Contents
Pancreatic surgery includes many subcategories that are designed to improve the quality of life of patients in the gastroenterology department.
The uniqueness of the presented gland lies in the fact that it is at the same time an organ that produces an external and internal secret. It is responsible for the production of enzymes that guarantee stable digestion. The secret enters through the excretory ducts into the intestine. Also, the body is a generator of hormones that go directly into the blood. If treatment is not provided in time, then the affected gland quickly fails, touching neighboring tissues due to its destabilization.
Especially dangerous is the option when a tumor of an oncological nature is found in the victim, whether it is a benign or malignant formation. Almost always, such a scenario requires intervention to remove the problem area.
Medical indications
Anatomically, the pancreas belongs to the upper abdomen, located behind the stomach. The localization site is quite deep, which presents some difficulty during surgery.
Schematically, the organ can be divided into three parts: body, tail, head. All of them are closely adjacent to adjacent organs. So, the duodenum goes around the head, and the back surface is adjacent to the right kidney with the adrenal gland. Part is in contact with the aorta, vena cava, spleen and important vascular pathways.
Because of such a dense anatomical fullness, people often wonder whether they do a partial or complete excision of an organ. But if an experienced surgeon is responsible for the procedure, then he will cope even with such complex tasks.
The unique organ impresses not only with its extensive functionality and location. It has a rather unusual structure, which provides not only connective tissue, but also a glandular counterpart. Additionally, the parenchymal component of the body has an abundant vascular network and ducts.
Doctors admit that this gland is little understood in terms of etiology and pathogenesis. Because of this, its cure often involves a long-term holistic approach. Sometimes even with positive dynamics, negative consequences appear.
Among the most common possible complications are:
- bleeding;
- suppuration;
- relapses;
- melting of the surrounding tissue;
- the release of an aggressive enzyme beyond the permissible limits.
Because of this, surgical technology is used only in exceptional cases, when it is clear that no other alternative methods will help to cope with the current situation. Removal of the problematic part of the abdominal cavity, or partially, will allow you to get rid of the constant pain syndrome, improve his well-being and even prevent death.
Among the main medical indications, experts note:
- acute inflammatory process;
- pancreatic necrosis;
- peritonitis;
- pancreatitis of a necrotic format with suppuration, which is an indication for emergency excision;
- abscess;
- trauma with subsequent bleeding;
- neoplasms;
- cyst;
- pseudocyst.
The last variation provides for soreness and outflow disturbances.
Depending on the primary source of the disease, the type of operation will be determined. The modern classification provides for the following varieties:
- necrectomy triggered by necrosis;
- total pancreatectomy;
- abscess drainage;
- cyst drainage.
Decisions on the need to excise only part of the organ, which is called resection, are considered separately. When it is necessary to remove the head, one of the most popular types of resection is used – pancreatoduodenal. And if lesions are found in the tail or body area, a distal resection format cannot be dispensed with.
Surgery to help patients with acute pancreatitis
After the victim is confirmed for acute pancreatitis, then at first the doctors try to restore their former health without surgery. But when alternative approaches do not give the desired result, then radical measures are indispensable.
Experts note that, despite the severity of the disease, there are no strict criteria for indications for the procedure for acute pancreatitis.
The main indicators of the need to involve surgery are:
- infected pancreatic necrosis, which is characterized by purulent fusion of tissues;
- ineffectiveness of conservative therapy for more than two days;
- abscesses;
- purulent accumulations in peritonitis.
Of particular difficulty, even for true professionals, is the necrotic course of the disease, when suppuration haunts about 70% of all victims.
Without radical solutions, mortality is 100%.
When infected pancreatic necrosis is confirmed in a patient, an open laparotomy is urgently prescribed for him with cleansing of dead cells and drainage of the postoperative bed.
According to statistics, about 40% of clinical cases require a second laparotomy in the future. Even an experienced gastroenterologist is unlikely to voice the exact time period. The reason for the repetition is called the need to completely get rid of harmful tissues affected by necrosis.
In particularly difficult scenarios, doctors do not even suture the abdominal cavity, leaving it open to quickly pack the problem area if there is a risk of bleeding.
Many registered in the gastroenterological department of the hospital are interested in the fact of how much such assistance costs. But there is no definite figure here, since it takes into account the peculiarity of each operation, together with the involved drugs, anesthesia and subsequent recovery. Doctors warn that if the patient has undergone surgery, then this is not the end of spending.
There is always a risk of needing a second intervention. The price will also increase due to the need to undergo a rather lengthy rehabilitation. Separately, the cost is affected by the need to resort to cholecystectomy. This measure is necessary if, along with the underlying disease, the victim also has cholelithiasis. Then, in one visit, the surgeon will get rid of the gallbladder.
What operation is indicated for abscesses
If a person has confirmed the presence of an abscess, then sending to the operating room should not be delayed. Especially when the abscess was a direct consequence of limited necrosis after the ingestion of an infectious agent. Sometimes the remote period of suppuration of the pseudocyst becomes the provocateur of the deviation.
Usually people ask what can be done in such a serious situation, besides surgery, but without an autopsy with drainage, a person’s life is unlikely to be saved. Depending on the area of the lesion, it will depend on which technology the gastroenterologist will prefer:
- open;
- laparoscopic;
- internal.
The first combination is based on laparotomy, which involves opening the abscess with drainage of its cavity until the area is completely cleared.
When a verdict is made in favor of laparoscopic drainage, a laparoscope is necessarily involved, with the help of which the opening of the problem point occurs accurately. Further, the expert removes non-viable tissues, establishes channels for the functioning of full-fledged drainage.
Difficult to perform and at the same time productive technique is internal drainage, the difficulty of which lies in opening the abscess through intervention through the back wall of the stomach. For a successful outcome, a laparotomy or laparoscopic approach is used.
The result is presented as the exit of malicious content through an artificially created fistula. The cyst obliterates over time, and the fistulous opening is tightened.
Is surgery necessary for a pseudocyst?
A pseudocyst is a consequence of an acute inflammatory process in the pancreas. From a physiological point of view, a pseudocyst is a cavity that has not received a formed membrane, and inside it there is pancreatic juice.
Some mistakenly believe that such a diagnosis is cancer, but in fact, getting rid of it is an order of magnitude easier than when diagnosing oncology. This applies even to situations where impressive clusters up to 5 centimeters in diameter have been found.
If you do not help the patient at this stage, then he will soon face numerous complications, which are expressed in:
- squeezing surrounding tissues or ducts;
- chronic pain sensations;
- suppuration up to the formation of an abscess;
- erosion of blood vessels with bleeding due to exposure to aggressive digestive enzymes;
- rupture of accumulations into the abdominal cavity.
Such sad scenarios are confirmed by numerous reviews of those who have already managed to go through such a difficult test. They were prescribed to alleviate the condition:
- percutaneous external drainage;
- excision of the pseudocyst;
- internal drainage, which is based on the creation of an anastomosis of the cyst with the stomach, or a cyst loop.
One of the options presented above is selected solely on the basis of the results of the analyzes.
Features of resection
Removal of a part of the organ is prescribed only when it is impossible to save health in another way. This usually occurs as a result of a tumor lesion, or after a recent injury, when the overall prognosis remains stably positive. Very rarely, radical excision is resorted to if a person has become a victim of chronic pancreatitis.
Due to some anatomical features of the gland’s blood supply, only one of two parts can be removed:
- head;
- body with a tail.
But the first solution provides for the obligatory excision of the duodenum, since the system has a single blood supply.
To reduce the percentage of risks of surgical intervention on the pancreas, physicians have developed several versions of resection. The most popular is the pancreatoduodenal variation, which is also called the Whipple method. The technology relies on extracting not only the affected head of the gland along with the circumflex organ of the duodenum, but also part of the stomach, gallbladder and neighboring lymph nodes.
Such an extensive intervention is shown in cancer of the Vater papilla or tumor, which is located in the indicated territory. But the matter does not end with excision, because the surgeon is obliged to build a drain for bile. For reconstruction, the remaining tissues of the gland are used. Outwardly, it will look like a specialist re-formed the damaged parts of the digestive tract from what was left in the abdominal cavity.
The recovery program provides for several anastomoses at once:
- gastric outlet with jejunum;
- pancreatic stump duct with intestinal loop;
- common bile duct with intestine.
Occasionally, based on the current situation at the time of the operation, surgeons prefer pancreatogastroanastomosis. It is based on the withdrawal of the pancreatic duct into the stomach, and not, as usual, into the intestines.
Distal variation is necessary to clear a tumor that is located in the body or tail. It is believed that this is a more severe case when it comes to malignant oncological formations. They are almost always inoperable because they invade the intestinal vasculature too soon. Because of this, surgeons are more likely to incline to such a radical decision if the benignness of the tumor has been confirmed.
Difficulties are added by the fact that the distal analogue necessarily covers the need to remove the spleen. Such a complex system is explained by the fact that the technique is associated with the spread of diabetes mellitus at the postoperative stage.
Sometimes plans have to be changed on the spot. When opening the abdominal cavity, the doctor may note a more extensive spread of the pathology, which will prompt him to use the last resort – total pancreatectomy. This means that a complete excision of the organ is planned for the sake of maintaining health.
What operations are done for chronic pancreatitis
Some patients believe that with diabetes, along with the concomitant destabilization of the activity of the gland due to chronic pancreatitis, only surgery will help out. But experts warn that with such a condition of the pancreas, one can only hope for relief of the condition, and not for a full recovery without the risk of relapse.
To help victims of the chronic form of such a dangerous disease, doctors have developed several practices in surgery:
- drainage of ducts, which is necessary with a pronounced problematic patency;
- resection with drainage of the cyst;
- resection of the head, which is characteristic of obstructive jaundice, duodenal stenosis;
- pancreatectomy for large lesions.
The stones that are deposited in the ducts deserve special attention. They partially or completely block the passage of the secret, which provokes an acute pain syndrome. With severe pain and the inability to alleviate their manifestations with the help of pharmacological substances, there is no other way out than the classical operation.
This technique is called wirsungotomy. It means cutting the duct to remove the stone, or draining above the level of the obstruction.
Organ transplant success
A relatively new word in pancreatic health surgery is transplantation. It was first produced in 1967. But even then, the researchers knew that it would be possible to change organs only together with the accompanying duodenum.
Despite the fact that after a kind of exchange it turns out to live with other internal organs for quite a long time, how long they live after such a transplant is not particularly encouraging. In official medicine, the longest life expectancy after a successful outcome was just over three years.
Due to too high risks for the patient, as well as a high threshold of complexity, this transplant is not in significant demand, even if the victim has been diagnosed with a malignant tumor.
Difficulties end with the fact that the gland is a hypersensitive component of the abdominal cavity. Even with a gentle touch with a finger, she receives significant injuries. If we add to this the need to sew a huge number of accompanying large and small vessels, then the manipulation turns into a many-hour test for all medical personnel and the patient.
With the search for a donor, everything is also not particularly smooth, since this organ is unpaired, which means that it can only be taken from a deceased person. He must not only be suitable in all respects, but also give prior permission for the use of his organs for those in need.
But even if you manage to get such a donor, then you need to deliver the right part of the peritoneum very quickly. The gland is sensitive to a lack of oxygen, and also begins irreversible processes half an hour after the cessation of stable blood flow.
This means that even after being carefully removed from the previous owner in freeze mode, it will survive no more than five hours. This is hardly enough to organize transportation even between neighboring transplant centers, and if you add time to the procedure itself, it becomes quite difficult.
If the victim was lucky and the organ was delivered as soon as possible, then the algorithm for its establishment includes:
- placement in the peritoneum;
- connection with the hepatic vessels;
- comparison with the splenic and iliac vessels.
This is technically difficult to implement, and is also accompanied by a high chance of death due to extensive bleeding and subsequent shock.
Postoperative period
After the patient is transferred from the operating room, he is prescribed parenteral nutrition for the first few days. In practice, this means the supply of special nutrient solutions that are injected through a dropper directly into the blood. If possible, the doctors insist on installing a special intestinal probe. Through it, the nutrient mixture is delivered directly to the intestines.
After three days, it is allowed to start drinking, and then, according to the circumstances, grated and semi-liquid food is prescribed, which should not contain salt, sugar. But even if the diet is followed thoroughly, a person may face some complications such as: purulent inflammation; bleeding; failure of anastomoses; diabetes; malabsorption or digestion of food.
But this happens quite rarely, so the chances of a successful recovery remain high. Unlike some other internal components, the removed pancreas does not pose a serious threat to the patient. With properly selected nutrition and maintenance with drug therapy, it will be possible to live for many years without a significant decrease in the quality of life.
It is only worth preparing for the fact that you will have to adhere to the diet until the end of your days, and also eat at least five times a day in small batches. It is necessary to ensure that the meal is light and without fat. You will have to completely abandon alcoholic beverages.
Instead of alcohol-containing liquids, it is better to give preference to enteric-coated enzyme preparations. The attending physician will individually select them for each of his wards separately.
You will need to get into the habit of measuring your blood sugar levels to avoid developing diabetes. According to statistics, it makes itself felt as a complication in only half of the cases.
Only when taking into account all of the above and a successful operation will it be possible to return to normal life again. Do not be afraid of a sharp weight loss in the first few months after surgery on the organ, as this is a common occurrence. The most important thing is to support the body with vitamins and a balanced diet in order to prevent the mechanism of immune failure from starting.