Surgical Procedures:
Pancreatic Cancer Surgery
Surgery offers the only chance of cure for most pancreatic cancers. Unfortunately, most cases will present when the cancer is incurable. For those cancers that are potentially curable, the type of operation depends on where the cancer occurs and what type of cancer it is.
Adenocarcinoma of the pancreas is the most common type and usually occurs in the head of the pancreas. Click here to learn more about adenocarcinoma of the pancreas.
Surgery for adenocarcinoma of the pancreas.
Surgery for adenocarcinoma of the pancreas involves major, open surgery. It is routine for patients to be admitted to the Intensive Care Unit postoperatively due to the scale of the procedure. Thorough preoperative anaesthetic consultation is mandatory to ensure optimal physical condition prior to surgery.
What is involved in the operation?
The operation itself involves a full general anaesthetic. Once anaesthetised, several procedures are carried out to ensure the safety of the patient prior to surgery commencing. These usually include
- Insertion of central line - special drip into larger neck veins to allow the anaesthetist access to administer drugs.
- Insertion of urinary catheter - allows careful measurement of kidney function during and after the operation.
- Nasogastric tube placement - fine tube passed through the nose and into the stomach to keep the stomach deflated.
- Arterial line - type of canula that is placed into the artery in the wrist. This allows constant, accurate blood pressure measurements during and after the operation.
The principles of the operation involve the removal of all the tumour with safe surgical margins. This involves removing the bottom end of the bile duct and gallbladder, part of the duodenum and part of the pancreas containing the tumour.
To accomplish this, an upper, midline incision approximately 30cm in length is made. Despite previous staging procedures, the abdominal cavity is thoroughly examined to exclude metastatic disease which staging tests sometimes miss. This occurs rarely with thorough preoperative staging techniques used by Dr Fenton-Lee.
Following this, the colon is mobilised away to allow access to the duodenum and pancreas. The duodenum is then mobilised and it, together with the head of the pancreas are carefully brought forward away from several important, large veins to ensure tumour has not invaded them.
If this can be achieved and tumour has not penetrated into these blood vessels, the operation is able to be completed. In some cases, even if tumour is adherent to blood vessels, it may be possible to continue.
The next step is to remove the gallbladder and free the bottom end of the bile duct. Once this is complete, the pancreas and duodenum are further freed from the back of the abdominal cavity.
The tumour and surrounding structures are then ready to be removed. This involves transecting the pancreas beyond the tumour, dividing the bile duct and also dividing the two ends of the duodenum. The specimen is then removed whole and sent to the laboratory for pathological examination.
Once the tumour mass has been removed, the gastrointestinal tract must be reconstructed. This involves three anastomosis, namely
- Pancreatico-jejunostomy - joining the pancreatic duct to the small bowel or jejunum.
- Gastro-jejunostomy - joining the two ends of bowel back together again.
- Choledocho-jejunostomy - joining the bile duct together to the bowel or jejunum again.
Once these three anastomoses have been completed, the abdominal cavity is irrigated with warmed saline to reduced the chance of infection. Drains are placed around the anastomoses and the abdomen is closed. Finally, a fine tube is placed into the small bowel and brought out through the surface of the skin. This is called a jejunostomy feeding tube and allows early feeding to commence prior to the patient being able to tolerate oral intake.
The operation itself takes between four and five hours to complete. The patient is then taken to Intensive Care for recovery.
What will i be like following surgery?
As with any major surgical procedures, post operative care and the prevention of complications is crucial to the success of the procedure.
All patients following surgery for pancreatic cancer are admitted to the intensive care unit. The main reason for this is to ensure breathing difficulties do not arise as the result of the prolonged operation. It also allows constant blood pressure and pulse monitoring immediately following the operation. The nasogastric tube, urinary catheter, arterial line and central line inserted at the beginning of the procedure remain. In addition, two abdominal drains and feeding catheter to the small bowel inserted at the completion of the operation are present. Most patients will also have special stockings and twice daily injections of an anti clotting medication to help prevent deep vein thrombosis.
The first three or four days are often the most crucial and difficult. Adequate pain control, early mobilisation and regular physiotherapy treatment to prevent chest infection is mandatory. Discharge from intensive care to the ward is usually achieved after 2-3 days.
No oral intake is allowed for the first 4-5 days to allow the anastomoses to begin healing and the bowel to recover after such major surgery. Early nutritional intake is commenced via the jejunostomy feeding. An oral diet can slowly be introduced over the next few days.
Nasogastric tube, urinary catheter, central lines and abdominal drains are gradually removed once mobilisation improves and diet is tolerated. Patients are able to return home once they are mobilising independently, pain control is achieved with oral medications and they are tolerating a normal diet. This is generally achieved between 10 to 14 days following the operation.
Prior to discharge, pathology results are discussed. If other forms of treatment such as chemotherapy are considered, this is arranged with specialist oncologists at St Vincent's Hospital during admission.
Due to the extent of the operation, rehabilitation and recovery continues at home and as an outpatient. Full recovery often takes six to twelve months to complete.
During this time, regular follow up with Dr Fenton-Lee in his rooms is arranged.
What complications can occur?
Despite the complexity and long recovery period of this procedure, complications are uncommon, but can include
- Bleeding/Infection
Significant bleeding during or following the operation is rare. Post operative infection within the abdomen or wound infections are also rare complications. These complications are reduced by the administration antibiotics at the time of operation.
- Chest problems
Chest infections and prolonged periods to recover full respiratory function were common in the past. With the introduction of improved pain control methods and regular physiotherapy, lung complications have vastly reduced.
- Anastomotic leaks
Leaks from any of the three anastomoses are possible but uncommon. The main purpose of the drains is to recognise leaks. In most cases, the drains adequately drain the leaks and no other treatment is required. Occasionally re-operation is required.
- Pancreatitis
Inflammation of the pancreas due to surgery can occur and range from being insignificant to being life threatening. It normally requires close monitoring, sometimes in Intensive Care. In most serious cases, it requires re-operation.
What about for other tumours of the pancreas?
Such extensive, radical surgery is not always required for all pancreatic cancers. For most Islet Cell cancers or cystadenomas, local excision only is required. Additionally, tumours that grow in the tail of the pancreas can be treated without having to perform complex anastomoses.
Dr Fenton-Lee is often able to treat tumours in the tail of the pancreas laparoscopically (keyhole surgery). This has enormous advantages including
- Reduced hospital stay
- Reduced post operative pain
- Improved recovery time
- Decreased post operative complications
- Better cosmetic result
Reduced post operative pain means that patients are able to get out of bed and mobilise sooner. Poor mobilisation after surgery is a significant contributor to complications such as lung infections, deep vein thrombosis and wound infections.
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