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Surgical therapy options
for pancreatic diseases
Operations on the pancreas are performed for a variety of reasons. The patient's disease and the symptoms caused by it are decisive for the choice of the method. The surgeon will usually talk to the patient before the operation and explain his plan. Occasionally, however, a somewhat different picture emerges during the operation than was discussed in the preliminary meeting, so that a slightly different approach must then be taken. Thus, the tailored approach of finding the right solution for each patient individually is possible.
Drainage operations
In these procedures, drainage disorders that have occurred during the disease are removed. Most commonly, pseudocysts, which can form during the course of pancreatitis, are operated on in this way. The pseudocyst is opened and connected to a deactivated loop of the small intestine so that the stagnant secretion can drain away.
If the entire pancreatic duct is dilated in the course of chronic pancreatitis, the entire pancreas is occasionally cut open and the gland thus opened is sewn onto a deactivated loop of the small intestine. This often leads to only a temporary improvement in the outflow of pancreatic secretion and thus to a reduction in pain.
If the duodenum is closed off by a pancreatic head tumor, the ingested food is no longer transported further. If it is not possible to remove the tumor completely from the patient, it is possible to make life easier for the patient and at least allow him to eat normally.
In this operation, the stomach is connected to an upper loop of the small intestine so that the passage of food is possible again, bypassing the closed duodenum. This procedure is called a gastroenterostomy. If the outflow of bile is prevented by a pancreatic head tumor, jaundice, a so-called icterus, develops. Digestive disorders and a massive itching often occur. This problem can be solved by a new connection of the bile duct to a loop of the small intestine. This procedure is called biliodigestive anastomosis.
Resection surgery
Due to tumors or inflammations of the pancreas, different operations become necessary. Here, both the surgical procedure and the sensible postoperative follow-up are not uniform but always tailored to the individual patient. In each case, part of the pancreas is removed.
In principle, the aim is to operate in a way that saves organs in order to preserve as much functional tissue as possible. In the case of tumors, a sufficient safety margin must always be maintained in the healthy tissue. Whether this is sufficient is checked by the pathologist who receives the diseased tissue for examination.
Complementary surgical methods
Operations on the pancreas - like many other operations - are suitable for keyhole surgery (so-called minimally invasive or laparoscopic surgery). This involves operating through four to five small incisions with the aid of a camera. The advantages over conventional surgical procedures lie primarily in the better cosmetic result and the often lower need for painkillers after the operation.
At Heidelberg University Hospital, we offer this surgical procedure for benign changes in the pancreas (cystic tumors, endocrine tumors, chronic pancreatitis).
Pancreatic left resection
This procedure is used for tumors or inflammation in the pancreatic tail or parts of the pancreatic body. In this operation, a more or less large part of the pancreas is removed. Usually, the pancreatic duct is closed at the dividing line. In some cases, drainage of the duct to an eliminated loop of small intestine is performed. Attempts are made to preserve the spleen during this operation. However, because the blood vessel supply of the pancreatic tail and spleen often share common connections, this is not always possible. In addition, the gallbladder is usually removed to prevent later complications.
The consequences after the operation depend on the removed parts of the pancreas, in many cases there is no dysfunction due to lack of digestive enzymes or diabetes mellitus. If the spleen had to be removed, changes in the defense against infections occur and an increase in the number of blood platelets (thrombocytes) can lead to an increased tendency to thrombosis.
Duodenum-preserving surgical intervention
A procedure used primarily for the treatment of chronic pancreatitis. The advantage of this method is that less tissue is lost and therefore the procedure is gentler on the organs. This also results in fewer late effects with equally good or better results compared to older operations.
In this operation, the pancreatic head is peeled out of the duodenum. This is technically very demanding. The bile duct must be spared so that the outflow of bile into the duodenum is not disturbed. The remaining pancreas is then sutured to an eliminated loop of small intestine. This part of the operation is particularly difficult because this connection between the pancreas, its duct and the sewn-on small intestine is subjected to considerable stress from the aggressive pancreatic secretions. The gallbladder is removed to prevent subsequent complications of biliary drainage. The stomach and duodenum are completely preserved. The pancreas, which is still formed, is directed to the upper part of the small intestine to the food and bile secretion so that digestion can function normally. Occasionally, if the bile duct cannot be detached from the inflamed tissue of the pancreatic head, it is also necessary to sew the bile duct to a loop of the small intestine (so-called biliodigestive anastomosis).
The consequences after the operation depend on the extent of the lost functions of the pancreas. Due to the disappearance of pain symptoms, the patient can usually eat normally again. Under these postoperative conditions, an accurate assessment of the remaining metabolic function can be made and the necessary treatment can be derived. (enzyme replacement, diabetes therapy, vitamin supplementation).
Pancreatic head resection according to Kausch/ Whipple
This operation was already performed at the beginning of the last century. However, it was not until the improvement of anesthesia conditions that it gained its breakthrough as a standard treatment for pancreatic head tumor in the middle of the last century. This method is still used today, but there are a large number of variations. In the classic "Whipple" procedure, 2/3 of the stomach, the duodenum, the gallbladder and the pancreatic head are removed. This allows access to the lymphatic drainage channels, the lymph nodes, which are important in tumor removal. To be on the safe side, these must also be removed so that they can then be examined by the pathologist. The first small metastases of pancreatic cancer are found in them. The difficulty of this operation is the connection of the remaining pancreas with an eliminated loop of small intestine, because at the anastomosis between intestine, pancreatic duct and pancreatic tissue the aggressive pancreatic secretion attacks the suture. Since the duodenum is removed, the bile duct must also be sutured into an eliminated loop of small intestine.
The consequences of this surgery may be due to various causes. The extent of pancreatic head resection determines the loss of pancreatic function with subsequent disorders (enzyme deficiency, diabetes mellitus and vitamin absorption deficiency). Furthermore, partial gastric resection can lead to various complications (dumping syndrome, lack of gastric reservoir, vitamin B 12 deficiency, bacterial miscolonization of the small intestine, etc.) The constrictions of the biliary tract anastomosis with subsequent obstruction of bile drainage or the mentioned bacterial miscolonization of the small intestine can lead to ascending biliary tract inflammation. In the variation of gastric preservation, constriction of the anastomosis at the newly created connection between the stomach and the intestine can lead to gastric emptying disorder.
Pancreatic head-preserving duodenum resection
This relatively new procedure makes it possible to spare the pancreatic head in the case of tumors of the papilla, i.e., the excretory duct of the bile and pancreatic secretions, by removing the duodenum alone. In this way, complicated suturing techniques become necessary because the pancreatic duct, the bile duct and the stomach have to be reconnected to the small intestine, but it is possible to operate in a very organ-sparing way. In the past, Whipple's operation had to be used for these patients.
Consequences of this operation can only be caused by disturbances at the anastomoses. However, since this technique is still relatively new, there are no large long-term studies available here.
Total pancreatectomy
In this operation, the entire pancreas is removed. Concomitantly, the spleen, 2/3 of the stomach, the duodenum, and the gallbladder are resected. Technically, this procedure is rather easier to perform than the classic Whipple due to the omission of the anastomosis with the pancreas. Again, the reduced stomach must be connected to the small intestine. However, the subsequent problems for the patient are considerable. Therefore, this operation is used only as a last resort, when there is no possibility of still preserving pancreatic tissue. In any case, a new connection must be made between the bile duct and an eliminated loop of the small intestine. There are now a number of variations on this operation as well, and attempts are made to preserve the stomach or the spleen or both.
The main problem with this surgery is the metabolic management of these patients. Diabetes is difficult to treat: It completely lacks its counterpart, glucagon, in addition to insulin. This means that there is a very high risk of hypoglycemia (low blood sugar). The complications mentioned in Whipple's can also occur due to gastric surgery, but they are more serious because diabetes requires regular food intake so that the injected insulin does not cause hypoglycemia. Resorption disorders, and vitamin deficiencies due to unsafe absorption of food are added. The removal of the spleen means a reduction in the body's defense against infections and often an increase in the number of thrombocytes (blood platelets) and thus an additional increase in the risk of thrombosis, which is increased in tumor patients anyway.
Pancreatic segment resection
If a small tumor is found in the pancreatic corpus, it can occasionally be removed in an organ-sparing manner.
This means the pancreatic head with the duodenum and the pancreatic tail with the spleen can be preserved. The difficulty of this operation is again the connection between the remaining pancreas parts and the intestine. Either the pancreatic head is closed at its end and the pancreas then drains normally into the duodenum, or a loop of small intestine is sewn onto the pancreatic duct and pancreatic tissue here. This loop must then also drain the secretion from the remaining pancreatic tail.
The consequences of this operation are rarely caused by the lack of pancreatic enzyme or insulin. Rather, problems may occur here due to the difficult surgical procedures. Therefore, this procedure should be performed only in special centers.
