HEPATOBILIARY COMBINED RESECTIONS

Primary cancer of the proximal bile ducts, so-called Klatskin hilar cholangiocarcinoma, is a rare form of cancer that arises in the bile ducts where they exit from the liver. It causes symptoms of jaundice, extremely itchy skin, very dark -coloured urine and pale faeces. Hilar cholangiocarcinoma, if it has not spread too far into the liver or to regional lymph nodes or distant organs, can be treated by removing the extrahepatic bile ducts together with a large part of the liver (right or left Trisectionectomy, depending on the location of the tumour), with reconstruction by anastomosing an isolated segment of the proximal small bowel (Roux loop) to the bile duct draining the remaining liver.

When do you need pancreatic surgery?

Pancreatic resections are done mainly for tumours of the pancreas and sometimes for chronic pancreatitis.

The pancreas is an organ that lies transversely across the upper abdomen, with the pancreatic head and uncinate process to the right of the midline and superior mesenteric artery and very intimately attached to the duodenum. The neck lies in the midline in front of the confluence of the portal vein, splenic vein, superior mesenteric vein and inferior mesenteric vein. The body and tail of the pancreas reside behind the stomach with the tip of the tail nearby the hilum of the spleen.

The pancreas comprises an exocrine gland, which produces digestive enzymes and secretes them into the duodenum and an endocrine component in glands (called Islets of Langerhans) scattered throughout the exocrine component. These endocrine glands secrete a number of hormones that are secreted directly into the blood. The best known of these hormones are insulin, glucagon, somatostatin and gastrin, but there are several other hormones produced.

Tumours of the pancreas may arise from the exocrine cells and duct cells, with the most common (and very lethal) cancer being known as pancreatic ductal adenocarcinoma (PDAC).

Tumours with very different biological behaviour can arise from the endocrine cells – pancreatic neuroendocrine tumours (pNETs). Some of these neuroendocrine tumours secrete hormones such as insulin, glucagon, vasoactive intestinal peptide, somatostatin and gastrin, which cause serious physiological effects by virtue of the excessive, unregulated hormone secretion and they are known as functioning pNETs. However, most pNETs are "non-functioning" and do not cause any clinical syndromes of excessive hormone secretion. Functioning and non-functioning tumours, although inherently malignant, usually have much more indolent growth than PDAC and other rarer tumours of the exocrine pancreas, even though they have often metastasised to distant organs by the time they are diagnosed.

Pancreatic tumours in the head and uncinate pancreas often present with obstructive jaundice due to invasion and obstruction of the main bile duct. They may also invade and obstruct the duodenum, and when they spread posteriorly, they can obstruct the portal vein, superior mesenteric artery and superior mesenteric vein. These tumours are often advanced and irresectable by the time they are diagnosed. However, if diagnosed before they have metastasised or invaded the hepatic or superior mesenteric artery, they can be removed in a formidable operation called a pancreatoduodenectomy, sometimes referred to as a Whipple procedure, which takes several hours to perform. This operation involves resection of the head and uncinate process of the pancreas, the duodenum, the common bile duct and the gallbladder, with reconstruction by anastomosing the proximal jejunum (small intestine) to the pancreatic neck, the common hepatic duct and to the stomach.

Pancreatic tumours in the body and tail of pancreas often present with vague abdominal pain and weight loss. If diagnosed before they have metastasised or invaded adjacent structures, they can be removed by way of a distal pancreatectomy and splenectomy.

After a pancreatectomy

After a pancreatectomy, the biggest danger is a leak from the pancreas, either the pancreatic anastomosis to the bowel or where the pancreatic neck is divided in the case of distal pancreatectomy. A leak from the anastomosis to the bile duct can also be very dangerous, with sepsis and fistulas causing serious illness.

The patient can expect to stay in the hospital for about two weeks if things go without complications and 3-4 weeks or more if there are complications which occur in about 1/3 Whipple resections.

There is a possibility of having pancreatic exocrine insufficiency or diabetes after pancreatic resections. If these do develop exocrine insufficiency is managed with capsules of pancreatic enzymes (Creon) taken with food, while diabetes is managed with a self-injection of insulin.

Following surgery for pancreatic cancer, it is very likely that the patient will be advised to undergo some form of adjuvant therapy with chemotherapy.

How colorectal surgery is performed

Colorectal surgery is performed most often for tumours of the colon or rectum and less often for inflammatory diseases such as complicated diverticular disease and inflammatory bowel disease. Traditionally it is done by open surgery, but more and more often now, it can be done laparoscopically, a minimally invasive modern technique via small incisions in the abdomen, through which ports are inserted and carbon dioxide, a harmless gas is used to distend the abdomen to create space to allow safe dissection and mobilisation of the bowel. Resections may be right hemicolectomy, left hemicolectomy, sigmoid colectomy, total colectomy, anterior resection of the proximal rectum or proctectomy with total mesorectal excision. Most of the time we can do a primary anastomosis (join) –terminal ileum to the colon, colon to colon, colon to rectum or colon to anus, depending on which parts are resected. If the surgeon deems the anastomosis to be at high risk of leakage, the surgeon may exteriorise the ileum through the abdominal wall into a bag, as an ileostomy, for a few months to reduce the severity of complications if there is a leak.

After colorectal surgery

After colorectal surgery, normal peristaltic contractions of the bowel are inhibited for a few days after the surgery, so the bowel needs to be decompressed by a tube passed through the nostril into the stomach. The patient needs to be monitored, and oral feeding is not allowed until normal peristaltic contractions of the bowel have returned. In the meantime, feeding will usually be given intravenously.

Anastomotic leakage is the most feared complication of colorectal surgery because a leak can result in severe sepsis that can be lethal and might require exteriorising the leaked anastomosis as a colostomy or ileostomy to salvage the situation. The risk of a leak is much greater if the bowel is allowed to become highly distended.

Depending on the length of bowel removed and the site of the anastomosis bowel movements after a colonic resection can be expected to be different from before, but usually quite manageable.

DR GRAHAM STAPLETON

Dr Graham Stapleton is registered with the Health Professions Council of South Africa as a General Surgeon.

He specialises in liver and pancreatic surgery, with particular emphasis on removal of tumours of the liver and pancreas as well as other gastrointestinal cancers. He also supervises palliative treatments such as endoscopic and percutaneous stenting of obstructed bile ducts for those patients whose cancers are advanced and not resectable.

+27 (0) 21-6716181

+27 (0)82-569-4427

1406 Netcare Christian Barnard Memorial Hospital
Cnr DF Malan Street & Rua Bartholemeu Dias Plain
Foreshore, Cape Town, 8001