Introduction to Pancreas The pancreas is a vital organ, located just below the liver and in the retroperitoneal space (anatomical space at the back of the abdomen). It has both exocrine (digestive enzymes) and endocrine (hormones) function, and plays a key role in maintaining blood glucose levels. The exocrine function of the pancreas involves secretion of enzymes into the duodenum to aid in digestion and absorption of nutrients. The endocrine function involves secretions of hormones to regulate blood glucose level and the main hormones are insulin (decreases blood sugar level) and glucagon (increases blood sugar level).
Pancreas Diseases The pancreas can be involved in a variety of disease process and injuries. Diseases of the pancreas can be classified to either an acute or chronic process. The most common acute disease of the pancreas is acute pancreatitis (inflammation of the pancreas).
Some of the causes of acute pancreatitis are:
Gallstones
Excessive consumption of alcohol with direct damage on pancreatic cells
Medications
Viral infections, e.g. mumps
Trauma
Gallstones and alcohol are the two most common cause of acute pancreatitis in the Western world. Recurrent acute pancreatitis can lead to chronic pancreatitis and the most common cause for chronic pancreatitis is excessive alcohol consumption.
Other potential causes for chronic pancreatitis are:
Congenital anatomical variant of the pancreatic duct
Genetic factors
Cystic fibrosis
Symptoms of Pancreatic Disease There are no specific symptoms that can be attributed to pancreatic disease and contributes to the late diagnosis of pancreatic cancer with vague symptomology.
Symptoms can include:
Upper abdominal (epigastric) discomfort/pain that radiates to the back
Back pain
Nausea and lack of appetite
Jaundice if the bile duct was obstructed by an abnormality at the head of the pancreas. Patients would report dark urine, pale stools and itchy skin, and yellow-tinged eyes.
Steatorrhoea due to a lack of secretion of digestive (exocrine) enzymes by the pancreas. This is characterised by loose, pale, floating and offensive-smelling bowel motions secondary to fat malabsorption in the intestine.
New-onset diabetes if the endocrine function of the pancreas is impaired by the cancer.
What is Pancreatic Surgery? Pancreatic surgery refers to a variety of surgical procedures that can be performed on the pancreas. Pancreatic surgery usually includes removing part of the pancreas, most commonly for pancreatic cancer. Occasionally, it can be performed for pre-cancerous lesions.
The more common pancreatic surgery include:
Pancreaticoduodenectomy (Whipple’s procedure)
Distal pancreatectomy
Total pancreatectomy
The type of surgery is dependent on the indication for surgery. Dr. Michael Chu will go through the indications and what the surgery involves during your consultation.
Pre-operative Assessment Initial Assessment Initial assessment will include blood tests (including CA19-9) and imaging of your pancreas (USS, CT, and/or MRI) to assess the extent of the pancreas cancer. These are performed to determine your suitability for pancreatic surgery. The results of these investigations will be discussed with you and treatment options will be outlined.
Anaesthetic Assessment Once a decision has been made to proceed with surgery, you will be requested to fill out an anaesthetic questionnaire. This will be reviewed by the anaesthetist that will be responsible for your care and you may be required to see the anaesthetist in person or sent for additional tests. Once you have completed the anaesthetic review, the date of surgery will be confirmed with you.
Types of Pancreatic Resection The two most common type of pancreatic resection are the Whipple’s procedure and distal pancreatectomy. The type of resection is dependent on the site of the cancer. Whipple’s procedure are performed by an open procedure (laparotomy) while in certain cases, it is feasible to perform distal pancreatectomy laparoscopically (keyhole). In rare occasions, a total pancreatectomy (complete removal of the pancreas) is indicated (if there is a large tumour or more than one tumour).
Pancreaticoduodenectomy (Whipple’s Procedure) This is performed for lesions at the head of the pancreas. An incision is made in the right upper quadrant of the abdomen and the abdominal cavity is entered into carefully. The incision can be a straight midline wound or more commonly, a “Reverse-L incision”.
The head of the pancreas will be removed with the following organs and tissues:
Distal (lower) end of the stomach
Duodenum
Gallbladder
Lower part of the bile duct
Lymph nodes (lymphadenectomy)
The reason these are removed concurrently are for complete removal of the cancer and because they share the same blood supply as the head of the pancreas. Once the resection phase has been completed, the pancreas, bile duct and stomach are re-connected to the jejunum (small bowel).
The procedure will be explained with the aid of a diagram during your consultation with Dr. Michael Chu.
Distal Pancreatectomy +/- Splenectomy This is performed for lesions at the tail and body of the pancreas. If the indication is for pancreas cancer, the spleen will also be removed. In pre-malignant cases, the spleen can be preserved. The reason for removal of the spleen is to obtain adequate clearance for the cancer and the surrounding lymph nodes, necessitating the removal of the splenic vessels which sits on top of the pancreas.
Distal pancreatectomy can be performed via a laparotomy or laparoscopic technique depending on the pancreas cancer. A laparotomy is usually performed via a midline wound. For laparoscopic distal pancreatectomy, a laparoscope (camera) is introduced via a small incision and three further small wounds are used to allow utility of laparoscopic surgical instruments. Once the pancreatic resection has been completed, the wound for the laparoscope is extended to allow removal of the resected pancreas +/- spleen.
Risk of Surgery There are risks with any surgery and can be divided into “General” or “Procedure-specific risks”. Pancreatic surgery is complex and recovery can be a long process.
General Risks
Wound infection
Venous thromboembolism (VTE), e.g. deep vein thrombosis (DVT) or pulmonary embolism (PE)
Incisional hernia at the wound site
Respiratory complications such as pneumonia (infection) or atelectasis (collapse) can occur secondary to poor inspiratory effort in the post-operative period and from prolonged ventilator support. This can usually be treated with antibiotics and may occasionally require drainage. To reduce the risk of post-operative respiratory complications, it is important for early mobilisation in the post-operative period to help expand the lungs.
Procedure-specific Risks from Pancreas Resection There are some rare but specific complications related to pancreatic resection:
Pancreatic leak
This is when pancreatic fluid leak out from the anastomosis (join of small bowel to pancreas) in Whipple’s procedure or from the cut surface of the pancreas in distal pancreatectomy. There will be a drain left in the abdominal cavity in all pancreatic resection and the fluid collected will be tested for amylase (one of the pancreatic enzymes), and this will allow us to detect for a pancreatic leak. In the majority of cases, the leak is mild and will self-resolve. Occasionally, further procedures may be required.
Bile leak
This occurs when the anastomosis of the bile duct to the small intestine leak bile fluid into the abdomen. This is a rare occurrence and will generally self-resolve.
Post-operative bleeding
This usually occurs in the setting of a pancreatic leak and may require radiological intervention to stop the bleeding from within the blood vessel (angiogram & embolisation). Rarely, a re-operation may be required.
Post-operative Infection in setting of Splenectomy
The spleen aids the body in fighting infection, particularly against encapsulated organisms. If the spleen is removed, you will be more prone to infections caused by these organisms. In that case, you will be given vaccination against these organisms to reduce the risk against these organisms.
Contraindications to Pancreatic Surgery All patients undergo a thorough assessment before deciding whether to proceed with pancreatic surgery. This will include clinical examination, blood tests and advanced imaging (CT or MRI Pancreas). Dr. Michael Chu will work alongside you at each step of the assessment and make sure you have a thorough understanding. If the potential benefit from surgery is less than the risks of surgery, surgery would not be recommended.
Post-Operative Management Depending upon the extent of the pancreatic resection, you may be required to be admitted to the High Dependency Unit (HDU) for the night of your surgery. You will be cared for on the ward after your HDU stay. There will be a number of checks performed by the nursing staff routinely, including overnight.
During your hospital stay, Dr. Michael Chu will review you twice a day and the anaesthetist will review you at least once a day. The ward staff are very experienced in caring for patients following pancreatic surgery and will be caring for you.
Post-operative Diet Patients are allowed to eat and drink as tolerated following surgery. On the night following surgery in HDU, patients are allowed to drink oral fluids as tolerated and then progress to a full diet as tolerated in the next 24-48 hours. Please ensure that you listen to your body with regards to appetite/hunger and if you feel full/bloated, do not try and push more oral intake. If required, a dietitian will visit you on the ward to advise you about post-operative dietary requirements and prescribe supplemental nutrition drinks as needed.
In the initial stages, you may find that eating small meals regularly throughout the day may be more tolerable than three large meals a day. As you improve, you will be able to adjust your dietary intake to suit your body. If you are really struggling with your oral intake, there are dietary supplements available and this can be liaised with a dietitian.
Post-operative Mobility You will be encouraged to mobilise as much as possible during your hospital stay to reduce the risk of post-operative lung complications and DVT. In the first post-operative day (this may be in HDU), you will be encouraged and assisted to mobilise into a chair, and sometimes for a short distance.
Post-operative Analgesia The majority of patients will have a mild discomfort post-operatively. Pain management will be managed between Dr. Michael Chu and the anaesthetist. It usually consists of regular paracetamol with addition of stronger analgesia (in the form of opioids) on an “as required” (PRN) basis.
Prophylaxis for Blood Clots (VTE) To prevent VTE, patients will require a daily injection to be self-administered subcutaneously in the abdomen. This will be for 28 days post-operatively and patients will be instructed how to administer this prior to their discharge.
Wound Care The surgical incision will be sutured with dissolvable sutures and do not require removal. Steristrips (thin-adhesive bandages) are placed over the incision to support the skin edge and reduce the tension on the wound, and are usually on for 10 days. On top of the Steristrips, a waterproof dressing is placed and should stay for at least 3-5 days. You are able to shower with this dressing and should be pat dry afterwards. Some patients prefer to leave the waterproof dressing for a bit longer and that is okay. If the Steristrips fall off earlier than 10 days, it is acceptable.
Once the dressing is removed and the wound appears clean and dry, the wound does not need further dressings. Occasionally, the wound may leak some “dark-ish” fluid or looks a little red, and this is not unusual. The staff will keep a close eye on the wound. If staples or non-dissolvable sutures are used to close the wound, these will need to be removed after 10-14 days. The district nurse will be able to do this for you. If you would like to use Vitamin E or Bio-Oil on the wound to reduce scar prominence, please do so after the first week.
Duration of Hospital Stay The majority of patients spend 5-6 days in hospital prior to discharge. The general criteria for discharge are: Mobilising independently, have an adequate oral intake (fluids and food), able to perform the majority of self-cares and only requiring oral analgesia.
Post-Operative Activity
Activity & Work
Patients are allowed to perform their regular activity as long as it is not too uncomfortable for them. However, it is recommended to be off heavy lifting or activity for 4-6 weeks. Most patients do return back to work after this period but some may take longer to do so. It normally takes ~3 months to return to normal activities. Additionally, most patients experience reduced energy level post-operatively for a few weeks and can be up to 6-8 weeks. Please be patient and give yourself time to recover.
Driving
It is recommended that patients should not drive for a minimum of 3 weeks post-pancreatic surgery. When you get home and feel ready to drive, sit in the car seat and ensure you are able to perform a full emergency stop/brake before you start driving. It is also advisable that you should be able to have the strength to control the car and respond quickly before you start driving.
Importantly, please check with your insurance policy and company to ensure that you do not invalidate your insurance policy by driving post-operatively.
Tubes & Drains
Feeding Tube
The feeding tube passes through the nose into the stomach and allows supplementary nutrition to be administered in the post-operative period in conjunction with a dietitian.
Drain
A drain will be routinely inserted during pancreatic surgery and allows drainage of any fluid (blood, pancreatic fluid or bile) that may leak out. The drain will be left in place for at least 3 days.
Urinary Catheter
A catheter is placed in the urinary bladder in the operating theatre to monitor urine output (kidney function) during the post-operative period. This is usually removed on post-operative day 2.
Post-Discharge Management When should I seek medical input? If you or your family have any concerns, please contact Dr. Michael Chu directly or his rooms, or the hospital. If it is a medical emergency, please dial 111 for an ambulance to take you the nearest acute hospital.
How does my General Practitioner (GP) know about my surgery? Dr. Michael Chu will send a letter to your GP summarising your hospital stay, and a copy of your operation note, to keep your GP up-to-date with your status. It is advisable that you make an appointment with your GP a few days after your discharge so they can physically assess your clinical status.
Dr. Michael Chu is happy to be contacted by your GP if they have any questions or concerns.
Common side-effects of surgery & solutions
Pain or discomfort
After an operation, a degree of discomfort is expected and usually improves over the first two weeks. In some patients, the discomfort may last for a few weeks. The aim of the prescribed analgesia is to ensure that the discomfort is manageable so that you can continue to improve physically. However, if the pain is worsening or you have any concerns of it’s duration (greater than two weeks), please contact your GP or Dr. Michael Chu
Bruising
There are usually bruising around the incision and may extend up to the ribs. The bruising may appear within 24-48 hours after surgery. If you feel that the bruising is worsening, becoming painful or there is discharge of pus from the wound, please contact Dr. Michael Chu.
Constipation
This is a common occurrence following any abdominal surgery. It is usually related to the opioids during general anaesthetic or those given post-operatively for analgesia. There are a few laxatives that can be obtained over the counter at the pharmacy or by prescription. Similarly, natural dietary supplements such as kiwi-fruit are also quite effective. Importantly, please drink plenty of fluid.
Frequently Asked Questions about Pancreatic Surgery What is the Recovery Period? The recovery period is at least 6-8 weeks before returning to normal activity. However, your gut function may take up to 6 months to normalise. You are encouraged to eat small regular meals rather than three large meals a day.
Do I need further chemotherapy after pancreatic surgery? This is dependent on the final pathology results and your clinical status following surgery. Each case is unique and will be discussed with an oncologist (medical cancer specialist) who are the specialist providing the chemotherapy.
What do I need to do to prepare for surgery? Once a proposed date for surgery has been set, you will need to follow these instructions:
Blood tests are taken 1-2 days prior to the day of surgery. This ensures that blood is available if you require a blood transfusion.
Specific instructions will be given on where and when to present for surgery
Specific instructions will be given on when to stop drinking and eating. It is important that you follow these instructions as it will pose an anaesthetic risk and we may have to cancel/delay your surgery.
You do not need to shave before coming into hospital
You will be advised on what normal medications to take on the day of surgery, but only take them with a small amount of water.
If you are on any blood thinners that affect clotting, please inform Dr. Michael Chu during your initial consultation, as they may need to be stopped well in advance of the day of surgery. If you are unsure about the medications, please ask Dr. Michael Chu and the anaesthetist.
What is the follow-up process for me? A follow-up will be arranged for you after you have been discharged from the hospital. Dr. Michael Chu's PA will get in contact with you and the follow-up is usually 1-2 weeks after leaving the hospital.
At the follow-up consultation, Dr. Michael Chu will go through with you:
How you are recovering
Operative findings
Pathology report from the surgery
Depending on your recovery and the pathology result, Dr. Michael Chu may recommend additional investigations, treatment or follow-up reviews. Dr. Michael Chu will ensure you are fully aware of the plan and answer any questions that may arise during the consultation.
If you have any questions or concerns during your post-operative period, please contact Dr. Michael Chu on +64 27 216 7288