- this is the standard procedure for the treatment for pancreatic head ( periampullary) cancers . It is a very complex procedure and requires highly technical surgical skills. It should be only performed in specialist centres by expert surgeons, who perform it regularly. It involves a resection part, this involves the removal of part of the stomach, the whole of the duodenum, part of the small bowel, the head of the pancreas, the bile duct and the gallbladder. This is followed by the reconstruction part, this involves the reconstruction of the pancreatic, biliary and gastric anatomy. The stomach and bile duct are joined to the small bowel and the pancreas can be joined to either the stomach or the small bowel. The reconstruction choices depends on intraoperative findings and surgeon's judgment.
What is the mortality rate?
- In pancreatic centres this should not exceed 3-5%.
What are the surgical risks?
- Anastomotic leakage: this procedure involves 4 joins ( stomach to small bowel, bile duct to small bowel, pancreas to small bowel, small bowel to small bowel ) . Any of these joins is at risk of leaking after the operation. The highest risk of leak is from the joins involving the pancreas. This risk is around 20% in most centres. However, drains (plastic tubes) are normally positioned near the join to drain any leak out of the abdomen. This permits a conservative management of this complication as the leak would normally heal within 2 weeks.
- Bleeding: it is a risk in any surgical procedure especially in major surgery. However, thanks to advances in surgical techniques, in expert hands blood loss is now significantly reduced and the need of intra operative blood transfusion is quite rare.
- Diabetes: around 60% of patients having this operation will be diabetic afterwards, this varies in severity from just having to change your diet all the way up to requiring Insulin.
- Malabsorption of food: almost all patients after a Whipple's operation require extra supplements of concentrated pancreatic enzymes to help digest their food. These are supplied as capsules to take with meals.
- Infection: this is a broad term that encompasses everything from a mild chest infection to abscesses inside the abdominal cavity.
These are potential risks and they are usually reversible. Very careful post operative care is needed to ensure their prompt identification and treatment.
Keyhole pancreatic surgery
- Laparoscopic distal pancreatectomy: this involves removing the left side of the pancreas ( body/tail). It is a more simple procedure that Whipple's procedure as less organs will be resected and there is no reconstructive part. The procedure is performed through 4-5 small incisions and the specimen is removed in a bag through a 3-5 cm supra pubic incision(similar to a cesarian section)In some cases the spleen may also need to be removed, this depends on the type of disease , its relation with vessels and its location.
Laparoscopic pancreatic bypass
- if the tumor is obstructing the duodenum and the bile duct but cannot be removed, the pancreas should be by passed to allow the passage of bile to be re-established. In most cases we try and treat the blockages without surgery by placing plastic or metal drainage tubes internally. This is done by passing a telescope via the mouth into the stomach and duodenum. If this does not work then a surgical by- pass would be the next option available. This can be done with keyhole surgery but in some cases it may need to be converted to the traditional open approach.
Laproscopic drainage of pseudocyst
- this procedure is performed for patients with collections of inflammatory fluid (pseudocysts) around the pancreas following pancreatitis.. Sometimes the pseudocyst can be treated endoscopicopically, but in some cases this may not be possible hence a surgical solution may be needed. This involved joining the cystic wall to the small bowel to create an internal continuous drainage.