What Happens in a Pancreatectomy?

A pancreatectomy is a type of surgery that removes part or all of your pancreas. It is used to treat conditions related to the pancreas, including pancreatic cancer. The goal of a pancreatectomy is to remove the area of the pancreas involved with cancer. It is only appropriate in patients in whom the cancer can be removed in its entirety and offers the potential for cure (which is why it is not recommended in patients with advanced or metastatic disease).

Before a pancreatectomy, several tests may be conducted to assess your general health. This includes standard medical tests, like a chest X-ray or electrocardiogram (EKG), and blood work. Your care team will also review your medical history and current medications.

You will be given details on how to prepare for surgery. Some preparations you can expect are:

• Avoiding food and drink for several hours before going to the hospital
• Stopping certain medications, such as blood thinners, for a short period of time before surgery
• Quitting smoking (if you’re a smoker) to improve your heart and lung health
• Refraining from alcohol use, which can cause complications like bleeding and infections

After checking into the hospital, you will have an intravenous (IV) line placed into a vein in your arm. This allows anesthesia, medication and fluids to be delivered.

If your surgery involves removing the tail of the pancreas, the spleen is typically removed as part of this operation. In this case, you’ll be given certain vaccinations or immunizations before or after your surgery. This is because the spleen is responsible for making antibodies that help fight infections.

Pancreatectomies are done under general anesthesia, where you are in a deep sleep so you do not feel any pain during the entire operation.

The type of pancreatectomy performed depends on the location of the cancer within the pancreas:

• A Whipple procedure is performed for cancers located in the head of the pancreas. In addition to the removal of the head of the pancreas, the first portion of the small intestine (the duodenum), part of the bile duct, and the gallbladder are also removed. The digestive tract is then reconstructed, including reconnecting the bile duct and pancreas to a loop of the jejunum (the second portion of the small intestine), as well as reconnecting the stomach to a downstream portion of the small intestine.
• A distal pancreatectomy is performed for cancers located in the body or tail of the pancreas. For this operation, the remaining part of the pancreas will be closed with sutures (stitches) or staples. As noted, the spleen is typically removed as part of a distal pancreatectomy.
• A total pancreatectomy is occasionally required for large cancers that involve most of the pancreas or for multifocal tumors that arise within multiple areas within the pancreas.

For all of the above operations, the surgeon will also remove nearby lymph nodes to reduce the risk of the cancer coming back. Moreover, examining these lymph nodes can determine more accurately how far the cancer has spread. This provides useful information about your prognosis and may help inform doctors’ decisions regarding additional treatment options after surgery.

There are different ways in which a surgeon may perform a pancreatectomy. This includes:

• Open surgery: The most common approach, this involves the surgeon making one long cut (incision) down the middle of the belly to get to the pancreas and other organs in the abdominal cavity.
• Laparoscopic (or keyhole) surgery: A minimally invasive procedure where the surgeon makes several small cuts in the belly to insert special tools. This includes surgical instruments and a long, thin tube with a lighted camera on its tip. This camera sends video to a monitor in the operating room, guiding the surgeon as they operate using the inserted surgical instruments. This is only suitable for some cases, particularly for patients undergoing a distal pancreatectomy.
• Robotic surgery: This is another type of minimally invasive operation. Similar to laparoscopic surgery, surgical instruments and a camera are inserted into the belly. However, the surgical tools are attached to a mechanical device called a robot. The surgeon sits at a console nearby and uses hand controls to direct the robot. The use of the robot, theoretically, allows for more precise, smaller cuts during the surgery.

Compared to open surgery, laparoscopic or robotic surgery may result in less blood loss, a shorter hospital stay, a faster recovery and fewer postoperative complications.

After the procedure, you can expect to spend at least one week in the hospital. As your digestive system heals, you will likely start with a clear liquid diet until your care team decides you’re ready to transition to solid foods. You will also be prescribed medication to manage your pain.

Apart from monitoring you for complications, your care team will also be keeping a close eye on your digestion and blood glucose levels post-surgery. They will need to be aware of how you are coping with reduced pancreatic function and make adjustments accordingly.

The surgical specimen will be sent to pathology and will be analyzed to determine if all the cancer was removed and if there were any cancer cells in the lymph nodes. The genetic and molecular features of the cancer can also be examined as part of this analysis. These results often take a week or more to return.

A pancreatectomy is a major surgery that comes with risks and complications, including:

• Leaking, bleeding and infection at the site of the surgical incision(s). If this happens, a tube may be inserted through the skin to drain the fluid from the wound. You may also be prescribed antibiotics to help treat the infection.
• Leaking from the surgical connections made between organs. For example, leakage where the pancreas connects to the small intestine is known as a pancreatic leak or pancreatic fistula. This can lead to abdominal infections and is managed with a combination of drainage tubes and antibiotics.
• Diabetes. The pancreas is responsible for making insulin, a hormone that regulates your blood sugar levels. Removing part or all of the organ can cause high blood sugar or diabetes.
• Compromised immunity. Part of the immune system, the spleen is responsible for making antibodies that help fight infections. If your spleen is removed as part of your pancreas operation, it can affect your immunity against certain diseases and increase the risk of infection, which is why vaccinations against certain bacterial species are administered.
• Delayed gastric emptying. This is a condition where the stomach takes too long to empty its contents, making it difficult to keep food down. Symptoms include nausea, vomiting and feeling full quickly. Delayed gastric emptying usually goes away in the weeks after the procedure. However, if it persists, you may require a temporary feeding tube to make sure you are receiving enough nutrition.
• Maldigestion and malabsorption. The pancreas produces digestive enzymes that break down fats, proteins and carbohydrates. Without sufficient enzymes (called exocrine insufficiency), you may have difficulty digesting and absorbing essential nutrients from food. This can cause bloating, stomach pain, changes in bowel habits (oily, floating stools), and significant weight loss. You may also develop vitamin and mineral deficiencies.

Your surgeon and cancer care team will explain these risks and complications thoroughly before surgery. Rest assured that the side effects can be managed.

Healing takes time, and recovering after a pancreatectomy can take up to several months. It depends on your overall health, the kind of surgery you have and any complications.

Here are some ways that the longer-term complications of surgery are managed:

• Being prescribed insulin or other diabetes medications to manage your blood sugar levels
• Taking supplemental enzymes, known as pancreatic enzyme replacement therapy (PERT), to aid digestion
• Making dietary changes to include smaller, more frequent meals without greasy or fatty foods
• Adopting other healthy lifestyle changes, such as a regular exercise program, as recommended by doctors

Rest assured that your care team will support and help you navigate the post-op healing process.