This condition is a sudden inflammation of the pancreas. Its intensity is more or less severe depending on the case.

In the occurrence of acute pancreatitis, certain digestive enzymes are massively released and activated directly in the pancreas. In fact, the enzymes will start autodigestion of the pancreas. Lesions are created in the organ, which can become necrotic in the most serious cases.

In general, excessive alcohol consumption or the migration of gallstones are known to be the cause of acute pancreatitis.

Indications for surgical treatment in acute pancreatitis are very rare. In most cases, surgery is unnecessary.

The gallbladder is in the form of a small sac 7 to 12 cm long connected to the bile ducts through the duodenum via the common bile duct. Pear-shaped, it stores bile produced by the liver. Bile allows the absorption of fat-soluble vitamins (A, D, E and K) and the digestion of fats. However, its role is moderately important in digestion.

When eating, the gallbladder contracts. It then releases the bile which is routed through the common bile duct and then into the small intestine.
After eating, the gallbladder begins to fill with bile which will be released during the next meal.

There are very many tumoral lesions of the pancreas. We will only mention a few of them here, including potentially malignant tumours.

The TIPMP

(Source: https://www.fmcgastro.org/postu-main/archives/postu-2012-paris/textes-postu-2012-paris/surveillance-des-tumeurs-intracanalaires-papillaires-et-mucineuses-du-pancreas %E2% 80%89-who-and-how/)
The papillary and mucinous intraductal tumor of the pancreas is a well-known disease. It is caused by an overgrowth of the ductal epithelium. In at least 60% of cases, the discovery is made fortuitously, now during an imaging examination carried out for another cause.
This type of tumor is benign, that is, it is not a cancerous form. However, there are risks of progression to a malignant (cancerous) form. The risk factors for a malignant evolution are rather well determined.
There are indications for surgery, based on a global consensus. If the surgical option is not chosen, a serious monitoring protocol should be put in place.

mucinous cystadenoma

(Source: https://www.fmcgastro.org/postu-main/archives/postu-2012-paris/textes-postu-2012-paris/conduite-a-tenir-diagnostic-devant-une-tumeur-cystique-du -pancreas/)
It is a cyst whose particularity is not to be in communication with the pancreatic ducts. It is almost always located in the body or in the tail of the pancreas. This type of pancreatic tumor is most frequently found in female subjects of mature age (between 40 and 60 years old).
Due to the high risk of cancerous degeneration (20%), preventive surgical resection is justified. In case of degeneration, the benign cyst transforms into cystadenocarcinoma.

pancreatic endocrine tumor

The classification of pancreatic endocrine tumors is broad.
They are classified according to their functional or non-functional character. In other words, this type of tumor is associated with signs of hormonal hypersecretion.
The risk of degeneration evolves according to the type of endocrine tumour.

Note: exocrine cells are the most numerous in the pancreas. Thus, most pancreatic cancers develop from exocrine cells.
We will only discuss one type of pancreatic cancer here.

Ductal adenocarcinoma of the pancreas

(Source: http://www.centre-hepato-biliaire.org/ Maladies/cancers/adenocarcinome-pancreas.html)
Pancreatic ductal adenocarcinoma is the most common form of pancreatic cancer. It affects between 1 to 10 people per 100,000 inhabitants.
It is a disease more common in male patients. Most patients diagnosed are over 50 years old.
Diabetes is an associated disease in half of pancreatic cancer cases.
The symptoms are:
sudden weight loss;
asthenia (significant fatigue);
anorexia (loss of appetite);
abdominal pain.
The examinations necessary to confirm the diagnosis should be carried out before considering surgery for pancreatic cancer:
blood test with liver test;
Abdominal ultrasound ;
then if cancer is suspected, blood test for assay of tumor markers;
to scan ;
echo-endoscopy;
biopsy if necessary.

Left pancreatectomies are more or less extensive. Depending on the size and location of the lesions to be removed, they may or may not involve the spleen. Its conservation is desirable, but not always possible.

The slice of pancreatic section is sutured but not connected to the intestine, which eliminates the risk described above of an anastomotic leak. Nevertheless, an isolated leak of pancreatic fluid can be externalized. Since there is no intestinal opening, source of infection, its consequences are much less serious.

Resection of the distal part of the pancreas (tail) and spleen can be performed laparoscopically. Other resections are possible, but infrequently performed: central resection leaving the head and tail of the pancreas in place, enucleation of a benign tumour, without removing the neighboring gland.

The CPD removes en bloc a set of united elements: the duodenum, the head of the pancreas, the common bile duct, and the gallbladder. Exeresis (ablation) is followed by a period of reconstruction. Its purpose is to restore continuity to the digestive tract. The most common assembly first connects the pancreas to the stomach, then the bile duct and the pylorus to the small intestine.
Pancreaticoduodenectomy must be performed by laparotomy. The incision will leave a scar of varying size on the patient’s abdomen.
Its duration ranges from 4 to 6 hours, depending on local difficulties and possible complications.
A blood transfusion may be necessary, especially in case of preoperative anemia.

Diet and pancreaticoduodenectomy

In the post-operative period, a probe is always left in place in the stomach (passing through the nose), for a period of four to eight days. Feeding by mouth is resumed only when bowel functions are restored.
Sometimes, especially if the pre-operative nutritional status is altered, a probe is placed during the operation in the small intestine to allow the rapid resumption (D1 or D2) of food (other than intravenously).

What complications for a pancreaticoduodenectomy

The essential complication of this major surgery is linked to the multiple digestive sutures, especially the suture uniting the pancreas to the stomach. A healing defect (responsible for an anastomotic fistula) is observed in almost 10% of cases in the large series in the medical literature. This complication can be the cause of local infections and reoperations for drainage.
Mortality related to this operation has dropped considerably over the past 20 years. It is now below 5% and remains strongly linked to the terrain (existence of pathologies associated with the heart, lungs, etc.), and to age.
From a distance, this surgical intervention makes it possible to lead a normal life, to have a normal diet (almost always with enzyme supplementation by tablets). It does not trigger diabetes (unless the pancreas left in place was also sick, as in chronic pancreatitis for example).

This is the surgery most often performed for cancer of the head of the pancreas or in the opening of the pancreatic duct (TIPMP). This surgery removes:

• the head of the pancreas and the duodenum (first part of the small intestine);
• the gallbladder;
• part of the common bile duct;
• the lymph nodes located near the head of the pancreas.

After removing these organs, the surgeon attaches the remaining end of the stomach to the jejunum (gastrojejunostomy). It also attaches the remaining part of the common bile duct and pancreas to the jejunum so that bile and pancreatic juices can flow into the jejunum. These juices help neutralize stomach acid and reduce the risk of an ulcer forming in the area.

Finally, the surgeon attaches the remaining end of the duodenum, which is connected to the stomach, to the jejunum (duodenojejunostomy). It also attaches the remaining part of the common bile duct and pancreas to the jejunum so that bile and pancreatic juices can flow into the jejunum.

Distal pancreatectomy is done when the tumor is in the body or tail of the pancreas. The surgeon removes the tail of the pancreas, or the tail and part of the body of the pancreas, along with nearby lymph nodes.

In cases where the tumor has spread to the spleen or to the blood vessels supplying the spleen, the surgeon will remove it. The head of the pancreas remains attached to the duodenum.

Surgeons rarely resort to total pancreatectomy. Multidisciplinary medicine can consider this surgery in several cases:

• if the cancer has spread throughout the pancreas;
• if there are cancer cells in many areas of the pancreas;
• if it is not possible to attach the pancreas to the small intestine without risk.

During this procedure, the surgeon removes the entire pancreas, duodenum (first segment of the small intestine), pylorus (lower section of the stomach which is connected to the duodenum), part of the common bile duct, the gall bladder and sometimes the spleen and nearby lymph nodes.

After removing these organs, the surgeon attaches the remaining end of the stomach to the jejunum (gastrojejunostomy). It also attaches the remaining part of the common bile duct to the jejunum so that bile can flow into the jejunum.

Since the entire pancreas is removed, patients will develop diabetes: they will need to take insulin. Diabetes is a disease that is often difficult to control.

The pancreas generally makes enzymes that help digest food. People who undergo a total pancreatectomy will therefore have to take enzyme replacement therapy for the rest of their lives.

Palliative surgery can be used to relieve symptoms of unresectable pancreatic cancer, either locally advanced or metastatic, or recurrent.

Tumors located in the head of the pancreas often block the common bile duct or duodenum. Palliative surgery may relieve the symptoms of the blockage. In some cases, a surgical bypass may be done to clear the blockage caused by a tumor in the pancreas.

The type of surgical bypass performed to help bile flow around the blockage is called a biliary bypass. Different types of biliary diversion are used depending on the location of the blockage:

• choledochojejunostomy connects the common bile duct to the jejunum (central part of the small intestine);
• hepaticojejunostomy connects the common hepatic duct to the jejunum. The common hepatic duct circulates the bile evacuated by the liver.

Gastric bypass, or gastrojejunostomy, attaches the stomach directly to the jejunum. This surgery is sometimes performed to avoid a second operation. Indeed, the probability of obstruction of the duodenum in case of progression of the disease is not negligible.

Pain under the ribs or towards the shoulders may appear the day after the operation. They are due to the gas required for laparoscopy. These pains always disappear in 24-48 hours.

This procedure generally responds well to analgesics.

We may be required to perform postoperative imaging to monitor the healing of the sutures.

Please note: you will not be allowed to eat for several days.

In the days following the operation, you can first gradually resume drinking. After a few days and as soon as your transit allows it, a liquid then solid food will be offered to you.

After this type of operation, intestinal transit can be temporarily modified with, for example, diarrhea, more frequent needs or more difficult evacuation or constipation or even occlusion. Most often, these phenomena are only transient, and the functioning of the intestine normalizes. Sometimes, however, these abnormalities are more persistent and may require drug treatment.

As soon as your transit returns to normal, we remove the urinary catheter, drains and catheters. These have allowed us to hydrate you and soothe your pain.

In the absence of complications, your hospitalization after pancreatic surgery lasts between 5 and 10 days. When you leave, pain medication is prescribed. In some cases, a home nurse will be needed to support you in certain actions.

You will gradually resume your daily activities and light activity.

A work stoppage of 4 weeks will be prescribed for you (taking into account the particularities of your work).

One month after the operation, you come to your postoperative consultation. Depending on the evolution of your condition, your surgeon then authorizes you to resume your physical and sporting activities.

Pain under the ribs or towards the shoulders may appear the day after the operation. They are due to the gas required for laparoscopy. These pains always disappear in 24-48 hours.

This procedure generally responds well to analgesics.

We may be required to perform postoperative imaging to monitor the healing of the sutures.

Please note: you will not be allowed to eat for several days.

In the days following the operation, you can first gradually resume drinking. After a few days and as soon as your transit allows it, a liquid then solid food will be offered to you.

After this type of operation, intestinal transit can be temporarily modified with, for example, diarrhea, more frequent needs or more difficult evacuation or constipation or even occlusion. Most often, these phenomena are only transient, and the functioning of the intestine normalizes. Sometimes, however, these abnormalities are more persistent and may require drug treatment.

As soon as your transit returns to normal, we remove the urinary catheter, drains and catheters. These have allowed us to hydrate you and soothe your pain.

In the absence of complications, your hospitalization after pancreatic surgery lasts between 5 and 10 days. When you leave, pain medication is prescribed. In some cases, a home nurse will be needed to support you in certain actions.

You will gradually resume your daily activities and light activity.

A work stoppage of 4 weeks will be prescribed for you (taking into account the particularities of your work).

One month after the operation, you come to your postoperative consultation. Depending on the evolution of your condition, your surgeon then authorizes you to resume your physical and sporting activities.

Precautions

It is advisable to take showers (the bath is to be avoided for a month).
Do not carry heavy loads (for at least one month).
In case of exposure to the sun, provide protection against UV (total sunscreen cream) the best solution is to wear clean clothing to cover the scar
Avoid practicing sport until the next consultation.
Your anesthetist may prescribe subcutaneous injections to prevent phlebitis or pulmonary embolism.

Bandages

You have to leave the scars exposed. Most often there is no need to bring in a nurse.
If threads are apparent on your scar they are absorbable, they can be wet and will disappear on their own. After your shower, dry the scars by very light dabbing with a clean towel.

Diet

The food will be determined according to the intervention which was carried out, and the particularities of your situation. You may need to fragment your diet by multiplying meals. All this information will be detailed to you when you leave by your surgeon, and a dietician can advise you. You may be prescribed pancreatic enzyme supplementation.

The results of the microscopic examination of the surgical specimen will be communicated to you during your hospitalization or during the postoperative consultation after one month.

The results of the pathological examination provide information on the nature of the tumor and its extension. This does not prejudge the consequences and the evolution. With these results, further treatment may be necessary.

Regular follow-up with clinical examination, blood test and scanner will be organised.