Transplant and Hepato-Pancreato-Biliary (HPB) Institute

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   Transplant and Hepato-Pancreato-Biliary (HPB) Institute

Understanding Your Pancreas

Your pancreas is located in your upper abdomen, behind your stomach and on top of your spine. It is divided into 3 parts: the head, which is located next to the small intestine, the body, and the tail, which is close to your spleen.

The pancreas has 2 main functions:

  1. Production of juices to help digest food.
  2. Production of hormones, like insulin.

Pancreas system
Pancreas

Problems with your Pancreas

Diseases of the pancreas can present with a variety of symptoms including abdominal pain, diarrhea, diabetes, or jaundice (yellowing of the eyes and skin).


Animated pancreas
Pancreatitis

Pancreatitis

Pancreatitis occurs when the pancreas becomes inflamed, which can be due to a variety of sources including alcohol use, gallstones, or medications.

  • About Pancreatitis

    What is pancreatitis?

    Pancreatitis is inflammation of your pancreas which can cause leakage of pancreatic fluid into other parts of the pancreas or surrounding areas.

    What are the signs and symptoms of pancreatitis?

    Pancreatitis often presents with sudden severe pain in your upper belly. You may also experience nausea, vomiting, fevers, chills and upper back pain.

    Why do I get pancreatitis?

    The most common causes of pancreatitis are gallstones and alcohol. Other, less common reasons are certain medications and diseases that run in your family. If you have one sudden attack, you have acute pancreatitis. Multiple attacks are called chronic pancreatitis, and lead to permanent damage of your pancreas and its function.

  • Diagnosis of Pancreatitis

    How is pancreatitis diagnosed?

    If you have symptoms of pancreatitis, your doctor may order blood tests or scans of your abdomen. Sometimes you may also need a procedure.

    Blood tests

    • Your doctor may check blood tests to look for an infection and check he function of your liver and pancreas.
    Blood Tests

    Imaging

    • Abdominal Ultrasound to look for gallstones in your gallbladder.
    • CT or MRI scan of your belly (or of the abdomen and pelvis) to look for gallstones and inflammation of the pancreas.
    Imaging

    Procedures

    • An Endoscopic Retrograde Cholangiopancreatography (ERCP) can remove gallstones that cause pancreatitis. Your doctor can perform and ultrasound at the same time called EUS, which can look at your pancreas.
    ERCP
  • Treatment of Pancreatitis

    How is pancreatitis treated?

    • Hospital admission and supportive care
    • Surgery for Pancreatitis

    Hospital Admission

    Some patients with pancreatitis have to be admitted to the hospital. You will receive intravenous fluids and pain medications until your pain has gone away.

    Some patients have more severe episodes of pancreatitis and might spend some time in the intensive care unit. Sometimes the treatment involves not eating which may require a feeding tube through your nose into your intestines until you get better.

     

    Surgery for Pancreatitis

    If you have gallstones, your gallbladder will be removed with an operation called a laparoscopic cholecystectomy after you have recovered from pancreatitis.

    Remove Gallbladder
    Gallbladder

    If your pancreas has been severely damaged, you can develop a pocket of fluid or infection which may require an endoscopy procedure or a surgery to drain it.



Darkspots in pancreas

Pancreatic Cysts

Pancreatic cysts are usually benign, but can sometimes lead to problems which require treatment. Some cysts can have the potential to turn into cancer.

  • Pancreatic Cysts

    What are pancreatic cysts?

    Pancreatic cysts are fluid filled masses within the pancreas. They can appear after an attack of pancreatitis, or found on A CT scan. Since some cysts are pre- cancers, accurate diagnosis is very important.

    What are the signs and symptoms of pancreatic cysts?

    Most pancreatic cysts are silent, but patients may experience:

    • Upper belly or back pain
    • Nausea/Vomiting
    • Acute onset of Diabetes

    What is my risk for getting pancreatic cysts?

    Pancreatic Pseudocysts can develop after an attack of pancreatitis. Mucinous Neoplasms of the pancreas have been linked to diabetes and chronic pancreatitis. They are sometimes more common in patients with a family history of pancreatic cancer.

    Pancreas Cyst

    Cysts We Treat

    • Pseudocysts
    • Serous cystadenomas
    • Mucinous Cystic neoplasms (MCN)
    • Intraductal Mucinous Neoplasms (IPMN)
    • Cystic Islet cell tumors
  • Diagnosis of Pancreatic Cysts

    How are pancreatic cysts diagnosed?

    If you have any symptoms of a pancreatic cyst, your doctor will order blood tests and pictures (imaging) of your belly. You will also need a biopsy to confirm the diagnosis.

    Blood tests

    • Blood counts and liver function tests
    • Ca19-9 and CEA levels. These blood tests are called “tumor markers,” and are often ordered, when patients have a “mass” in the pancreas.
    Blood Tests

    Imaging

    • CT or MRI scan of your belly (or of the abdomen and pelvis) to look at the cyst in the pancreas. Often cysts are discovered on a CT scan, which was done for a different reason. This test will allow your doctor to evaluate, if your cyst needs to be removed with surgery
    Imaging

    Procedures

    • Endoscopic Ultrasound (EUS): Your doctor inserts a camera into your intestines through your mouth, so your pancreas can be seen. Usually a needle biopsy and some fluid is taken for analysis.
    ERCP
  • Treatment of Pancreatic Cysts

    How are pancreatic cysts treated?

    TIf you have a cysts which is concerning for cancer, you will be presented in our multidisciplinary tumor board, where your doctors will discuss your case. You might need to have your cyst removed with surgery. If surgery is not recommended, your doctor may repeat evaluation every 3-6 months to follow the cyst.

    How are pancreatic cysts from pancreatitis treated?

    If you have a pancreatic cyst due to pancreatitis, you might not need any treatment, unless you have symtoms. If you cannot eat and your cyst does not get smaller, your doctor might recommend a procedure or surgery called cystgastrostomy.



Pancreas Tumor
Pancreatic Cancer

Pancreas Tumors

Tumors in the pancreas can be either benign or cancerous.

  • Pancreas Tumors and Pancreatic Cancer

    What is pancreatic cancer?

    Pancreatic Cancer occurs when the cells of the pancreas grow out of control. The pancreas has cells that form ducts and cells that produce hormones like insulin. Both types of cells can turn into cancer cells.

    Ampullary

    What are the signs and symptoms of pancreatic cancer?

    Pancreatic Cancer is often silent in early stages. Patients may present with:

    • Abdominal and back pain
    • Poor appetite, nausea, vomiting, weight loss
    • Jaundice (yellow skin and eyes)
    • Bowel blockage
    • High blood sugars and Diabetes

    What is my risk for getting pancreatic cancer?

    Smoking, diabetes, obesity and pancreatitis increase your risk of getting pancreatic cancer. There are diseases that run in families, which increase the risk of pancreatic cancer.

    Pancreatic Cancer

    Tumors We Treat

    Cancers

    Pre-Cancers

  • Diagnosis of Pancreatic Cancer

    How is pancreatic cancer diagnosed?

    If you have any symptoms of pancreatic cancer, your doctor may order blood tests and pictures (imaging) of your belly. You will also need a biopsy to confirm the diagnosis.

    Blood tests

    • Complete blood count (CBC) to check your blood count.
    • Comprehensive Metabolic Panel (CMP) to check your electrolytes and liver function.
    • Ca19-9 and CEA levels. These blood tests are called “tumor markers,” and will give your doctor a chance to follow your response to treatment.
    Blood Tests

    Imaging

    • CT or MRI scan of your belly (or of the abdomen and pelvis) to look for a mass in the pancreas. This test will allow your doctor to evaluate, if your tumor can be removed with surgery.
    Imaging

    Procedures

    • Endoscopic Ultrasound (EUS): Your doctor inserts a camera into your intestines through your mouth, so your pancreas can be seen. Usually a small needle biopsy is taken at that time for diagnosis.
    • An Endoscopic Retrograde Cholangiopancreatography (ERCP) is another form of endoscopy that allows your doctor to place a stent into the bile duct for patients with jaundice. This can be done at the same time as the EUS.
    ERCP
  • Treatment of Pancreatic Tumors and Cancer

    How is pancreatic cancer treated?

    The treatment of pancreatic cancer depends on the stage of the tumor, and involves a multidisciplinary team of doctors, nurses and medical support staff:

    • Medical Oncology
    • Gastroenterology
    • Surgery
    • Radiation
    • Dietary and Social work, Palliative care.

    Every patient seen here will be presented in our multidisciplinary tumor board, where we will devise your individual treatment plan. This plan may include:

    We strongly encourage and support all of our patients to participate in clinical trials. We are happy to talk to you about clinical trials during your clinic visit.

Cystgastrostomy

A cystgastrostomy is a procedure or surgery, which allows the fluid from your pancreatic cyst to drain into the stomach.

This can be done by your gastroenterologist during endoscopy or surgeon with laparoscopic surgery. A small hole will be made in your stomach right over the cyst, and the edge of the stomach and cyst will be sewn together. You will be able to eat and drink normally after your surgery.

Radiation Therapy

Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is therapy using ionizing radiation, generally as part of cancer treatment to control or kill malignant cells and normally delivered by a linear accelerator.

Chemotherapy

Chemotherapy is a type of cancer treatment that uses one or more anti-cancer drugs as part of a standardized chemotherapy regimen. Chemotherapy may be given with a curative intent, or it may aim to prolong life or to reduce symptoms.

Multidisciplinary Tumor Board

A Multidisciplinary Tumor Board is a team of doctors and nurses who discuss your individual case to recommend the best treatment options for you based on your specific information. The members of Tumor Board include:

  • Surgeons
  • Oncologists
  • Radiologists
  • Pathologists
  • Gastroenterologists
Tumor Board
Tumor Board Meeting

When does Tumor Board meet?

Usually once a week

When will I be presented at Tumor Board?

The Tumor Board needs to have the latest imaging available to make accurate recommendations. Patients are typically presented after all of the appropriate tests are completed.

Am I allowed to participate in Tumor Board?

Because multiple patients are presented at a single Tumor Board, having patients attend is discouraged for privacy concerns. However, you will learn the recommendations of the Tumor Board at your next clinical appointment.

Cholecystectomy

cholecystectomy

Patients, who have recovered from pancreatitis due to gallstones, may need to have their gallbladder removed surgically. The procedure is called a cholecystectomy, and can be done with a camera and small incisions (laparoscopic) or through a larger cut (open). During the operation the cystic duct and artery have to be clipped and cut. The gallbladder will be separated from the liver, and removed.

Patients can usually leave the hospital the day after the operation after laparoscopic surgery. They able to eat a regular diet, and will be given medication for pain at their incision (cut).

Pancreatic Surgery

If surgery is part of your treatment plan, your doctor will likely suggest one of two surgical procedures:


Whipple Procedure
(also called Pancreaticoduodenectomy)

Before whipple
Before
after whipple
After

During surgery, the head of the pancreas, the gallbladder, the first part of the bowel called the duodenum, part of the stomach and bile duct are removed. New connections called “anastomoses” are made between the bile duct and the bowel, the pancreas and the bowel and the stomach and the bowel. These new connections are necessary for you to eat and digest your food.


Distal Pancreatectomy

The body or tail of the pancreas and the spleen are removed. No new connections or “anastomoses” are made. You will need vaccinations before surgery, because your spleen usually eliminates certain types of bacteria.

distal pancreatectomy

Vein resection and reconstruction

If your tumor grows into the portal vein, which is the main blood vessel to liver passing behind the pancreas, your surgeon might have to remove a small piece, when removing a tumor. The portal vein can be repaired.

venin resection and reconstruction
Vein Resection & Reconstruction

Insulinoma

This is a tumor of pancreatic island cells, which make insulin. Insulin controls the blood sugar. If there is too much insulin in the blood, the blood sugar will drop to a dangerously low level. Most insulinomas are benign (not cancer). Some are associated with a genetic disease called MEN 1. Those tumors have a higher chance of being a cancer (malignant).

Signs and symptoms

Patients with an insulinoma may feel light-headed, confused, weak, sweaty, always hungry and have blurry vision.

Diagnosis

In addition to the workup for any pancreatic tumor, there is a specific blood test for an insulinoma. The patient’s blood will be checked for blood sugar and insulin levels after fasting for at least 24 hours.

Treatment

Insulinomas will always be removed by surgery, even if they have spread beyond the pancreas. If the tumor is small, it can be enucleated.

Enucleation means that only the part of the pancreas containing the tumor will be removed. This is almost always done by laparoscopy, which involves a camera and surgical instruments being inserted into the abdomen through small cuts. The tumor can be taken out of the abdomen through one of these small incisions.

For larger tumors in the head or tail of the pancreas, that patient will need a Whipple procedure or distal pancreatectomy.

What is a Whipple Procedure?

The Whipple procedure, or pancreaticoduodenectomy, is the most common surgery to remove tumors in the pancreas. Surgery to remove a tumor offers the best chance for long-term control of all pancreatic cancer types. The Whipple removes and reconstructs a large part of the gastrointestinal tract and is a difficult and complex operation.

Distal Pancreatectomy

A distal pancreatectomy (pan-krea-tek-tuh-me) is a surgery that removes a tumor from the body or tail of your pancreas.

Glucagonoma

This is a tumor of the islet cells that make Glucagon. Glucagon helps regulate the blood sugar by releasing sugar into the blood. Patients with excess glucagon will have a high blood sugar (hyperglycemia), which cannot be controlled with medication. Glucagonomas are often malignant (cancer).

Signs and symptoms

Patients with a glucagonoma can have a rash on their arms and legs, blood clots in their legs or lungs and experience all the effects of having a high blood sugar such as extreme thirst, dry mouth and skin, frequent urination, weakness and fatigue.

Diagnosis

In addition to the standard workup for a pancreatic tumor, glucagon levels can be measured in the blood after at least 8 hours of fasting.

Treatment

Glucagonomas will be removed with surgery. Patients with a tumor in the head of the pancreas need a Whipple procedure and in the body or tail of the pancreas a distal pancreatectomy.

What is a Whipple Procedure?

The Whipple procedure, or pancreaticoduodenectomy, is the most common surgery to remove tumors in the pancreas. Surgery to remove a tumor offers the best chance for long-term control of all pancreatic cancer types. The Whipple removes and reconstructs a large part of the gastrointestinal tract and is a difficult and complex operation.

Distal Pancreatectomy

A distal pancreatectomy (pan-krea-tek-tuh-me) is a surgery that removes a tumor from the body or tail of your pancreas.

Somatostatinoma

This is a tumor of the islet cells that make somatostatin, which plays an important role in regulating blood sugar and other aspects of digestion. Somatostatinomas are often malignant.

Signs and symptoms

Patients with a somatostatinoma can experience all the effects of having a high blood sugar such as extreme thirst, dry mouth and skin, frequent urination, weakness and fatigue. They may have diarrhea, foul-smelling, fatty stools (steathorrhea) and gallstones.

Diagnosis

In addition to the standard workup for a pancreatic tumor, somatostatin levels can be measured in the blood after at least 8 hours of fasting. A special imaging test called an octreotide scan can be helpful, when a small tumor cannot be found on CT scan, MRI or Endoscopic Ultrasound.

Treatment

Somatostatinomas will be removed with surgery. Patients with a tumor in the head of the pancreas need a Whipple procedure and in the body or tail of the pancreas a distal pancreatectomy.

What is a Whipple Procedure?

The Whipple procedure, or pancreaticoduodenectomy, is the most common surgery to remove tumors in the pancreas. Surgery to remove a tumor offers the best chance for long-term control of all pancreatic cancer types. The Whipple removes and reconstructs a large part of the gastrointestinal tract and is a difficult and complex operation.

Distal Pancreatectomy

A distal pancreatectomy (pan-krea-tek-tuh-me) is a surgery that removes a tumor from the body or tail of your pancreas.

Gastrinoma

This is a tumor of the islet cells that make gastrin. Gastrin stimulates the stomach to release acid, which helps with the digestion of food. Patients with too much gastrin and acid will have diarrhea and stomach ulcers. Gastrinomas are often malignant (cancer) and the most common pancreas tumors in patients with a genetic disease called MEN1.

Gastrinoma

Signs and symptoms

Patients with gastrinoma can have ulcers that cannot be treated with medication, acid reflux diarrhea and abdominal and back pain.

Diagnosis

In addition to the standard workup for pancreatic tumors, gastrin levels in the blood can be measured after fasting for at least 8 hours. A hormone named secretin can be given, and the amount of acid in the stomach can be measured, if the gastrin blood test is not conclusive. A special imaging test called an octreotide scan can be helpful, when a small tumor cannot be found on CT scan, MRI or Endoscopic Ultrasound.

Treatment

Gastrinomas will be removed with surgery. Patients with a tumor in the head of the pancreas need a Whipple procedure and in the body or tail of the pancreas a distal pancreatectomy.

What is a Whipple Procedure?

The Whipple procedure, or pancreaticoduodenectomy, is the most common surgery to remove tumors in the pancreas. Surgery to remove a tumor offers the best chance for long-term control of all pancreatic cancer types. The Whipple removes and reconstructs a large part of the gastrointestinal tract and is a difficult and complex operation.

Distal Pancreatectomy

A distal pancreatectomy (pan-krea-tek-tuh-me) is a surgery that removes a tumor from the body or tail of your pancreas.

VIPomas

This is a tumor of the islet cells that make vasoactive intestinal peptide (VIP), which plays an important role in regulating other hormones and the body’s salt and water balance in digestions. VIPomas are often malignant.

Signs and symptoms

Patients with a Vipoma will have watery diarrhea and dehydration. The potassium levels in the blood will be low, and they may experience muscle weakness, cramps, tingling or numbness.

Diagnosis

In addition to the standard workup for a pancreatic tumor, VIP levels can be measured in the blood. While potassium will be low in the blood, potassium and sodium will be high in the stool.

Treatment

Somatostatinomnas will be removed with surgery. Patients with a tumor in the head of the pancreas need a Whipple procedure and in the body or tail of the pancreas a distal pancreatectomy.

What is a Whipple Procedure?

The Whipple procedure, or pancreaticoduodenectomy, is the most common surgery to remove tumors in the pancreas. Surgery to remove a tumor offers the best chance for long-term control of all pancreatic cancer types. The Whipple removes and reconstructs a large part of the gastrointestinal tract and is a difficult and complex operation.

Distal Pancreatectomy

A distal pancreatectomy (pan-krea-tek-tuh-me) is a surgery that removes a tumor from the body or tail of your pancreas.

Nonfunctioning Pancreatic Neuroendocrine Tumors

Pancreatic neuroendocrine tumors, which arise from islet cells, but do not make hormones are called nonfunctional. They represent the majority of pancreatic neuroendocrine tumors, and can be benign (not cancer) or malignant (cancer).

Signs and symptoms

Patients with nonfunctioning pancreatic neuroendocrine tumors can have vague symptoms such as diarrhea, indigestion abdominal and back pain, which worsen as the tumor grows in size. If the tumor is in the head of the pancreas, patients may become jaundiced.

Diagnosis

In addition to the standard workup for a pancreatic tumor, the patient’s blood will be checked for chromogranin A levels.

Treatment

Nonfunctioning pancreatic neuroendocrine tumors will be removed with surgery. Patients with a tumor in the head of the pancreas need a Whipple procedure and in the body or tail of the pancreas a distal pancreatectomy.

What is a Whipple Procedure?

The Whipple procedure, or pancreaticoduodenectomy, is the most common surgery to remove tumors in the pancreas. Surgery to remove a tumor offers the best chance for long-term control of all pancreatic cancer types. The Whipple removes and reconstructs a large part of the gastrointestinal tract and is a difficult and complex operation.

Distal Pancreatectomy

A distal pancreatectomy (pan-krea-tek-tuh-me) is a surgery that removes a tumor from the body or tail of your pancreas.

Surgical removal of the tumor in the pancreas might also be recommended, if patients have metastases in other organs i.e. the liver.

Cystic Neoplasms of the Pancreas

Cystic neoplasms of the pancreas are different types of fluid-filled masses, which are benign (not cancer), but can become cancer over time. The type of cystic neoplasm is important for treatment.

These are the different types:

  • Intraductal mucinous neoplasm (IPMN): This tumor s associated with the tubes (ducts) in the pancreas, which transport digestive juices to the intestine. The fluid is thick and called mucin. IPMN can become cancer.
  • Mucinous cystic neoplasm (MCN): This tumor is in the pancreas, but not associated with ducts. It is filled with mucin. MCN can become cancer.
  • Serous cystic neoplasm (SCN): This tumor is in the pancreas, but not associated with ducts. It is filled with thin (serous) fluid. SCN can become cancer.
  • Solid pseudopapillary tumor: This tumor can occur anywhere in the pancreas, and is dense and not always fluid-filled. It occurs more common in young women. It is not cancer, but can become cancer.

Signs and Symptoms

Most cystic neoplasms do not cause any symptoms, and are discovered by chance, when patients get a CT scan, MRI or ultrasound for another reason. As they grow, these tumors can cause pain, yellowing of the skin and diabetes.

Treatment

The patient’s care team will recommend if the pancreatic cyst needs to be removed. Patients with a tumor in the head of the pancreas need a Whipple procedure and in the body or tail of the pancreas a distal pancreatectomy.

What is a Whipple Procedure?

The Whipple procedure, or pancreaticoduodenectomy, is the most common surgery to remove tumors in the pancreas. Surgery to remove a tumor offers the best chance for long-term control of all pancreatic cancer types. The Whipple removes and reconstructs a large part of the gastrointestinal tract and is a difficult and complex operation.

Distal Pancreatectomy

A distal pancreatectomy (pan-krea-tek-tuh-me) is a surgery that removes a tumor from the body or tail of your pancreas.

Pseudocysts

Pancreatic pseudocysts are fluid filled masses in the pancreas. They form as a result of injury to the pancreas after acute pancreatitis.

Signs and Symptoms

Large pseudocysts can cause pain and difficulty eating. When pseudocysts get infected, patients present with fevers, chills and low blood pressure, and require immediate treatment.

Treatment

Most pancreatic pseudocyst cause no symptoms, and require no treatment. If a cyst does not resolve without treatment, patients may require a cystgastrostomy. Infected pseudocysts are treated with antibiotics and need to be drained like an abscess.

A cystgastrostomy is a procedure or surgery, which allows the fluid from your pancreatic cyst to drain into the stomach.

This can be done by your gastroenterologist during endoscopy or surgeon with laparoscopic surgery. A small hole will be made in your stomach right over the cyst, and the edge of the stomach and cyst will be sewn together. You will be able to eat and drink normally after your surgery.