An endocrine gland is a specialized organs that are found in different parts of the body that secrete hormones.
Hormones are chemical substances that are delivered directly into the blood from endocrine organs. Hormones can produce profound effects on many parts of the body. For example insulin is a hormone that controls blood sugar levels. Testosterone is a hormone that causes the development of male sexual characteristics.
The excessive amounts of hormones in the blood produce markedly abnormal effects on the body. For example in normal individuals insulin is secreted from pancreatic islet cells in just the right amount to keep your blood sugar levels within normal limits. In patients with insulin producing islet cell tumors of the pancreas, excessive insulin is produced in the blood that cause large decreases in blood sugar levels so that patients suffer from severe effects of low blood sugar also called as hypoglycemia. Many of these tumours can be benign(not cancerous) but the effects of excess hormones from the tumour can be serious leading to conditions like hypoglcaemic coma and death.
The adrenal gland is really two organs in one. The outer part of the adrenal is called the cortex and the inner part of the adrenal medulla. The two parts of the adrenal perform different functions and have different embryological origins.
Adrenal tumors should be removed by surgery. Some of the procedures offered for adrenal tumors are:
These tumors tend to be slow growing tumors that are treatable even after they have metastasized to other organs like liver or lymphnodes. Islet cell tumors can produce dramatic symptoms since up to half of these tumors may secrete hormones that produce side effects due to excessive secretion of the hormones.
The following types of carcinoid (neuroendocrine) tumors are recognized:
Surgical removal of non-functioning islet cell tumors is often curative. These tumors typically tend to be large and therefore enucleation of the tumor is usually not possible.
Our approach is to remove these tumors preferentially laparoscopically. An open procedure is usually offered to the patient if there is metastases, for large tumors, if there is invasion of the major blood vessels around the pancreas by the tumor, and by patient preference. For all other patients, the laparoscopic procedure is offered as the treatment of choice.
Functional islet cell tumors often present in a dramatic fashion due to secretion of excessive amounts of hormones such as insulin, gastrin, or glucagon. These tumors tend to present at a very early stage when the tumor is tiny and is often not readily detectable.
Localization of these tumors in the pancreas is an important consideration since the tumors may be very small, only a few millimeters in size, when the patient presents with major symptoms.
The Whipple operation was first described in the 1930’s by Allan Whipple. In the 1960’s and 1970’s the mortality rate for the Whipple operation was very high. Up to 25% of patients died from the surgery. This experience of the 1970’s is still remembered by some physicians who are reluctant to recommend the Whipple operation.
Today the Whipple operation has become an extremely safe operation. At tertiary care centers where a large numbers of these procedures are performed by a selected few surgeons, the mortality rate from the operation is less than 4%. Studies have shown that for good outcomes from the Whipple surgery, the experience of the center and the surgeon is important. Personally, over the last 2 decades I have done Whipple operation with a nil 30-day surgical mortality.
In the Whipple operation the head of the pancreas, a portion of the bile duct, the gallbladder and the duodenum is removed as appropriate with surrounding lymphnodes. Occasionally a portion of the stomach may also be removed. After removal of these structures the remaining pancreas, bile duct and the intestine is sutured back into the intestine to direct the gastrointestinal secretions back into the gut.
A Whipple operation is performed for
Over the last 15 years major pancreatic centers developed excellent results for the Whipple surgery. In almost all the major centers the death rate from this surgery is now less than 5%. Personally over the last 2 decades I have done whipple operation with a nil 30 day surgical mortality.
The overall survival after the whipple operation for pancreatic adenocarcinoma is about 20% to 30% at five years after surgery. Patients without spread of cancer into their lymph nodes may have up to a 40% survival. The actuarial survival is less than 5% at five years for patients with pancreatic adenocarcinoma who are treated with chemotherapy alone.
The operation is usually curative in patients with benign or low grade cancers of the pancreas.
We recommend that most patients with pancreatic cancer should have chemotherapy and radiation therapy after the operation based on the histopathology report. Recent studies from Johns HopkinsUniversity have shown that the survival rate can be increased by as much as 10% by adding chemotherapy and radiation therapy to the surgery for patients with pancreatic adenocarcinoma. This will be discussed with the patient after surgery based on spread of tumour to the lymph nodes, surrounding tissues and margin of clearance along with vascular and perineural invasion. We do not recommend any further treatment for patients who have benign tumors of the pancreas and in patients with neuroendocrine tumors of the pancreas.
During the Whipple operation part of the pancreas, i.e., the head of the pancreas, is removed. Pancreatic tissue produces insulin that is required for blood sugar control. The islets of Langerhans, i.e., insulin producing cells are concentrated in the tail of pancreas. However when pancreatic tissue is removed the body’s insulin releasing capacity is reduced and thus the risk of developing diabetes is present.
Our experience has been that patients who are diabetic at the time of surgery or who have an abnormal blood sugar level that is controlled on a diet prior to surgery have a high chance for the severity of the diabetes becoming worse after the surgery. On the other hand patients who have completely normal blood sugar prior to surgery with no history of diabetes and do not have chronic pancreatitis have a low probability of developing diabetes after the Whipple operation.
Will I be able to do all the things that I am currently doing.
There is acceptable alteration of lifestyle after the Whipple operation. Most patients are able to go back to their normal functional levels.
Researchers at John Hopkins University mailed surveys to Whipple operation survivors who had been operated on at Hopkins between 1981 and 1997. The questionnaire was broken down into sections that looked at physical abilities, psychological issues and social issues; an additional section evaluated functional capabilities and disabilities. Scores were reported as a percentile, with 100 percent being the highest possible score. The same questionnaire was then sent to a group of healthy individuals and a group of patients who had laparoscopic gallbladder removal.
Responses from this study at Johns hopkins were tallied from 188 Whipple survivors, 37 laparoscopic gallbladder surgery patients and 31 healthy individuals. Whipple survivors on average rated their physical quality of life a 79, compared with an 83 among laparoscopic surgery patients and an 86 among healthy people. For psychological issues, Whipple survivors rated their quality of life to be a 79, compared with an 82 for laparoscopic surgery patients and an 83 among healthy people. Looking at social issues, Whipple survivors ranked their quality of life at an 81, compared with an 84 among laparoscopic surgery patients and an 83 among healthy individuals. There were no statistical difference amongst these groups.
The Whipple operation is a complex operation with a risk of developing complications. In the hands of surgeons who are experienced with this surgical operation the complication rate is usually very low.
Pancreatic Fistula
During the Whipple operation part of the pancreas, i.e., the head of the pancreas, is removed. Pancreatic tissue produces insulin that is required for blood sugar control. The islets of Langerhans, i.e., insulin producing cells are concentrated in the tail of pancreas. However when pancreatic tissue is removed the body’s insulin releasing capacity is reduced and thus the risk of developing diabetes is present.
Our experience has been that patients who are diabetic at the time of surgery or who have an abnormal blood sugar level that is controlled on a diet prior to surgery have a high chance for the severity of the diabetes becoming worse after the surgery. On the other hand patients who have completely normal blood sugar prior to surgery with no history of diabetes and do not have chronic pancreatitis have a low probability of developing diabetes after the Whipple operation.
Gastroparesis (Paralysis of the Stomach)
The first five to six days after the surgery, you will be provided with intravenous fluids until your bowel function returns. After your bowel function have returned you will begin on a diet of clear liquids and your diet will progress to a regular diet as you tolerate it.
In up to 25% of patients, the stomach may remain paralyzed after the surgery and it may take up to 4 to 6 weeks for the stomach to adapt to the changes after the surgery to function normally. During this period you may not a tolerate a diet very well. If you fall in this category then you will be provided with nutrition through a small feeding tube that your surgeon has placed into the intestine at the time of surgery. In almost all patients the stomach function returns to normal after this 4 to 6 week period after the surgery.
Some of the long-term consequences of the Whipple operation include the following:
The pancreas produces enzymes required for digestion of food. In some patients removal of part of the pancreas during the Whipple operation can lead to a diminished production of these enzymes. Patients complain of bulky diarrhea type of stool that is oily. Long-term treatment with oral pancreatic enzyme supplementation usually provides relief from this problem.
Senior Consultant Single Keyhole Laparoscopic Surgeon
MBBS, M.S (Gen Surg – KEMH, Bombay), FAMS
Over 30 years of clinical experience in gastrointestinal and metabolic surgery
His clinical focus includes:
Dr. Ravi routinely performs laparoscopic (keyhole) and endoscopic procedures, which are associated with smaller incisions and faster recovery times compared to traditional open surgery.
(Based on standard clinical outcomes for minimally invasive techniques.)
He holds a university academic appointment and is actively involved in teaching medical students and surgical trainees in Singapore, reflecting his commitment to medical education and continuous learning.
Dr. Ravi is affiliated with various international and local professional bodies including:
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