Pancreas

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What is the Pancreas?

The pancreas is a very important organ found deep in the abdomen, in charge of making Insulin to control blood sugar levels, in addition to making pancreatic juice that contains pancreatic enzymes to help with digestion.

Common Symptoms of Pancreatic Diseases

Pancreas disease symptoms vary between benign diseases and cancerous diseases. Common symptoms depend on the nature of the problem but in general include:

Treating Pancreatic Diseases

Pancreatic Cancer

Treatment of pancreatic cancer should be done by a team of specialists in various medical disciplines, including surgeons/surgical oncologists, medical oncologists, radiation oncologists, gastroenterologists, endocrinologists, radiologists, nutritionists and support groups. Pancreatic cancer treatment is a multimodality treatment and includes surgery, chemotherapy and sometimes radiation therapy. Recent advances include immunotherapy if other treatments fail, in addition to palliative therapy.

Chemotherapy

Most pancreatic cancer patients will require chemotherapy at some point in their treatment. Current recommendations suggest chemotherapy being given after surgical resection is achieved, in tumors that can be surgically resected. We have moved to give chemotherapy to patients who have a tumor that cannot be fully removed by surgery, and then offer surgery if the tumor responds to chemotherapy.

Radiation Therapy

Similar to chemotherapy, radiation therapy is an important part of the multimodality approach to pancreatic cancer, it might be given before or after surgery depending on the stage of the disease.

Surgery

Surgery is done as a curative approach or a palliative approach in pancreatic cancer. As a curative surgery, the goal is surgically remove the cancer in its entirety. Palliative surgery is done of the tumor cannot be fully removed, then bypass procedures will be done to correct the bile duct obstruction and the stomach obstruction that are resulted from involvement by the neighboring tumor.

Pancreatitis

Pancreatitis, also known as inflammation of the pancreas occurs in acute and chronic forms. Acute pancreatitis is usually self-contained, and resolves spontaneously as soon as the triggering factor for the inflammation is corrected, and this is most likely related to gallbladder stones obstruction the pancreas or alcohol use. Chronic pancreatitis is a very different disease, most commonly related to chronic alcohol use, however can also be related to biliary stone disease, autoimmune where the body’s own immunity turns against the pancreas, it can be familial and happens in families who have a certain gene mutation and it can also happen because of undiscovered small tumors of the pancreas. Chronic pancreatitis harbors a 20% lifetime risk of pancreatic cancer if left untreated.

Surgery of the Pancreas

The extent of surgery of the pancreas is dictated by the location of the disease, whether a tumor, malignant or pre-malignant, or pancreatitis. Pancreas surgery is one of the biggest and most involving surgeries in the abdomen, and that is due to the proximity of the pancreas to vital organs, in addition to important blood vessels. The pancreas is divided to a head and neck part, which is the big bulky part of the pancreas gland, the body and the tail.

The Whipple Procedure

For some patients who happen to have the disease in the head or neck of the pancreas, a Whipple procedure is indicated. The classic Whipple procedure is named after Allen Whipple, who was the first surgeon to perform the operation in 1935. The procedure is also known as pancreaticoduodenectomy, and it involves removal of the head of the pancreas, the first part of the small intestine (duodenum), in addition to a part of the bile duct, gallbladder, and a small part of the stomach. The pancreas, bile duct and the stomach are then reconnected to the intestines.

Distal Pancreatectomy

When the disease is found in the body or the tail of the pancreas, surgery is usually shorter and less challenging as it involves less organs. The body and tail of the pancreas are removed in addition to the spleen most of the time as it would be close and involved by the disease. Distal pancreatectomy can be easily done using minimally invasive surgery, using the small incisions camera technique, and we recently started performing these procedures using robotic surgery

Other Procedures for Chronic Pancreatitis

There are a few other procedures done for chronic pancreatitis, and these are called drainage procedure, examples are Beger, Frey and Puestow procedures. These are usually done in certain circumstances where the aim of the procedure is the drain the pancreatic duct into the intestine as the usual drainage channel is obstructed or involved by the disease.

Before Surgery

The Day of Surgery

Discharge Instructions after Pancreatic Surgery

You just had pancreatic surgery and completed your hospital stay after the procedure. It is now safe to be discharged home. Your surgeon will be keeping a close eye on your progress even if are at home. Healing from a pancreatic surgery usually takes weeks.

Activity:

We encourage resuming walking and light activity immediately; as soon as you are sure you are not going to have issues with dizziness or lightheadedness. You may resume driving when it is comfortable to walk up and down stairs, when you feel safe driving and when you are not taking narcotic pain medications. You should be able to slam on the brakes to avoid an accident without causing any pain. Don’t plan on any strenuous activities, like sports or going to the gym, until your postoperative office appointment. Your surgeon may have specific instructions to add to this; usually these are outlined to you before surgery. The bottom line: if it hurts, don’t do it!

Eating:

The basic rule is take in what your body is telling you. It takes about two-three weeks at least after pancreas surgery in order to resume a normal diet. Your stomach will be slow at digesting food especially after a Whipple procedure, this process might be faster if you had a distal pancreatectomy with the small incisions technique. Some find it easier to digest bland foods, light foods, or predominantly liquids. Whipple patients have strict instructions given to them by their surgeon prior to discharge home. It is not uncommon that you will be discharged home on a liquid diet for the first two weeks after surgery. Make sure you stay hydrated, and avoid excessive caffeine. Raw fruits, raw vegetables, dairy products and carbonated beverages should be avoided as they cause gas pain. Alcohol is not allowed for a few months after pancreatic and liver surgery. Most Whipple patients will have a feeding tube and will be sent home on tube feeds; very specific instructions will be given to you regarding the tube feed formula and the way these are administered. We strongly recommend being on supplements like Ensure or Boost after surgery for a few weeks.

Elimination:

Constipation is very common after surgery. We recommend staying well hydrated, and using over the counter stool softeners if it happens, try to avoid laxatives. Do not let more than 48 hours go by without a bowel movement without starting the above medications. If they fail to help within another 24 hours, call our office. Diarrhea is common if you are taking antibiotics. If you have this problem, we would suggest either probiotics while you are on the antibiotics, or eating yogurt with active cultures. If diarrhea occurs more than 4-6 times daily for more than 48 hours, call us. Make sure your doctor is aware of any chronic difficulties with urination (like prostate trouble) before surgery.

Wound care:

Surgical wounds will have either glue or steri-strips (butterfly tapes) on them, often covered with gauze. Glue, steri-strips, or waterproof plastic dressings can all get wet the day after surgery (unless your surgeon advises differently). Wounds with visible staples or sutures can get wet in the shower after 48 hours. Do not submerge your wound (tub bathing or swimming) for one week. If you have a feeding tube, do not submerge in water until this tube is removed. If you have a surgical drain, do not submerge in water until that drain is removed. While soap will not harm the wound, do not scrub it. Do not apply peroxide or other chemicals. After 48 hours, change or remove gauze dressings or Bandaids. Do not leave soiled or wet dressings on the wound beyond 48 hours. Most wounds can then remain uncovered, unless you have been told otherwise. Light gauze covering to prevent chafing is acceptable if you wish. You may notice a slight drainage (usually pink or reddish in color) from the incision site. This is normal and not a cause for concern. Light pinkness immediately surrounding the incision, and not spreading over time, is normal. Bruising is common and may extend for up to an inch. Spreading redness, progressive swelling with bruising, and malodorous drainage are not normal and should prompt a call to our office.

Drains:

If you are sent home with surgical drains, you will likely be given instructions at the time of discharge for care of them, and a log sheet to record the output. It is important to note the daily output of the drain(s) so we will know when to remove them. Drains that empty into a suction bulb or attached bag can get wet in the shower. If there is gapping of the skin around the drain, Neosporin or similar ointment may be used to protect the area while you shower. Do not submerge the drain site underwater, such as tub bathing or swimming. Slight pinkish or yellowish drainage from around the tube is normal while it is in place, as is a small amount of redness at the site. Gauze over the site may help protect your clothing from staining. Foul smelling or copious drainage around the drain, or spreading redness around the drain, is not normal and should prompt a call to our office. If the drain reservoir fails to hold suction when you squeeze it, or if the drainage suddenly drops to near zero, call our office.

Normal care of drains includes emptying the fluid in the reservoir every 8 hours and recording the amount per 24 hour period. Bring this record to your postoperative appointment. The fluid may need to be emptied more frequently if the drainage is heavy. Fluid will often be red at first, then pink, then yellow as the wound heals. Stringy material in the tubing or reservoir is normal.

Medications:

Prescription pain medications are there to help you recover comfortably, but stop them as soon as you are able. Side effects of nausea, vomiting, dizziness, fatigue, poor appetite, and above all constipation, are common. If you have these issues, try to use Ibuprofen and Tylenol instead (see below). Do not use alcohol or drive if you are taking prescription pain medications. Unless you are told differently by your surgeon or primary doctor, you can take 400 mg ibuprofen every 4-6 hours, or 800 mg every 8 hours, for the first 3-5 days after surgery, for a maximum dose of about 2400 mg/day (refer to the label for specific dosing based on age and weight). It is best if you can take some food with this medication. Tylenol should also be used around the clock to help with the baseline pain after surgery. It can be taken in conjunction with ibuprofen, and with your prescription (unless your prescription already contains acetaminophen--which is Tylenol). Be very careful not to exceed the dosage on the bottle. Taking more than 4 grams/day is not advisable. Blood thinners should only be restarted after surgery according to the plan discussed with you by your surgeon or prescribing doctor before surgery. If this was not made clear to you, call our office. All other medications should be resumed once you get home. Vitamins and supplements are not necessary to help you heal, unless you have a known deficiency. You may resume them after you get home if you wish. We would suggest sleep aids not be used while you are on narcotic pain medications.

If Difficulties Arise:

Please call us if any problems or questions arise. We can be reached any time, including evenings and weekends, by calling our office number (703) 359-8640 and selecting to speak to the on call physician.

Call your doctor if you have any of the following:

  • Fever over 101°F or chills
  • Increasing pain, redness, or drainage at an incision site
  • Yellowing of the skin or eyes, or brown colored urine
  • Vomiting or nausea that lasts more than 12 hours
  • Prolonged diarrhea
  • Chest pain or shortness of breath
  • Inability to urinate within 8 hours of discharge