Surgery (Active Treatments)
1) What can I expect before my operation?
The decision to proceed with an operation is usually made at the surgical clinic, where the surgeon will discuss the outcome of the multidisciplinary team meeting with you and often your family, and then having discussed the pros and cons of an operation with you, you will come to a joint decision as to your preferred treatment approach. You do not need to agree with the recommendation of the MDM, but surgery will only be offered to patients when a tumour is diagnosed at a stage where there is a potential for curative resection.
Where the “shared” decision is to proceed to surgery, the next phase will to attend the hospital for a pre operative assessment review. The aim to identify any medical issues that could be addressed before an operation and reduce complications. The process of an “Enhanced Recovery After Surgery (ERAS)” may be discussed with you, and will involve several blood tests, an assessment with a specialist nurse and sometimes an anaesthetist. The aim is to shorten the delays between admission and surgery, and to avoid issues that may delay surgery being only identified at the last minute.
2) Potentially Curative Resection
2.1) The “Whipple” Operation
In its early stages, pancreatic cancer can be treated by a “Whipple” operation. This operation was first described by an Italian, Allesandro Codivilla in 1898, popularised in Europe by Dr Walther Kausch from Germany in 1909, but has become associated with Dr Alan Whipple from New York in the 1930s. It is also known as a “pancreatoduodenectomy”. This is a major operation that should only be carried out by a specialist surgeon, so you may have to travel to a specialist unit to have it carried out.
What happens during a Whipple operation?
The operation normally lasts for between four and seven hours. The surgeon aims to completely remove the cancer, in order to give you the best chance of a cure. The head of the pancreas, a portion of the bile duct, the gallbladder and the duodenum are also removed, along with part of the stomach. After their removal, the remaining pancreas, bile duct and stomach are joined up to the intestine. This allows the pancreatic juice, bile and food to flow into the gut, so that digestion can proceed normally.
The surrounding lymph nodes will also be removed, in case these contain tumour cells, as the lymph nodes are often the first place to which the tumour spreads. The chance of the cancer recurring depends on the type of tumour you have. This will only be confirmed after your operation, when the pathologist examines the removed pancreas.
2.2) Distal Pancreatectomy
The pancreas lies at the back of the upper abdomen behind the stomach. It is about 15cm long and shaped like a tadpole. The large rounded section on the right hand side of the body is called the head of the pancreas, the middle section is called the body and the narrow part is known as the tail.
A distal pancreatectomy involves removal of the pancreatic body and tail, leaving the pancreatic head, duodenum and bile duct intact. The artery and vein supplying and draining the spleen run either alongside or through parts of the pancreatic tail and a cancer operation for a tumour situated in the pancreatic tail often also requires removal of the spleen.
The body of pancreas is divided usually at the level of the main blood vessels running from the intestine to the liver and the remaining cut surface of the pancreas closed using sutures or staples. Because there is no part of the intestine requires to be resected, the magnitude of the operation is less than that of a “Whipple resection”, usually taking 4-5 hours, and can also sometimes be performed laparoscopically. The head of the pancreas is larger than the tail, a distal pancreatectomy removes around 40% of the pancreas volume. The surrounding lymph nodes will also be removed, in case these contain tumour cells, as the lymph nodes are often the first place to which the tumour spreads.
Recovering from a distal pancreatectomy:
As with a resection of the pancreatic head, you will normally spend the first few days in a High Dependency Unit. You will often have a drip in your arm, a drip( central line) in your neck to measure your fluid balance, and a cannula in an artery in you wrist to monitor your blood pressure. A unrinary catheter will ensure your kidneys are working well. You will often wither have an epidural or wound catheters to numb your surgical wound and a button to press to deliver extra pain relief should this be required (patient controlled analgesia). You will also usually have a small surgical drain that will stay in position for a few days .
How quickly these tubes are removed will vary from centre to centre, but there is increasing evidence that an ERAS approach leads to better recovery. Similarly, when you can start drinking and eating will be “Unit” specific, but if you are in an ERAS unit there will be no restriction on your intake.
Patients with pancreatic tumours are also prone to clots in major veins (deep venous thrombosis which can move to the lungs to cause pulmonary embolism), and to prevent this you will have daily injections of heparin under the skin, have anti-embolism stockings, and the injections will usually be continued for 28 days even though you go home.
If you have had your spleen removed as part of the operation, you will be started (and will need to continue) on antibiotics, usually amoxicillin if you are not penicillin allergic. Once every 5 years you will need three vaccines to prevent potential infections.
Discharge from Hospital is usually between 5 and 7 days assuming no complications arise. Minor complications are common but major complications are fortunately relatively rare. Complications can be related to the wound (infection, scarring, herniation), stress on the major organs ( heart attack, stroke, chest infection, kidney failure), leaks from the cut edge of the pancreas( fistula), intra-abdominal collections, infection or bleeding requiring percutaneous drainage or re-operation. There is a mortality (death rate) associated with distal pancreatectomy but this usually around 1-2%.
3) Palliative Bypass
Surgical procedure to bypass a blockage in the stomach
Bypass surgery can be carried out if you are being sick and your stomach is not emptyting properly. This is caused by a blockage at the outlet of the stomach that joins the duodenum (first part of the small bowel). This blockage is called “gastric outlet obstruction”.
This operation is called a “gastro-jejunostomy”. You will have a general anaesthetic and your surgeon may use keyhole surgery (laparoscopy) or make a small incision in your stomach called a mini-laparotomy. The surgeon connects the part of your small bowel just below the duodenum directly to your stomach. This allows food to pass from the stomach into your bowel.
Recovery from a gastro-jejunostomy is fairly quick. You will be able to start drinking fluids the evening after your operation and gradually introduce solid food. You will be able to go home once your eating and drinking have improved.
Surgical procedure to bypass a blockage in the bile duct
If your bile duct is blocked, you are jaundiced and the surgeon is unable to put a stent in, bypass surgery can be carried out to relieve the blockage. This operation is called a “hepatico-jejunostomy”.
You will have a general anaesthetic and your surgeon will make an incision in your stomach called a laparotomy. This may be under your right ribs or down the middle of your abdomen. The surgeon will join the bile duct directly to your small bowel (the jejunum). This allows bile to flow from the liver into the small bowel and in time the jaundice should fade. You will be able to go home when your jaundice is getting better
Sometimes a “double bypass” operation is performed to relieve a blockage (or potential blockage) in both the stomach and the bile duct.
4) Recovering from an operation for cancer of the pancreas
Changes in your diet
The pancreas produces enzymes to aid digestion and absorption of food and nutrients. Because of this, any kind of surgery that removes part or all of the pancreas will affect your ability to digest and absorb food and nutrients.
It is important after any surgery to try and have as nutritious a diet as possible, in a form that you are able to take, and which provides the best amounts of nutrients.
Try to take enough calories and protein in a form that you can cope with, either as liquids, soft diet or normal foods.
Try to have a good variety of protein foods such as meat, chicken, fish, eggs, milk and cheese, as well as foods that provide energy such as bread, pasta, rice, potatoes and cereals.
Small frequent meals with snacks such as crackers and cheese, full fat yogurts, cakes and biscuits, are often easier to take.
Foods such as fruit and vegetables provide vitamins and minerals, and should be included daily.
The dietitian may provide advice or supplementary information on managing your diet.
5) Things that can happen after surgery
By far the most significant complication following a pancreatico-duodenectomy is where one of the anastomosis (the joins between the bowel and the liver and pancreas) do not heal properly, allowing the contents of the intestine to leak outside the bowel. When surgical drains have been left near to the joins, the leaking fluid may be controlled, and no other intervention required. However, if the leak is making you unwell, this may require further surgery or the insertion of a drain under X-ray control to regain control.
Delayed emptying of the stomach
Sometimes your stomach may take longer to adapt to the changes after surgery and your food may not be able to pass through efficiently. You may need to stick to a liquid diet only for a while. Alternatively, you may need to take your nourishment through a naso-gastric tube until the problem goes away.
Some patients may release a milky type of fluid (chyle) into their abdominal drain after surgery. Chyle is lymphatic fluid that builds up in the abdomen following trauma due to surgery. This resolves by reducing or stopping your oral intake for a period of time. Your dietitian or surgeon may feel that you should have artificial feeding during this period to support your nutritional intake.
Problems with absorption
When you have had part of your pancreas removed, you may notice your stools (motions) have become pale, loose and greasy. You can correct this by taking a pancreatic enzyme capsule, called Creon or Pancrex, which will help you to digest your food.
Feelings after a major operation
Some people may overwhelmed after surgery and this can lead to feelings of confusion and frequent changes of mood. These emotions are part of the process that many people go through in trying to come to terms with their illness. There may be times when you want to be left alone to sort out your thoughts and feelings. Other members of your family may experience similar emotions.
We would encourage you, though, to stay in close, routine contact with friends and family if you can, so that you can share your problems with those who care about you. We would also encourage you to continue with your daily life as much as practicable, so that you can ease your way back into normal life as quickly and easily as possible.
Your pancreatic team will always be ready to offer support and help both to you and your family, no matter what your feelings or circumstances.