Prof John Windsor

Surgical Disease of the Pancreas

There are types of pancreatic disease that sometimes warrant surgical treatment. These are acute gallstone pancreatitis, severe acute pancreatitis, chronic pancreatitis, pancreatic cancer, pancreatic cysts, and pancreatic neuroendocrine tumours.

Acute gallstone pancreatitis

The commonest cause of acute pancreatitis in Auckland is gallstone disease. To prevent recurrent attacks of pancreatitis it is important to remove the source of gallstones, the gallbladder. With mild acute pancreatitis the gallbladder is removed (cholecystectomy) prior to discharge from hospital. With more severe acute pancreatitis the cholecystectomy may need to be delayed.

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Severe Acute Pancreatitis

The hallmark of severe acute pancreatitis is death of portions of the pancreas, setting the stage for infection. If this occurs surgery may be required to drain infection and remove the dead tissue. This is usually preceded by percutaneous drainage and will usually require management in an intensive care unit.

Chronic pancreatitis

Surgery for chronic pancreatitis has been shown to be an effective treatment when the pancreatic duct is dilated to more than 5-7mm and when the patient has pain that is made worse immediately after eating. Decompression of the pancreatic duct relieves the pressure and pain in the majority of patients. The best procedure for this is called a
Frey procedure.

Pancreatic cancer

The pancreas produces many different types of cancer. The most common form (adenocarcinoma) is also the most aggressive form. When this develops in the head of the pancreas patients tend to present with jaundice. When this develops in the body or tail of the pancreas it can grow quite large before making its presence known. Surgery is the only way to gain long-term survival but it is only possible in the minority of patients. Before deciding whether surgery is appropriate or not it is important to stage the disease by CT scanning and sometimes laparoscopy. This is to determine whether the disease is confined to the pancreas or whether it has spread. If the cancer is confined to the pancreas then surgery will be offered as long as the patient is fit enough to withstand it. Removing a cancer from the head of the pancreas is called a Whipple’s procedure. This operation is also performed for cancers of the duodenum, ampulla and bile duct. Removing a cancer from the body and tail of the pancreas is called a distal pancreatectomy.

Occasionally when it is not clear whether the cancer can be removed by surgery a combination of chemotherapy and radiotherapy might be offered to try and make it possible (downstaging). After a cancer has been removed successfully it is usual to offer chemotherapy, especially if there is cancer in some of the lymph nodes removed at the time of surgery.

Pancreatic cysts

The frequent use of scanning often finds incidental pancreatic cysts. These can be benign or malignant (cancer) and it is important to try and determine this before advising surgery. This is because some patients can be managed by ‘keeping an eye’ on the cyst be repeated scanning and only operating if there are concerns with growth or changes. Cysts can also be sampled by endoscopic ultrasonography and fine needle aspiration. If cysts are more than 3 cm in diameter, responsible for symptoms or have any sinister features on scanning, surgery will be advised.

After pancreatitis it is possible to develop a collection of fluid in or around the pancreas. These are filled with pancreatic juice and are called pseudocysts because they do not have a proper wall. While many spontaneously resolve some require drainage or surgery. This will usually when they are causing symptoms or a blockage.

Pancreatic neuroendocrine tumours

These interesting tumours arise from specialised cells in the pancreas (islet cells) that produce a range of hormones that help control our metabolism. They can behave in a very benign fashion, be quite malignant, or anything in between. These tumours will usually require surgery.

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