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The pancreas is an organ that resides deep
in the abdomen.
It rests against the backbone in front of
two major
blood vessels called the aorta and the
inferior vena cava.
It is also covered by the stomach and the
liver.
The pancreas is divided into three
anatomical portions, the head, body, and
tail.
The head of the pancreas is surrounded by
the duodenum the
part of the intestine that connects the
stomach to the small bowel.
The tail of the pancreas resides in the
hylum of the spleen.
The pancreas has two very important
functions most
of the gland is involved in producing the
digestive enzymes that are collected in
the main
pancreatic duct, and then emptied into the
duodenum.
These enzymes are involved in the
digestion of fats, sugars and proteins.
There are also small microscopic groups of
cells
dispersed throughout the pancreas, called
the Islets of Langerhans.
These small groups of cells produce a
variety of hormones,
including insulin, that are released
directly into the blood and help
regulate a variety of different functions,
the most important of which
is keeping the blood sugar, or glucose, in
a normal range.
Glucose is the main source of energy for
the body.
A variety of benign and malignant tumors
can arise
in the pancreas, often in the head of the
gland.
Tumors in this area present a particular
problem because the head of the pancreas
is
at an important crossroads where the
pancreatic
duct empties its digestive enzymes into
the duodenum.
And the bile duct delivers bile from the
liver and gall bladder.
If a malignant tumor such as a pancreatic
cancer arises in the head of the
pancreas, it will often block both the
pancreatic duct and bile duct.
Resulting in a patient turning yellow, or
becoming jaundiced.
When the bile duct is obstructed by
a tumor, bilirubin, a yellow substance
produced
in the liver, is no longer able to empty
into the duodenum and be excreted.
And backs up in the blood, and the patient
turns yellow.
This is often first noticed in the whites
of the patient's eyes.
Yellow jaundice is often the first clue
that the patient has a pancreatic tumor.
Weight loss and abdominal pain may also be
symptoms of a pancreatic tumor.
When these symptoms are present, the
physician will order a
cat scan to look for a tumor or other
important signs.
Such as a dilated bile duct in the liver
or a dilated pancreatic
duct, both of which can be caused by tumor
obstructing the ducts.
If cancer is diagnosed, the physician will
use the CAT scan
and possibly a variety of other tests to
stage the cancer.
And determine whether the tumor has spread
beyond the pancreas.
If it has not the cancer's considered
resectable and the patient is a candidate
for an operation called the Whipple
operation or a pancreaticoduodenectomy.
The whipple procedure or
pancreaticoduodenectomy is a major
operation that often takes between five
and six hours.
The patient is admitted to the hospital,
prepared for
surgery and then put to sleep with general
anesthesia.
After the patient's abdomen is prepped
with an antiseptic, and draped
appropriately, generally the operation is
performed through a midline incision.
Under certain circumstances the operation
can also now
be done laprascopically through four or
five small incisions.
However, most operations are still done
through an open incision.
Once the incision is made, the surgeon
carefully explores the abdomen to confirm
that the tumor has not spread beyond the
pancreas and its surrounding area.
And therefore can still be surgically
removed.
Because the head of the pancreas is
located so deep within the abdomen.
Many structures have to be divided before
the tumor can be removed.
The gall bladder is mobilized and the bile
duct leading to the duodenum is divided.
Next, the duodenum is divided to preserve
the entire stomach as
well as the Pyloris valve in the first
portion of the duodenum.
This is referred to a pylorus-preserving
Whipple procedure.
In some cases, the surgeon may perform a
classic Whipple
procedure where a portion of the stomach
is also removed.
The neck of the pancreas is divided being
certain that no
tumor is left behind in the neck or body
of the gland.
One of the most important steps in
this operation involves removing the
pancreas and tumor
from two important vessels that supply
blood to
the intestines and return it to the liver.
These are called the Superior Mesenteric
artery
and the Superior Mesenteric and Portal
veins.
Occasionally if these structures are
involved with tumor,
portions of these important veins are also
removed.
This dissection is quite complicated and
prolongs the operation.
The proximal small bowel, called the
jejunum is divided allowing
the entire specimen to be mobilized and
removed from the body.
Once the specimen consisting of the
pancreas containing the tumor.
And the surrounding tissues is removed,
the reconstruction
is then carried out in a step wise
fashion.
Generally, the remaining pancreas is
reconnected or anastomosed to
the proximal small bowel in an end to side
fashion.
Next, several inches beyond the first
anastamosis,
the bile duct is reconnected to the
jejunum.
Finally downstream from the bile duct
anastamosis,
either the duodenum or stomach is
reattached to
the jejunum depending upon whether a
pylorus
preserving or a classic Whipple has been
performed.
So in summary, a Whipple operation, or
pancreaticoduodenectomy, removes
a portion of the pancreas containing the
tumor, the
gallbladder and distal bile duct, and most
of the
duodenum along with a section of small
bowel or jejunum.
The reconstruction includes a nastimosine
or reattaching the pancreas,
the bowel duct and duodenum, or stomach,
to the small bowel or jejunum.
Patients undergoing this extensive
operation are often placed in an intensive
care unit for observation for the first 24
hours after surgery.
The next day following surgery the patient
is gotten out of bed.
Often ambulated in the nasogastric tube
that is placed through
the nose down into the stomach during the
operation is removed.
Many patients will start taking sips of
water during the first post-operative day,
and usually will be discharged from the
intensive care unit and go to a floor.
The second day after surgery, patients
often start taking liquids.
And as early as the third post-operative
day, may actually begin on solid foods.
Drains are frequently left in place after
the operation,
to collect any secretions that may be
present after surgery.
If appropriate, the two drains are removed
on the fourth and fifth post-operative
days.
If a patient has done well with no
post-operative complications, they may
leave the hospital as early
as the sixth or the seventh day, but
a hospitalization of about eight days is
the average.
After a recovery period of several weeks,
the vast majority
of patients will be able to resume a
normal life.
Depending upon the type of tumor and lymph
node involvement, chemotherapy or
radiotherapy or both, maybe indicated
starting six or eight weeks after surgery.
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