PANCREAS

At the very back lies the bony spine; on this the large blood vessels (arteries and veins) run along this and cross under the head of the pancreas. The pancreas is covered in front by the stomach, on the right the pancreas head by the duodenum and on the left the pancreas tail by the spleen. The pancreatic tissue itself is formed from many small delicate lobules, which in turn are composed of glandular cells. Their outlets collect and eventually empty into the main duct, the ductus Wirsungianus, which passes horizontally through the pancreas and, together with the large bile duct, ends in the duodenum.

This leads to itchy skin, yellowing of the eyes, light-colored stools and dark urine. Unfortunately, there are no investigations, examinations or imaging procedures for this disease that can confirm or exclude the tumor with certainty. Thus, the physician must differentiate pancreatic carcinoma from chronic pancreatitis and from other gastrointestinal diseases by means of precise questioning of the patient and performing further diagnostics. These include questions about dietary habits, alcohol consumption, weight loss, and upper abdominal pain.

The physical examination primarily involves palpation of the upper abdomen with an evaluation of the gallbladder and liver. Sometimes a severely enlarged but painless gallbladder can be palpated. This is known as the Courvoisier sign, which can indicate the presence of a tumor. Laboratory tests will be used to record pancreatic and biliary levels and to determine the tumor markers CEA and CA 19-9. They are increased in the advanced stages of the disease, but unfortunately, not only characteristic of this tumor. Certainly the doctor will do an ultrasound of the upper abdomen.

This can be used to see masses or lesions in the area of the pancreas and to assess dilated or obstructed bile ducts and pancreatic ducts, as well as changes in liver tissue. After that, further diagnostics will be done on a completely individual basis. A CT scan or MRI can easily detect pancreatic tumors one centimeter or larger in size and show lymph node changes as well as growth that extends beyond the organ. If papillary tumors (confluence of pancreatic and biliary ducts) are suspected, endoscopic methods (ERCP) will be used to assess outflow obstruction, visualize ducts, and obtain tissue samples (brush cytology).

The classic surgical treatment option for an operable tumor in the head consists of the duodenopancreatectomy according to Kausch Whipple: the head of the pancreas, the pylorus, the duodenum, the bile ducts and the gallbladder are radically removed and the drainage channels via the small intestine are restored. For many years, this operation was considered very dangerous and not very successful. Today, advances in surgery, modern anesthesia procedures, and excellent as well as forward-thinking intensive care and critical care medicine have led to good surgical outcomes. Also, today it seems that the state of health after such surgery is satisfactory and rather superior to the non-surgical procedures. The indication and execution of this technically difficult operation belongs in the hands of a very experienced and highly specialized surgeon and should be discussed in detail with the patient, with specialists in gastroenterology and oncology, and with the general practitioner.

After leakage control, an amylase determination from the abdominal secretion of the drains, these are removed after four days, and the food build-up is started cautiously, with the gastric tube in place, when intestinal noises are already audible at the same time. Some blood values are also closely monitored, such as lipases, amylases and blood glucose, which may need to be controlled with additionally administered insulin.

Some patients may experience temporary gastric emptying disorders. Over the next few days, an assessment can then be made of the extent to which pancreas function is impaired and whether replacement of digestive enzymes and administration of insulin will be necessary over the long term.

Today, it is undisputed that a total removal of the malignant tissue should be followed by a subsequent treatment with chemotherapy in order to prevent the recurrence of the disease or to delay it as long as possible.

Nevertheless, the prognosis of these tumors is still very serious, as often, despite removal of the tumor, small portions of it must be left in the body. This has led many doctors to believe that the surgery is not promising. Nevertheless, we consider the notification of a surgery to be useful, because on the one hand it is often only through surgical treatment that the diagnosis can be definitively established at all, and on the other hand it is also often only during the operation that it becomes clear whether a tumor can be removed or not.

Therefore, strong research efforts worldwide are mainly focused on improved methods in early detection, but also on new therapeutic options to be able to improve the prognosis of this tumor in the coming years.

Johann Georg Wirsung, professor of anatomy in Padua, discovered the large excretory duct of the pancreas in 1642, which is still named after him today: Ductus Wirsungianus. “But (…)”, he wrote to his teacher Jean Riolan, not knowing what he had actually found, “(…) should I call it artery or vein? I never found blood in it, but I did find a cloudy juice that acted on the silver probe like a corrosive liquid (…)”. The story came to a bloody end: a year after his discovery, Wirsungianus was murdered on his doorstep by a student. Was there a dispute about who had been the actual discoverer of the passage?

In 1869, Paul Langerhans, a medical student of only 22 years of age, came across the islet cells of the pancreas as part of his doctoral thesis, but did not know what function they had. About twenty years later, Oskar Minkowski and Joseph Freiherr von Mering removed the pancreas from a dog to observe the effects on sugar metabolism. The dog developed all the symptoms of diabetes, and the two researchers were able to detect glucose and acetone in the urine. This proved the connection between a malfunction of the pancreas and a subsequent development of diabetes. After Frederick Grant Banting and Charles Best discovered the substance produced by the islet cells, insulin, around 1920, it took only three years before the first insulin preparation to appear on the market – saving thousands of diabetics patients, for whom there was no hope before

The great surgeons of the time still considered the pancreas to be an “surgeon-hostile organ” with regard to its anatomical location and its its inherently fragile tissue. The surgeries were extremely surgically challenging and high risk for the patient. But the surgeon Carl Gussenbauer, successor of Theodor Billroth in Vienna, was an innovative mind. He had already developed the first artificial larynx as an assistant and was not deterred by such a delicate situation as that of the pancreatic pseudocyst, a complication of chronic pancreatitis. He found a procedure that allowed the fluid to be drained from these cysts.

In 1909, Walter Kausch broke new ground in Berlin by performing the first radical pancreatectomy, which always included removal of parts of the stomach and duodenum. In the 1930s, Allen O. Whipple revisited this technique for removal of a pancreatic tumor, but performed it in two separate procedures because of the high surgical risk. Since then, the “Whipple-Kausch” has been further perfected by many great surgeons and at the same time the procedure has become a standard procedure that is also very safe for the patient.

Patients are also often the first to complain of nausea and vomiting, food intolerance and bloating, without pain. Thus, the physician must differentiate chronic pancreatitis from other gastrointestinal diseases by questioning the patient in detail. These include questions about dietary habits, alcohol consumption, weight loss, and upper abdominal pain. It is important that the patient describes his/her pain, its frequency, intensity and localization as precisely as possible.

The physical examination primarily involves palpation of the upper abdomen with an evaluation of the gallbladder and liver. Furthermore, the color of the skin must be assessed (yellowing with bile stasis). The next step in the examination will be a blood test, in which the levels of the two most important pancreatic substances (lipase and amylase) will be determined. Furthermore, the blood sugar value and certain liver values are of interest in order to rule out bile stasis. Finally, imaging techniques are used to confirm the diagnosis. The ultrasound of the abdomen gives the physician a good orientation regarding all organs in the upper abdomen. At the same time, calcifications in the area of the pancreas can be easily detected and provide an initial indication of the disease.

However, the exact assessment of the size and condition of the pancreas can only be made on the basis of a CT scan of the abdomen (Figs. 2a, 2b and 3). If necessary, an ERCP scan will attempt to visualize the common bile duct and the main pancreatic duct. This complex and precise diagnosis is made in order to be sure that there is “only” a chronic inflammation in the pancreas and that a tumor is not behind the symptoms.

In some patients, the fat-soluble vitamins A, D, E, and K may need to be replaced via intravenous administration. However, the main focus of conservative therapy is individually adapted pain therapy with centrally and/or peripherally acting analgesics (Morphine/Panadol). For many years, the increase in pressure in the pancreatic duct as well as calcification of the tissue were held responsible for the pain in chronic pancreatitis, whereas more recent studies also show changes in local nerve components. If these measures are not effective against the pain, ERCP examination will be used as interventional therapy. Interventional means an intervention that lies between conservative and surgical therapy. This involves the endoscopically controlled dilatation of the pancreatic duct and/or the bile duct, possibly with the insertion of a small tube (stent) to improve the drainage of the bile and the digestive juices

Surgical procedures are only used when pain cannot be relieved conservatively, the pancreatic duct is significantly obstructed, or bile and digestive juice cannot drain into the duodenum due to an enlarged pancreatic head. The previously mentioned complications of chronic pancreatitis, such as pseudocysts, abscesses, and hemorrhage, are also requires surgical therapy. Generally, a distinction is made between draining procedures and cutting away (resecting) procedures, with the surgeon’s goal always being to preserve as much pancreatic tissue as possible so as not to further limit glandular function. All surgeries explicitly belong in the hands of a highly specialized surgeon, as excellent planning, “high-tech” materials, and above all a great deal of surgical experience are required. The difficulty lies in suturing different types of tissue together, for example, suturing together pancreatic tissue and small intestine tissue: try to sew a piece of smooth silk with thread to a piece of soft butter. This example is relatively close to the surgical challenge.

During drainage, the congested and enlarged duct of the pancreas is “only” drained into the small intestine, but the chronically inflamed tissue of the pancreatic head is left in place. The procedure is called pancreaticojejunostomy (small bowel section).

The head of the pancreas and the adjacent duodenum are exposed. At the lower edge of the pancreas, the portal vein (large vein supplying blood from the intestines to the liver) is located and completely dissected free behind the neck of the pancreas. Subsequently, the main bile duct is cut, the gallbladder is removed, and the neck of the pancreas is detached.

The entire head of the pancreas is detached from adhesions against the posterior portion of the abdomen (retroperitoneum), and the duodenum is transected. In a further phase, part of the small intestine is sutured to the neck of the pancreas, the bile duct is sutured in about 15 cm away, and finally the stomach stump is connected to the small intestine.

At the same time, some blood values are closely monitored: Lipases, amylases and blood glucose, which may need to be controlled with additionally administered insulin. After leakage control, an amylase determination from the abdominal secretion of the drains, these are removed after four days, and the food build-up begins carefully with the gastric tube in place. Some patients may experience temporary gastric emptying disorders. Over the course of the next few days, it will then be possible to assess the extent to which pancreatic function is impaired and whether replacement of digestive enzymes and administration of insulin will be necessary in the long term.

In the fig. 14, a CT scan six months after surgery shows a decrease in calcifications in the body and tail and a decompressed and restored pancreatic duct to normal caliber.

Johann Georg Wirsung, professor of anatomy in Padua, discovered the large excretory duct of the pancreas in 1642, which is still named after him today: Ductus Wirsungianus. “But (…)”, he wrote to his teacher Jean Riolan, not knowing what he had actually found, “(…) should I call it artery or vein? I never found blood in it, but I did find a cloudy juice that acted on the silver probe like a corrosive liquid (…)”. The story came to a bloody end: a year after his discovery, Wirsungianus was murdered on his doorstep by a student. Was there a dispute about who had been the actual discoverer of the passage?

In 1869, Paul Langerhans, a medical student of only 22 years of age, came across the islet cells of the pancreas as part of his doctoral thesis, but did not know what function they performed. About twenty years later, Oskar Minkowski and Joseph Freiherr von Mering removed the pancreas from a dog to observe the effects on sugar metabolism. The dog developed all the symptoms of diabetes, and the two researchers were able to detect glucose and acetone in the urine. This demonstrated the link between pancreatic dysfunction and subsequent development of diabetes. After Frederick Grant Banting and Charles Best discovered the substance produced by the islet cells, namely insulin, around 1920, it took only three years for the first insulin preparation to come onto the market – saving thousands of diabetics patients, for whom there was no hope before

The great surgeons of the time still considered the pancreas to be an “surgeon-hostile organ” with regard to its anatomical location and its inherently fragile tissue. The surgeries were extremely surgically challenging and high risk for the patient. But the surgeon Carl Gussenbauer, successor of Theodor Billroth in Vienna, was an innovative mind. He had already developed the first artificial larynx as an assistant and was not deterred by such a delicate situation as that of the pancreatic pseudocyst, a complication of chronic pancreatitis. He found a procedure that allowed the fluid to be drained from these cysts.

In 1909, Walter Kausch broke new ground in Berlin by performing the first radical pancreatectomy, which always included removal of parts of the stomach and duodenum. In the 1930s, Allen O. Whipple revisited this technique for removal of a pancreatic tumor, but performed it in two separate procedures because of the high surgical risk. Since then, the “Whipple thimble” has been further perfected by many great surgeons, and the procedure has at the same time become a standard unilateral procedure that is also very safe for the patient.