Adam Bartlett
Adam Bartlett : 09 6234 789
Adam Bartlett FRACS PhD - HPB, Laparoscopic and General Surgeon

Patient Info

Pancreas Surgery

Pancreas-Surgery-Adam-Bartlett

The pancreas is located deep in the body, behind the stomach, just anterior to the vertebral body. It is shaped a little bit like a fish – extending almost horozontally from the first part of the small bowel (duodenum) on the right to the hilum of the spleen on the left. It is about 15 cm long and less than 5 cm wide. The pancreas is composed of two types of glands. The exocrine pancreas makes up the majority of the gland. It makes pancreatic "juice" that is composed of enzymes that help to break down food you eat. The pancreatic juice is secreted into the pancreatic duct that joins the bile bile to empty the contents into the first part of the small intestine (duodenum). The endocrine pancreas is composed of clusters of cells called islets, that make hormones like insulin that help balance the amount of sugar in the blood.

Cancer can develop in both the exocrine and endocrine cells of the pancreas. Tumors formed by the exocrine cells are much more common. Not all of the tumors in the pancreas are malignant, some are benign. It is important to know whether a tumor is from the exocrine or endocrine part of the pancreas as it is treated in different ways, and has a different prognosis.

Exocrine tumours are the most common type of pancreas cancer. The majority arise within the glands of the exocrine pancreas and are called adenocarcinomas. A special type of cancer called ampullary cancer arises within the distal bile duct where it empties into the small intestine. This type of cancer often presents with jaundice, so is usually found at an earlier stage. Adenocarcinoma of the pancreas is typically an aggressive tumour with a poor outcome unless it can be completely removed. Treatment of exocrine cancer of the pancreas depends upon the stage of the cancer. Unfortunately most patients with adenocarcinoma of the pancreas present too late to be removed by surgery, and are managed palliatively. Even if curative resection is possible, only around one in five patients will be cured.

Endocrine tumours of the pancreas are rare. They are also known as islet cell tumors or neuroendocrine tumors (NET) and are divided into different types depending upon the hormones that they produce. Most endocrine pancreatic tumours are benign, but they can be malignant. Rarely, the pancreas is a site for secondaries (metastases) from cancers elsewhere. Some tumours can present as cysts. The majority are benign and can be safely watched.

What tests are done to establish the diagnosis?

You would have undergone radiological imaging, either CT or MRI, of the pancreas to make the diagnosis and stage the extent of the tumour. It may be necessary to perform an Endoscopic Retrograde Cholangio Pancreatogram (ERCP) to extablish the diagnosis or alleviate jaundice if the tumour involves the distal bile duct. This is an endoscopic procedure, where a flexible scope is passed into the first part of the small bowel, and stents are able to be introduced into the pancreatic and bile duct. Occasionally you will need to have an endoscopic ultrasound (EUS) to help identify the tumour, take tissue or to determine whether or not it is operable.

What is the goal of pancreatic resection?

Pancreatic resection refers to the removal of a portion of the pancreas. This operation is usually done to remove various types of liver tumors. The principal aim of performing pancreatic resection is to completely remove the tumor without leaving any tumor behind. The success of pancreatic resection depends upon the location, size and type of tumor.

What patients require a pancreatic resection?

Pancreatic resection is mainly performed to remove pancreatic cancer. Most patients who require pancreatic resection have a primary cancer that has arisen within the pancreas, usually adenocarcinoma. Less commonly tumours can arise from the endocrine pancreas. Sometimes it is not possible to determine whether the tumour is benign or malignant and resection is performed to remove the tumour and establish the diagnosis. Biopsy of the pancreas is not routinely recommended as it has the potential to cause bleeding and spread of the cancer.

How is the pancreas resected?

There are two principal types of operations;

  1. Removal of the head of the pancreas, the duodenum and bile ducts (including gallbladder) with or without the distal stomach – known as a pancreaticoduodenectomy or Whipple's procedure. The Whipple operation is performed for cancer that is located in the head of the pancreas.
  2. Removal of the body and or tail of the pancreas with or without the spleen – known as a distal pancreatectomy. It is performed for tumours that are located in the neck, body or tail of the pancreas. It is technically more straight forward than a Whipple, and can be performed either by an open operation or laparoscopically.

What are the potential complications?

Pancreatic surgery is associated with significant risks. The risks are higher if the patient is older or has significant other medical conditions. Most patients (70%) will have a fairly straightforward course, but potential complications include;

Pancreatic leak (fistula). The anastomosis (join) between the pancreatic duct and small bowel can leak resulting in pancreas juice pooling within the abdominal cavity. This can be life threatening, and requires drainage. It occasionally requires further interventions or even further surgery. It can mean a long time in hospital until the leak heals on its own.

Bile leak. Leakage from the bile duct anastomosis is less common, and usually self limiting. It normally only requires drainage.

Gastric outlet obstruction (gastroparesis). Failure of the stomach to empty into the small bowel, may occur in upto 10-20% of patients. This results in persisting nausea and vomiting. Treatment is usually by feeding distal to the stomach with a tube and administration of medication to help increase the strength of stomach contractions.

Abdominal collections. Refers to the accumulation of fluid in the abdominal cavity that can become infected. It is usually managed by placement of percutaneous drains, and does not require reoperation.

Diabetes mellitus. Depending upon the amount of pancreas that is removed, and the quality of the remnant, you may develop diabetes due to insufficient islet cells to produce insulin.

Bleeding either at the time of surgery or soon after, may require blood transfusion or re-operation. In most instances it resolves without further intervention and is unusual.

Exocrine insufficiency. If insufficient exocrine pancreas remains following resection, then you will be unable to adequately digest food. Most patients with pancreatic insufficiency present with diarrorhoea and on testing a stool sample are found to have insufficient enzymes. Treatment involves administration of pancreatic enzyme supplements prior to meals.

Respiratory complications (infection, collapse, fluid collections) are not uncommon as a result of prolonged ventilator support and poor inspiratory effort post-operatively. This may require antibiotic treatment or drainage.

General risks of surgery including wound infection, deep vein thrombosis (DVT), pulmonary embolism, or development of a hernia at the incision site. There is an increased risk of post- operative complications if you are overweight or if you smoke.

Is there a chance of dying from this operation?

There is a risk of dying associated with any operation. The risk of dying following a pancreatic resection depends upon the extent of the resection and your other medical conditions. About 5 patients in every 100 undergoing a Whipple's operation will die within the peri-operative period as a result of a complication. The risks associated with a distal pancreatectomy are lower. You will be able to discuss your personal risks that apply to your surgery with the surgeon and anaesthetist prior to your operation. Because a pancreatic resection is generally performed after a diagnosis of cancer, the risk of not having the surgery is balanced against the risks of the surgery itself.

What happens before the operation?

This very much depends on upon the reason that you require a pancreatic resection. You would have undergone imaging of your liver, CT or MRI, to stage the extent of the disease, and had a number of blood tests and other investigations to determine your suitability for the operation. Prior to being scheduled for theatre the findings of these investigations will be discussed with you, and the various treatment options outlined. Once you have agreed to proceed with surgery, you will be asked to complete an anaesthetic questioner. This will be passed onto the anesthetist that will be looking after you during the operation. Depending upon your medical status you may require an appointment to see the anaesthetist in person or be sent for other investigations. You will need to have bloods taken immediately prior to your proposed date of surgery to ensure that blood is available in the event that you require a blood transfusion. You will be given specific instructions about when to stop eating and drinking, please follow these carefully as otherwise this may pose an anaesthetic risk and we may have to cancel your surgery. You should bath or shower before coming to hospital as you normally would. You do not need to shave any of the abdominal hair. You should take all your normal medication even on the day of surgery with a small amount of water. If you are on any medication that affects blood clotting you need to let the surgeon know well in advance of your surgery, as they may need to be stopped. If there is a chance that the spleen will also be removed then it is preferable to have vaccinations prior to surgery to reduce the chance of post-splenectomy sepsis.

What happens when I arrive at the hospital?

You will be seen by the nursing staff and taken to your room. You will be asked to change into a theatre gown. The surgeon and anaesthetist will visit you and answer any questions that you have. You will be asked to sign a consent form, and the surgeon will mark the operative site with indelible ink to avoid any potential confusion. You will be taken into the operating room by a nurse who will with you until you are asleep.

How long will I be in hospital?

Most patients will be in hospital between 10 to 14 days following a Whipple's operation, and 5 to 7 days after a distal pancreatectomy. At the time of discharge you will be mobilizing independently, eating and drinking a reasonable diet and able to undertake most self cares. It normally takes approximately 3 months to get back to your normal activities. This is very individual and it may take longer.

What happens after the operation?

You will be woken in the operating room after the operation has been completed, and taken into the recovery area. You will have an intravenous line in you arm and usually a larger central line in the jugular vein in your neck that are attached to fluid, and enables the staff to give you medication. A small cannula will be in the radial artery in your wrist that is used to monitor your blood pressure continuously. You will have an oxygen mask over your mouth that will administer supplemental oxygen. You will have a feeding tube in your nose that passes into your stomach to decompress your stomach and allow feed to be administered post-operatively. A drain will be left in your abdomen to drain any fluid that may collect at the pancreatic resection bed, and this will remain in for 3-5 days. You will have a catheter in your urinary bladder to monitor your kidney function, and this is removed usually on day 2 or 3. You will be able to drink as soon as you wish after the procedure, but it is advised that you take it slowly. It is very important in the first 24 hours after your operation that we are able to monitor your condition closely. For this reason you will more than likely be cared for in a High Dependency Unit (HDU). There are a number of checks that will be routinely performed, over this time including throughout the night.

How much pain will I experience post-operatively?

Most people experience moderate pain, which is readily, controlled using a combination of treatments. The anaesthetist will have a discussion with you prior to the operation regarding how your pain will be controlled. It is our usual practice to combine local nerve blocks (intra-thecal, epidural or wound catheters) with systemic analgesia (intravenous or oral painkillers). You will be given patient controlled analgesia (PCA) post-operatively which allows you to control the administration of the painkillers. Once you are tolerating a reasonable diet, the PCA will be removed and you will be given oral painkillers as required. You will experience some pain/discomfort from your wounds, especially on movement, and you will need to communicate the severity of the discomfort to the medical staff looking after you so that the medication can be optimized to your needs. At the time of discharge you will be given a supply of painkillers and post-operative instructions on what to take when. After about 14 days most patients are only requiring minimal analgesia to control their pain.

What will need to be done to care for my wound?

The operation is usually performed through a transverse incision or a reversed "L" in the right upper quadrant of your abdomen, depending upon your body shape. The skin is re-approximated using dissolvable sutures that do not need to be removed post-operatively. Steri-strips (thin white tape) are placed along the incision, and a waterproof dressing is placed over. The dressing will be left undisturbed for at least 3 days post-operatively to try and avoid contamination. You will be able to shower each day as the dressing is waterproof. Once the dressing has been taken down by your surgeon and it appears clean and dry the wound will be left without a dressing and you can shower as normal, taking care not to use any strong soaps or creams around the area. It may be that your wound leaks some darkish fluid or looks a little inflamed. This is not unusual and the staff will observe it closely. Occasionally stitches or staples will be used to close the skin. These will need to be removed after 10 days, and can be done by the district nurse. It is ok to use Bio-oil on the incisions after the first week to help reduce scar prominence.

How long will it take to recover from the anaesthetic?

Whilst most of the effects of anaesthesia wear off in a few hours, it is common to have poor concentration and memory for a few days thereafter. After any major operation it takes some time to get back to feeling yourself again. Once all the tubes and drains have been removed it is not uncommon to feel easily tired and emotionally upset. This is normal and as time passes you will begin to feel more like yourself again. Try to be patient with yourself and allow yourself some time to get over your operation.

When can I return to normal activities?

You will be expected to transfer, with assistance, to a chair the day following your operation. Most patients are walking short distances around the ward by the second day. The physiotherapist will visit you on the ward and assist in getting you mobile and give you some simple exercises that will help. The quicker you mobilse the easier it is to get moving. It becomes easier as the various tubes and lines are removed. Upon discharge from the hospital you can return to normal physical and sexual activities when you feel comfortable. You should avoid heavy lifting (more than 6kg) and vigorous exercises for at least six weeks following the operation. It is normal to feel tired after surgery, so take some rest, two or three times a day, and try to get a good nights sleep.

Will I need chemotherapy afterwards?

That will depend upon the reason for undertaking the pancreatic resection and the outcome of the surgery. Chemotherapy is usually recommended after resection of pancreatic adenocarcinoma. Many of the other cancers are treated by surgery alone. Your case will be discussed at a multi-disciplinary meeting after the pathology has been formally reported with an oncologist.

Will I need radiotherapy?

No usually, unless the tumour extends close to the resection margin. Sometimes it is administered prior to pancreatic resection in an attempt to shrink the tumour.

When can I start driving?

You should not drive for at least four weeks post-operativel. Before driving you should ensure that you could perform a full emergency stop, have the strength and capability to control the car, and be able to respond quickly to any situation that may occur. Please be aware that driving whilst unfit may invalidate your insurance, and you should check with the conditions of your insurance policy as they do vary

When can I return to work?

You can return to work as soon as you feel up to it. This will depend on how you are feeling and the type of work that you do. If you have a relatively sedentary job then you may feel ready to return within 3-4 weeks. If you are involved in manual labor or heavy lifting you need to avoid straining for at least 6 weeks.

What can I eat?

You can resume drinking immediately following the operation, and increase your solid intake slowly. You may require supplemental feeding with a tube placed either through your nostril or the skin at the time of your operation. It is not unusual to lose your appetite. It will recover, as you get better. Fluids are often better tolerated than solids, and it is often recommended that you try soft foods before resuming a normal diet. The dietician will visit you on the ward to give you advice about your diet and will prescribe supplement drinks if you need them. Once at home, there are no dietary restrictions, and you should try and eat a balanced healthy diet.

When will my bowel movements return to normal?

It may take three or four days to have a normal bowel movement. If you have not had a bowel movement three days after surgery, you will be commenced on a mild laxative. Alternatively Alpine tea, prune juice or kiwifruit may be equally effective. Once at home, you should monitor your bowels as you may require laxatives for some weeks as a result of the painkillers that you are taking.

Will I require on going follow-up post-operatively?

Yes you will be seen at approximately one week following discharge from hospital, then at 4-6 weeks at which time a CT is usually performed. Depending on the pathology of the resected specimen and your progress, you may require additional treatment. In order to monitor you for tumour recurrence so that it is diagnosed early if it does recur, you will require ongoing blood tests and imaging at regular, usually 6 monthly, intervals.

When should I seek help?

If you have concerns then either ring the surgeon directly or the hospital for advice. If it is medical emergency then dial 111 for an ambulance to take you to an acute hospital. You should let us know if you have a discharge of blood or pus coming from your wounds, develop a fever over 38.5 ° C, vomiting or diarrhea, inability to have a bowel movement after four days, have persistent pain not relieved with your prescribed painkillers or persistent abdominal distension (bloating of your tummy) or develop increasing pain or swelling around your wounds.

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