What is Surgery for Pancreatic Diseases and Cancers?
Pancreatic Diseases and Cancer Surgery is the surgical field that deals with the diagnosis and treatment of benign and malignant (pancreatic cancer) tumors of the pancreas, pancreatitis, pancreatic cysts, traumatic pancreatic injuries and their complications.
Scope of Pancreatic Surgery
Pancreatic surgery includes the treatment of the following conditions:
Pancreatic Tumors: Surgical treatment of both benign and malignant tumors.
Chronic Pancreatitis: Surgical intervention can be performed if pancreatic inflammation turns into a long-term condition.
Acute Pancreatitis and its complications: Endoscopic and surgical treatment of severe necrotizing pancreatitis and its complications (Pancreatic Pseudocyst and WON).
Pancreatic Cysts and cystic tumors: Includes serous cystadenoma, solid pseudopapillary tumor, IPMN and MCNs.
Traumas and Injuries: Surgical procedures performed when the pancreas is damaged as a result of blows to the abdomen.
The Importance of Pancreatic Surgery
Pancreatic surgery requires a very delicate surgical intervention because the pancreas is in close contact with other vital organs and sits on the main vessels of the body. During surgery, the liver, small intestine, spleen, and both the arteries and veins of the stomach are carefully peeled off to remove the pancreas and surrounding tissue. Therefore, the risk of complications during surgical procedures is high. In addition, especially in whipple (pancreaticoduodenectomy) surgery, since the removal procedure requires both the Pancreas and Bile Duct and Stomach anastomosis, that is, 3 anastomoses, complications may arise due to the healing problem of these anastomoses during the postoperative recovery period. All these long-term surgical procedures can be meticulously and correctly performed by experienced hands (HPB Surgeons) and can reduce the very high complications, and also, foreseeing possible complications, taking precautions and performing the necessary radiological or endoscopic interventions early and correctly can reduce postoperative deaths to ZERO. At the same time, a radical surgery in accordance with oncological principles can extend the patient’s expected life and increase the quality of life. Poorly managed postoperative complications both reduce the patient’s quality of life and cause long hospital stays, economic and social losses. In addition, additional treatments such as chemotherapy cannot be received or may cause deficiencies in patient treatment due to delays.
The performance of pancreatic surgeries by HPB surgeons who are experts in this field, such as Prof. Dr. Kemal Dolay, results in both correct and radical oncological surgeries and surgery with a postoperative death probability close to ZERO due to early and correct management of possible complications.
What is PANCREAS and What Does It Do?
The pancreas is a small organ located in the upper abdomen, weighing approximately 75-100 grams and measuring 15-20 cm in length. It is surrounded by the stomach, small intestine, liver, spleen and gallbladder. The healthy functioning of the pancreas is critical for our overall health.
The pancreas is one of the important organs of our body. It has two main functions: digestion and blood sugar regulation. Its contribution to the digestive process is to secrete digestive enzymes called amylase, lipase and proteinases into the duodenum, breaking down the fats, proteins and carbohydrates in the food we consume and ensuring that they can be absorbed from our intestines in smaller pieces.
At the same time, the pancreas regulates our blood sugar by secreting hormones such as insulin and glucagon. Insulin lowers blood sugar by making the sugar in the blood available to cells, while glucagon raises blood sugar by releasing stored sugar.
The pancreas, in addition to digestion, neutralizes stomach acid coming to the duodenum with the bicarbonate it produces, preventing ulcers from forming.
Interestingly, unlike many other important organs, it is possible to live without the pancreas with the help of modern medicine. Patients who have had their entire pancreas removed can survive by taking digestive enzymes orally with meals and injecting insulin for blood sugar.
Who Performs Pancreatic Cancer Surgery?
Since pancreatic cancer surgery is a very difficult and complex surgical procedure, it is better to have better results (low complication and mortality rate) when such surgeries are performed by HPB surgeons who focus on liver, bile duct and pancreatic surgery.
Qualities to Look for in a Pancreatic Cancer Surgeon
Field of Expertise: It is important for the surgeon performing the surgery to have experience especially in pancreatic cancers.
Education and Certificates: A surgeon who has received training and distinction in advanced techniques should be preferred.
Surgery Center: Hospitals where the surgery will be performed should have intensive care, advanced radiological imaging devices such as Computerized Tomography and MRI, Angiography device for interventional radiology and necessary materials. Consultation from relevant branches should be possible for diabetes, hypertension and infectious complications.
Multidisciplinary Approach: The care of patients who have undergone pancreatic cancer surgery usually involves more than one branch physician. It is important for the surgeon to adapt to this teamwork and seek consultation when necessary. Pancreatic cancer treatment is a multidisciplinary approach where different treatment methods such as surgery, chemotherapy and radiotherapy are used together. In this process, it is of great importance for an experienced surgeon to determine the right treatment plan in terms of extending the patient’s life expectancy and improving the quality of life.
The Role of Prof. Dr. Kemal Dolay in Pancreatic Cancer Surgery
Prof. Dr. Kemal Dolay is a leading surgeon who offers his patients a multidisciplinary approach and advanced treatment methods in complex surgical diseases such as pancreatic cancer. The successful results he achieves, especially in complex surgeries such as the Whipple procedure, significantly increase the quality of life of patients. Low complication rates and high patient satisfaction are remarkable in the operations performed under Dolay’s management. This success is possible thanks to his expert team in the field and the importance he attaches to current treatment methods.
The Importance of Choosing a Surgeon
Choosing a surgeon in pancreatic cancer treatment is a critical decision that directly affects the patient’s life expectancy and quality of life. Consulting with different surgeons and getting a second opinion helps patients make an informed decision. In this process, the surgeon’s area of expertise, experience, patient approach and surgical techniques used are of great importance.
Surgeries performed under the guidance of experienced surgeons such as Prof. Dr. Kemal Dolay allow patients to achieve more successful results.
PANCREATIC CANCER
Why is pancreatic cancer the worst among cancer types?
Pancreatic cancer has no specific complaints and progresses insidiously. It does not cause complaints in the early stages. When it starts to complain, it mimics other diseases. Due to late presentation, most patients have advanced cancer and only 20% of patients who apply to a surgeon are able to undergo surgery.
In addition, since it is an organ hidden behind the stomach, liver, intestines, gallbladder and spleen, it is also difficult to diagnose.
Pancreatic cancer cells are biologically very aggressive, the tumor grows quickly, spreads quickly to surrounding organs and lymph nodes and metastasizes rapidly by going to the liver.
It is also quite resistant to chemotherapy drugs.
For this reason, it ranks 10th in frequency among all cancers today and ranks third in cancer-related deaths. It is estimated that it will rise to 1st place in cancer deaths in the USA in 2050.
What is the First Sign of Pancreatic Cancer?
Pancreatic cancer usually does not show any symptoms in the early stages, and the symptoms that appear when it progresses can usually be associated with other health problems. It is also called the “silent killer” because it is mostly diagnosed in the late stages. However, when pancreatic cancer symptoms develop, the following may occur:
Pain: Constant or occasionally severe pain in the upper abdomen can be a symptom of pancreatic cancer. This pain can also spread to your back or shoulders. In the early stages, there is slowly developing, intermittent, upper stomach pain that increases with blunt meals. As the disease progresses, the pain becomes severe and constant. It decreases when you bend forward. Back pain, which is seen in 1 in 4 patients, indicates that the tumor has reached the vascular-nerve structures behind the abdomen.
Weight Loss and Loss of Appetite: Rapid weight loss is the most common symptom. It is often accompanied by loss of appetite.
Jaundice: Jaundice manifests itself with the yellowing of the skin and eyes. This condition is seen in 80-90% of pancreatic head cancers and develops due to the cancer blocking the adjacent bile ducts.
4. Unexplained Loss of Appetite: Long-term loss of appetite, especially without a significant change in your eating habits, may indicate pancreatic cancer.
Diabetes: Pancreatic cancer can affect insulin production, which can affect sugar metabolism, which can cause sudden onset or exacerbation of diabetes. 20% of pancreatic cancer patients have new-onset Diabetes.
Nausea and Vomiting: When the tumor grows too large and blocks the stomach outlet or duodenum, it can cause nausea and vomiting.
Stool Changes: Stool color may lighten due to jaundice, and stool may be oily and watery due to pancreatic exocrine insufficiency.
Fatigue and Weakness: Cancer can weaken the body, which can cause general weakness and fatigue.
Rate of Complaints and Examination Findings Related to Pancreatic Cancer
Complaints
- Weakness 86%
- Weight loss 85%
- Anorexia 83%
- Abdominal pain 79%
- Epigastric pain 71%
- Dark urine 59%
- Jaundice 56%
- Nausea 51%
- Back pain 49%
- Diarrhea 44%
- Vomiting 33%
- Steatorrhea 25%
- Thrombophlebitis 3%
Most common findings:
- Jaundice 55%
- Hepatomegaly 39%
- Right upper quadrant mass 15%
- Cachexia 13%
- Courvoisier sign 13%
- Epigastric mass 9%
- Ascites 5%
The Importance of Early Diagnosis
Recognizing the early symptoms of pancreatic cancer, the diagnosis and treatment process are of vital importance. Recognizing the disease at an early stage increases the chance of success of surgical intervention and other treatment methods. For example, the most effective condition that prolongs life is that pancreatic cancer can be surgically removed at an early stage.
Early Diagnosis and Treatment with Prof. Dr. Kemal Dolay
As a surgeon specialized in the field of pancreatic cancer, Prof. Dr. Kemal Dolay ensures that patients have early diagnosis and access to the right treatment options. He meticulously examines the radiological images of patients, such as tomography (CT) and MRI, by opening them in special programs, and investigates whether there are any other findings other than the reports. He also consults these films with radiologist specialized in liver, pancreatic and biliary diseases radiology. He encourages regular check-ups especially for people at risk for pancreatic cancer (chronic pancreatitis, pancreatic cysts, small pancreatic neuroendocrine tumors) and offers personalized solutions.
Factors That Increase Pancreatic Cancer Risk
There are many factors that increase the risk of pancreatic cancer. Some of these factors are:
Age and Gender: Pancreatic cancer is generally more common in older individuals. The risk increases significantly after the age of 60, 80% of patients are between the ages of 60-80, and it is less common in young people. In addition, pancreatic cancer is more common in men and blacks than in women.
Smoking: Smoking is the most important factor that increases the risk of pancreatic cancer. The risk of cancer is 2.5 times higher in smokers than in non-smokers. Chemical substances in cigarette smoke can damage pancreatic cells and trigger cancer development. Smoking is responsible for 30% of pancreatic cancers. The risk decreases by 48% in the 2nd year after quitting smoking, and the risk due to smoking disappears in 10-15 years. Smoking is responsible for 43% of cancer deaths in men and 15% in women in the USA.
Family History: People with a history of pancreatic cancer in close relatives have a 2-fold higher risk of developing this cancer. Especially if a direct family member (mother, father, sibling, etc.) has pancreatic cancer, the individual’s risk increases much more. However, 5-10% of pancreatic cancers are hereditary, and 90-95% are sporadic.
Obesity: Being overweight or obese can affect hormonal imbalances in the body and increase inflammation, increasing the risk of pancreatic cancer.
Diabetes: Type 2 diabetes can cause high insulin levels. This can cause pancreatic cells to grow faster than normal, increasing the risk of cancer. In addition, some people with pancreatic cancer may be diagnosed with cancer after being diagnosed with diabetes.
Chronic Pancreatitis: Chronic pancreatitis is chronic inflammation of the pancreas. This long-lasting inflammation can turn normal cells into cancer cells, which can increase the risk of pancreatic cancer by 5-20 times.
Diet: A diet high in fat, especially saturated fat and cholesterol, may increase the risk of pancreatic cancer. Inadequate fruit and vegetable consumption may also increase the risk.
Alcohol Consumption: Excessive alcohol consumption can damage and inflame the pancreas, which can increase the risk of pancreatic cancer.
Environmental Factors: Exposure to certain chemicals (such as benzene and organic solvents), pesticides, and other toxic substances can increase the risk of pancreatic cancer.
Genetic Mutations: Certain genetic syndromes (such as Lynch syndrome) or mutations in certain genes, such as BRCA1 and BRCA2, can increase the risk of pancreatic cancer. Such genetic changes can run in families.
Having one or more of these factors can increase the risk of pancreatic cancer, but they are not enough to make a diagnosis on their own. Therefore, regular health checks are important for evaluating risk factors and early diagnosis.
Pancreatic cysts: Neoplastic pancreatic cysts (IPMN and mucinous cysts) are also conditions that increase the risk of cancer.
Do great sadness and stress invite cancer?
It is certain that great sadness and stress cause a weakening of the human immune system. Experiments have shown that chronic stress increases the growth and spread of an existing tumor, but there is no evidence in human studies that these situations definitely cause pancreatic cancer. In the face of great distressing events, people may start drinking alcohol or smoking, gain weight by eating too much, prefer an introverted and sedentary life, and in this way indirectly invite cancer.
Which Doctor Treats Pancreatic Cancer?
Pancreatic cancer usually shows obvious symptoms in the early stages, so it requires multidisciplinary treatment for the correct diagnosis and treatment process. Pancreatic cancer treatment is managed by physicians with different specialties coming together. Doctors who deal with pancreatic cancer usually come from the following departments:
General Surgeons (Pancreatic Surgery Specialists, HPB surgeons)
Surgical treatment of pancreatic surgery is usually performed by general surgeons who are competent in HPB. The HPB surgeon performs the most common and difficult surgical method used in the treatment of pancreatic cancer, such as the Whipple procedure (pancreaticoduodenectomy). The treatment that prolongs the life of a patient with pancreatic cancer the most is surgical resection.
Radiologists
Diagnostic radiologists evaluate the Ultrasound (USG), CT and MRI films used in the diagnosis of pancreatic cancer. Re-evaluation with the HPB surgeon in councils ensures better results. In necessary cases, interventional radiologists have an important place in the process as part of the complication management or surgery.
Oncologists (Cancer Specialists)
Medical oncologists plan chemotherapy treatment for all patients before and after surgery in cases of pancreatic cancer.
Radiation oncologists plan radiation therapy when necessary.
Gastrointestinal Endoscopists
When EUS is sometimes required for diagnosis or in cases of inflammatory jaundice, ERCP and stent placement are performed by endoscopists.
Palliative Care Specialists
When pancreatic cancer progresses to advanced stages, palliative care components come into play. Pain management, nutrition and psychological support contribute greatly to the quality of life of patients.
Prof. Dr. Kemal Dolay and Pancreatic Cancer Treatment
The experience of HPB surgeons such as Prof. Dr. Kemal Dolay is of great importance in the treatment of pancreatic cancer, especially in surgical intervention. Dolay adopts a multidisciplinary approach to the treatment of pancreatic cancer, combining treatment methods such as surgery, chemotherapy and radiotherapy. He also creates the most appropriate treatment plans by collaborating with gastroenterologists, oncologists and radiologists during the treatment process of patients.
The Role of Prof. Dr. Kemal Dolay in Pancreatic Diseases and Cancer Surgery
Prof. Dr. Kemal Dolay is recognized as an important authority in pancreatic diseases and cancer surgery. With both his academic knowledge and clinical experience, he makes significant contributions to the surgical treatment of pancreatic cancer and the management of other pancreatic diseases. Prof. Dr. Dolay’s expertise in the field includes not only advanced surgical interventions, but also a multidisciplinary approach that improves the quality of life of patients.
Expertise and Experience in the Field
Prof. Dr. Kemal Dolay has extensive training and experience in pancreatic cancer and other pancreatic diseases. Prof. Dr. Dolay, who has extensive experience in surgeries such as the Whipple procedure (pancreaticoduodenectomy), produces critical solutions in the treatment process of patients and achieves successful results.
Advanced Surgical Methods and Innovative Techniques
Prof. Dr. Kemal Dolay achieves successful results by using surgical techniques in pancreatic diseases and cancer surgeries. These techniques allow patients to recover faster with less invasive interventions.
Modern surgical methods such as endoscopic surgery (ERCP, Cystogastrostomy), Laparoscopic surgery and robotic surgery are among Prof. Dr. Dolay’s methods.
Early Diagnosis and Risk Management
Prof. Dr. Kemal Dolay emphasizes that early diagnosis of pancreatic cancer has a great impact on the life expectancy of patients. Close monitoring of risky patients, and if advanced radiological examinations are needed in case of suspicion of disease, early diagnosis can be achieved with methods such as EUS and ERCP.
Patient-Centered Treatment and Improvement of Quality of Life
Prof. Dr. Dolay’s approach to his patients is not limited to surgical intervention. At every stage of the treatment process, he produces rapid solutions in cooperation with other specialist doctors and aims to obtain psychosocial support and increase quality of life.
After surgery, the recovery process of patients, postoperative care and pain management are managed by Prof. Dr. Dolay.
Contributions to Education and Research
Prof. Dr. Kemal Dolay is an important figure not only with his clinical practice but also with his contributions to the academic field.
Various scientific articles have been written on pancreatic surgery and he has made important contributions to the literature of this field.
As an educator, he organizes trainings for young surgeons who have the training of general surgeons and shares his experiences. In this way, the application of the most up-to-date methods in pancreatic surgery is contributed.
PANCREATIC CANCER WHIPPLE SURGERY (PANCREATICODUODENECTOMY)
What is Whipple Surgery?
Whipple surgery is one of the most difficult surgeries performed in periampullary tumors and especially pancreatic head cancers, where the pancreatic head, duodenum, gallbladder, external bile ducts and sometimes a part of the stomach are removed, and the regional lymph nodes adjacent to the pancreas are removed together.
In Which Cases and Why is Whipple Surgery Performed?
- Pancreatic Cancer: The most common cause is pancreatic head cancer.
- Bile Duct Cancers: This surgery may also be preferred in cancers located in the lower part of the bile ducts.
- Duodenal Cancers: Whipple surgery may also be required in cancers occurring in this region.
- It is a surgical treatment method that is rarely used in the treatment of benign diseases such as chronic pancreatitis, which cannot be distinguished from cancer, and cystic diseases located in the head of the pancreas.
Purpose of Whipple Surgery
- Removal of the Tumor: Completely removing the cancerous tissue from the body.
- Removal of Surrounding and Regional Lymph Nodes: As much as possible, leaving no lymph nodes in the area where the tumor could spread.
- Reconnection of the Digestive System: Reconnection of the remaining parts to each other so that the removed organs can perform their functions.
How is Whipple Surgery Performed?
In Whipple surgery, sometimes a part of the stomach, duodenum and part of the small intestine, the head of the pancreas (sometimes the body of the pancreas is also included), a part of the bile duct, gallbladder, hepatic artery, mesenteric artery, Portal vein, Celiac trunk and lymph nodes around the pancreas are removed. Whipple surgery can be performed openly, laparoscopically or robotically.
How Long Does Whipple Surgery Take?
Whipple (pancreaticoduodenectomy) surgery can take between 5-8 hours depending on the difficulty of the case and whether it is radical. This period also includes the creation of 3 new paths (anastomoses) for the stomach, bile and pancreatic juice to flow into the intestines after the cancerous area is completely removed.
What is the Hospital Stay After Whipple Surgery?
The average hospital stay after Whipple surgery is 6-10 days. The patient is up and walking the day after the surgery. Oral nutrition, breathing and walking exercises are performed. Patients who can eat comfortably are discharged home in 6-10 days if there are no major complications. In the meantime, blood thinning injections that are started the day after the surgery are continued after discharge. The patient is called for a check-up again in the 2nd week and first month of the surgery.
How Should Nutrition Be After Whipple Surgery?
Nutrition is very important after Whipple surgery. Water is started orally in moderation on the first day after the surgery, then gradually switched to soft and solid foods that are watery. In order for the food to be digested more easily, 5 meals should be eaten per day and at least 10 glasses of water should be drunk. Additional vitamins given by the doctor should be consumed in a controlled manner. When the nutrition returns to normal, alcohol, fatty and sugary foods that are harmful to health should not be consumed.
Whipple Surgery and Pancreatic Cancer
➡️The pancreas is an important organ. It controls both our digestion and sugar.
➡️Pancreatic cancer is a very insidious and aggressive tumor.
➡️It is very difficult to detect early due to its location in the abdomen.
➡️Complaints occur late.
➡️In case of delay in diagnosis, sometimes the patient is not suitable for whipple surgery because the tumor surrounds the important vessels in the surrounding area. In these cases, the HPB surgeon discusses the patient’s information in tumor councils and re-evaluates after treatments such as Chemotherapy and Radiotherapy, and the patients who become suitable can be operated on.
Is Whipple Surgery Safe?
➡️It is one of the biggest surgeries in surgery, Whipple surgery.
➡️Whipple surgery, which is performed by an expert and experienced surgical team and HPB Surgeons, has a very high success rate.
➡️With the surgery, cancerous and tumorous organs and the surrounding lymph nodes are completely removed and the area is cleaned.
Is Biopsy Necessary Before Whipple Surgery?
➡️EUS and biopsy are not required for tumors that cause complaints in the pancreas and are thought to be cancerous on CT or MRI.
➡️Whipple surgery is preferred directly without performing a biopsy in experienced centers around the world.
➡️Performing unnecessary biopsy increases the cost, may cause complications and may cause the risk of tumor spread.
Recovery After Whipple Surgery
➡️The recovery process, which usually starts with a 6-10 day hospital stay, may vary depending on the patient.
➡️Post-operative care should be done very carefully for rapid recovery. Patients should stay away from heavy sports activities for at least 10 weeks.
➡️By going to the doctor regularly for check-ups, the person can adapt to a normal life.
What are the Risks of Whipple Surgery
As with every surgical procedure, there are some risks in Whipple surgery:
- Bleeding: There is a risk of bleeding during or after surgery.
- Infection: Infection may occur in the surgical area.
- Pancreatic leak: Pancreatic fluid leaks into the abdominal cavity after surgery.
- Vascular occlusion: Clot formation in the veins.
- Digestive problems: Vomiting, loss of appetite, diarrhea or constipation.
Can a patient whose entire pancreas is removed live?
Absolutely. Patients who have their entire pancreas removed face two problems: the first is insulin-dependent diabetes; the second is indigestion, which is corrected with digestive pills given orally.
Are There Any Promising Developments in Pancreatic Cancer Treatment?
There are currently two important conditions that prolong life in pancreatic cancer. First, early diagnosis can increase the remaining life by 6 times.
Secondly, since pancreatic cancer surgery is difficult, the surgery performed by hepatopancreatobiliary (HPB) surgeons, who are specialized in this field after their general surgery specialization, namely Liver, Pancreatic and Bile Disease surgeons in fully equipped hospitals with HPB units, extends life. In fact, this issue has recently been reported in the US media: “Patients with pancreatic cancer are going the extra mile to extend their lives.” Reuters reported that US pancreatic cancer patients go to an HPB center instead of the nearest hospital to have this surgery, and that by traveling an extra 200 km, they extend their lives by 25% and spend less time in the hospital by reducing surgical complications.
What is the relationship between pancreatic cancer and nutrition?
There are definite relationships between pancreatic cancer and nutrition. Hippocrates (460-370 BC) was the first to state in the records that eating habits and lifestyle are the main factors determining health. In studies on immigrants, prostate cancer is 25 times less and breast cancer is 10 times less in an Asian living in Asia, while this situation is reversed in those who migrated to the West and it is concluded that the main factor is nutrition. As in all gastrointestinal system cancers, it is known that eating a Western-style diet (high-calorie, fatty fast foods, fatty meat, eggs, rice/pasta, snacks, pizza, pie, potatoes, cake, high-calorie alcoholic beverages, mayonnaise) increases the risk of pancreatic cancer. Conversely, a Mediterranean-style diet (fish, seafood, plant products, fresh fruit, vegetables, olive oil) with plenty of vegetables and fruits and legumes reduces the risk of cancer.
What Should We Do to Protect Ourselves from Pancreatic Cancer?
Sedentary lifestyle, smoking habits, fatty animal proteins, processed foods, salt, sugar, alcohol and obesity are the factors that are blamed for chronic diseases and cancer formation. Therefore, the most important individual precautions to protect yourself from cancer are to stay away from cigarettes and tobacco products, follow a Mediterranean diet, stay away from alcohol and fatty ready-made foods, do sports and stay fit and not gain weight. In addition, if there is pancreatic cancer in the family, if there is no family history of diabetes but diabetes suddenly occurs or if there is recurrent pancreatic inflammation, it is necessary to cooperate with the doctor in terms of pancreatic cancer.
Can pancreatic cancer be prevented?
There is no definitive preventive measure yet, but it can be reduced with the measures we have mentioned above.
Finally, what are your suggestions for extending life in pancreatic cancer?
Most importantly, early diagnosis extends life by 6 times. After being diagnosed with pancreatic cancer, the life of the patients can be extended with a patient-specific multidisciplinary approach (HPB surgeon, gastroenterologist, medical oncologist, radiation oncologist, diagnostic and interventional radiologist and nuclear medicine specialist) in hospitals with 24-hour hepatopancreatobiliary surgery units specialized in this field.
History of Pancreatic Surgery
The first pancreatic tumor resection was performed by Friedrich Trendelenburg in 1882, and he performed distal pancreatectomy due to spindle cell sarcoma. Halsted described the first successful surgery, transduodenal local resection and bilio-pancreaticoduodenal anastomosis, on a patient with periampullary tumor causing obstructive jaundice in 1898. Alessandro Codivilla performed the first pancreaticoduodenectomy (PD) on a 46-year-old male patient with a pancreatic head tumor in 1898, but the patient died on the 18th postoperative day. Walther Kaush performed the first successful two-stage pancreaticoduodenectomy in 1909, and Hirschel performed the first successful single-stage pancreaticoduodenectomy in 1914. By the 1910s, 20 pancreatic resections had been reported in the literature and hospital mortality was 45%.
Pancreaticoduodenectomy, which we perform on pancreatic head and periampullary tumors and is one of the most difficult surgeries in surgery: The life story of Allen O. Whipple (1881-1963), the father of the Whipple surgery, caught my attention and I wanted to share it with you. Whipple was born in Urmia, South Azerbaijan, in 1881 and lived there until he was 14. He published the results of the two-stage pancreaticoduodenectomy surgery he performed on 3 patients with periampullary tumors in 1935: In the first stage, he sewed the bile (cholecystogastrostomy) and small intestine (gastrojejunostomy) to the stomach to correct jaundice and provide nutrition, and 3-4 weeks later, he performed a partial duodenum and pancreatic head resection, and applied suture ligation without anastomosis to the Wirsung and Santorini ducts. Two out of three patients died after surgery. In 1940, he performed his single-stage surgery on a patient who was diagnosed with stomach cancer but had a pancreatic head tumor. Whipple, who spoke 6 languages including Turkish, performed the pancreaticoduodenectomy surgery that is named after him 37 times throughout his career.
Pancreatic resection was not reported for a long time until Whipple’s successful two-stage pancreaticoduodenectomy in 1935. Whipple first performed cholecystogastrostomy and gastrojejunostomy (for the correction of jaundice and coagulopathy and for good nutrition), then 2-3rd continent duodenectomy + Wirsung and Santorini ligation 3-4 weeks later. He reported 3 patients in his first article, 2 of whom died postoperatively and the other survived. 5 years later, Whipple performed his classic single-stage surgery: complete duodenectomy and antrectomy with the pancreatic head ™. When he performed a laparotomy on this patient, thinking of gastric cancer, he detected a pancreatic head tumor, but since there was no jaundice or malnutrition, he performed it in a single session. He performed an anesthetic GJ and choledochojejunosomi in this surgery, and the patient lived for 9 years with the diagnosis of non-functioning islet tumor. Whipple performed 37 pancreaticoduodenectomy surgeries (30 periampullary, 7 chronic pancreatitis) throughout his career. Allen Whipple was born in 1881 as the child of a missionary family in Urmia, southern Azerbaijan, and lived there for 14 years. He learned 6 languages, including Turkish. In the 40 years after Wipple, morbidity after PD was generally 40-60% and mortality was 20-40%. After becoming chief of surgery at John Cameron Hopkins in 1984, he centralized pancreatic surgery (HPB Surgery) and technical advances, which reduced mortality to a very low level (1-2%) and caused this surgery to become widespread. Cameron Ann Surg published its own series of 1000 consecutive PDs in 2006 and reported a mortality rate of 1%. Cameron performed his 2000th Whipple surgery at Johns Hopkins in March 2012 at the age of 75.
PANCREATIC CYST
What is a Pancreatic Cyst?
Pancreatic cysts usually appear as fluid-filled sacs in the pancreas. It is a common type of cyst due to the emergence and widespread use of advanced imaging techniques. In abdominal MRIs (magnetic resonance imaging) taken in the West, pancreatic cysts are detected incidentally in almost half of the elderly (40-50%). Cystic tumors of the pancreas constitute 10% of all pancreatic tumors. They can be benign or malignant.
How is Pancreatic Cyst Diagnosed?
It is diagnosed with USG (Ultrasonography), CT (Computed Tomography) or MRI (Magnetic Resonance Imaging) performed for the abdomen. However, USG may be mistaken in obese people and those with excessive intestinal gas. In these cases, diagnosis can be easily made with fine-scan CT or MRI. To understand whether a pancreatic cyst contains cancer suspicion, the best radiological imaging should be performed with drug-assisted MR-MRCP. In some cases, it may be necessary to view the cyst with the endoscopic USG method called EUS and take a sample for analysis in order to make a better decision.
What are the Symptoms of Pancreatic Cysts?
Many pancreatic cysts do not show symptoms. Cysts that form without causing any complaints in the patient are usually detected in Tomography (CT) or MRI (MRI) taken during routine health checks. Cysts that reach a certain size may present themselves with severe abdominal pain. As a result of the cyst applying pressure to the stomach, symptoms such as weight loss and early satiety may also be observed. Jaundice and pancreatitis may sometimes develop in very large cysts.
What are the Types of Pancreatic Cysts?
Pancreatic cysts that can cause cancer are grouped under four headings. Just as the effect of the cysts in the body is different, treatment methods also vary depending on the type of cyst. There is also a pseudocyst due to pancreatitis, which is inflammation of the pancreas that does not cause cancer but is life-threatening.
* Serous Cystic Tumors: SCN
* Mucinous Cystic Tumors: MCN
* Intraductal Papillary Mucinous Tumors: IPMN
* Solid Pseudopapillary Cystic Tumors: SPN
Serous Cyst of the Pancreas SCN
Serous Cystic Neoplasia, serous cystadenoma (SCN) patients are usually women and over the age of 60.
It often does not cause any complaints and is detected incidentally in a tomography or MRI taken for another complaint.
It is easy to diagnose with well-taken tomography and contrasted MRI.
Since the rate of transformation into cancer is less than 1%, it does not require routine surgery.
If it causes complaints such as pancreatitis and early satiety, jaundice due to its size, or if it grows rapidly and structures suspicious of cancer are seen in the cyst, it requires surgery.
Mucinous cysts of the pancreas MCN
Mucinous cystic neoplasia (MCN) is the most common cystic tumor of the pancreas. The majority of patients are women and over the age of 40. It is often seen in the tail and corpus of the pancreas.
They may consult a doctor with abdominal pain, recurrent pancreatitis, gastric emptying problems and/or palpable swelling in the abdomen. If there is jaundice and/or weight loss, it often means that there is cancer.
Mucinous cystic tumors of the pancreas turn into cancer, and depending on their size, the rate of cancer at the time of diagnosis is an average of 20% (10-50%).
Requires surgical treatment
IPMN Cysts of the Pancreas
IPMN (Intraductal Papillary Mucinous Neoplasm) cysts are seen at similar rates in men and women and usually peak in the 60s-70s.
Most IPMN cysts are detected incidentally on CT or MRI performed due to abdominal discomfort or vague abdominal pain.
IPMN cysts can be seen more frequently in smokers, diabetics, those with a family history of pancreatic cancer, those with Peutz-Jegers and FAP syndromes.
They are divided into three: 1. Main IPMN, 2. Side IPMN and 3. Mixed type IPMN
Do Side IPMN Cysts of the Pancreas Become Cancerous?
* Approximately half of Side IPMNs have multiple cysts.
* Most do not cause complaints, they are detected incidentally.
* The rate of cancer development in 5 to 10 years has been found to be 2% and 20%. 10-15% of all HD-IPMNs are malignant,
* If the cystic tumor is larger than 3-4 cm, causes complaints, in elderly and male patients, if there is a solid component mural nodule in the cyst and if there are enlarged pathological lymph nodes adjacent to the cyst, if there is dilatation in the pancreatic duct, the CANCER RISK is high.
The definitive solution is to remove the cystic pancreatic area SURGICALLY.
Pancreatic Anadal-IPMN Cysts
*50% of patients with pancreatic anadal-IPMN cysts have abdominal pain due to mucous secretion obstructing the pancreatic duct, 25% have recurrent attacks of acute pancreatitis, and sometimes they may also present with jaundice.
*Some patients may be incorrectly diagnosed with chronic pancreatitis.
*Since the rate of PANCREATIC CANCER development in anadal-IPMN cysts can reach up to 70%, the DEFINITE treatment in patients whose general condition is suitable for surgery is SURGERY
What is Pancreatitis? What are the Types of Pancreatitis?
It is a painful disease that occurs with inflammation of the pancreas. There are two types of pancreatitis: Acute pancreatitis (the type that causes sudden and severe pain, nausea, vomiting, and can even cause death by rotting the pancreas and its surroundings). Chronic pancreatitis (the type that occurs occasionally, has a mild course but continues chronically)
What is Acute Pancreatitis?
Acute pancreatitis is an acute, that is, sudden inflammation of the pancreas. Inflammation in the pancreas causes damage to the pancreatic cells and the organs adjacent to the pancreas and causes temporary or permanent dysfunction. If acute pancreatitis is very severe, it can be fatal or cause pseudocyst or WON (can cause walled necrosis) in the late stage. The two most common causes are gallstones and alcohol use.
What is Chronic Pancreatitis?
It is a chronic pancreatitis that occurs in individuals with environmental or other risk factors. As a result of chronic and progressive inflammation, irreversible destruction develops in the organ. The tissues that are destroyed are replaced by scar tissue. Depending on the degree and extent of destruction in the pancreatic tissue, there is a loss of pancreatic functions at varying degrees.
Chronic pancreatitis cannot be stopped after it starts, but it is slowed down by eliminating the causes and the patient’s complaints are brought under control, thus improving the quality of life.
How Is Acute Pancreatitis Diagnosed?
In patients presenting with severe abdominal pain, especially after a heavy meal or alcohol intake, accompanied by nausea and vomiting, we should consider acute pancreatitis. Abdominal pain sometimes radiates to the waist in a belt-like manner. If there is an increase in amylase and lipase in the blood test and swelling in the pancreas in the ultrasonography, it is quite easy to diagnose acute pancreatitis. If there is doubt in the diagnosis despite these tests, a contrast-enhanced tomography should be performed for definitive diagnosis.
How Is Pancreatitis Treated?
After the diagnosis of acute pancreatitis is made, the patient is hospitalized, and some additional tests are performed to determine whether the disease will be severe or mild for the treatment plan.
The most important treatment is to give plenty of serum intravenously, to provide support with effective painkillers and stomach protectors. The idea of “letting patients starve and resting the pancreas” has been a wrong practice for many years, and has been abandoned today.
Most cases of mild acute pancreatitis due to gallstones recover in 2-5 days, and are discharged after gallbladder surgery. Those with severe pancreatitis require intensive care.
Can Pancreatitis Be Prevented?
The best way to prevent pancreatitis is to have a healthy lifestyle. The goals should be:
- Maintaining a healthy weight
- Exercising regularly
- Eating a Mediterranean diet
- Avoiding alcohol
- Quitting smoking
- Using diet and recommended medications regularly in familial hypercholesterolemia
Healthy lifestyle choices will help prevent gallstones, which cause 40% of acute pancreatitis cases. In addition, if you are diagnosed with gallstones that are causing the complaint, having your gallbladder removed surgically will prevent gallstone pancreatitis.
Does Pancreatitis Recur?
Painful attacks recur in chronic pancreatitis. Attacks can be reduced and made milder by quitting smoking, quitting alcohol, taking preventive measures and supportive treatments.
If you do not identify the condition that caused the acute pancreatitis and find a solution, pancreatitis will recur at a high rate. For example, if you have gallbladder surgery in acute pancreatitis due to gallstones, pancreatitis will not recur.