What is the Pancreas?
The pancreas is a very important organ found deep in the abdomen; it produces insulin to control blood sugar levels, in addition to making pancreatic juice that contains pancreatic enzymes that help with digestion. It is located deep in the abdomen, behind the stomach and on top of the spine in the back.
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. Pancreatic juice is secreted into a series of ducts that make the main pancreatic ducts that empties into the first part of the intestines called the duodenum. It is located deep in the abdomen, behind the stomach and on top of the spine in the back.
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:
- A dull type pain beneath the breast bone that radiates to the back. In benign diseases of the pancreas like pancreatitis, the pain is due to the inflammation of the pancreas gland. In tumors or cancers of the pancreas, pain is usually due to compression of the tumor to surrounding organs in the abdomen.
- Nausea, upset stomach, or vomiting
- Jaundice (a buildup of bile chemicals in the blood), which causes yellowing of the skin and eyes, dark urine, and itching. This is usually caused by a blockage of the bile duct that carries bile from the liver to the intestine.
- Weight loss, poor appetite and aversion to food.
- Fatigue, depression.
What are Pancreas Diseases?
Tumors of the pancreas originate from multiple types of cells that constitute the pancreas. Not all pancreas tumors are malignant and some of them can be pre-malignant or benign. Tests and sometimes biopsies need to be done to assess for malignancy. The most common type of pancreatic malignant tumors originates from pancreas cells that line the pancreatic duct, and it is called pancreatic ductal adenocarcinoma. Another type of cells called endocrine cells give rise to a tumor called pancreatic neuroendocrine tumor. Treatment and prognosis of these two different pancreatic tumors differ significantly, thus the importance of understanding which type of tumor the patient has. Pancreatic papillary pseudo tumors are a rare entity with a malignant potential.
Risk factors for pancreatic cancer include smoking, prolonged history of chronic pancreatitis, certain familial cancer syndromes, obesity, diabetes.
Diagnosis and Treatment of Pancreatic Cancer
Signs and symptoms of pancreatic cancer include:
- Weight loss
- Decreased appetite
- New onset diabetes
- Abdominal or back pain
Tests done to diagnose pancreatic cancer include:
- Blood tests: pancreatic cancers can produce certain types of chemicals called tumor markers like Carbohydrate Antigen 19-9 (CA19-9) or Carcinoembryonic Antigen (CEA),these are not diagnostic but can be used to track tumors.
- Scans: Computed Tomography (CT), Magnetic Resonance Imaging (MRI), or PositronEmission Tomography (PET) are multiple imaging techniques used to detect pancreatic tumors including size and location, in addition to sites of disease spread to other areas of the body.
- Endoscopic Retrograde Cholangiopancreatography (ERCP): this is an endoscopic test done by your gastroenterologist, usually used to diagnose and sometimes treat blocked bile ducts by placing a stent inside of the duct in order to drain the liver and treat jaundice.
- Endoscopic Ultrasound and Fine Needle Aspiration (EUS/FNA): this is also anendoscopic test done to visualize the tumor using an ultrasound probe mounted on the tip of an endoscope, this can scan the pancreas from inside the stomach or the intestine and get biopsies for diagnosis.
Treatment of pancreatic cancer should be performed 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.
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.
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 pancreatic cancer is done for curative or palliative reasons. As a curative surgery, the goal is to 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.
Pancreas cysts are common findings on imaging studies. Certain cysts are benign in nature and do not require surgery however other cyst can be premalignant in nature and can degenerate into cancers, some of these include Intraductal Papillary Mucinous Neoplasms (IPMN), or Mucinous Cystic Neoplasms (MCN). There are specific indications for surgery when a pancreatic premalignant cyst is diagnosed. Pancreatic pseudocyst are also cystic lesions of the Pancreasresulting from inflammation of the pancreas, these do not carry a malignant potential, however they can cause local compression symptoms and can require surgery.
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, 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. Chronic pancreatitis is a common indication for pancreatic surgery in very specific cases.
Surgery of the Pancreas
The extent of surgery of the pancreas is mainly dictated by the location of the disease, or whether it is done for tumors 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 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.
Very rarely, certain tumors involve the whole gland and thus a total pancreatectomy is required.
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.
Pancreatic Pseudocyst Surgery
A pancreatic pseudocyst us a false cyst of the pancreas that results after inflammation of the pancreas called pancreatitis. The pancreas leaks pancreatic juice into the surroundings. The body tries to contain this pancreas juice leak by forming a wall or membrane around the leaked fluid thus forming a pseudocyst. These form over a long period of time and become mature. The majority of pseudocysts are reabsorbed by the body and do not cause symptoms. Rarely these are large enough and compress surrounding organs and needs to be surgically drained into a near by organ, usually the stomach and sometimes the intestines.