This page contains information regarding the most common surgical approaches we use to manage certain diseases of the pancreas, mainly pancreatic cancer and other benign and non-benign tumors.
Surgical options
You have been advised that an operation to remove the tumor from your pancreas may be possible. There are several different operations used to treat pancreatic tumors. We know that removing this tumor by an operation is the only way in which it may be cured.
To find out whether this is possible for you, we will look at:
- The size of the tumor.
- Where it is in the pancreas.
- Whether it has grown into the tissues around the pancreas.
- Whether the tumor has grown into the major blood vessels in or around the pancreas.
- Whether it has spread to any other parts of the body.
The answers to some of these questions can be found from your pre-operative tests. We will have looked at the CT scan you had. Your scans may show the size and position of the tumor, which helps us plan your surgery. Scans may also show up cancer spread to other parts of the body. Sometimes spread of the tumor to other organs or major blood vessels may only be confirmed at the time of surgery and preclude you from a major resection.
If it is possible to remove your tumor you may be offered one of the following operations namely:
Whipple’s operation (pancreaticoduodenectomy)
Total pancreatectomy
Distal pancreatectomy
These are highly specialised operations that require great surgical skill and expertise, as well as intensive monitoring and care during and after the operation. We perform these operations on a regular basis and have a team of doctors that understand the intricacies involved in this type of surgery at all levels.The second diagram shows how you will look inside after the operation when the cancer has been removed
Having your operation
Before your surgery, you will need to see a physician for
a pre-operative appointment. The same physician will generally look after you in the post-operative period in the Intensive care unit or high-care unit. The physician will have all your safety checks carried out which include:
- Blood tests to check your general health and kidney function.
- A chest X-ray and lung functions test to check your lungs are healthy.
- Tests to check your heart is healthy (an ECG)
.
- Further tests may be necessary based on individual needs.
You may have had some of these tests while your cancer was being diagnosed. Blood tests may have to be done often because the balance of chemicals in your blood can change so quickly. It is important that your surgeon knows your blood chemical levels are accurate and up to date.
Informed consent forms will be filled in and have to be signed by you before the surgery. This will be done in the rooms of the surgeon. We will provide you with DVT stockings which help to prevent clots in the legs and an abdominal binder which helps with pain control and to help wound healing and closure. These have to be purchased by yourself before the surgery and are not essential but recommended by our team.
Your physiotherapist will teach you breathing and leg exercises. You can help yourself to get better by doing these exercises after your operation. You should do them as often as you are told you need to.
Breathing exercises will help to stop you getting a chest infection and leg exercises will help to stop clots forming in your legs. Both these complications of surgery can happen because you are not moving around as much as you would normally. Your nurses will encourage you to get up and about as soon as possible after your operation. Remember – if you stop or reduce your smoking before your operation, you will significantly reduce your risk of getting a chest infection after your surgery. When you go into hospital for your operation, your surgeon and anaesthetist will all come to talk to you about what will happen. Your surgeon will explain what is going to be done and what to expect when you come round from the anaesthetic. Do ask as many questions as you need to. The more you know about what is going to happen, the less frightening it will seem. We believe in the benefits of complementary medicine. We offer a healer to come and visit you at your bedside the morning of the surgery. This will help prepare your body for the surgery and to help put your mind at ease. This is completely optional. Medical aides do not cover this treatment and payment will be for your own account. The cost can be discussed with your surgeon or healer. Please speak to your surgeon about this if you are keen.
Total pancreatectomy
This is very major surgery. It involves taking out the whole of the pancreas, your duodenum, a small portion of your stomach, the gall bladder and part of your bile duct, the spleen and many of the surrounding lymph nodes. As you will not have any pancreas left after this surgery, you will need lifelong insulin injections to prevent the development of diabetes. Furthermore, you will need enzyme supplementation, which involves taking a tablet before every meal to assist your digestive system to absorb some of the nutrients in the food you eat. Getting over this type of surgery is hard work. It will take time to get back to eating normally
Complications of major pancreatic surgery
A complication is something that happens after surgery that makes your recovery more difficult. Chest infections or blood clots are both common complications after any surgery.
All these operations are major surgery and involve certain risks. Make sure you discuss the possible complications with your surgeon and ask all the questions you need to ask. It is important that your family members are given the chance to talk things through with the surgeon as well.
The most common complications and the percentage of patients who develop them are:
- Bleeding 5%: You may have bleeding shortly after your operation because a blood vessel tie is leaking or because your blood is not clotting properly. Bleeding in a few days following surgery can occur because there is infection or a leak from your pancreatic join to the intestine. The manner in which the bleeding episode is treated depends on what is causing it.
- Leak or fistula 10-15% : A ‘fistula’ is an opening. In this case, it means that part of the internal stitching to the digestive system has come apart or broken down. This results in some of the digestive juices being able to get into your abdomen. Drains put in during the operation will be left in until the fistula dries up. The fistula then usually heals on its own. Sometimes surgery is needed to repair the leak or fistula.
- Infection 25% : Infection can develop because there is blood or tissue fluid collecting internally around the operation site or because there is internal bleeding. If you develop an internal infection, you will be given antibiotics through your drip. Abscesses or any fluid that has collected internally will need to be drained. Draining the abscess is performed usually by putting in a drainage tube. The needle or tube is guided into place with X-ray or ultrasound.
- Chest infection : is a common complication of many operations.
It happens because you are not moving around enough, or breathing deeply enough after your surgery. What you would normally cough up stays in your lungs and becomes a focus for infection. You can help prevent this by doing your deep breathing exercises. The physiotherapists and nurses will get you up as soon as possible to help you get moving. You will have had heart tests before your surgery, but these are very big operations and do increase the strain on your heart.
- Heart Problems : Some people develop heart problems after surgery that weren’t evident before the operation. Complications after surgery can be very serious. They are becoming less common as more of these operations are done in specialist centers.
Nonetheless, as many as 5-9% of people who have this major surgery die directly as a result of complications after their operation.
When resection of the tumor is not possible
Sometimes it is not possible to remove the cancer, even though your specialist thought resection was possible based on the scans.
This could be because the cancer has grown around the major blood vessels surrounding the pancreas, or because the cancer has spread to the liver. These findings are not always seen by looking at scans and X-rays.
In cases when the surgeon finds it not possible to resect the cancer then a bypass is performed. There are two parts generally to a bypass, which are performed at the same operation. A ‘biliary bypass’ is when the surgeon can cut the bile duct above the blockage and can reconnect it to the intestine. This bypass nearly always means that you will not become jaundiced again.
Sometimes the duodenum can become blocked by the cancer and so to prevent this from happening the surgeon can attach the small bowel directly to the stomach. This allows food you are digesting to pass through the bowel. This ‘gastric bypass’ nearly always means that you will not experience extreme vomiting which is a symptom of the duodenum becoming blocked.
This operation does not offer any chance of a cure but may enable you to live a life with better quality and less symptoms of your cancer.
Type of anesthesia
This procedure can only be performed under a general anesthetic. This means your anethetist will put you to sleep entirely for the whole duration of the operation.
You will meet your anethetist on the morning of the operation in the hospital. He/she will require you to fill in a form to gain insight into which anesthetic would be best suited for you. Our anethetists are also in close contact with your physician that you saw before the operation. We have a great team of anethetists that have also developed specific expertise for these kind of operations. Please feel free to ask them any questions that you may have regarding your anesthetic.
Immediately after the operation
You will wake up in an Intensive care unit or high care unit. This is nothing to worry about. These are places where you can have close nursing care and your surgeon, anaesthetist and physician can keep a close eye on your progress. As soon as your doctors are sure you are recovering well, you will be moved back to the ward. This is usually in 48-72 hours. Generally if you are awake enough, the surgeon will see you in the evening after the operation to tell you if you have had a resection of the cancer or a bypass.
When you wake up, you will have several different tubes in place. This can be a bit frightening but it helps to know what they are all for. You will have:
- Drips (intravenous infusions) to give you drugs and fluids until you are eating and drinking again.
- Tubes into your neck and arms to measure your blood pressure.
- One or more tubes coming out of your abdomen near your wound. These wound drains stop blood, bile and tissue fluids collecting around the operation site, as well as wound catheters that instill a local anesthetic into the wound for pain control.
- A tube down your nose into your stomach (nasogastric tube) to drain it and stop you feeling sick. Another tube through your nose to your bowel to feed you while all the surgical joins heal.
- A tube into your bladder (catheter) so that your urine output can be measured.
- Epidural – a tube into your back to give you a constant supply of pain killers. You may also have a blood pressure cuff on your arm and a little clip on your finger to measure your pulse. At first, your blood pressure will be monitored through the tubes that go into your neck and arms. These go directly into your main blood vessels and give your doctors a more accurate measurement than a blood pressure cuff on your arm would. Your urine output will also be monitored because it can help to show whether you have too much fluid or are becoming dehydrated.
Painkillers
You will almost certainly have some discomfort for the first week or so but there are many different pain-killing drugs you can have. It is important to tell you doctor or nurse as soon as you feel any pain. They need to help to find the right type and dose of painkiller for you. Painkillers work best when you take them regularly so don’t suffer in silence. Our experience is that epidurals work well to control the pain. However, if this doesn’t work for you we can try other ways to give painkillers.
Eating and drinking
We need to let the surgical joins in your abdomen heal andso we rest your digestive system by restricting your eating immediately after the operation and for at least 5 days afterwards. A 30ml tot of water can be taken orally each hour to moisten your mouth. In addition after surgery to any part of the digestive system, the bowel often stops working for a while. Until it starts up again and we are confident you are healing internally, you will not be able to eat or drink. Once you can eat and drink, you will be able to try sips of fluids. Gradually the amount you are allowed to drink will increase and soon you will be able to try other fluids as well as water. Once you are able to drink without being sick, your drip and nasogastric tube can come out and you can start to eat a light diet.
Your wound
The wound from the operation will be covered up when you come round. It will be left covered for a couple of days. Then the dressings will be changed and the wound cleaned. The wound drains will be left in until they stop draining fluid. Wound drains can usually be taken out about a week after your operation. This may be longer if there is any fluid leakage in the operation area. Your stitches will be left in for about two weeks.
The shape of the cut used for this operation is vertical, along the midline of the abdomen just below the rib cage up to the naval with a slight extension to the right side in the shape of a “J”. Nerve endings are cut during the operation which may leave you with some numbness around the scar site. People who have experienced this numbness do not usually report that it makes a difference to their lives.
Getting up
This may seem impossible at first. Moving about helps you to get better but you will need to start very gradually. Your physiotherapist may visit you regularly after your operation to help you with your breathing and leg exercises. Your nurses will encourage you to get out of bed and sit in a chair one or two days after your surgery. They will help you with all the drips and drains. Over the next couple of days, the tubes and bags will start to be taken out. Then, it will be much easier to get around and you will really feel that you are beginning to make progress.
Making progress
After a few days you will be able to be up and about more. Gradually you will start to feel better. You will be able to eat more. Frequent small meals are easier to manage than three large meals a day. It may be helpful to you to see a dietician whilst you are in hospital who can give help and further advice.
What should I eat?
During any illness it is essential to keep as strong and nutritionally well as possible. It is not unusual for your appetite and eating habits to be affected by pancreatic cancer. It is likely that your overall food intake will be less than normal but there are ways of working around this. For example it may be easier to take several small meals throughout the day. This food does not have to be ‘proper’ dinners but can be snack food instead. You could try:
- Toast, teacakes, scones, muffins with butter, jam or peanut butter
- Soups, either ‘cream of’ or with extra milk added to boost calories
- Cheese, beans, tinned fish on toast or a jacket potato, or cheese and crackers
- Ice cream or a small dessert, full fat yoghurt or fromage frais
- Cereal with whole milk, milky drinks with biscuits, cake or a flapjack
The suggestions above include high fat and sugar foods as these are much higher in calories to make up for what you are not eating at the moment. Your dietician can give you further help with this. Often people with pancreatic cancer have difficulty digesting fats. The pancreas produces digestive juice called enzymes to break down foods, particularly fats. If you are not able to do this then you can develop digestive symptoms including indigestion and wind often described as a ‘gurgly stomach’. Your bowel motions can also
change they can be pale greasy and float in the toilet making them difficult to flush away, this is caused by undigested fats in the stools. It is important to control this if possible, as this can cause weight loss. As your appetite may be poor, we do not want to restrict your food in any way, and so we ask you to take pancreatic enzymes in the form of a capsule. There are different makes of capsule Creon, Nutrizym and Pancrex, but they all work in the same way.
The capsules are taken just before you eat and the amount you need depends upon the amount and type of food you are going to eat.
Higher fat foods such as chips, sausages, pies, pastries, cakes and any fried food will need more enzymes to help digest them. The best way to judge how effective the capsules are is to monitor your bowel habits. If you still have signs of not digesting your fats, i.e. floating stools then you need to increase the amount of pancreatic enzymes you are taking with your food.
It is important to find the right balance of pancreatic enzymes that work for you to ensure you are digesting your food. Your dietician, doctor or specialist nurse can give you further help.
Going home
Most patients are home within 7-10 days of this operation.
Going home can be a very emotional time. You may be looking forward to it and dreading it in equal measure. These feelings are normal. Please do not feel as if you are cut off from the hospital team, we are on the end of a phone. If you feel you need to speak to one of the medical team you can do this by phoning our rooms (012 677 4874 or 012 644 1327) or ward 1E in Unitas (012 677 8227) or surgical 1 in Midstream (012 652 9175) and asking them to take a message. Alternatively, you can phone our emergency line which is 012 333 6000 or send us an e-mail at clinical@generalsurgery.co.za.
Alternatively, you could ring the hospital switchboard (Unitas 012 677 8000 or Midstream 012 652 8000) and ask to be connected to the surgeon on duty for the firm.
It can take up to three months before you regain full fitness after your operation.
You should only start to drive again when you feel you are able to perform an emergency stop comfortably and safely. You can discuss this with your surgeon.
Coming back for check-ups
You will be asked to book a follow-up appointment to come back to see your surgeon when you leave the ward. Please see our contact details in your discharge pack or visit us on Facebook or our home page:www.generalsurgery.co.za.
When you come to our rooms for your follow-up visit you will have an opportunity to ask questions, it may be a good idea to write these down beforehand. If you had a bypass instead of a Whipple’s (pancreatic resection) procedure then you may see an oncologist (cancer doctor) as well as a surgeon when you come back for follow-up. The results of any histology will be discussed with you. Histology is when the tissue removed during the operation is looked at under the microscope. The results of histology will usually confirm that the tumor removed was cancer. Our rooms are often very busy and you may have to wait for a short time. Please bear with us if you have to wait.
Transfusion necessary
It is seldom necessary for blood transfusions during this type of surgery despite its magnitude. That is because we take great care during operating and we use a machine called a cell-saver. When there is blood loss during the surgery, the blood gets suctioned into a bag which is connected to the cell-saver machine. That blood is then filtered and can be given back to you. In this way we can limit the amount of blood transfusions that we may have to give with the added advantage that it is your own blood.
It may however still be necessary to give you blood if the blood loss is severe. This is not something that happens frequently but we are always prepared for any eventuality and we may decide during the surgery that it is necessary to administer a blood transfusion when your blood levels are too low. Please inform your surgeon if you cannot receive blood transfusions due to religious or medical reasons. Please also inform your surgeon if you have had any previous reactions to any prior blood transfusions.
