Tuesday, April 3, 2012

Removing the pancreas (total pancreatectomy) for Pancreatic Cancer



What is a total pancreatectomy?

A total pancreatectomy is performed to treat pancreatic cancer. The procedure involves the removal of the entire pancreas, as well as the spleen, gallbladder, common bile duct, and portions of the small intestine and stomach. By removing the pancreas, the chance of removing the entire tumor is increased. This procedure is used when malignant cells have invaded most of the pancreatic tissue.

Unfortunately, a total pancreatectomy leaves the patient unable to produce pancreatic enzyme for digestion and insulin for controlling blood glucose level. When the entire pancreas is removed, the endocrine cells in it are also removed, which will leave you with no islet cells. Because islet cells make insulin, which controls blood sugar levels in the body, removal of the entire pancreas will result in diabetes. You will then be dependent on insulin injections. And will be required to take supplemental enzymes and insulin for the remainder of your life. 

Total pancreatectomy is sometimes used prophylactically to prevent onset of pancreatic cancer in patients found to have precancerous conditions like Intraductal Papillary Mucinous Neoplasms (IPMN). While the procedure ensures pancreatic cancer will not develop in the future, it also guarantees insulin-dependent diabetes and should be discussed thoroughly and carefully with your physician. 

Not long ago, total pancreatectomy (TP) has been abandoned by many surgeons because of its lack of benefits and other major drawbacks. The potential benefits of TP, including its cancer treatment related as well as its technical advantages, did not prove to be valid. Problems associated with insulin-deprived diabetes mellitus and high perioperative morbidity and mortality rates were not easily manageable. However, in the new era of pancreatic surgery, new indications for TP have been defined. These have been paralleled by improvements in surgical technique, multidisciplinary management and postoperative intensive care. These factors have transformed TP into a relatively safe and reasonable surgical procedure with excellent perioperative morbidity and mortality, as well as good long-term outcome.

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The Procedure

Most patients stay in the hospital for 7 to 10 days. Because of the location of the pancreas, it may be necessary to remove part of the stomach, the duodenum, the end of the common bile duct, the gallbladder, and the spleen.

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The surgeon will reconnect your stomach and remaining portion of your common bile duct to the jejunum. The jejunum is the second part of the small intestine. This ensures that food and bile flow into your small intestines. The operation takes 4 to 6 hours.

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Preparing for your Surgery

Please contact your insurance company to verify coverage and determine whether a referral is required. You will be asked to pre-register with the appropriate hospital and provide demographic and insurance information. This must be completed at least five to ten days before the date of surgery. Your surgeon will give you specific instructions on how to prepare for your surgery.

The spleen is part of your body’s immune system. If it will be removed, your doctor may want you to have a Pneumovax vaccination before the surgery. This will help protect you against certain types of infection. You can get it before the operation on a day when you come in to see the doctor. You can also get it after your operation when you return for a follow-up visit.

Your bowels must be clean before surgery. You may have to complete a bowel preparation procedure at home. Your nurse will give you these instructions and review what you must do.  You will get a booklet called Getting Ready for Surgery. You will also get a fact card called Common Medicines Containing Aspirin and Nonsteroidal Anti- Inflammatory Drugs. If you have not received these, please ask your nurse for them. Review them carefully. They explain what you should do before surgery. You must stop taking vitamin E and any medicine that has aspirin in it 10 days before your surgery. You must stop taking drugs such as ibuprofen (Motrin or Advil) 48 hours before surgery. The fact card lists all of the common medicines that have these drugs. It also lists the medicines that you can take instead.

Anesthesia

You will have a pre-operative interview with an anesthesiologist who will ask you questions regarding your medical history. A pancreatectomy is performed under general anesthesia which will keep you asleep during surgery.

During the Surgery

The goal of a total pancreatectomy is to remove the entire pancreas and the attached organs. First, the end of the stomach is divided off and detached. This part the stomach leads to the small intestine, where the pancreas and bile duct both attach. In the next step, the pancreas is removed along with the connected section of the small intestine. The common bile duct and the gallbladder are also removed. To reconnect the intestinal tract, the stomach and the bile duct are connected to the small intestine.

Several tubes are implanted for postoperative care. To prevent tissue fluid from accumulating in the operated site, a temporary drain leading out of the body may be implanted. Also, a Gastrostomy or G-tube leading out of the stomach will help prevent nausea and vomiting, and a Jejunostomy or J-tube inserted into the small intestine will serve as a channel for supplementary feeding.

Recovery


You will be ready to go home when you:
  • Can eat a regular diet.
  • Show no signs of complications.

Your doctor will give you discharge instructions and prescriptions for any medicines you need. Your nurse will review these instructions with you. You will get a printed copy to keep. The case manager will arrange for any home care before you leave. Many patients need visiting nurse services at home. In general, your first post-operative visit will be 10 to 14 days after you leave the hospital. This will be indicated on your discharge instruction sheet. Please call your doctor’s office to schedule the appointment.

Ability to return to work and/or normal activities varies among patients. You will be encouraged to return to normal activities, such as showering, driving, walking up stairs, light lifting and work, as soon as you feel comfortable. No heavy lifting or straining for six to eight weeks after open surgery. If taking narcotic medications for pain, you should not drive.

Note that you will have a single long scar as a result from the incision.

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Special Instructions

  • A common complaint that patients have after this surgery is lack of appetite. Try to eat small amounts of your favorite foods often throughout the day. It is important to eat a balanced diet. It will help your body heal faster. It can help you keep your blood sugar levels within your target range. It is important that you do not skip entire meals because this could cause low blood sugar or hypoglycemia. Low blood sugar can be very serious if it is not treated. The diabetes nurse educator will give you booklet on how to treat it and other information to help you manage your diabetes. Always carry a source of sugar with you. It can be hard candy or glucose tablets. Take it immediately if you have any symptoms of hypoglycemia.
  • Feeling tired (fatigue) is common after surgery, and may last for 6 to 8 weeks. This will improve slowly over time. Try to increase your activity level every day to help manage your fatigue. Get up, get dressed, and walk. You may need a nap during the day, but try to stay out of bed as much as possible so you will sleep at night. Ask your nurse for the booklet, Handling Fatigue During and After Cancer Treatment, if you haven’t already received it.
  • When you go home, you may still have some incisional pain that requires pain medicine. Take it as directed when you need it. Remember, your pain medicine will let you do the things that will help you gain strength and recover faster. They are important. However, pain medicines cause constipation. Take extra fluids and fiber, and use a stool softener such as docusate (Colace). As the pain lessens, acetaminophen (Tylenol) may be enough to control it.

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Managing Diabetes

The thought of being diabetic may seem overwhelming. You will be one of millions who live with diabetes. Most live normal lives. During your hospital stay, you will see a diabetes nurse educator. This nurse will work closely with you and your care partner to prepare you for managing your diabetes. You will be taught:
  • How diabetes affects your body.
  • What foods to eat and what ones to avoid.
  • How to check your blood sugar.
  • How to give yourself an injection of insulin.

You must see a doctor close to home who will help you manage your diabetes after you leave the hospital. An endocrinologist is a doctor who specializes in diabetes.





Sources and Additional Information:





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