Distal Pancreatectomy and Splenectomy

info sheet

(Removal of the tail of the pancreas and spleen)

The information here is a guide and reflects only the views of Dr Slater, Prof. Fawcett and Dr Hodgkinson.

WHY DO I NEED THIS OPERATION

The most common reasons to carry out this surgery are cancer of the tail of the pancreas, cysts of the tail of the pancreas – both benign and cancerous, chronic pancreatitis and swollen blood vessels to the spleen (splenic artery aneurysm). The spleen is commoly removed at the same time because the blood supply to the spleen is intimately connected to the pancreas. Cancer of the pancreas is a very serious condition that often presents itself when it is very large. Making a diagnosis of cancer of the tail of the pancreas, with a biopsy prior to surgery is generally very difficult and may not be possible. The pancreas tends to develop a great deal of scarring or reaction that interferes with interpreting a pre-operative needle biopsy. It is common to biopsy a cancer in this region and obtain a benign report. Thus, it is up to the surgeon's judgment whether or not the patient has cancer and would benefit from this surgery. The presence of cancer will be determined after surgery by the pathologist when they assess the pancreas under the microscope. A result from the pathologist can take anywhere from 2 – 7 days.

The decision to proceed to this type of surgery is very complicated and this is the main reason why it is important to be operated on by a surgeon with a great deal of experience with operations for cancer of the pancreas. His/her judgment will be valuable in determining whether or not a tumor is present and if it is removable. Sometimes distal pancreatectomy may be done with keyhole surgery. This technique is not suitable for cancer and is only used for tumors in the very tail of the pancreas.
Sadly, there are cases where at the time of surgery the surgeon will determine that the cancer is not removable. This is commonly due to the finding of secondary cancer in the liver. Another reason may be the cancer’s relationship to vital blood vessels supplying blood to the liver. These blood vessels cannot be removed without threat to the patient’s life. If this is the case, the surgeon may not be able to remove the cancer. This will be discussed fully with you and your family after the surgery.

WHAT DOES THE PANCREAS DO?

The pancreas has two purposes.

WHAT DOES the operation INVOLVE?

Distal Pancreatectomy and splenectomy is performed as follows:


WHAT TO EXPECT IMMEDIATELY AFTER SURGERY

Pain Relief

On the first day after surgery, there may be a moderate amount of discomfort at the site of the operation.
You will have some form of pain relief. There will will usually be a choice of:

Your anaesthatist will discuss the pros and cons of each, prior to surgery. Either option may not be suitable for every person.
Every effort will be made to minimize the discomfort and make it bearable. Your doctors and nurses will be monitoring your level of pain frequently.
When you are back on a normal diet, you will be converted to oral pain relief.

Drain tubes

You will have a number of  plastic tubes in your body following surgery. They will vary a little depending on your particular case. They will be removed at variable times following your surgery under the direction of the surgeon. All tubes except for the IV in your hand, will be placed under anaesthesia.

Eating

The spleen and pancreas are just behind the stomach. As a consequence your stomach may take a few days to begin to work again. You will not have anything to eat or drink for the first few days after surgery. An intravenous drip will provide you with the necessary fluids. In most cases you will have a nasogastric tube (NG) in your nose that will remove the stomach contents until your stomach recovers. Your surgeon will let you know when you will be able to eat.

Urinating/Bowel Movements

During the first few days after the surgery, the tube placed in your bladder will drain your urine. You will probably not have a bowel movement until several days after the surgery.

Intensive Care

Sometimes, you will be looked after in intesive care for at least the first day after your surgery. Your continued stay here will depend on your condition.

Activity

You can expect your nurse and physiotherapist to help you to get out of your bed on the first day after surgery. You will be able to walk short distances even with all of the tubes and intravenous lines. As each day passes your tolerance for walking and sitting in a chair will increase. This is extremely important to prevent pneumonia, clots in the legs and loss of general condition. You can expect to have to wear stockings on your legs whilst in hospital to prevent clots and have an injection of heparin twice a day under the skin for the same reason.

Your Incision

You can expect to have a waterproof bandage over your incision for the first several days. Your surgeon will remove the dressing at the appropriate time. You will be able to shower with the waterproof dressing on. It is quite common to have a small amount of leakage from the wound.
Most commonly, you will not have stitches to remove, they will be of the dissolving type.

Other Important Information

You can expect to see your surgeon every week day. On weekends or in times when your surgeon is operating elsewhere, you will see one of the practice partners. All are very experienced in this type of surgery and commonly assist each other in the operating theatre.
We will make every effort to keep you informed of your progress. We are always honest and open with you and your family. Feel free to ask questions.

Length of Stay in Hospital

On average most patients will expect a 10 day - 2 week hospital stay. This time however differs greatly for individual patients. Some stay shorter, some much, much longer. You will not be discharged before you can walk unaided and care for yourself.

WHAT ARE THE COMPLICATIONS THAT MAY HAPPEN IMMEDIATELY AFTER SURGERY FOR DISTAL PANCREATECTOMY AND SPLENECTOMY?

This is complex surgery with many potential complications. In the hands of surgeons who are experienced, the complication rate is usually very low.
The most serious and specific complications that may be seen after this operation include:

Pancreatic Fistula

After the tumor is removed from the pancreas, the cut end of the pancreas is stapled and sutured closed. The pancreas is a very soft and sometimes fatty organ and in some patients, this suture line may not heal very well. If this happens, then patients develop leakage of pancreatic juice. Pancreatic leak of any degree occurs in approx. 10-20% of patients.

This is usually leaks into the soft plastic drain that the surgeon leaves at the time of the surgery and is controlled without any ill effect to the patient. In most patients that develop a leak of pancreatic juice, the leak heals on its own.

Occasionally the drain doesn’t cope with all the drainage and the patient will need either a new drain tube – placed by the x-ray department or may need to be re-operated on to drain the pancreatic juice. This re-operation occurs in 1-4% of patients undergoing this procedure.
The drain tube will remain in place until the pancreas dries up – this unfortunately can take MONTHS.

Gastroparesis paralysis of the stomach

It is quite common (about 10% of patients) for the stomach to remain paralyzed for a short time after a distal pancreatectomy. The small bowel however begins to function in the first one to two days after surgery. You may experience vomiting that required the re-insertion the tube down your nose into you stomach.

Other immediate complications of this surgery

Like all major surgery there are a number of serious complications that may occur. These must be dealt with on a case-by-case basis. Some of these complications are:

WHAT ARE THE CONSEQUENCES OF LIFE WITHOUT A SPLEEN?

The spleen is part of the immune system – it is there to filter bacteria and release cells to fight these bacteria. It also helps the body to remove worn out red blood cells and stores platelets - another component of blood. Generally day-to-day life without a spleen goes on completely as normal. However, some precautions must be taken. All splenectomy patients are given vaccinations against pneumococcus, HIB and meningococcus either before or after surgery. The risk of life-threatening infection after splenectomy is very low, but patients and their families must always by aware they are susceptible to these infections and seek help early if they feel unwell. We recommend you wear a medical bracelet stating you have no spleen. Patients with no spleen should always have any bacterial infection – no matter how minor treated promptly with antibiotics and should carry antibiotics if they go overseas. The other problem after splenectomy is a temporary elevation of the platelet count. Platelets help the blood to clot. They are stored in the spleen and after its removal the levels rise. This increases the risk of clots in the legs and lungs. Your platelet count will be monitored and if it is high, it will be treated with an aspirin (150mg). This deactivates the platelets. You will continue to take this until the platelet count is normal.

AFTER DISCHARGE

What are the long-term complications of the Distal pancreatectomy?

Some of the long-term consequences of this operation include the following:

Malabsorption

The pancreas produces a substance (enzyme) that digests food. In some patients, removal of part of the pancreas can lead to a decreased production of this enzyme. Patients complain of diarrhea that is very oily and floats in the toilet bowl. Treatment consists of taking oral pancreatic enzyme pills and usually provides excellent relief from this problem. About 5% of all pancreatectomy patients may require these supplements.

Diabetes

Another role of the pancreas is to produce insulin that controls blood sugar levels. During the operation the neck and tail of the pancreas are removed. Therefore, the risk of developing diabetes is present.
In general, 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 or obesity have a low probability of developing diabetes after the operation.

Alteration in diet

After a distal pancreatectomy, we generally recommend that the patients eat smaller meals and snack between meals to allow better absorption of the food and to minimize symptoms of feeling of being bloated or getting too full.

Loss of weight

It is common for patients to lose up to 5% of their body weight. The weight loss usually stabilizes very rapidly and most patients after a small amount of initial weight loss are able to maintain their weight and do well.

How you may feel

You may feel weak or "washed out" when you go home. You might want to nap often. Even simple tasks may exhaust you. You may loose your taste for food.
You might have trouble concentrating or difficulty sleeping. You might feel depressed. These feelings are usually transient and can be expected to resolve in 2-4 weeks.

Your medications

Your surgeon will discuss with you which medications you should take at home. If needed, you will go home with a prescription for pain medicine to take by mouth.

Your incision

Your dressing will be removed before you leave the hospital and if it is not leaking it will be left open to the air. You may wear clothes over the top of it.
Your incision may be slightly red along the cut. This is normal. You may gently wash dried material around your incision and let water run over it. Pat dry with a towel. Do not rub soap or moisturizer into your incision for at least 4 weeks or until it is fully healed. After this you may rub vitamin E cream along the wound.
It is normal to feel a ridge along the incision. This will go away. It is normal to have a patch of numbness under the wound.
You may see a small amount of clear or light red fluid staining your dressing or clothes. If it is minor cover that part of the incision with a pad. If leakage is severe, you should contact your surgeon.
Over the next few months your incision will fade and become less prominent.

Activity

Listen to your body, if it is hurting, don’t continue with the activity.
Do not drive until you have stopped taking narcotic pain medication and feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you see your surgeon at your next visit.
Don't lift more that 10 kg for 6 weeks. (This is about the weight of a briefcase or a bag of groceries) This applies to lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You may swim after 4 weeks
Heavy exercise may be started after 6 weeks - but use common sense and go slowly at first.
You may resume sexual activity when you feel ready unless your doctor has told you otherwise.

Costs to be incurred from this surgery

The surgeons in this practice do not charge any out of pocket expenses for your in hospital stay. We will bill your health fund directly.
The health funds do not cover outpatient care and there will be some out of pocket fees for the initial outpatient consultations.
There may be other out-of-pocket fees from your anaesthetist and any other specialists who are asked to look after you. You should ask them ahead of time any out of pocket costs. Ask your surgeon who will be performing your anaesthetic and you can make enquiries with them about any out-of-pocket expenses.
We use a drug after your surgery called Octreotide to slow down the juices made by the pancreas. It incurs and out of pocket expense of $300-400. We feel that this decreases the risk of pancreatic leak. Please let us know if you do not wish for us to use this drug.