Pancreatic cancer has one of the most serious outcomes of all cancers. It is the 5th commonest cause of cancer death in Australia, similar to other countries despite its relative rarity. In Australia there were 2663 new cases of pancreatic cancer diagnosed in 2010, accounting for 2% of all cancer diagnoses. In 2011 pancreatic cancer contributed to 5% of all cancer deaths. Population based studies showed 5 year survival rates of only 7% due in large part to the fact that only about 20% of patients present with an early diagnosis allowing for curative treatment.
Once the diagnosis of pancreatic cancer has been made it is necessary to determine whether the tumour is removable by surgery and hence “resectable.” This means the tumour must be localised to the pancreas in order to be treated with curative intent. Operability or resectability is determined principally using computed tomography (CT) scanning with intravenous (IV) contrast.
Current criteria for operability includes the absence of secondary disease to other organs, lack of involvement of major arteries and suitable segment of adjacent large veins (portal vein and superior mesenteric vein) to allow for venous reconstruction.
Fitness for Surgery
In addition to operability determining a person’s fitness for surgery is vital for a favourable outcome. Both left and right sided pancreatic surgeries are major abdominal surgery. To be considered for pancreatic surgery a person needs to have a good performance status, adequate kidney and liver function, adequate blood parameters and a good cardiovascular system. Additional assessments of cardiac status including functional assessments are often indicated according to the individual person. Diabetes is commonly associated with pancreas cancer and good sugar control needs to be optimised prior to the surgical period.
Jaundice (a yellow tinge of the skin and conjunctiva) is a frequent presenting complaint for tumours on the right hand side (head) of the pancreas. Patients with jaundice have a number of changes that affect the kidney, liver, heart and immune system. There is considerable discussion regarding whether temporary relief of jaundice prior to major surgery is of benefit for an individual person and this would be discussed on an individual basis.
Nutritional assessment will be included in the pre-operative work up for someone being considered for pancreas surgery. Loss of appetite and weight loss are very common among patients with pancreas cancer. Weight loss of more than 10% of body weight or low blood protein levels are associated with an increased risk of complications. Maintaining nutrition is a high priority in the management of pancreatic cancer as well as preserving muscle mass. Nutritional supplements, sometimes including pancreatic supplements, and regular exercise are recommended
Pancreaticoduodenectomy (Whipple procedure)
Why do I Need this Operation
Common reasons to perform this surgery are, cancer of the head of the pancreas, bile duct, duodenum or ampulla. For these cancers, Whipple’s operation offers the only chance of cure.
There are also many non-cancerous conditions that are treated with this procedure: eg cysts of the head of the pancreas and bile duct, pancreatitis, to remove a pre-cancerous tumour and rarely even for gallstones lodged in the head of the pancreas.
It should be noted, that it is sometimes difficult to obtain a definite diagnosis of cancer either before or during the surgery. The pancreas tends to develop a great deal of scarring or reaction that interferes with interpreting a pre-operative needle biopsy. It is common to biopsy a cancer in this region and only obtain a benign report. Thus, it is up to the surgeon’s judgement whether or not the patient has cancer and would benefit from this surgery. The presence of cancer will be determined by the pathologist when they assess the removed specimen under the microscope.
The decision to proceed to this type of surgery is very complicated and is the main reason why it is important to be operated on by a surgeon with a great deal of experience with operations for cancer of the pancreas and bile duct. His/her judgement will be valuable in determining whether or not a tumour is present and if it is removable.
There are several instances at the time of surgery, when the surgeon will determine that the cancer is not removable due to its relationship to important blood vessels supplying blood to the liver and bowel. These blood vessels cannot be removed without threat to the patient’s life. If this is the case, the surgeon will perform a biliary bypass procedure to drain away the jaundice and the cancer will not be removed. This will be discussed fully with you and your family after the surgery.
The Whipple’s procedure is performed in two stages:
1. Removal stage
Removal of the gallbladder (cholecystectomy), the common bile duct (choledochectomy), the head of the pancreas, duodenum, a small part of the small bowel, the lymph glands in the area and sometimes part of the stomach.
2. Reconstruction stage
Consists of attatching the pancreas to the jejunum, the bile duct to the jejunum and finally the stomach is attached to the jejunum to allow food to pass through.
What to Expect Immediately after Surgery
On the first day after surgery, there may be a moderate amount of discomfort at the site of the operation.
You will have some form of pain relief. There will be your choice of:
- Epidural (if medically suitable)
PCA and painbuster – a button to press with strong pain killers in it combined with a tiny catheter in the wound providing local anaesthetic.
- Your anaesthetist will discuss the pros and cons of both type with you prior to surgery and it is your choice.
- Every effort will be made to minimize the discomfort and keep it bearable. Your physicians and nurses will be monitoring your level of pain control frequently.
- When you are back on a normal diet, you will be converted to oral pain relief.
You will have a number of plastic tubes in your body following surgery. They will vary a little depending on your particular medical need. They will be removed at variable times following your surgery under the direction of the surgeon.
1. IV line: In your arm and in your neck (placed under anaesthesia) to give you fluids and pain relief after surgery.
2. Urinary catheter: tube placed in your bladder so you don’t have to get up to pass urine
3. Abdominal drain tubes: two or three soft plastic drains coming out of your abdomen that are placed around the pancreas to drain any fluid, bile or pancreatic juice, so it does not collect in you abdomen.
4. Stomach/small bowel feeding tube: a double barrelled tube that sits in your small bowel and emerges through the skin. It has the dual function of draining fluid from your stomach whilst feeding your small bowel with high energy food. This tube is not used in all cases.
You will not have anything to eat or drink for the first several days after surgery. An intravenous infusion will provide you with the necessary fluids. In some cases you will have a nasogastric tube (NG) in your nose which will remove the stomach contents until your stomach and intestines recover. A feeding tube also called a jejunostomy tube may be inserted to help with feeding after the surgery. Your surgeon will let you know when you will be able to eat.
During the first few days after the surgery, the tube placed in your bladder will drain your urine. You will probably not have a bowel movement until several days after the surgery.
It is likely you will be looked after in intensive care for at least the first day after your surgery. Your continued stay here will depend on your condition
You can expect your nurse and physiotherapist to help you to get out of your bed on the first day after surgery. You will be able to walk short distances even with all of the tubes and intravenous lines. As each day passes your tolerance for walking and sitting in a chair out of bed will increase. This is extremely important to prevent pneumonia, clots in the legs and loss of general condition. You can expect to have to wear stocking on your legs whilst in hospital to prevent clots and have an injection of heparin twice a day under the skin for the same reason.
You can expect to have a bandage over your incision for the first several days. Your surgeon will remove the dressing at the appropriate time. You will be able to shower with the waterproof dressing on. It is quite common to have a small amount of leakage from the wound.
Most commonly you will not have stitches to remove, they will be of the dissolving type.
Other Important Information
You can expect to see your surgeon every day. On weekends or in times when your surgeon is operating elsewhere, you will see one of the practice partners. All are very experienced in this type of surgery and commonly assist each other in the operating theatre.
We will make every effort to keep you informed of your progress. We are always honest and open with you and your family. Feel free to ask questions.
Length of Stay in Hospital
On average most patients will expect a 2-3 week hospital stay. This time however differs greatly for individual patients. Some stay shorter, some much, much longer. You will not be discharged before you can walk unaided and care for yourself.
What are the complications that may happen immediately after surgery for Whipple’s operation?
The Whipple’s operation is a complex surgery with many potential complications. In the hands of surgeons who are experienced, the complication rate is usually very low.
The most serious and specific complications that may be seen after this operation include:
After the tumour is removed from the pancreas, the cut end of the pancreas is sutured back into the bowel so that pancreatic juices can mix with food and be absorbed. The pancreas is a very soft and sometimes fatty organ and in some patients, this suture line may not heal very well. If this happens, then patients develop leakage of pancreatic juice.
This usually leaks into the soft plastic drain that the surgeon leaves at the time of the surgery and is controlled without any ill effect to the patient. In most patients who develop a leak of pancreas juice, the leak heals on its own.
Occasionally the drain doesn’t cope with all the drainage and the patient will need to be re-operated on to drain the pancreatic juice. This re-operation occurs in 1-4% of patients undergoing Whipple’s procedure.
Gastroparesis – paralysis of the stomach
It is quite common (about 25% of patients) for the stomach to remain paralysed for a variable time after a Whipple’s operation. The small bowel however begins to function in the first one to two days after surgery.
It may take up to 4-6 weeks for the stomach to adapt to the changes after the surgery. This may mean that you cannot take anything by mouth during this time and you will have to remain in the hospital. It also may mean that you may require continuous drainage of your stomach to prevent vomiting. (Done with a tube in the nose, or a tube through the skin of your abdomen into your stomach)
If you experience a prolonged period of time where your stomach does not work, it can be emotionally very difficult time for you and your family. It is easy to loose spirit and feel quite “down”. Rest assured, the stomach will start working again in its own time and when this occurs it usually does so rapidly.
Other immediate complications of this surgery
Like all major surgery there are a number of serious complications that may occur. These must be dealt with on a case by case basis. Some of these complications are:
Death: approx. 1% of all patients having this type of operation.
Bleeding: either in the first 2-3 days requiring return to surgery or delayed bleeding from a ruptured artery some weeks after surgery. You may require a blood transfusion.
Infections: Wound, pneumonia, urine, bile duct, intra-abdominal, epidural related, IV line related, related to the gastrostomy tube.
Punctured lung secondary to the IV line in your neck.
Clots in the legs that may travel to the lungs.
Stomach ulcer that may or may not bleed. This may present as a vomit of blood or black bowel motions.
Urinary catheter complications: unable to pass urine after catheter removed especially in men.
Weight loss: it is common to loose about 10% of starting body weight after this surgery. (approx. 5-10kg)
Wound pain and prolonged numbness under the wound.
Hernia of the wound.
What are the long term complications of the Whipple’s operation?
Some of the long term consequences of the Whipple operation include the following:
The pancreas produces a substance (enzyme) that digests food. In some patients, removal of part of the pancreas during the Whipple’s operation can lead to decreased production of this enzyme. Patients complain of diarrhoea that is very oily. Treatment consists of taking oral pancreatic enzyme pills and usually provides excellent relief from this problem. About 40-50% of all Whipple’s patients may require these supplements.
Another role of the pancreas is to produce insulin that controls blood sugar levels. During the Whipple’s operation the head of the pancreas is removed. Therefore, the risk of developing diabetes is present.
In general, patients who are diabetic at the time of surgery or who have an abnormal blood sugar level that is controlled on a diet prior to surgery have a high chance for the severity of the diabetes becoming worse after the surgery. On the other hand patients who have completely normal blood sugar prior to surgery with no history of diabetes and do not have chronic pancreatitis or morbid obesity have a low probability of developing diabetes after the Whipple’s operation.
Alteration in diet
After a Whipple’s operation, we generally recommend that the patients ingest smaller meals and snack between meals to allow better absorption of the food and to minimise symptoms of feeling of being bloated or getting too full.
Approximately one in five patients who have a Whipple’s operation have a temporary problem in which the stomach does not empty well after eating. This may cause nausea, vomiting, and loss of appetite. It usually resolves on its own within 2-6 weeks after the operation.
Loss of weight
It is common for patients to lose up to 5 to 10% of their body weight compared to their weight prior to their illness. The weight loss usually stabilizes very rapidly and most patients after a small amount of initial weight loss are able to maintain their weight and do well.
Passing drain tubes in stool
Your surgeon may place several soft pieces of plastic tubing during your surgery to hold open your bile duct and pancreatic duct. These may pass with your bowel motion at any time after your surgery. It is common not to notice them. If you do notice them, it is completely normal. DO NOT retrieve them from the toilet bowl.
How you may feel
You may feel weak or “washed out” when you go home. You might want to nap often. Even simple tasks may exhaust you.
You might have trouble concentrating or difficulty sleeping. You might feel depressed.
These feelings are usually transient and can be expected to resolve in 2-4 weeks.
Your surgeon will discuss with you which medications you should take at home. If needed, you will go home with a prescription for pain medicine to take by mouth.
Your dressing will be removed before you leave the hospital and if it is not leaking it will be left open to the air. You may wear clothes over the top of it.
Your incision may be slightly red along the cut. This is normal. You may gently wash dried material around your incision and let water run over it. Pat dry gently with a towel. Do not rub soap or moisturizer into your incision until at least 4 weeks or it is fully healed.
It is normal to feel a ridge along the incision. This will go away. It is normal to have a patch of numbness under the wound.
Do not use any ointments on the incision unless you were told otherwise.
You may see a small amount of clear or light red fluid staining your dressing or clothes. If it is minor, cover that part of the incision with a pad. If staining is severe, you should call your surgeon.
Over the next few months your incision will fade and become less prominent.
Do not drive until you have stopped taking narcotic pain medication and feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid travelling long distances until you see your surgeon at your next visit.
Don’t lift more than 10kg for 6 weeks. (This is about the weight of a briefcase or a bag of groceries) This applies to lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You may swim after 4 weeks.
Heavy exercise may be started after 6 weeks – but use common sense and go slowly at first.
You may resume sexual activity when you feel ready unless your Doctor has told you otherwise.