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The pancreas is an organ that resides deep in the abdomen.
It rests against the backbone in front of two major
blood vessels called the aorta and the inferior vena cava.
It is also covered by the stomach and the liver.
The pancreas is divided into three
anatomical portions, the head, body, and tail.
The head of the pancreas is surrounded by the duodenum the
part of the intestine that connects the stomach to the small bowel.
The tail of the pancreas resides in the hylum of the spleen.
The pancreas has two very important functions most
of the gland is involved in producing the
digestive enzymes that are collected in the main
pancreatic duct, and then emptied into the duodenum.
These enzymes are involved in the digestion of fats, sugars and proteins.
There are also small microscopic groups of cells
dispersed throughout the pancreas, called the Islets of Langerhans.
These small groups of cells produce a variety of hormones,
including insulin, that are released directly into the blood and help
regulate a variety of different functions, the most important of which
is keeping the blood sugar, or glucose, in a normal range.
Glucose is the main source of energy for the body.
A variety of benign and malignant tumors can arise
in the pancreas, often in the head of the gland.
Tumors in this area present a particular
problem because the head of the pancreas is
at an important crossroads where the pancreatic
duct empties its digestive enzymes into the duodenum.
And the bile duct delivers bile from the liver and gall bladder.
If a malignant tumor such as a pancreatic cancer arises in the head of the
pancreas, it will often block both the pancreatic duct and bile duct.
Resulting in a patient turning yellow, or becoming jaundiced.
When the bile duct is obstructed by
a tumor, bilirubin, a yellow substance produced
in the liver, is no longer able to empty into the duodenum and be excreted.
And backs up in the blood, and the patient turns yellow.
This is often first noticed in the whites of the patient's eyes.
Yellow jaundice is often the first clue that the patient has a pancreatic tumor.
Weight loss and abdominal pain may also be symptoms of a pancreatic tumor.
When these symptoms are present, the physician will order a
cat scan to look for a tumor or other important signs.
Such as a dilated bile duct in the liver or a dilated pancreatic
duct, both of which can be caused by tumor obstructing the ducts.
If cancer is diagnosed, the physician will use the CAT scan
and possibly a variety of other tests to stage the cancer.
And determine whether the tumor has spread beyond the pancreas.
If it has not the cancer's considered resectable and the patient is a candidate
for an operation called the Whipple operation or a pancreaticoduodenectomy.
The whipple procedure or pancreaticoduodenectomy is a major
operation that often takes between five and six hours.
The patient is admitted to the hospital, prepared for
surgery and then put to sleep with general anesthesia.
After the patient's abdomen is prepped with an antiseptic, and draped
appropriately, generally the operation is performed through a midline incision.
Under certain circumstances the operation can also now
be done laprascopically through four or five small incisions.
However, most operations are still done through an open incision.
Once the incision is made, the surgeon carefully explores the abdomen to confirm
that the tumor has not spread beyond the pancreas and its surrounding area.
And therefore can still be surgically removed.
Because the head of the pancreas is located so deep within the abdomen.
Many structures have to be divided before the tumor can be removed.
The gall bladder is mobilized and the bile duct leading to the duodenum is divided.
Next, the duodenum is divided to preserve the entire stomach as
well as the Pyloris valve in the first portion of the duodenum.
This is referred to a pylorus-preserving Whipple procedure.
In some cases, the surgeon may perform a classic Whipple
procedure where a portion of the stomach is also removed.
The neck of the pancreas is divided being certain that no
tumor is left behind in the neck or body of the gland.
One of the most important steps in
this operation involves removing the pancreas and tumor
from two important vessels that supply blood to
the intestines and return it to the liver.
These are called the Superior Mesenteric artery
and the Superior Mesenteric and Portal veins.
Occasionally if these structures are involved with tumor,
portions of these important veins are also removed.
This dissection is quite complicated and prolongs the operation.
The proximal small bowel, called the jejunum is divided allowing
the entire specimen to be mobilized and removed from the body.
Once the specimen consisting of the pancreas containing the tumor.
And the surrounding tissues is removed, the reconstruction
is then carried out in a step wise fashion.
Generally, the remaining pancreas is reconnected or anastomosed to
the proximal small bowel in an end to side fashion.
Next, several inches beyond the first anastamosis,
the bile duct is reconnected to the jejunum.
Finally downstream from the bile duct anastamosis,
either the duodenum or stomach is reattached to
the jejunum depending upon whether a pylorus
preserving or a classic Whipple has been performed.
So in summary, a Whipple operation, or pancreaticoduodenectomy, removes
a portion of the pancreas containing the tumor, the
gallbladder and distal bile duct, and most of the
duodenum along with a section of small bowel or jejunum.
The reconstruction includes a nastimosine or reattaching the pancreas,
the bowel duct and duodenum, or stomach, to the small bowel or jejunum.
Patients undergoing this extensive operation are often placed in an intensive
care unit for observation for the first 24 hours after surgery.
The next day following surgery the patient is gotten out of bed.
Often ambulated in the nasogastric tube that is placed through
the nose down into the stomach during the operation is removed.
Many patients will start taking sips of water during the first post-operative day,
and usually will be discharged from the intensive care unit and go to a floor.
The second day after surgery, patients often start taking liquids.
And as early as the third post-operative day, may actually begin on solid foods.
Drains are frequently left in place after the operation,
to collect any secretions that may be present after surgery.
If appropriate, the two drains are removed
on the fourth and fifth post-operative days.
If a patient has done well with no
post-operative complications, they may leave the hospital as early
as the sixth or the seventh day, but
a hospitalization of about eight days is the average.
After a recovery period of several weeks, the vast majority
of patients will be able to resume a normal life.
Depending upon the type of tumor and lymph node involvement, chemotherapy or
radiotherapy or both, maybe indicated starting six or eight weeks after surgery.
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