A total pancreatectomy is unusual to do and is only done when disease involves the entire pancreas and no other surgical options are available. The operation involves the removal of entire pancreas, the gall bladder, common bile duct, duodenum (the first portion of the small intestine), a small portion of the jejunum (the second portion of the intestine), the pyloric antrum and pylorus (the bottom third of the stomach),lymph nodes near the pancreas and the spleen. The procedure requires the skill of highly trained, specialized surgeons to ensure the best outcomes.
The Surgical Procedure
- General anesthesia is given for the procedure. After anesthesia is initiated an ET (endotracheal) tube will be placed into your airway through your mouth and will be attached to a breathing machine (ventilator). The ET tube will assist your breathing while under general anesthesia. A NG (naso-gastric) tube will also be placed through your nose and into your stomach when you are in the operating room to prevent nausea and vomiting.
- The incision used to perform the operation can be horizontal or vertical.
- After the incision is made, your Surgeon will inspect the pancreas and surrounding area to ensure that the surgery can still be performed safely. (On occasion, your Surgeon will visualize disease that was too small to be identified on pre-operative scans which would indicate that surgical treatment is no longer appropriate).If the disease has been found to be unresectable, your Surgeon will proceed with the necessary steps to minimize any long term problems that could be caused by the disease.
- The procedure usually takes approximately 4–8 hours, depending upon each patient and the extent of the disease.
- During surgery, a Nurse will come to the surgical waiting area to give updates about the procedure to family and friends. When the procedure is complete, your Surgeon will provide a final update.
Potential Complications of Surgery
In addition to the typical risks and complications associated with abdominal surgery, some specific to a total pancreatectomy include:
- Weight loss – of 10–15 pounds is common after surgery. You will regain some weight as you recover from surgery with the return of your appetite and increased nutritional intake.
- Diabetes – will occur as a result of removing the pancreas. The pancreas is responsible for producing Insulin, a hormone which regulates the body’s blood sugar level and for maintaining good health. Because your body will no longer have the ability to produce Insulin, you will be required to take Insulin by injection and follow a diabetic diet for the remainder of your life.
- Pancreatic enzyme insufficiency – will become a problem as a result of the pancreas being removed. Pancreatic enzyme replacement therapy will be ordered by your physician to help aid digestion.
- Delayed gastric emptying–occurs when the stomach takes much longer than usual to empty its contents because of the surgery. This condition often resolves itself in 7–10 days as the stomach begins to heal and resume its normal functions. If it does not, your Surgeon will discuss the best way to treat this situation.
- Blood loss – in most patients does not require a blood transfusion. Some patients may require a transfusion if surgery and blood loss is extensive.
- Hospital stay – on average is 7–14 days, depending upon each person’s situation.
- IV – intra-venous access is started on all patients by inserting a small needle into the vein which allows patients to receive hydration, medicine and nutrition.
- After surgery – you will go to the PACU (Post Anesthesia Care Unit) immediately after the procedure for careful monitoring. This stay is usually for a few hours. When your Surgeon feels you are stable, you will be transferred to a regular surgical floor, but may go to another unit in the hospital if your Surgeon feels that you need to be monitored more closely.
- Pain medication – is given to each patient using a PCA (Patient Controlled Analgesia) pump, an IV pain medication delivery system which allows you to personally control the delivery of pain medication the first few days after surgery. You will then be taken off of the PCA pump and progressed to pain medication by injection and/or orally.
- NG tube – will remain in until it is felt that any nausea or vomiting is controlled, typically 2 days.
- Drainage tubes – are placed in the abdomen, near the surgical site, during surgery. The drainage tubes will lead out of the body and will drain to small suction devices. This allows for drainage of the fluids that are produced as a result of surgery and the healing process. As healing takes place, the drainage from the surgery will decrease and the tubes will be removed when your Surgeon thinks appropriate. You may go home with drainage tubes and will be taught how to manage them.
- Insulin – will be given on a sliding scale (an individualized dose based on each person’s blood sugar level) to regulate your blood sugar and assist in healing.
- Eating – may begin once your surgeon feels your digestive system is ready. You will begin on clear liquids and advance to regular food as instructed and tolerated.
- An Endocrinology consultation – will be requested. An Endocrinologist is physician who specializes in the endocrine system, which regulates your body’s hormones. An Endocrinologist, who specializes in the treatment of diabetes, will visit you in the hospital to evaluate your situation and provide a treatment plan for you.
- The Diabetes Nurse Practitioner – will also visit you in the hospital, typically around 3 days after your surgery. The Diabetes Nurse Practitioner will provide you with educational material about diabetes, Insulin and diet. She will also serve as a resource for you in the future.
- TPN (total parenteral nutrition) – may be given post-operatively to provide IV nutrition if needed, otherwise you will be given liquids and then advanced to a regular diabetic diet before going home.
- Blood clots – are prevented post-operatively by the use of a SCD (sequential circulating device) on your legs to promote circulation. Heparin injections may also be given SQ (subcutaneously, a small injection under the skin).
- Activity – begins one day after surgery by sitting up in a chair and walking. You may shower 24–48 hours after surgery or as directed by your healthcare provider.
- Vaccines – are recommended for all patients who undergo a splenectomy. The spleen plays an important role with the immune system and when it is removed you will become more susceptible to certain infections. You may receive vaccines such as pneumovax and H.flu to help fight infections.
Discharge planning will begin a few days before you are ready to leave the hospital and may involve the help of a Discharge Planning Nurse from the Hospital’s Department of Case Management. Your discharge instructions will be given to you the day of discharge. Discharge instructions include the following:
- Diet – instructions will be given to you by a nutritionist prior to discharge and will be based on your nutritional intake at the time of discharge.
- Medication – prescriptions will be given to you before discharge, including medications for pain, medication to help control the secretion of acids created in the stomach and possibly for pancreatic enzyme replacement.
- Pain – post-surgical pain is common and will improve over time. It is important that you take your pain medication as prescribed. Please let your health care provider know if your pain medication is not working (or if it is too strong) so that it can be modified.
- Constipation – is common post-operatively due to inactivity and decreased nutrition and fluid intake. It is also a common side effect of the pain medication. A stool softener/laxative should be included with your daily medications.
- Incision care – is important. The incision site should be kept clean and dry and will heal over time. The staples used for the surgery will be removed at a post-op visit. A little tenderness and drainage at the incision site is normal, but if you notice increased drainage, a foul odor, increased redness or tenderness, please notify your health care provider.
- Activity – after surgery is recommended. You are encouraged to return to all of your normal activities as soon as you feel able, but should not lift anything over 5 pounds or drive a car until your healthcare provider gives you permission to do so. You may feel some pain as you resume activity; this is normal. A good rule of thumb is to “push to the pain, but not through the pain”. If you experience any sharp pain that does not resolve or gets worse, notify your healthcare provider immediately.
- Follow-up appointments – will be given to you at the time of discharge, if not previously arranged, and are usually 7–14 days after discharge.
- Help at Home – is available. There are several agencies that can provide support depending upon your specific needs after discharge. Examples of support include: skilled nursing, nurses assistants, physical therapy, nutrition or IV support and medical equipment. Discuss your concerns and needs with your Nurse prior to discharge.
- Recovery time – is typically 6–8 weeks after surgery. You can plan on resuming normal activities around 6 weeks post-operatively, but this can vary among patients. Please be patient with yourself, you have just had extensive surgery.
Pathology Results are usually ready in approximately 7 days after surgery and can be given to you before you leave the hospital if you wish. If not, they will be given to you and discussed at your first post-op visit.
When to Call Your Health Care Provider
- Temperature greater than 100.4.
- Increased or foul smelling drainage from your incision site.
- Increased pain or redness at your incision site.
- Pain, nausea or vomiting that is increased or not controlled by your current medication.
- Diarrhea or constipation that is not controlled.
- Anything that is of concern to you, as only communication with your health care team can ensure your best outcome.