Distal Pancreatectomy

Distal pancreatectomy is a procedure performed to remove the tail and body of the pancreas while leaving the pancreatic head in place.

This procedure is performed to treat:

1. Pancreatic tumours affecting the body and tail of pancreas
2. Pancreatic cystic tumours
3. Pancreatic pseuodcysts
4. Chronic pancreatitis
5. Injury to the pancreas due to trauma

The spleen is often removed in this operation as the splenic artery and vein are intimately related to the pancreas body and tail and are, thus, often involved in the same pathological process.
Compared to operations that remove head of the pancreas e.g. Whipple procedure, a distal pancreatectomy is performed in much less time and requires a shorter hospital stay and recovery. In certain conditions, the procedure may be performed with laparoscopy.

The Surgical Procedure – Distal Pancreatectomy

The operation is done under general anaesthesia. When you are asleep, the anaesthetist will insert an ET (endotracheal) tube into your airway via the mouth and connect it to a ventilator machine. Often, you will have a NG (nasogastric) tube passed from your nose into the stomach to deflate the stomach and prevent nausea and vomiting.

Open procedure

This is the most common way to perform this operation. The operation usually takes 3-4 hours.
The incision used for this operation is either a horizontal one across the upper abdomen or a vertical one in the middle of the upper abdomen depending on your body shape.
The pancreas and other abdominal contents are inspected to check for disease that was too small to be picked up by CT scan. The operation may need to be modified accordingly.
The pancreas body and tail together with spleen are freed from their usual attachments and the vessels are tied and the pancreas is divided with a stapler and the stapled end is sutured for reinforcement of the staple line. One or two soft drains are placed at the operation site and their ends are brought out of the abdomen and connected to small bottles.

Laparoscopic Distal Pancreatectomy (key-hole surgery)

In selected conditions the operation can be performed by laparoscopy (key-hole) surgery. This is performed through five small cuts to inflate the abdomen with gas and inserted a laparoscope which is a long telescope 10 mm wide with a camera attached to the end of it. Special long narrow instruments are used to perform the dissection and divide the pancreas with stapler. At the end of the operation, one of the cuts is enlarged to remove the resected part inside a special bag. Laparoscopic distal pancreatectomy is not suitable if cancer is confirmed or suspected or if the disease process is advanced.

Complications of Distal Pancreatectomy

Specific Complications

1. Pancreatic fistula: leakage of pancreatic juice from the divided end of the pancreas can occur despite stapling the pancreas and suturing the divided end. If this occur, the drain will be kept in place until the pancreas leak settles. You may be given a medication to stop the pancreas from producing juices. Rarely, you may need to be placed on TPN (intra-venous nutrition) and stop eating to reduce the stimulus on pancreas to produce juices.
2. Diabetes: The main bulk of the pancreas is located in the head region on the pancreas. This is preserved in this operation thus preserving the main cell mass that produces insulin. For this reason, most patients do not become diabetic after surgery.  However, patients who are prone to diabetes may become diabetic. Patients who are already have diabetes may need more insulin after the operation.
3. Pancreatic enzyme insufficiency: The pancreas produces enzymes that help with the digestion of food. Depending on the amount of the pancreas removed and the health of the remaining part of the pancreas. Some patients needs pancreatic enzyme supplements to help with the digestion and absorption of food.
4. Bleeding: Blood transfusion is not required in most patients. Occasionally some patients require a blood transfusion. 

General Complications

1. Cardiovascular problems: heart attacks and strokes. Both are very rare.
2. Respiratory problems: pneumonia and aspiration.
3. Wound infection or urinary infection
4. Clots in the legs that may travel to the lungs. This is a rare but serious complication.
5. Wound pain and abnormal (keloid) scarring.
6. Death from general anaesthetic. This is very rare (1 in 40,000).
7. Chipped teeth and sore throat form the insertion of the breathing tube.
8. Drug reactions.

What happens after the surgery?

After you wake up from the anaesthesia, you will be taken to the recovery room to recover from the anaesthesia. After that you will go to the HDU (high dependency unit) for a close monitoring for a a day or two then you are transferred to the surgical ward. On average you will spend about 7 days in the hospital.
IV drip: You will have an intra-venous line inserted prior to the operation and this will be used afterward as well. Through it you will receive fluids and medications.
Pain control: Each patient is given a PCA (Patient Controlled Analgesia) pump. This is a pump that you control to pump pain medication into the intra-venous line. The nurses will show you how to use the pump and the anaesthetist will check on you every day until your pain can be controlled by oral tablets.
NG tube: will be kept in place until nausea settles, typically in two days.
Drains: Drains are used to remove fluid that are produced by the healing process after surgery. This decreases with time. The drains are removed at the appropriate time. Occasionally you may go home with a drain in place and you will be taught how to manage it.
Urinary catheter: A tube to drain urine from the bladder will be placed while you are under anaesthesia prior to commencing surgery. This will be kept in place until you are off the pain pump and able to mobilize, typically in 3 days.
Wound Care: The wound will be closed with dissolving suture or stainless steel skin clips and a water proof dressing is applied. You are able to have a shower the day after the operation. The dressing is kept in place for 3-5 days. Skin clips are removed at 10 days after the operation by your GP or in my rooms at your first follow-up check-up.
Eating: Soon after surgery you can have ice to suck and sips of water to keep you comfortable. Once gut function returns after surgery you will start drinking then advanced to regular food as tolerated.
Blood clots prevention: Like in any major surgery, clots can form in the legs and pelvis veins as result of decreased activity and the stress of surgery. These can move to the lungs and are a serious problem. They are prevented by fitting you with elastic stockings and heparin injections under the skin through-out your hospital stay. During the operation and while staying in the HDU you will also be fitted with calf compressors that message you leg muscles to promote circulation. After going home I encourage you to continue wearing the elastic stockings until you are back to your usual activities (one month).
Vaccines: The spleen plays an important role in the immune system. After removing the spleen you will become more susceptible to certain infections. Prior to the operation you need to have vaccines against pneumococus, H. influnzae, and meningococcus as well as the yearly flu vaccine. These are best given two weeks prior to the operation. It is important to see your GP at the first signs of any infection any time after surgery.
Activities: The day after surgery you will begin by sitting up in a chair and walking with the physiotherapist. You will be shown some breathing exercises to do to prevent chest infection. After going home you are encourage to return to normal activities as soon as you feel able. Do not lift weights of more than 10 kilos for six weeks after surgery. You will notice you get tired and need a nap in the afternoon after going home. This is normal and expected.
Recovery time: It takes about 4-6 weeks to return to normal activities.
Follow-up: I will see you in my clinic in 1-2 weeks after going home. If you have any worries about anything come and see me at any time. Important problems to watch for are: 

1. Fever >38 degrees or chills.
2. Increasing pain or redness around the incision.
3. Foul smelling or creamy wound discharge.
4. Increasing pain, nausea or vomiting
5. Diarrhoea or constipation that is not controlled.
6. Shortness of breath or chest pain when you take a deep breath.
7. If you are concerned about anything.