Overview of Pancreatectomy
A pancreatectomy is a medical term that refers to the surgical removal of all or part of the pancreas. It’s a procedure that can be performed in many different ways, depending on whether the issue with the pancreas is benign (not harmful in effect) or malignant (very harmful in effect).
The doctor performing the surgery needs to not only know how to execute these diverse surgical techniques, but also needs a deep understanding of what the pancreas looks like (anatomy), how to diagnose conditions before surgery (preoperative diagnostic modalities), and how to take care of the patient after the surgery (postoperative management).
While there have been many advancements in the techniques used to operate on the pancreas over time, it still remains a complex and difficult procedure. This surgery calls for a lot of skill, experience, and sound judgment on the doctor’s part.
The best way to perform this operation, the conditions that require it, any conditions that may prevent it from being performed, as well as the evaluation and different surgical methods used for various types of pancreatic resections (removal of parts), will be covered here.
However, a specific type of pancreatectomy, called a Pancreaticoduodenectomy (or a Whipple procedure), that comes with unique steps, challenges, and care requirements, will be discussed separately.
Anatomy and Physiology of Pancreatectomy
The pancreas is a long, flat gland found in your abdomen, or belly. This organ is important because it helps your body digest food and controls your blood sugar levels. The pancreas has both “endocrine” and “exocrine” functions. These fancy terms just mean that part of the pancreas works like a factory, making hormones like insulin which are directly pumped into your bloodstream (that’s the endocrine part). The other part of the pancreas, the exocrine part, makes enzymes which helps break down the food you eat.
The pancreas sits deep inside your belly, behind your stomach and liver, and spans from the right to the left side of your body. It consists of five parts: the head, the uncinate process, the neck, the body, and the tail. The head is the broadest part and is located near the beginning of your small intestine. The uncinate process is like an extension of the head tucked underneath the body of the pancreas. The neck is the thin segment of the pancreas; then comes the body and at the far end is the tail, which is the most movable part. Everyone’s pancreas is a little bit different. For example, some people might not have the uncinate process, or it could be unusual in shape and size.
The pancreas developed from two parts (the ventral and dorsal buds) that emerged from the early stages of the embryo and later joined together. This merging of the buds also made the two main tubes (ducts) that carry the pancreatic enzymes. The main duct (Wirsung’s duct) and a smaller side duct (Santorini’s duct). These ducts join the common bile duct (which carries bile from the liver) to form a single tube before draining into the second section of the small intestine.
The blood supply to the pancreas comes from two main arteries – the celiac artery and the superior mesenteric artery. The celiac artery gives off branches that supply the part of the pancreas near the stomach and the beginning of the small intestine. The other artery, the superior mesenteric artery, provides blood to the rest of the pancreas. Given the rich blood supply, it’s important for doctors to have a clear picture of the pancreas and surrounding blood vessels before any surgery to avoid complications.
The veins of the pancreas typically follow the same routes as the arteries, draining the blood away from the pancreas and back to the heart. Just like there are many variations in the arteries that supply the pancreas, not everyone’s veins follow the exact same route.
Why do People Need Pancreatectomy
There are different types of surgeries used to remove parts or all of the pancreas. Which one is used depends on many factors, including the comfort and skill level of the surgeon with each technique.
A total pancreatectomy, or removal of the entire pancreas, may be necessary in several cases. This could be due to cancer in various parts of the pancreas, recurring cancer, complications from a previous surgical procedure known as a Whipple procedure (which removes parts of the pancreas and other organs to treat pancreatic cancer), or multiple occurrences of a particular type of growth in the pancreas. People with a genetic predisposition to pancreatic cancer or experiencing constant pain due to chronic pancreatitis (inflammation of the pancreas) might also need this operation.
A distal pancreatectomy is when the surgeon removes the left side of the pancreas. This may be needed for benign or cancerous growths in the body or tail (the thin, pointed part) of the pancreas, chronic pancreatitis in these areas, a pseudocyst (fluid-filled sac) that involves the tail of the pancreas, injury to the end of the pancreas, or a problem with the pancreatic duct in the body or tail.
A central pancreatectomy is when the surgeon removes the middle section of the pancreas. This might be the best method for benign or other non-threatening growths in the neck or the part of the pancreas just to the left of the neck, when a growth cannot be removed from these areas, or in case of an injury to these areas. Another thing to consider is whether it’s worth it to keep the distal pancreatic tail (part of the pancreas after the body), which would require at least 5 to 6 cm of it to be remaining.
When a Person Should Avoid Pancreatectomy
There are certain situations where a person may not be suitable for certain types of surgery due to their overall health or specific complications. These include:
– Medical conditions that make surgery too dangerous
– Poor overall health or physical wellbeing
– A condition that affects the blood’s ability to clot and stop bleeding
When it comes to procedures using a laparoscopic technique, which is a type of surgery that uses smaller incisions and a camera, it can be unsuitable for:
– People who are severely overweight (this can depend on the surgeon expertise)
– Anyone who has had major surgery in the abdomen before, as this can lead to scar tissue complicating the procedure
– Cases with advanced cancer, particularly those affecting blood vessels (again, this depends largely on the surgeon’s level of skill)
– Those who can’t tolerate the procedure of inflating the abdomen with gas, which is usually done for a better view during the surgery
A total pancreatectomy, a surgery to remove the entire pancreas, is not suitable for:
– Tumors that can be removed while still retaining some healthy pancreas tissue through another type of surgery
Central pancreatectomy, a surgery that removes the middle part of the pancreas, is not suitable for:
– Pancreatic cancer, when it’s not possible to completely remove all the cancerous tissues and affected lymph nodes
A distal pancreatectomy, which removes the body and tail (the left side) of the pancreas, isn’t suitable for:
– Tumors on the pancreas that can’t be fully removed with this type of surgery or if a complete removal of the tumor (called an R0 resection) can’t be achieved.
Equipment used for Pancreatectomy
In an operating theatre, certain things are needed that you will not see. These include sterile drapes, gowns, and gloves to ensure a clean environment. The doctor will need a set of surgical tools, threads (known as sutures), and special stapling devices used during surgery.
There’s also a machine called a ‘cell saver’. This can recover blood lost during surgery and give it back to you, which can be very helpful. If your surgery is being done using a laparoscope (a small instrument with a camera that lets the surgeon see inside your body through a small cut), other items such as video monitors, camera lenses, scissors, graspers, dissectors, staplers, energy devices, and sutures are also required for laparoscopic procedures.
An ultrasound machine might be used to get a better look at the area being operated on. A code cart, which is a set of drawers on wheels filled with drugs and equipment necessary for emergency medical situations, is always present. You’ll also have an anesthesiologist to provide the anesthesia, making sure you don’t feel any pain during the operation.
Arterial and venous lines, long and thin plastic tubes, will be inserted into your blood vessels to give medicines, fluids or to take blood samples. A Foley catheter, which is a flexible tube, may be put into your bladder to help with the flow of urine. Closed suction drains might also be placed to help drain fluid or blood that may gather around the surgical area and surgical loupes, or magnifying glasses, may be used by the surgeon to assist in the operation.
Who is needed to perform Pancreatectomy?
During surgery, there are many important roles carried out by different professionals in the medical team. This includes the anesthesia team who are responsible for administering safe doses of anesthesia to keep you comfortable and pain-free during the surgery.
Also in the room for surgery are the operating room (OR) personnel. These are typically nurses and scrub techs who assist the surgeon by handing them the necessary tools and ensuring sterilization measures are followed.
The main person in charge during the surgery is the surgeon. This is a specially trained doctor who carries out the surgical procedure.
In most cases, the surgeon is assisted by a first assistant. This assistant can be a doctor, physician assistant, or nurse who provides hands-on assistance during surgery.
Sometimes a skilled Ultrasonographer may also be required. This person uses an ultrasound machine – a device that uses sound waves to create detailed images of structures within your body – to guide the surgeon. Their role becomes crucial when there isn’t an ultrasound immediately available in the operating room for the surgeon’s use.
Lastly, there may be a Cell Saver Technician present. This person operates the cell saver machine, a device that collects and cleans the blood lost during surgery so it can be given back to you. This can reduce the need for blood transfusions.
Preparing for Pancreatectomy
Before any surgery on the pancreas, a patient must go through a strict assessment. Doctors will look at the patient’s medical history, previous surgeries and current health conditions. They will also consider the patient’s symptoms and family history of cancer. If the patient is to have surgery for cancer, a special blood test called Ca19-9 is typically done to confirm the presence of cancer, see if it has spread, and provide a baseline for after-surgery checks.
Imaging or visualization of the pancreas are necessary for diagnosis and planning. CT scans can show the exact location and size of a problem area. They also give information on whether any surrounding structures are affected, which indicates if surgery is possible. In addition to morphology, CT scans help estimate resectability – how much of the tumor can be physically removed.
Doctors also use a procedure called an endoscopic ultrasound. This gives clearer views of blood vessels, helps estimate how much of the mass can be removed, and can even provide a tissue sample for biopsy. This procedure is especially helpful for smaller problems like cysts.
Magnetic Resonance Imaging (MRI) is also used. MRI is great for identifying changes in the pancreas and nearby ducts and has become more common even after surgery for monitoring any changes.
Positron Emission Tomography (PET) scans are occasionally used, but they have strengths and weaknesses. PET scans can sometimes not detect small problem areas and may yield false negatives if the patient’s blood sugar level is too high. However, when CT and PET scans are combined, the accuracy significantly increases. This combination is particularly helpful when cancer markers increase after surgery.
Overall, doctors consider multiple factors, test results, and imaging techniques to assess the patient’s condition, decide if surgery is feasible and plan the surgery accordingly. This is all done to ensure the best possible outcomes and reduce any risks associated with surgery.
How is Pancreatectomy performed
Medical technologies have greatly advanced over the past decade, including minimally invasive methods to manage non-cancerous or cancerous growths. Earlier, laparoscopic techniques (using small incisions and a camera to perform surgery) were only used to determine the stage of pancreatic cancer. Now, many surgeons use robotic or laparoscopic techniques to perform various types of surgeries on the pancreas. These methods cause less pain after surgery, shorter hospital stays, less blood loss during surgery, faster return to usual activities, less risk of post-surgery digestion issues, and overall fewer complications.
Laparoscopic techniques are complex and should be performed by surgeons with advanced training in minimally invasive surgical techniques. The surgeon must be comfortable using high-tech equipment like laparoscopic ultrasound, laparoscopic staplers, and suturing tools.
Patients with a suspected cancerous growth in the pancreas usually undergo a diagnostic laparoscopy first. This involves inserting a camera through small incisions in the abdomen to visualize the internal structures and detect any cancer spread. If no spread is confirmed, the surgeon can continue with the main laparoscopic surgery or switch to an open surgery method, based on the team’s usual practice, and the specific situation of the patient.
Open surgery techniques involve larger incisions and are more invasive. Preparations for this type of surgery typically include reviewing all preoperative imaging, obtaining patient consent, and placing the patient on the operating table in the supine position (laying flat face upward). Additional steps may be taken based on patient factors, surgeon and anesthesiologist’s judgment, and comfort level. A formal pause is taken to confirm the correct patient, procedure, and position, and the administration of preoperative antibiotics to prevent infections. Once the abdomen is prepared in a sterile manner, the surgery proceeds with a variety of retractors used to open up the abdomen, explore the anatomy, and work on the pancreas accordingly.
The detailed procedures for various pancreatic surgeries, such as total pancreatectomy (removal of the entire pancreas), vary but generally involve maneuvering the organ for exposure, tracking and dissecting the necessary arteries and vessels, handling associated structures such as the gallbladder, liver, and small bowel, and finally, completing the case with meticulous attention to avoid unnecessary injury and complications.
In this process, it’s essential to handle all structures involved with great care and precision. The exact procedures will depend on the specific surgery being performed and the unique internal anatomy and condition of the patient. Both open and laparoscopic techniques aim to treat the patient effectively, prompt recovery, and minimize complications.
Possible Complications of Pancreatectomy
After pancreatic surgery, there can be some potential complications which, if not identified and managed quickly, can significantly affect the patient’s health.
One common complication after a pancreatomy, or surgical removal of the pancreas, is the development of fistulas. Fistulas are abnormal connections that form between body parts. After pancreas surgery, up to 60% of patients may experience fistulas. Most often, these fistulas are mild and can be managed with continued drainage, and will heal on their own over time. However, in rare and severe cases, they may lead to severe infection and failure of multiple body systems. In such cases, immediate surgical intervention is required.
There can also be a risk of developing diabetes postoperatively, especially when a large portion of the pancreas is removed during the surgery. This happens in less than 10% of cases. It is known as pancreatogenic diabetes and along with it, patients can also face other issues such as fat accumulation in liver, nutrient malabsorption with fatty stools, eye diseases, nerve damage, and increased risk of heart disease.
An additional complication can be splenic infarction, which is the death of spleen tissue due to inadequate blood supply or clotting. This can occur postoperatively when blood vessels of the spleen are tied off during certain procedures. This can lead to the formation of an abscess, or a pouch with pus. It can also cause the formation of varices, or enlarged blood vessels, in the stomach.
Another potential issue is delayed gastric emptying, meaning the stomach takes longer than normal to pass food into the small intestine. It can occur in up to half of all patients post-surgery. This can prolong a patient’s hospital stay and lower their quality of life until it is resolved.
Also, the newly created surgical connections, or anastomoses, can leak, leading to further health complications. Regardless of the technique used to create the connections, there’s still a substantial risk of leakage.
Finally, there can be bleeding within the abdomen (intra-abdominal hemorrhage) after surgery which can be due to multiple causes. At the beginning of the post-surgery period, it might be due to an incomplete stopping of bleeding. Later, it can be due to leaks from the pancreas eroding into blood vessels or causing a breakdown in the surgical connection site. Wound complications can also occur; these are especially common among patients with poor nutrition or conditions like diabetes and obesity.
What Else Should I Know About Pancreatectomy?
Pancreatic surgery involves complex procedures that can be used to treat a variety of conditions. The type of surgery a patient needs will be based on a thorough diagnosis and a detailed understanding of the issue with their pancreas. When the correct surgery and technique is chosen, conditions, whether they are cancerous or not, can be treated very effectively.
Carrying out pancreatic surgery requires great skill and care, as there can be complications after the surgery which can significantly impact a patient’s wellbeing and quality of life.
In recent years, there have been numerous advancements in pancreatic surgery. One such advancement is the increasing use of minimally invasive surgery. This type of surgery can help reduce pain after surgery, shorten the time patients need to stay in the hospital, and allows patients to return to work more quickly.