Pancreas
Pancreas is a soft gland located behind the stomach. It is a complex organ with a dual role. It has three portions, namely the head, body, and tail. The head of the pancreas lies within the ‘C’ bend of the duodenum to the right of the midline, and its tail lies in close proximity to the spleen in the left upper abdomen.
It has an exocrine function wherein it produces juices for digestion, and it also has a very critical endocrine role, producing hormones like insulin and glucagon required for the maintenance of blood sugars.
Though nestled between other organs, diseases of the pancreas can be severe and life-threatening. It is susceptible to trauma, infections, and malignancies.
Commonly Seen Conditions:
- Acute and Chronic pancreatitis
- Necrotizing or gangrenous pancreatitis
- Cystic lesions of pancreas
- Benign tumours
- Cancers or malignancies
1. Frey's Procedure for Chronic Pancreatitis
Repeated inflammation of the pancreas, due to different reasons, can result in the deposition of calcium in the gland and stones in the ductal system, significantly impairing the function of the gland – production of hormones and digestive juices.
Symptoms:
- Recurrent severe abdomen and back pain
- Vomiting
- Fevers
- Jaundice
- New onset diabetes
- Passing oily stools
- Loss of weight and appetite
Diagnosis:
- Clinical examination
- Blood investigations
- CT abdomen and pelvis (pancreatic protocol) with oral and intravenous contrast
- MRCP
- Endoscopic ultrasound
Treatment:
- Medical management
- Endoscopic management
- Surgical management – Laparoscopic / Open Frey’s head coring and lateral pancreatico-jejunostomy
Laparoscopic / Open Frey’s Head Coring and Lateral Pancreatico-Jejunostomy:
Here, the head portion of the pancreatic gland, which is the cause of all symptoms, is thinned out or removed to a large extent as possible. The duct is opened all along its length, and stones are cleared. Then, an alternate route is created for the pancreatic juices to empty into the intestines (Jejunum). This can be performed through both open and laparoscopic techniques.
2. Cysto-gastrostomy or Jejunostomy for Pseudocysts & Walled Off Pancreatic Necrosis (WOPN)
Pseudocysts occur when, following an attack of pancreatitis, fluid accumulates and becomes localized in the abdomen, typically around the pancreas. These collections may communicate with the main pancreatic duct and can be infected or sterile. Large fluid collections can compress adjacent structures, leading to symptoms.
Symptoms:
- Recurrent abdomen and back pain
- Vomiting
- Intolerance to oral feeds
- Distension or fullness of abdomen
- Fevers
- Jaundice
- New onset diabetes
- Loss of weight and appetite
Diagnosis:
- Clinical examination
- Blood investigations
- CT abdomen and pelvis (pancreatic protocol) with oral and intravenous contrast
- MRCP
- Endoscopic ultrasound
Treatment:
- Endoscopic management
- Surgical management – Laparoscopic / Open Cysto-gastrostomy / Cysto-jejunostomy
Laparoscopic / Open Cysto-gastrostomy / Cysto-jejunostomy:
Based on the location of the fluid collection and the thickness of the wall around it, the technique and type of surgery is determined. Simply put, the cyst fluid is provided an alternate route to empty into the stomach or intestine, using either staplers or sutures.
3. Enucleation of Cystic Lesions
Simple or benign cysts of the pancreas can vary in size and number, from small ones detected during imaging for other conditions to large ones causing symptoms. Cysts may be functional, secreting hormones, or non-functional, and not all cysts require intervention.
Symptoms:
- Recurrent abdomen and back pain
- Vomiting
- Intolerance to oral feeds
- Distension or fullness of abdomen
- Jaundice
- Diarrhea
- Sweating
- Palpitations
- Variations in blood sugars
Diagnosis:
- Clinical examination
- Blood investigations
- CT abdomen and pelvis (pancreatic protocol) with oral and intravenous contrast
- MRCP
- Endoscopic ultrasound
Treatment:
- Endoscopic management
- Surgical management – Laparoscopic / Open enucleation of cysts
Laparoscopic / Open Enucleation of Cysts:
Depending on the location, characteristics, and wall thickness of the cyst, the appropriate intervention is chosen. The cyst is carefully separated from surrounding structures and removed entirely.
4. Necrosectomy for Necrotizing Pancreatitis
Necrosis is the unhealthy or dead portion of tissue, and in this case, we are dealing with necrosis of pancreatic tissue. Necrotizing pancreatitis is commonly seen after a severe attack of pancreatitis or trauma, and it can be either infected or uninfected, involving single or multiple areas around the pancreas.
Symptoms:
- Abdomen and back pain
- Fevers
- Vomiting
- Intolerance to oral feeds
- Distension or fullness of abdomen
- Jaundice
- Variations in blood sugars
- Sepsis
- Shock
Diagnosis:
- Clinical examination
- Blood investigations
- CT abdomen and pelvis (pancreatic protocol) with oral and intravenous contrast
- MRCP
- Endoscopic ultrasound
Treatment:
- Endoscopic management
- Percutaneous drainage
- Surgical management – Laparoscopic / Open necrosectomy
Laparoscopic / Open Necrosectomy:
In patients who do not improve with conservative or other modes of treatment, necrosectomy may be required. The unhealthy, dead tissue is carefully separated and removed, and drains are placed in the cavity to allow for regular post-operative washouts.
5. Distal Pancreatectomy for Tumours and Trauma
Tumours and cancers can develop in any part of the pancreas, including the left or distal portion known as the tail. These tumours vary in type, and treatment depends on the specific type. Additionally, trauma to the abdomen, either blunt or penetrating, can result in pancreatic injury.
Symptoms:
- Tumours: Abdominal pain, back pain, nausea, vomiting, excessive sweating, palpitations, loss of weight and appetite
- Trauma: Abdominal pain, back pain, giddiness, abdominal fullness, fevers, difficulty breathing, vomiting
Investigations:
- Clinical examination
- Blood investigations
- CT scan of the chest, abdomen, and pelvis
Treatment:
- Conservative treatment and follow-up
- Surgery: Laparoscopic / Open Distal Pancreatectomy, +/- splenectomy
Laparoscopic / Open Distal Pancreatectomy, +/- Splenectomy:
Using a laparoscopic technique through small keyholes, the portion of the pancreas containing the tumour is removed with staplers, while preserving the rest of the gland. In some cases, the adjacent spleen may also need to be removed in certain scenarios.
6. Whipple's Procedure for Peri-ampullary Cancers
Cancers affecting the head portion of the pancreas, the lower portion of the bile duct, the ampulla (its opening), or the first portion of the small intestine (duodenum) are gradually increasing in incidence.
Symptoms:
- Jaundice
- Abdominal pain
- Fever
- Loss of weight
- Loss of appetite
- Vomiting
- Abdominal fullness
- Upper and central back pain
Diagnosis:
- Clinical examination
- Blood investigations
- CT scan of the abdomen and pelvis with oral and intravenous contrast
- Endoscopic ultrasound +/- ERCP and biopsy
- +/- PET-CT
Treatment:
- Surgery – Whipple’s procedure
- Chemotherapy
Whipple’s Procedure - Laparoscopic / Open:
The portion containing the cancer is removed along with a portion of the stomach, small intestine, head portion of the pancreas, and bile duct. Using the small intestine (Jejunum), continuity of all organs is restored. In suitable candidates, laparoscopic techniques can be used.
