Treatment of the pancreas at the Sachsenhausen Clinic, Germany, Frankfurt

Treatment of the pancreas

The pancreas is a small organ located between the stomach, the duodenum and the spleen, that is important for metabolism in the body. The pancreas has a body, a head and a tail. The metabolic hormones glucagon and insulin produced by the pancreas regulate, increase or decrease blood sugar levels. In addition, the pancreas generates enzymes for the biochemical breakdown (digestion) of eaten food in the intestines.

A disorder or a serious disease of the pancreas has a negative effect on metabolism and digestion. There may be a number of serious diseases, such as acute or chronic pancreatitis (inflammation of the pancreas) or cancer of the pancreas or a cyst or a pancreatic fistula. Sugar imbalance can also cause diabetes mellitus.

Causes of Acute Pancreatitis

There are various causes behind acute pancreatitis, the most common being alcohol abuse and biliary tract disorders. The other, more rarely occurring causes:

  • Fat metabolic disorders
  • Hyperfunction of the thyroid gland
  • Some drugs, such as antibiotics and painkillers
  • Bacterial or viral infections
  • Helminthic invasion
  • Tumors
  • Autoimmune diseases
  • Heredity
  • Blunt abdominal trauma

Symptoms of Acute Pancreatitis

Acute pancreatitis often occurs unexpectedly and with intense abdominal pain. The following symptoms may be signs of acute pancreatitis:

  • Sudden intense pain in the upper abdomen
  • Waist radial pains in the back and chest
  • Nausea and vomiting
  • Excessive meteorism
  • Fever
  • A feeling of exhaustion and weakness

These symptoms do not necessarily indicate pancreatitis, they are similar, for example, to a heart attack, so a thorough diagnosis in the hospital is necessary to decide on the further course of treatment.

Diagnosis

The following measures are important to confirm the diagnosis of acute pancreatitis:

  • Identifying blood counts
  • Ultrasound examination
  • Endoscopic examination
  • Functional tests to measure the amount of enzymes

If there is no doubt about the diagnosis of acute pancreatitis, the doctors will start treatment.

Course of the Disease in Case of Acute Pancreatitis

Acute pancreatitis can be treated in most cases without surgery. The treatment comprises mainly the refusal to eat and drink. Only about 20 % of acute pancreatitis cases are associated with serious complications, most patients recover within two or three weeks without any serious complications. In more complicated cases, this can lead to bacterial infection with pus formation, which makes it necessary to use a washing catheter and antibiotic treatment.

If the pancreatic tissue is destroyed by a severe acute pancreatitis, pancreatic surgery may be required. However, the course of the disease differs greatly from patient to patient, and doctors decide on the need for surgery in each case.

Causes Behind Chronic Pancreatitis and Pancreatic Cancer

With chronic pancreatitis, the symptoms are very much like those with acute pancreatitis, but with a particularly intense pain in the upper abdomen. Although acute pancreatitis eventually subsides after treatment, it always appears in a chronic form. The most common causes, apart from others, are:

  • Alcoholism
  • Smoking
  • Genetic predisposition
  • Hyperfunction of the thyroid gland
  • Inadequate fat metabolism

In the long term, the undertreated chronic pancreatitis can cause pancreatic fibrosis. In the worst case, chronic pancreatitis can lead to the development of malignant pancreatic carcinoma. However, pancreatic cancer can occur all of a sudden without pancreatitis and without any obvious cause.

Various Surgical Techniques for the Pancreas

If the treatment of chronic pancreatitis with medications does not lead to the desired effect or there is pancreatic cancer, pancreas surgery is inevitable. There are various techniques at the disposal of the attending surgeon:

  • Frey’s procedure
  • Traverso procedure
  • Whipple procedure
  • Total pancreatectomy

Frey’s procedure is mainly used to treat chronic pancreatitis, when the head of the pancreas is affected.

During the Whipple procedure (also known as Kausch-Whipple procedure), with pancreatic cancer, in addition to the head of the pancreas, the gallbladder, the bile duct, the duodenum and one third of the stomach are removed.

The Traverso procedure, when the stomach remains intact, is used for small tumors.

During resection of the pancreas the tail of the pancreas and the spleen are removed, and in case of total pancreatectomy the whole pancreas, as well as the duodenum, the spleen, the lower bile duct and the gallbladder are removed.

The attending doctor decides which technique is appropriate for the particular case. In the case of pancreatic cancer, chemotherapy or radiation therapy are used in addition to surgery.

Whipple Procedure

The Whipple procedure is an operation in the upper abdomen during which the pancreas is partially or completely removed. It is an extremely difficult operation that should only be performed in specialized centers.

The Whipple procedure is used to treat various pathological changes in the head of the pancreas or adjacent tissue. These include malignant neoplasms (carcinomas), inflammation or occlusions. The "head of the pancreas" refers to the thick right third of the pancreas which is close to the duodenum and part of the bile duct.

The most common cause for using the Whipple procedure is pancreatic cancer which usually comes from the head of the organ. It is an extremely aggressive disease. The tumor grows rapidly and spreads early over the lymphatic and blood vessels in the nearby organs. It is therefore important to work on a large scale to eliminate the possible spread of cancer.

The operation is divided into resection, i.e. removal of organs and reconstruction, restoration of the gastrointestinal tract. The main procedure lasts from five to six hours and is performed under general anesthesia.

The Whipple procedure involves access to the organs through a long transverse incision in the upper right abdomen. Then there follows the so-called search for the tumor. The surgeon needs to identify with the naked eye how far the malignant tissue has spread and which organs are affected. If the tumor has already spread too far, it cannot be surgically removed and the doctor will recommend palliative care.

During the Whipple procedure, the doctor can remove the following organs:

  • The head of the pancreas, the whole pancreas, if necessary
  • The duodenum and possibly part of the stomach
  • The gallbladder and parts of the bile ducts
  • Adjacent lymph nodes

Depending on how far the tumor has spread, the surgeon partially or completely removes the pancreas and parts of the stomach. In most cases, however, our doctors try to remove as little as possible. Unfortunately, it is often no longer possible to remove the whole tumor, as it is often diagnosed too late. Even if the resection is as wide as possible, cancer returns in 95% of cases.

The surgeon sutures the removed small intestine to the rest of the pancreas and connects the stump of the gallbladder to the intestine. To restore a continuous gastrointestinal tract, the doctor sutures the stomach with a piece of the small intestine about 40 centimeters away from the connection with the bile duct. Then the doctor closes the surgical wound with a careful hemostasis and connects them. The patient is taken to the recovery department, where he or she is examined by the doctors and nurses.

All surgical procedures involve general risks that the patient should know. These include:

  • Bleeding and bruises
  • Injury to adjacent organs
  • Nerve damage, sometimes with irreversible damage
  • Infections

Moreover, there are certain complications that may arise during or after the Whipple procedure:

  • Fistula: for example, there may be unnatural connections between the intestines and other organs
  • Organ failure of the liver, kidneys or heart
  • Suture rupture (postoperative hernia)
  • Intestinal obstruction
  • Diabetes mellitus: if the whole pancreas has been removed, patients can no longer produce insulin
  • Stomach upset and weight loss after surgery
  • Anastomosis leakage: surgical connections between the biliary tract, stomach and intestines leak or break

Another typical complication that may occur after the Whipple procedure is the so-called dumping syndrome. If parts of the stomach have been removed during the procedure, it can no longer perform its reserve function. The mush which usually remains in the stomach for a certain period of time and is digested before it enters the small intestine shortly after it is taken. This sometimes leads to severe hypotension and nausea after eating (early discharge) and causes hypoglycemia (late discharge) a few hours later.

As this is a serious procedure, the patient will be given a long stay in our hospital after the Whipple procedure. Approximately three-four weeks. If there are complications, you may also need long-term inpatient care.

Since pancreatic cancer spreads quickly and some cancer cells can already be found all over the body, chemotherapy, which usually takes six months, is required in addition to surgery.

After the pancreas has been removed, the enzymes it produces in healthy people need to be supplied from outside. This is called substitution therapy. As a result, most patients generally have no symptoms. However, the removal of various organs can cause some discomfort.

Rehabilitation after Pancreatic Surgery

Inpatient, polyclinic or outpatient treatment after pancreatic surgery should be started as a follow-up treatment within 14 days after discharge from the hospital and usually lasts for three weeks and can be longer.

As the person concerned, you will learn how to cope with the physical and emotional aspects of rehabilitation, how to change your diet and get help in dealing with problems.

Prof., Dr. med. Plamen Staikov

Prof., Dr. med. Plamen Staikov

Medical Director, Head physician

Holger Bahn

Holger Bahn

Senior physician

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