Pancreatic Surgeries

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What Are Pancreatic Surgeries?

Pancreatic Surgeries are surgical procedures that are done to treat and manage several conditions and diseases that affect the pancreas. The pancreas is an important organ of the body that has exocrine and endocrine functions which are to help in digestion and to maintain blood glucose levels. Several conditions or diseases can affect the pancreas some of which may require surgical intervention for management. 

Is Pancreatic Surgeries an elective or an emergency procedure?

Pancreatic Surgeries are mostly done as elective procedures. 

Types

Pancreatic Surgeries may be done as open surgeries or laparoscopic procedures. Several pancreatic surgical procedures are available depending on the underlying condition that is being treated.

Some of these Pancreatic Surgeries include:

  • Pancreatectomy - Complete removal of the pancreas
  • Partial pancreatectomy - Removal of a part of the pancreas
  • Pancreaticosplenectomy - Removal of the pancreas along with the spleen
  • Retrograde distal pancreatic splenectomy
  • Antegrade distal pancreatic splenectomy
  • Spleen preserving distal pancreatectomy - Removal of the tail of the pancreas while leaving the spleen behind
  • Pancreaticoduodenectomy/pylorus-preserving pancreaticoduodenectomy /Whipple's procedure

Indications

Some indications for Pancreatic Surgeries include the following:

  • Pancreatectomy:
    • Chronic pancreatitis
    • Malignant or benign exocrine tumors
    • Malignant or benign endocrine tumors
    • Symptomatic serous cystadenoma
    • Mucinous tumors
    • An intraductal papillary mucinous tumor (IPMT)
    • Cystic pancreatic neoplasms
    • Solid pseudopapillary tumor of the pancreas
    • Malignant pancreatic tumors
  • Partial-pancreatectomy/pancreatic splenectomy/ Spleen-preserving pancreatectomy:
    • Locally resectable adenocarcinomas of the pancreas
    • Solid pseudopapillary tumors
    • Chronic pancreatitis
    • Pseudocysts
    • Suspected malignancy
    • Stenosis of the medial to distal pancreatic duct
    • Pancreatic stones
    • Serous cystadenomas
  • Whipple’s procedure:
    • Noncancerous periampullary tumors that cannot be treated with local resection
    • Duodenal tumors
    • Pancreatic ductal adenocarcinoma
    • Pancreatic islet cell carcinoma
    • Malignant intraductal papillary-mucinous neoplasm (IPMN)
    • Ampullary carcinoma
    • Distal Common Bile Duct Carcinoma or cholangiocarcinoma
    • Duodenal carcinoma

Contraindications and risk factors

Some contraindications for Pancreatic Surgeries include:

  • Inability to undergo general anaesthesia
  • Severe cardiopulmonary dysfunction
  • Coagulopathies
  • Widespread metastatic cancer
  • Vascular invasion of cancer
  • Peritoneal carcinosis

Investigations before the procedure

Some investigations that are done before Pancreatic Surgeries include:

  • Laboratory tests:
    • CBP and ESR
    • Coagulation profile and blood typing
    • Liver and renal function tests
    • Complete urine examination
    • Blood glucose/HbA1c
  • Imaging tests:
    • Chest X-Ray
    • Abdominal ultrasound
    • Echocardiography
    • Contrast-enhanced CT scan
    • MRCP - Magnetic resonance cholangiopancreatography
  • Procedures:
    • ERCP - Endoscopic retrograde cholangiopancreatography
    • Endoscopic ultrasound
    • Electrocardiography (ECG) 

Preoperative advice

Before Pancreatic Surgeries, the following is usually done:

  • The risks and benefits of the procedure are explained
  • Anticoagulant medication may be stopped a few days before the surgery
  • Antibiotic prophylaxis may be started a few days before the surgery
  • Pancreatic enzyme supplements may be given before the surgery
  • Nothing by mouth after midnight on the night before surgery

Intraoperative details

Duration: Pancreatic Surgeries can last between 3 to 6 hours or more depending on the procedure.

Anaesthesia: Antibiotic surgeries are done under general anaesthesia with epidural pain management for postoperative pain.

Description of the procedure

With the individual lying on his/her back, iv lines and a urinary catheter is put in place, and after the general anaesthetic has taken effect either a subcostal incision or a midline incision is given in the abdomen. If laparoscopic surgeries are being done then, multiple small incisions are given in the abdomen and abdominal insufflation is done; fibre optic scope and other surgical instruments are introduced through the incisions to perform the pancreatic surgery.

Depending on the procedure that is being done, the head of the pancreas, the tail of the pancreas, the entire pancreas, a part of the duodenum, a part of the stomach, the spleen, may be resected and removed. In some procedures, the remaining part of the pancreas and the pancreatic duct may be attached to a loop of the intestine. Other procedures such as removal of pancreatic stones, drainage of cysts, resection of locally resectable tumors, etc., are done.

Once the procedure is complete the abdominal incisions are closed with sutures; in laparoscopic surgeries, insufflation is done, surgical instruments are removed and the abdominal incisions are closed with sutures.

Postoperative details

After Pancreatic Surgeries, the following are done:

  • The individual is moved to a recovery room and then to an ICU and monitored until awake and stable
  • Cardiopulmonary functions are monitored
  • Feeding is through a nasogastric tube which is removed after bowel function returns

Common post-procedure occurrences:

  • Pain
  • Nausea
  • Lightheadedness and fatigue

Discharge: Usually 7 to 10 days after the procedure.

Medications: Pain relievers and antibiotics are prescribed.

Review: Usually one week after discharge and periodic checkups thereon.

Resumption of normal activity: Usually 4 to 8 weeks after the procedure.

Role of diet/ Exercise/ Lifestyle changes

Some measures that may be taken after Pancreatic Surgeries include:

  • Avoid strenuous activity for at least 2 to 4 weeks after the procedure
  • Follow a diet as advised by the physician

Complications

Some complications that may be seen after Pancreatic Surgeries include:

  • Intraoperative and postoperative bleeding
  • Surgical site infection
  • Pancreatic fistula
  • Anastomotic leakage
  • Intra-abdominal abscesses
  • New-onset insulin-dependent diabetes
  • Small bowel obstruction
  • Delayed gastric emptying
  • Sepsis
  • Cardiac complications
  • Pneumonia
  • Renal failure
  • Multi-organ failure
  • Respiratory failure
  • Death 

Prognosis

The prognosis of Pancreatic Surgeries depends on the underlying condition that is being treated and the general health of the individual. Pancreatic Surgeries for certain conditions results in the alleviation of symptoms and a better quality of life. The risk of mortality and morbidity of Pancreatic Surgeries is increased in men, and the presence of obesity, history of smoking, long term use of steroids, and the presence of neurologic disease.

Indications for hospitalization if required

Hospitalization will be required for Pancreatic Surgeries.

Suggested clinical specialist/ Department to consult for the procedure

Pancreatic Surgeries are done by specialists from the Department of Interventional Endoscopic Surgery and Surgical Gastroenterology.

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