Pancreas is a retroperitoneal organ, divided into head, body and tail. It lies posterior to the stomach. The head part is surrounded by the duodenum and distal part of the common bile duct (CBD) passes through this part. Tumor located in this part causes duodenal and CBD obstruction leading to vomitting and jaundice respectively
Pancreatic juice is secreted into the pancreatic duct, Near the duodenum this duct joins with the terminal part of CBD and form a common channel called as ampulla of vater. Periampullary cancer include carcinoma of head of pancreas, distal CBD and duodenum near ampulla of vater
The pancreas has got dual function, exocrine & endocrine.
The exocrine function means pancreas releases digestive enzymes which help in digestion. The main digestive enzyme released is amylase and lipase, helping in fat digestion. This is the reason fat digestion is first and most commonly affected in pancreatic disorders
The endocrine function include synthesis of hormones which mainly regulate carbohydrate levels in our body. the main include insulin & gulcagon. Pancreatic disease patients are prone to develop diabetes mellitus and hypoglycemia
Inflammation of pancreas is acute pancreatitis, most common pancreatic disorder .There are two main reasons one is Alcohol intake and other is Gallstone, Diagnosis is based on increased serum amylase and lipase level and the typical pain abdomen localized to epigastric region and radiating to back; CECT abdomen is done after 72 hrs of onset of pain abdomen to assess the severity of acute pancreatitis.
The course of disease is counted from the day of onset of pain abdomen, Organ failure in the first 72 hr carry a bad prognosis and high mortality rate; Initial phase is body inflammatory response to pancreatitis and can last up to 2-3 weeks, during this phase chances of pancreatic infection is less; After 4th week patient can develop pancreatic abscess and later on acute fluid collection may organize to pseudocyst.
First 2-3 weeks patients require critical care; Respiratory and Inotropic supports if required, Enteral nutrition should be started as early as possible; Most common indication of surgery in these patients is a Pancreatic abscess.
After an episode of acute pancreatitis if peri-pancreatic fluid collection does not resolve then after four weeks these are termed as pseudocysts, Not all pseudocyst require intervention because many of these pseudocyst remain stable or regress; however cyst which are increasing in size and causing pressure symptoms or develop complication require intervention, As many of this Pancreatic Pseudocyst communicate with pancreatic duct simple external drainage is not effective, these require some type of internal drainage into bowel; these drainages can be done either by endoscopy or surgical intervention; MRI abdomen will tell whether the contents of the cyst are liquidified or solid, because if the contents are solid endoscopy drainage will not be success; Surgical intervention are cysto-gastrostomy or cysto-jejunostomy depending on location and size of cyst.
Alcohol intake is the most common cause of chronic pancreatitis. Repeated inflammation of the pancreas due to alcohol leads to pancreatic atrophy and loss of pancreatic function
Pancreatic duct dilatation due to pancreas atrophy, calcification’s, ductal stones are hallmarks of chronic pancreatitis
Patient complain of severe pain abdomen which become constant requiring frequent hospital admissions. These patients become narcotic drugs dependent, because of severe pain
Loss of pancreatic function leads to diabetes and steatorrhea. Steatorrhea is passing undigested fat in the stool. The stools are typically bulky, frothy and difficult to flush
Pancreatic Head Cancer
Risk factors for pancreatic cancer include smoking, alcohol, chronic pancreatitis; Pancreas is divided into three parts head, neck and body region, Symptoms depend at the site of tumor location, if the cancer is located in the head region patient present with jaundice/vomiting and if in neck and body region pain and abdomen mass as the main symptom; weight loss and decreased appetite are common symptom; CECT abdomen is done which show any local and distant spread; If the tumor is resectable the standard surgical procedure is Whipple procedure (Pancreatico-duodenectomy) if the tumor is located in the head region; and if the tumor is located in body and tail region the standard surgical procedure is distal pancreatectomy with splenectomy
Pancreas Body & Tail Cancer
The incidence of cancer in the pancreatic body & tail is less as compare to head malignancy. Because of the location,these tumors grow to big size before they become symptomatic.
Most commonly patient present with pain abdomen or lump abdomen, when investigated for these symptoms are diagnosed to have pancreatic cancer
The chances of metastases are high in these patients and staging laparoscopy is must for these cancer
Because pancreas is retro-peritoneal organ, pancreas injury is rare in trauma; Generally pancreas trauma is managed conservatively, pancreas injury is divided into proximal when it involves head and distal when it involves body and tail, when there is complete transaction of the pancreatic duct distal pancreatectomy is done, Pancreatic injury patients may develop pancreatic fistula later on.
Pancreatic Duct Stone
Laparoscopic Pancreatic Surgery
Pancreatic surgery are complex major abdominal surgeries. Experience and skills determine the outcome. Most of these surgeries are performed by open approach. But with the advancement in the Laparoscopy techniques and instruments, Nowadays most surgery can be performed by this minimally invasive approach by trained GI Surgeon or Laparoscopic Surgeon or Pancreatic surgeon
Most commonly surgery performed Laparoscopy are pancreatic necrosectomy and internal pseudocyst drainage which develop after an episode of acute pancreatitis. Pancreatico-jejunostomy for chronic pancreatitis
Whipple procedure is done most commonly by open approach , but some advance laparoscopic centres in the world are doing this complex surgery Laparoscopy