The pancreas is an organ which lies just under the curvature of the stomach, behind the transverse colon and deep within the abdomen. The function of the pancreas is complicated, but one could say that it primarily does two things. It produces enzymes which are useful for the digestion of food. This functional part of pancreas is called as exocrine pancreas. The second functional component secretes hormones which, among other things, help maintain and regulate body blood sugar levels. These are usually grouped together as discrete clusters within pancreas called the ‘Islet of Langerhans’. This forms the endocrine component of pancreas. A smaller subgroup of this component secrete locally active hormones and is known as paracrine pancreas
Prancreatic cancer or malignancy is a tumor (or growth) in which an aggregation of individual cells begins to grow in a rapid, uncontrolled and abnormal manner; and which may spread by aggressive local extension or by the seeding of other organs through blood vessel channels or via the lymphatic system. Further, under the microscope, the appearance and arrangement of these carcinoma cells can appear as duct-like (or “adeno”) giving the term adenocarcinoma. This is the most common form of pancreatic cancer.
About three-quarters of exocrine tumors of the pancreas arise in the head and neck of the pancreas Some of these carcinomas arise in the body of the pancreas, and less than ten percent arise in the tail of the pancreas
Endocrine tumors have a different natural history than the exocrine tumors. They tend to be slower growing and have a better prognosis. The treatment of neuroendocrine tumors of the pancreas is distinct from that of adenocarcinoma of the pancreas. This also essentially consists of resectional surgery. Some cases will need hormone manipulating drugs such as somatostatin or its analogues. Some cases will also need chemotherapy.
Generally, the most common symptoms of adenocarcinoma of the pancreas include:
As these are all fairly non-specific symptoms, there is often delay in getting to the final diagnosis. The most common physical sign of pancreatic cancer is jaundice, with or without associated itching.
Often lab results show a high bilirubin (bile pigment found in the serum) and elevated liver function enzymes. The CA 19-9 marker, a Lewis blood group-related mucin, is frequently elevated in adenocarcinoma of the pancreas.
Surgery is a treatment of choice for patients who have adenocarcinoma of the pancreas that is surgically removable. Careful selection of patients for surgery is important. since surgical removal is associated with the best outcome diagnostic testing to identify patients suitable for surgery is extremely important. Appropriate diagnostic testing will also avoid unnecessary surgeries in patients whose tumors are too advanced for surgical removal. We also do scans for heart and lungs to make sure this group of patients are fit for surgery as most of the patients are of elderly age group. I have done in patients upto 78 years and would offer the operations in age group up to 80 years and beyond if they are extremely fit. I have maintained a nil 30 day surgical mortality for all my Whipple’s operation over the years.
The surgical procedure that is done depends on the location of the tumor in the pancreas. For tumors that occur in the head (which is the first part) of the pancreas, the Whipple operation is usually performed. For tumors that are located in the body and tail of the pancreas a distal pancreatectomy that removes the distal half of the pancreas is recommended. The results of surgery have dramatically improved in the last two decades such that today the mortality (death) rate from surgery is less than 2% in experienced hands.
Many patients will require chemotherapy and radiation therapy after the surgery based on lymphnode status, involvement of neurovascular bundle, histological grading and size of tumour and microscopic clearance of margins. Patients with unresectable tumors are often treated with chemotherapy and radiation therapy, and in some patients response to the treatment may allow subsequent surgical removal of the tumor.
The majority of these tumors are non-malignant or benign, however even malignant tumors have five year survival rates in the order of 40 to 80% depending on the tumor type. In view of the excellent outcome, aggressive surgical therapy is indicated for these tumors, and the part of the pancreas that is affected by the tumor is removed.
My emphasis has been to preserve as much of the pancreas as possible when removing benign and precancerous tumors to minimize the consequences of removal of large amounts of the pancreas such as diabetes and malabsorption (inability to digest food). I offer procedures like central pancreatectomy where only the central portion of the pancreas is removed for tumors in this location preserving the head and body and tail of the pancreas. I also offer laparoscopic procedures that emphasize minimal access surgical technique for more rapid recovery like laparoscopic distal pancreatectomy for cancerous tumours and laparoscopic spleen preserving distal pancreatectomy for benign tumors of the pancreas.
The pancreas plays an important role in the digestion of food and in regulation of blood sugar. Loss of pancreatic tissue after surgical removal increases the risks for the development of diabetes mellitus and mal-absorption of food.
Preservation of pancreatic tissue is an important goal during surgery for pancreatic and biliary diseases to reduce the risks of loss of pancreatic tissue.
This procedure is indicated for patients who have low-grade malignant or benign tumors in the neck (in the middle of the pancreas). Removal of tumors in this area otherwise often require removing a large portion of the normal pancreas by surgical procedures such as either an extended Whipple operation or a subtotal pancreatectomy (removal of 80% of the pancreas).
We offer a highly specialized surgical procedure that removes only the tumorous portion of the neck of the pancreas. We therefore preserve the head of the pancreas avoiding the Whipple operation and also the body and tail of the pancreas.
Many functional pancreatic islet tumors such as insulinoma and gastrinoma are small tumors usually less than 1 to 2cm. Furthermore the tumors are often on the surface of the pancreas. The tumors have a lining around them that separates them from the pancreas.
An operation called enucleation is often performed for these tumors. In this operation the tumor is shelled out from the pancreas without removing any pancreatic tissue. We also offer Laparoscopic enucleation of a pancreatic islet cell tumor. This allows rapid recovery, early discharge from hospital and early return to work.
Neuroendocrine tumors of the pancreas (islet cell tumors) are much less common than tumors arising from the exocrine pancreas. About 75% of these tumors are “functioning.” That is they are found to be producing symptoms related to one or more of the hormone peptides that they secrete
Except for insulinomas, very roughly about 60% of islet cell tumors are malignant. This rate contrasts with about 10% of insulinomas which are eventually found to be malignant. The sites of metastasis of islet cell tumors most commonly are the liver and the lymph nodes in the vicinity of the pancreas.
Carcinoid cancer or carcinoid tumour is the other name for these neuroendocrine tumors. The symptoms and signs of carcinoid tumors range widely, and depend on the location and size of the tumor, on the presence of metastases, and secretions. They can appear to the surgeon as firm nodules bulging into the intestinal lumen (can originate from pancreas, lungs, thymus, appendix, and ovaries, etc.), with possible local expansion, and possible metastases to mesenteric lymph nodes, liver, ovaries, peritoneum, testes, prostate, spleen and other anatomic locations. Carcinoid tumors can secrete any number of hormonal, growth and other factors. The treatment of choice for localized islet cell tumors is generally curative surgery.
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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