lesion is less than 2cm with no spread of cancer to lymph nodes may have up to a 40%  five years survival. Survival is less than 5% at five years for patients with pancreatic cancer treated with chemotherapy alone or palliative measures.

The operation is usually curative in patients with benign and precancerous lesions of the pancreas.

Further treatment after surgery:

it is generally recommended that the patient get what is called adjuvant chemotherapy  and sometimes radiation therapy, there is a bout 10%  survival improvement from such added treatment. Patients who have benign tumors of the pancreas and in patients with neuroendocrine tumors of the pancreas will require no further treatment.

Diabetes after a Whipple operation

During the Whipple operation the head of the pancreas, is removed. Pancreatic tissue produces the hormone insulin, which is required for blood sugar control. When pancreatic tissue is removed there is always a risk of becoming diabetic; the estimated risk is 20%. Patients who are diabetic prior to surgery or who have an altered glucose tolerance that is controlled by diet prior to surgery have a higher risk for the diabetes becoming worse after surgery. Patients who have normal blood sugar prior to surgery  and do not have chronic pancreatitis have a low  risk of developing diabetes after the Whipple operation.

Diet after  Whipple’s operation:

There is no dietary restriction after the operation. Usually the patient is seen by a dietician and instructed to have several small meals during the day and avoid drinking liquids at the time of the meals .Due to the nature of the operation some patients may not tolerate very sweet foods and may need to avoid this due to the dumping phenomenon that follow the operation.

Recovery and quality of life

There is acceptable alteration of lifestyle after the Whipple operation. Most patients are able to go back to their normal functional levels. But that will take several weeks and can be prolonged due to postoperative complications. Fatigue is very common after such surgery also the appetite will take a few weeks to recover.

Immediate complications:

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The Whipple operation is a complex operation with a high risk of developing complications. The problems and complications that may be seen after this operation include:

  • Pancreatic fistula: the cut end of the pancreas is sutured back into to the intestine so that pancreatic secretions flow back into the intestine. The pancreas is a soft organ often with a small duct and in some patients this suture line may not heal that well. If this happens then patients develop leakage of pancreatic juice. Usually the surgeon leaves a drain in the abdomen close to that anastomosis.  Usually the leakage heals on its own, but the drain needs to be left in for a while. It is uncommon for patients to be re-operated for this complication.
  • Delayed gastric emptying: Patients will be given intravenous fluids until  bowel function returns. After  that the patient is allowed clear liquids and diet will progress to a regular diet as tolerated. Poor emptying of the stomach may take up to 4 to 6 weeks to recover. The patient may need alternative method to provide feeding

Long-term complications of the Whipple operation:

  • Steatorrhoea (malabsorption): The pancreas produces enzymes required for digestion of dietary fat and proteins. reduced production of enzymes leads the patient to have bulky diarrhea , the stool is very greasy and difficult to flush. Long-term treatment with pancreatic enzyme supplementation usually provides relief given as tablets with each meal and snacks.
  • Alteration in diet: After the Whipple operation the patients is instructed to have smaller meals and snack between meals to allow better absorption of the food and to minimize symptom.
  • Loss of weight: patients usually lose up to 10% of their body weight compared to their weight prior to surgery. Most patients will eventually be able to maintain their weight.

Distal pancreatectomy

A distal  pancreatectomy is used to treat a number of lesions involving the the body and tail of the pancreas including:

  • Adenocarcinoma
  • Cystadenoma (mucinous/serous)
  • Neuroendocrine tumours that arise from the islet cells
  • Lymphoma
  • Pancreatic necrosis
  • Papillary cystic neoplasms
  • Chronic pancreatitis
  • Trauma

The operation is often done via keyhole approach that will be applicable to benign conditions and low grade or precancerous lesions particularly neuroendocrine tumours.

For adenocarcinoma of the pancreas body and tail usually the operation is done in an open fashion to ensure that all cancer and draining lymph nodes are removed.

The spleen is often preserved for distal pancreatectomy, if the surgeon has to remove the spleen then the patient will need antibiotics, prophylaxis and vaccination for three types of bacterial infection that can manifest as pneumonia, meningitis or septicaemia. These infections are very rare but they can lead to life threatening infections.