Pancreatectomy
Pancreatectomy
Definition
Purpose
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives
Definition
A pancreatectomy is the surgical removal of the pancreas. A pancreatectomy may be total, in which case the entire organ is removed, usually along with the spleen, gallbladder, common bile duct, and portions of the small intestine and stomach. A pancreatectomy may also be distal, meaning that only the body and tail of the pancreas are removed, leaving the head of the organ attached. When the duodenum is removed along with all or part of the pancreas, the procedure is called a pancreaticoduodenectomy, which surgeons sometimes refer to as “Whipple’s procedure.” Pancreaticoduode-nectomies are increasingly used to treat a variety of malignant and benign diseases of the pancreas. This procedure often involves removal of the regional lymph nodes as well.
Purpose
A pancreatectomy is the most effective treatment for cancer of the pancreas, an abdominal organ that
KEY TERMS
Chemotherapy— A cancer treatment that uses synthetic drugs to destroy the tumor either by inhibiting the growth of the cancerous cells or by killing the cancer cells.
Computed tomography (CT) scan— An imaging technique that creates a series of pictures of areas inside the body, taken from different angles. The pictures are created by a computer linked to an x-ray machine.
Endoscopic retrograde cholangiopancreatography (ERCP)— A procedure to x-ray the ducts (tubes) that carry bile from the liver to the gallbladder and from the gallbladder to the small intestine.
Laparoscopy— In this procedure, a laparoscope (a thin, lighted tube) is inserted through an incision in the abdominal wall to determine if the cancer is within the pancreas only or has spread to nearby tissues and if it can be removed by surgery later. Tissue samples may be removed for biopsy.
Magnetic resonance imaging (MRI)— A procedure in which a magnet linked to a computer is used to create detailed pictures of areas inside the body.
Pancreas— A large gland located on the back wall of the abdomen, extending from the duodenum (first part of the small intestine) to the spleen. The pancreas produces enzymes essential for digestion, and the hormones insulin and glucagon, which play a role in diabetes.
Pancreaticoduodenectomy— Removal of all or part of the pancreas along with the duodenum. Also known as “Whipple’s procedure” or “Whipple’s operation.”
Pancreatitis— Inflammation of the pancreas, either acute (sudden and episodic) or chronic, usually caused by excessive alcohol intake or gallbladder disease.
Positron emission tomography (PET) scan— An imaging system that creates a picture showing the location of tumor cells in the body. A substance called radionuclide dye is injected into a vein, and the PET scanner rotates around the body to create the picture. Malignant tumor cells show up brighter in the picture because they are more active and take up more dye than normal cells.
Radiation therapy— A treatment using high energy radiation from x-ray machines, cobalt, radium, or other sources.
Ultrasonogram— A procedure where high-frequency sound waves that cannot be heard by human ears are bounced off internal organs and tissues. These sound waves produce a pattern of echoes which are then used by the computer to create sonograms, or pictures of areas inside the body.
secretes digestive enzymes, insulin, and other hormones. The thickest part of the pancreas near the duodenum (a part of the small intestine) is called the head, the middle part is called the body, and the thinnest part adjacent to the spleen is called the tail.
While surgical removal of tumors in the pancreas is the preferred treatment, it is only possible in the 10-15% of patients who are diagnosed early enough for a potential cure. Patients who are considered suitable for surgery usually have small tumors in the head of the pancreas (close to the duodenum, or first part of the small intestine), have jaundice as their initial symptom, and have no evidence of metastatic disease (spread of cancer to other sites). The stage of the cancer will determine whether the pancreatectomy to be performed should be total or distal.
A partial pancreatectomy may be indicated when the pancreas has been severely injured by trauma, especially injury to the body and tail of the pancreas. While such surgery removes normal pancreatic tissue as well, the long-term consequences of this surgery are minimal, with virtually no effects on the production of insulin, digestive enzymes, and other hormones.
Chronic pancreatitis is another condition for which a pancreatectomy is occasionally performed. Chronic pancreatitis—or continuing inflammation of the pancreas that results in permanent damage to this organ—can develop from long-standing, recurring episodes of acute (periodic) pancreatitis. This painful condition usually results from alcohol abuse or the presence of gallstones. In most patients with the alcoholinduced disease, the pancreas is widely involved, therefore, surgical correction is almost impossible.
Description
A pancreatectomy can be performed through an open surgery technique, in which case one large incision is made, or it can be performed laparoscopically, in which case the surgeon makes four small incisions to insert tube-like surgical instruments. The abdomen is filled with gas, usually carbon dioxide, to help the surgeon view the abdominal cavity. A camera is inserted through one of the tubes and displays images on a monitor in the operating room. Other instruments are placed through the additional tubes. The laparoscopic approach allows the surgeon to work inside the patient’s abdomen without making a large incision.
If the pancreatectomy is partial, the surgeon clamps and cuts the blood vessels, and the pancreas is stapled and divided for removal. If the disease affects the splenic artery or vein, the spleen is also removed.
If the pancreatectomy is total, the surgeon removes the entire pancreas and attached organs. He or she starts by dividing and detaching the end of the stomach. This part of the stomach leads to the small intestine, where the pancreas and bile duct both attach. In the next step, he removes the pancreas along with the connected section of the small intestine. The common bile duct and the gallbladder are also removed. To reconnect the intestinal tract, the stomach and the bile duct are then connected to the small intestine.
During a pancreatectomy procedure, several tubes are also inserted for postoperative care . To prevent tissue fluid from accumulating in the operated site, a temporary drain leading out of the body is inserted, as well as a gastrostomy or g-tube leading out of the stomach in order to help prevent nausea and vomiting. A jejunostomy or j-tube may also be inserted into the small intestine as a pathway for supplementary feeding.
Diagnosis/Preparation
Patients with symptoms of a pancreatic disorder undergo a number of tests before surgery is even considered. These can include ultrasonography, x-ray examinations, computed tomography scans (CT scan), and endoscopic retrograde cholangiopancreatography (ERCP), a specialized imaging technique to visualize the ducts that carry bile from the liver to the gallbladder. Tests may also include angiography, another imaging technique used to visualize the arteries feeding the pancreas, and needle aspiration cytology, in which cells are drawn from areas suspected to contain cancer. Such tests are required to establish a correct diagnosis for the pancreatic disorder and in the planning the surgery.
Since many patients with pancreatic cancer are undernourished, appropriate nutritional support, sometimes by tube feedings, may be required prior to surgery.
Some patients with pancreatic cancer deemed suitable for a pancreatectomy will also undergo chemotherapy and/or radiation therapy. This treatment is aimed at shrinking the tumor, which will improve the chances for successful surgical removal. Sometimes, patients who are not initially considered surgical candidates may respond so well to chemoradiation that surgical treatment becomes possible. Radiation therapy may also be applied during the surgery (intraoperatively) to improve the patient’s chances of survival, but this treatment is not yet in routine use. Some studies have shown that intraoperative radiation therapy extends survival by several months.
Patients undergoing distal pancreatectomy that involves removal of the spleen may receive preoperative medication to decrease the risk of infection.
Aftercare
Pancreatectomy is major surgery. Therefore, extended hospitalization is usually required with an average hospital stay of two to three weeks.
Some pancreatic cancer patients may also receive combined chemotherapy and radiation therapy after surgery. This additional treatment has been clearly shown to enhance survival rates.
After surgery, patients experience pain in the abdomen and are prescribed pain medication. Follow-up exams are required to monitor the patient’s recovery and remove implanted tubes.
A total pancreatectomy leads to a condition called pancreatic insufficiency, because food can no longer be normally processed with the enzymes normally produced by the pancreas. Insulin secretion is likewise no longer possible. These conditions are treated with pancreatic enzyme replacement therapy, which supplies digestive enzymes; and with insulin injections. In some case, distal pancreatectomies may also lead to pancreatic insufficiency, depending on the patient’s general health condition before surgery and on the extent of pancreatic tissue removal.
Risks
There is a fairly high risk of complications associated with any pancreatectomy procedure. A recent Johns Hopkins study documented complications in 41% of cases. The most devastating complication is postoperative bleeding, which increases the mortality risk to 20–50%. In cases of postoperative bleeding, the patient may be returned to surgery to find the source of hemorrhage, or may undergo other procedures to stop the bleeding.
One of the most common complications from a pancreaticoduodenectomy is delayed gastric emptying, a condition in which food and liquids are slow to leave the stomach. This complication occurred in 19% of patients in the Johns Hopkins study. To manage
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
A pancreatectomy is performed by a surgeon trained in gastroenterology, the branch of medicine that deals with the diseases of the digestive tract. An anesthesiologist is responsible for administering anesthesia and the operation is performed in a hospital setting, with an oncologist on the treatment team if pancreatic cancer motivated the procedure.
this problem, many surgeons insert feeding tubes at the original operation site, through which nutrients can be fed directly into the patient’s intestines. This procedure, called enteral nutrition, maintains the patient’s nutrition if the stomach is slow to recover normal function. Certain medications, called promotility agents, can help move the nutritional contents through the gastrointestinal tract.
The other most common complication is pancreatic anastomotic leak. This is a leak in the connection that the surgeon makes between the remainder of the pancreas and the other structures in the abdomen. Most surgeons handle the potential for this problem by checking the connection during surgery.
Normal results
After a total pancreatectomy, the body loses the ability to secrete insulin, enzymes, and other substances; therefore, the patient has to take supplements for the rest of his or her life.
Patients usually resume normal activities within a month after surgery, although they are asked to avoid heavy lifting for six to eight weeks and not to drive as long as they take narcotic medication.
When a pancreatectomy is performed for chronic pancreatitis, the majority of patients obtain some relief from pain. Some studies report that one-half to three-quarters of patients become free of pain.
Morbidity and mortality rates
The mortality rate for pancreatectomy has decreased in recent years to 5-10%, depending on the extent of the surgery and the experience of the surgeon. A study of 650 patients at Johns Hopkins Medical Institution, Baltimore, found that only nine patients, or 1.4%, died from complications related to surgery.
QUESTIONS TO ASK THE DOCTOR
- What do I need to do before surgery?
- What type of anesthesia will be used?
- How long will it take to recover from the surgery?
- When can I expect to return to work and/or resume normal activities?
- What are the risks associated with a pancreatectomy?
- How many pancreatectomies do you perform in a year?
- Will there be a scar?
Unfortunately, pancreatic cancer is the most lethal form of gastrointestinal malignancy. However, for a highly selective group of patients, a pancreatectomy offers a chance for cure, especially when performed by experienced surgeons. The overall five-year survival rate for patients who undergo pancreatectomy for pancreatic cancer is about 10%; patients who undergo pancreaticoduodenectomy have a 4–5% survival at five years. The risk for tumor recurrence is thought to be unaffected by whether the patient undergoes a total pancreatectomy or a pancreaticoduodenectomy, but is increased when the tumor is larger than 1.2 in (3 cm) and the cancer has spread to the lymph nodes or surrounding tissue.
Alternatives
Depending on the medical condition, a pancreas transplantation may be considered as an alternative for some patients.
Resources
BOOKS
Bastidas, J. Augusto, and John E. Niederhuber. “The Pancreas.” In Fundamentals of Surgery. Edited by John E. Niederhuber. Stamford: Appleton & Lange, 1998.
Mayer, Robert J. “Pancreatic Cancer.” In Harrison’sPrinciples of Internal Medicine. Edited by Anthony S. Fauci, et al. New York: McGraw-Hill, 1997.
PERIODICALS
Cretolle, C., C. N. Fekete, D. Jan, et al. “Partial elective pancreatectomy is curative in focal form of permanent hyperinsulinemic hypoglycaemia in infancy: A report of 45 cases from 1983 to 2000.” Journal of Pediatric Surgery 37 (February 2002): 155–158.
Lillemoe, K. D., S. Kaushal, J. L. Cameron, et al. “Distal pancreatectomy: indications and outcomes in 235 patients.” Annals of Surgery 229 (May 1999): 698–700.
McAndrew, H. F., V. Smith, and L. Spitz. “Surgical complications of pancreatectomy for persistent hyperinsulinaemic hypoglycaemia of infancy.” Journal of Pediatric Surgery 38 (January 2003): 13–16.
Patterson, E. J., M. Gagner, B. Salky, et al. “Laparoscopic pancreatic resection: single-institution experience of 19 patients.” Journal of the American College of Surgeons 193 (September 2001): 281–287.
ORGANIZATIONS
American College of Gastroenterology. 4900 B South 31st St., Arlington, VA 22206. (703) 820-7400. http://www.acg.gi.org.
American Gastroenterological Association (AGA). 4930 Del Ray Avenue, Bethesda, MD 20814. (301) 654-2055. http://www.gastro.org.
National Cancer Institute (NCI). NCI Public Inquiries Office, Suite 3036A, 6116 Executive Boulevard, MSC8322 Bethesda, MD 20892-8322. (800) 422-6237. http://www.cancer.gov.
OTHER
NIH CancerNet: Pancreatic Cancer Homepage. [cited July 1, 2003]. http://www.cancer.gov/cancerinfo/types/pancreatic.
Caroline A. Helwick
Monique Laberge, Ph.D.
Pancreatectomy
Pancreatectomy
Definition
A pancreatectomy is the surgical removal of the pancreas. A pancreatectomy may be total, in which case the entire organ is removed, usually along with the spleen, gallbladder, common bile duct, and portions of the small intestine and stomach. A pancreatectomy may also be distal, meaning that only the body and tail of the pancreas are removed, leaving the head of the organ attached. When the duodenum is removed along with all or part of the pancreas, the procedure is called a pancreaticoduodenectomy, which surgeons sometimes refer to as "Whipple's procedure." Pancreaticoduodenectomies are increasingly used to treat a variety of malignant and benign diseases of the pancreas. This procedure often involves removal of the regional lymph nodes as well.
Purpose
A pancreatectomy is the most effective treatment for cancer of the pancreas, an abdominal organ that secretes digestive enzymes, insulin, and other hormones. The thickest part of the pancreas near the duodenum (a part of the small intestine) is called the head, the middle part is called the body, and the thinnest part adjacent to the spleen is called the tail.
While surgical removal of tumors in the pancreas is the preferred treatment, it is only possible in the 10–15% of patients who are diagnosed early enough for a potential cure. Patients who are considered suitable for surgery usually have small tumors in the head of the pancreas (close to the duodenum, or first part of the small intestine), have jaundice as their initial symptom, and have no evidence of metastatic disease (spread of cancer to other sites). The stage of the cancer will determine whether the pancreatectomy to be performed should be total or distal.
A partial pancreatectomy may be indicated when the pancreas has been severely injured by trauma, especially injury to the body and tail of the pancreas. While such surgery removes normal pancreatic tissue as well, the long-term consequences of this surgery are minimal, with virtually no effects on the production of insulin, digestive enzymes, and other hormones.
Chronic pancreatitis is another condition for which a pancreatectomy is occasionally performed. Chronic pancreatitis—or continuing inflammation of the pancreas that results in permanent damage to this organ—can develop from long-standing, recurring episodes of acute (periodic) pancreatitis. This painful condition usually results from alcohol abuse or the presence of gallstones. In most patients with the alcohol-induced disease, the pancreas is widely involved, therefore, surgical correction is almost impossible.
Description
A pancreatectomy can be performed through an open surgery technique, in which case one large incision is made, or it can be performed laparoscopically, in which case the surgeon makes four small incisions to insert tube-like surgical instruments . The abdomen is filled with gas, usually carbon dioxide, to help the surgeon view the abdominal cavity. A camera is inserted through one of the tubes and displays images on a monitor in the operating room . Other instruments are placed through the additional tubes. The laparoscopic approach allows the surgeon to work inside the patient's abdomen without making a large incision.
If the pancreatectomy is partial, the surgeon clamps and cuts the blood vessels, and the pancreas is stapled and divided for removal. If the disease affects the splenic artery or vein, the spleen is also removed.
If the pancreatectomy is total, the surgeon removes the entire pancreas and attached organs. He or she starts by dividing and detaching the end of the stomach. This part of the stomach leads to the small intestine, where the pancreas and bile duct both attach. In the next step, he removes the pancreas along with the connected section of the small intestine. The common bile duct and the gallbladder are also removed. To reconnect the intestinal tract, the stomach and the bile duct are then connected to the small intestine.
During a pancreatectomy procedure, several tubes are also inserted for postoperative care . To prevent tissue fluid from accumulating in the operated site, a temporary drain leading out of the body is inserted, as well as a gastrostomy or g-tube leading out of the stomach in order to help prevent nausea and vomiting. A jejunostomy or j-tube may also be inserted into the small intestine as a pathway for supplementary feeding.
Diagnosis/Preparation
Patients with symptoms of a pancreatic disorder undergo a number of tests before surgery is even considered. These can include ultrasonography, x ray examinations, computed tomography scans (CT scan), and endoscopic retrograde cholangiopancreatography (ERCP), a specialized imaging technique to visualize the ducts that carry bile from the liver to the gallbladder. Tests may also include angiography , another imaging technique used to visualize the arteries feeding the pancreas, and needle aspiration cytology, in which cells are drawn from areas suspected to contain cancer. Such tests are required to establish a correct diagnosis for the pancreatic disorder and in the planning the surgery.
Since many patients with pancreatic cancer are undernourished, appropriate nutritional support, sometimes by tube feedings, may be required prior to surgery.
Some patients with pancreatic cancer deemed suitable for a pancreatectomy will also undergo chemotherapy and/or radiation therapy. This treatment is aimed at shrinking the tumor, which will improve the chances for successful surgical removal. Sometimes, patients who are not initially considered surgical candidates may respond so well to chemoradiation that surgical treatment becomes possible. Radiation therapy may also be applied during the surgery (intraoperatively) to improve the patient's chances of survival, but this treatment is not yet in routine use. Some studies have shown that intraoperative radiation therapy extends survival by several months.
Patients undergoing distal pancreatectomy that involves removal of the spleen may receive preoperative medication to decrease the risk of infection.
Aftercare
Pancreatectomy is major surgery. Therefore, extended hospitalization is usually required with an average hospital stay of two to three weeks.
Some pancreatic cancer patients may also receive combined chemotherapy and radiation therapy after surgery. This additional treatment has been clearly shown to enhance survival rates.
After surgery, patients experience pain in the abdomen and are prescribed pain medication. Follow-up exams are required to monitor the patient's recovery and remove implanted tubes.
A total pancreatectomy leads to a condition called pancreatic insufficiency, because food can no longer be normally processed with the enzymes normally produced by the pancreas. Insulin secretion is likewise no longer possible. These conditions are treated with pancreatic enzyme replacement therapy, which supplies digestive enzymes; and with insulin injections. In some case, distal pancreatectomies may also lead to pancreatic insufficiency, depending on the patient's general health condition before surgery and on the extent of pancreatic tissue removal.
Risks
There is a fairly high risk of complications associated with any pancreatectomy procedure. A recent Johns Hopkins study documented complications in 41% of cases. The most devastating complication is postoperative bleeding, which increases the mortality risk to 20–50%. In cases of postoperative bleeding, the patient may be returned to surgery to find the source of hemorrhage, or may undergo other procedures to stop the bleeding.
One of the most common complications from a pancreaticoduodenectomy is delayed gastric emptying, a condition in which food and liquids are slow to leave the stomach. This complication occurred in 19% of patients in the Johns Hopkins study. To manage this problem, many surgeons insert feeding tubes at the original operation site, through which nutrients can be fed directly into the patient's intestines. This procedure, called enteral nutrition, maintains the patient's nutrition if the stomach is slow to recover normal function. Certain medications, called promotility agents, can help move the nutritional contents through the gastrointestinal tract.
The other most common complication is pancreatic anastomotic leak. This is a leak in the connection that the surgeon makes between the remainder of the pancreas and the other structures in the abdomen. Most surgeons handle the potential for this problem by checking the connection during surgery.
Normal results
After a total pancreatectomy, the body loses the ability to secrete insulin, enzymes, and other substances; therefore, the patient has to take supplements for the rest of his/her life.
Patients usually resume normal activities within a month. They are asked to avoid heavy lifting for six to eight weeks following surgery and not to drive as long as they take narcotic medication.
When a pancreatectomy is performed for chronic pancreatitis, the majority of patients obtain some relief from pain. Some studies report that one-half to three-quarters of patients become free of pain.
Morbidity and mortality rates
The mortality rate for pancreatectomy has decreased in recent years to 5–10%, depending on the extent of the surgery and the experience of the surgeon. A study of 650 patients at Johns Hopkins Medical Institution, Baltimore, found that only nine patients, or 1.4%, died from complications related to surgery.
Unfortunately, pancreatic cancer is the most lethal form of gastrointestinal malignancy. However, for a highly selective group of patients, a pancreatectomy offers a chance for cure, especially when performed by experienced surgeons. The overall five-year survival rate for patients who undergo pancreatectomy for pancreatic cancer is about 10%; patients who undergo pancreaticoduodenectomy have a 4–5% survival at five years. The risk for tumor recurrence is thought to be unaffected by whether the patient undergoes a total pancreatectomy or a pancreaticoduodenectomy, but is increased when the tumor is larger than 1.2 in (3 cm) and the cancer has spread to the lymph nodes or surrounding tissue.
Alternatives
Depending on the medical condition, a pancreas transplantation may be considered as an alternative for some patients.
See also Pancreas transplantation.
Resources
books
bastidas, j. augusto, and john e. niederhuber. "the pancreas." in fundamentals of surgery. edited by john e. niederhuber. stamford: appleton & lange, 1998.
mayer, robert j. "pancreatic cancer." in harrison's principles of internal medicine. edited by anthony s. fauci, et al. new york: mcgraw-hill, 1997.
periodicals
cretolle, c., c. n. fekete, d. jan, et al. "partial elective pancreatectomy is curative in focal form of permanent hyperinsulinemic hypoglycaemia in infancy: a report of 45 cases from 1983 to 2000." journal of pediatric surgery 37 (february 2002): 155–158.
lillemoe, k. d., s. kaushal, j. l. cameron, et al. "distal pancreatectomy: indications and outcomes in 235 patients." annals of surgery 229 (may 1999): 698–700.
mcandrew, h. f., v. smith, and l. spitz. "surgical complications of pancreatectomy for persistent hyperinsulinaemic hypoglycaemia of infancy." journal of pediatric surgery 38 (january 2003): 13–16.
patterson, e. j., m. gagner, b. salky, et al. "laparoscopic pancreatic resection: single-institution experience of 19 patients." journal of the american college of surgeons 193 (september 2001): 281–287.
organizations
american college of gastroenterology. 4900 b south 31st st., arlington, va 22206. (703) 820-7400. <http://www.acg.gi.org>.
american gastroenterological association (aga). 4930 del ray avenue, bethesda, md 20814. (301) 654-2055. <http://www.gastro.org>.
national cancer institute (nci). nci public inquiries office, suite 3036a, 6116 executive boulevard, msc8322 bethesda, md 20892-8322. (800) 422-6237. <http://www.cancer.gov>.
other
nih cancernet: pancreatic cancer homepage. [cited july 1, 2003]. <http://www.cancer.gov/cancerinfo/types/pancreatic>.
Caroline A. Helwick Monique Laberge, Ph.D.
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
A pancreatectomy is performed by a surgeon trained in gastroenterology, the branch of medicine that deals with the diseases of the digestive tract. An anesthesiologist is responsible for administering anesthesia and the operation is performed in a hospital setting, with an oncologist on the treatment team if pancreatic cancer motivated the procedure.
QUESTIONS TO ASK THE DOCTOR
- What do I need to do before surgery?
- What type of anesthesia will be used?
- How long will it take to recover from the surgery?
- When can I expect to return to work and/or resume normal activities?
- What are the risks associated with a pancreatectomy?
- How many pancreatectomies do you perform in a year?
- Will there be a scar?
Pancreatectomy
Pancreatectomy
Definition
Pancreatectomy is the surgical removal of the pancreas. Pancreatectomy may be total, in which case the whole organ is removed, or partial, referring to the removal of part of the pancreas.
Purpose
Pancreatectomy is the most effective treatment for cancer of the pancreas, an abdominal organ that secretes digestive enzymes, insulin, and other hormones. The thickest part of the pancreas near the duodenum (small intestine) is called the head, the middle part is called the body, and the thinnest part adjacent to the spleen is called the tail.
While surgical removal of tumors in the pancreas is preferred, it is only possible in the 10-15% of patients who are diagnosed early enough for a potential cure. Patients who are considered suitable for surgery usually have small tumors in the head of the pancreas (close to the duodenum, or first part of the small intestine), have jaundice as their initial symptom, and have no evidence of metastatic disease (spread of cancer to other sites).
Pancreatectomy is sometimes necessary when the pancreas has been severely injured by trauma, especially injury to the body and tail of the pancreas. While such surgery removes normal pancreatic tissue as well, the long-term consequences of this surgery are minimal, with virtually no effects on the production of insulin, digestive enzymes, and other hormones.
Chronic pancreatitis is another condition for which pancreatectomy is occasionally performed. Chronic pancreatitis—or continuing inflammation of the pancreas that results in permanent damage to this organ—can develop from long-standing, recurring episodes of acute (periodic) pancreatitis. This painful condition usually results from alcohol abuse or the presence of gallstones. In most patients with alcohol-induced disease, the pancreas is widely involved, therefore, surgical correction is almost impossible.
Precautions
Pancreatectomy is only performed when surgery provides a clear benefit. Patients who have tumors that are obviously not operable should be carefully excluded from consideration.
Description
Pancreatectomy sometimes entails removal of the entire pancreas, called a total pancreatectomy, but more often involves removal of part of the pancreas, which is called a subtotal pancreatectomy, or distal pancreatectomy, when the body and tail of the pancreas are removed. When the duodenum is removed along with all or part of the pancreas, the procedure is called a pancreaticoduodenectomy, which surgeons sometimes refer to as "Whipple's procedure." Pancreaticoduodenectomy is being used increasingly for treatment of a variety of malignant and benign diseases of the pancreas.
Regional lymph nodes are usually removed during pancreaticoduodenectomy. In distal pancreatectomy, the spleen may also be removed.
Preparation
Patients with symptoms of a pancreatic disorder usually undergo a number of tests before surgery is even considered. These can include ultrasonography, x-ray examinations, computed tomography scans (CT scan), and endoscopic retrograde cholangiopancreatography (ERCP), an x-ray imaging technique. Tests may also include angiography, an x-ray technique for visualizing the arteries feeding the pancreas, and needle aspiration cytology, in which cells are drawn from areas suspected to contain cancer. Such tests aid in the diagnosis of the pancreatic disorder and in the planning of the operation.
Since many patients with pancreatic cancer are undernourished, appropriate nutritional support, sometimes by tube feedings, may be required prior to surgery.
Some patients with pancreatic cancer deemed suitable for pancreatectomy will undergo chemotherapy and/or radiation therapy. This treatment is aimed at shrinking the tumor, which will improve the chances for successful surgical removal. Sometimes, patients who are not initially considered surgical candidates may respond so well to chemoradiation that surgical treatment becomes possible. Radiation therapy may also be applied during the surgery (intraoperatively) to improve the patient's chances of survival, but this treatment is not yet in routine use. Some studies have shown that intraoperative radiation therapy extends survival by several months.
Patients undergoing distal pancreatectomy that involves removal of the spleen may receive preoperative medication to decrease the risk of infection.
Aftercare
Pancreatectomy is major surgery. Therefore, extended hospitalization is usually required. Some studies report an average hospital stay of about two weeks.
Some cancer patients may also receive combined chemotherapy and radiation therapy after surgery. This additional treatment has been clearly shown to enhance survival from pancreatic cancer.
Removal of all or part of the pancreas can lead to a condition called pancreatic insufficiency, in which food cannot be normally processed by the body, and insulin secretion may be inadequate. These conditions can be treated with pancreatic enzyme replacement therapy, to supply digestive enzymes, and insulin injections, to supply insulin.
Risks
The mortality rate for pancreatectomy has improved in recent years to 5-10%, depending on the extent of the surgery and the experience of the surgeon. A study of 650 patients at Johns Hopkins Medical Institution, Baltimore, found that only nine patients, or 1.4%, died from complications related to surgery.
There is still, however, a fairly high risk of complications following any form of pancreatectomy. The Johns Hopkins study documented complications in 41% of cases. The most devastating complication is postoperative bleeding, which increases the mortality risk to 20-50%. In cases of postoperative bleeding, the patient may be returned to surgery to find the source of hemorrhage, or may undergo other procedures to stop the bleeding.
One of the most common complications from a pancreaticoduodenectomy is delayed gastric emptying, a condition in which food and liquids are slow to leave the stomach. This complication occurred in 19% of patients in the Johns Hopkins study. To manage this problem, many surgeons insert feeding tubes at the original operation site, through which nutrients can be fed directly into the patient's intestines. This procedure, called enteral nutrition, maintains the patient's nutrition if the stomach is slow to recover normal function. Certain medications, called promotility agents, can help move the nutritional contents through the gastrointestinal tract.
The other most common complication is pancreatic anastomotic leak. This is a leak in the connection that the surgeon makes between the remainder of the pancreas and the other structures in the abdomen. Most surgeons handle the potential for this problem by assuring that there will be adequate drainage from the surgical site.
KEY TERMS
Chemotherapy— A treatment of the cancer with synthetic drugs that destroy the tumor either by inhibiting the growth of the cancerous cells or by killing the cancer cells.
Computed tomography (CT) scan— A medical procedure where a series of x rays are taken and put together by a computer in order to form detailed pictures of areas inside the body.
Magnetic resonance imaging (MRI)— A medical procedure used for diagnostic purposes where pictures of areas inside the body can be created using a magnet linked to a computer.
Pancreas— A large gland located on the back wall of the abdomen, extending from the duodenum (first part of the small intestine) to the spleen. The pancreas produces enzymes essential for digestion, and the hormones insulin and glucagon, which play a role in diabetes.
Pancreaticoduodenectomy— Removal of all or part of the pancreas along with the duodenum. Also known as "Whipple's procedure" or "Whipple's operation."
Pancreatitis— Inflammation of the pancreas, either acute (sudden and episodic) or chronic, usually caused by excessive alcohol intake or gallbladder disease.
Radiation therapy— A treatment using high energy radiation from x-ray machines, cobalt, radium, or other sources.
Ultrasonogram— A procedure where high-frequency sound waves that cannot be heard by human ears are bounced off internal organs and tissues. These sound waves produce a pattern of echoes which are then used by the computer to create sonograms or pictures of areas inside the body.
Normal results
Unfortunately, pancreatic cancer is the most lethal form of gastrointestinal malignancy. However, for a highly selective group of patients, pancreatectomy offers a chance for cure, especially when performed by experienced surgeons. The overall five-year survival rate for patients who undergo pancreatectomy for pancreatic cancer is about 10%; patients who undergo pancreaticoduodenectomy have a 4-5% survival at five years. The risk for tumor recurrence is thought to be unaffected by whether the patient undergoes a total pancreatectomy or a pancreaticoduodenectomy, but is increased when the tumor is larger than 3 cm and the cancer has spread to the lymph nodes or surrounding tissue.
After total pancreatectomy, the body loses the ability to secrete insulin, enzymes, and other substances, therefore, certain medications will be required to compensate for this. In some cases of pancreatic disease, the pancreas ceases to function normally, then total pancreatectomy may be preferable to other less radical forms of the operation.
When pancreatectomy is performed for chronic pancreatitis, the majority of patients obtain some relief from pain. Some studies report that one half to three quarters of patients become free of pain.
Resources
BOOKS
Bastidas, J. Augusto, and John E. Niederhuber. "The Pancreas." In Fundamentals of Surgery, edited by John E. Niederhuber. Stamford: Appleton & Lange, 1998.