It owes its endocrine function to groups of cells known as islets, which produce a number of important hormones, most notably insulin, glucagon, somatostatin and gastrin. Its role in the digestive system is served by its exocrine fate and consists in the secretion of pancreatic fluid, which contains enzymes involved in the breakdown and absorption of nutrients by the small intestine.
The pancreas is located in the upper abdomen, behind the stomach, in the “arms” of the duodenum, at the point where the stomach ends and the small intestine begins. It consists of the head, which is in close contact with the duodenum, the body, and the tail, which rests on the spleen. “Pancreatic enzymes are concentrated in the pancreatic duct, which runs along the gland and flows into the duodenum, along with the gallbladder, into Vater’s mucus.”
Common diseases of the pancreas
Pancreatitis
It is an acute or chronic inflammation of the organ and is of various etiologies. In terms of its acute form, in the western world, the most common cause is cholelithiasis, followed by alcoholism.
Acute pancreatitis
It is a serious disease, which presents many and systemic complications such as cardiorespiratory problems, renal failure, coagulation and nutrition disorders up to multiorgan failure or even sepsis, with tragic consequences for the patient. Depending on its severity, it is divided into mild, moderate and heavy.
Diagnosis
The suspicion of the disease is raised by the clinical picture, which includes:
Abdominal pain, often after a fatty meal. It is typical to describe the pain as shingles, which extends to the back and is relieved in the knee position.
• Stretching (swelling) of the abdomen
• Vomiting
• Inability to expel gas and feces (ileum)
Hypotension, anuria (inhibition of urination) and even shock (severe conditions).
Imaging diagnostic tests:
• General blood, serum and urine amylase, inflammation markers, biochemical liver tests, special tests
• Ultrasound and CT scan.
It is treated with conservative measures and support of vital functions, and quite often, the patient is admitted to an Intensive Care Unit. Surgery is considered necessary in advanced stages of the disease. These are surgeries aimed at clearing necrosis and draining abscesses in critically ill patients who do not respond to conservative treatment. However, surgery is required to treat local complications of the disease.
What are the local complications of acute pancreatitis?
Pancreatic pseudocysts: These are cystic formations containing pancreatic fluid containing enzymes. Their treatment is surgical drainage.
• Pancreatic ascites: It is the filling of the peritoneal cavity with pancreatic fluid. It can cause a large increase in intra-abdominal pressure and a variety of clinical symptoms. It is treated with drainage surgeries and endoscopic techniques.
• Pancreatic fistulas: It is the development of direct or indirect communication of the pancreatic duct with other organs (stomach, duodenum, small or large intestine). They are treated with special operations depending on the organ involved. It should be noted that acute pancreatitis due to gallstones is definitively treated only by removal of the gallbladder.
Chronic pancreatitis
This term describes a chronic process of inflammation of the organ that leads to alteration of its structural composition and functional insufficiency. The most common cause in the western world is alcoholism. The patient with chronic pancreatitis has 4 main problems:
• Hard to control diabetes
• Absorption syndrome
• Chronic pain
• Pancreatic ascites.
It is treated conservatively, with insulin and a supplement of pancreatic enzymes. Pancreatic ascites and pain that is not regulated by non-drug drugs are treated with different types of surgeries. It should be noted that pancreatic transplantation is also in the quiver of modern surgery, although not yet widely used.
Neoplasms of the pancreas
“The pancreas consists of the endocrine and exocrine (as we call them) fate. The exocrine gland is responsible for the production of digestive enzymes that make up what is referred to as “pancreatic juice” and is an essential element for digestion. “The endocrine system produces a number of hormones such as insulin and glucagon that interrelate regulate blood sugar levels, somatostatin, pancreatic polypeptide, gastrin and several more, with specialized actions”, adds Mr. Koza.
Depending on the point of excursion of a tumor in the pancreas, it is characterized as a tumor of endocrine or exocrine degree. Tumors of the endocrine gland are quite often hormone-producing, resulting in the manifestation of a characteristic clinical picture, and also often are a subset of certain clinical syndromes (syndromes of multiple endocrine tumors). The suspicion of their diagnosis is raised by the clinical hormonal disorder they cause and is confirmed by measuring the specific hormone.
The most common tumors are: Insulinoma with mainly produced hormone insulin and clinical picture of hypoglycemia. Glucagonoma with mainly produced hormone glucagon and clinical picture of diabetes but also characteristic necrotic rash, somatostatinoma with mainly produced hormone somatostatin, which does not produce a typical clinical picture. Gastrinoma with mainly produced hormone gastrin, which causes by various mechanisms the hypersecretion of gastric fluid and manifests a picture of severe ulcers in the stomach, duodenum and small intestine as well as diarrhea. In some cases, the location, ie the imaging of the tumor, is quite difficult, as, not infrequently, these are small tumors. For this reason, in addition to the classic imaging methods, modern special techniques such as special scintigraphy, endoscopic and intraoperative ultrasound, and even angiographic techniques are used.
Their treatment is resection, either by denucleation, if possible, or by standard resection of the part of the organ that carries the tumor.
Tumors of the external part
They are the ones that appear most often. They do not produce any hormone, they do not have a typical picture, they develop for a long time silently, without noticeable symptoms and they become clinically obvious in advanced stages.
Benign tumors and cysts:
• Serous cystadenoma
• Mucosal cystadenoma
•   IPMN.
Benign tumors of the pancreas, if diagnosed, are treated, depending on their size, nature and their location on the organ, with a partial resection of the affected part of the pancreas.
Malignant tumors:
“When we talk about pancreatic cancer, we are talking about adenocarcinoma. Pancreatic adenocarcinoma remains one of the least curable cancers today.
“This is due to the fact that it is often diagnosed in advanced stages, as well as the fact that the organ is adjacent to large vessels and structures that are very quickly infiltrated by the disease and make the tumor unoperable”, the doctor points out.
What are the symptoms?
• Pain in the upper abdomen and back
• Jaundice with yellow skin and eyes, dark brown urine and colorless stools
Weakness due to overconsumption of nutrients by cancer cells – the body lacks essential nutrients and energy
• Anorexia
• Nausea and vomiting, because the tumor can cause obstruction of the duodenum or small intestine
Depression, which can sometimes be the first symptom of the disease
• Thrombophlebitis, migratory, without obvious etiology, in people without obvious pathology.
Diagnostic access
The diagnosis is made by mainly imaging methods, ie by ultrasound and computed tomography. MRI, MRI-MRA, MRCP, ERCP, endoscopic ultrasound for biopsies and staging or angiography may be required to clarify the anatomical relationships of the tumor to surrounding structures and to plan surgery. PET – CT imaging is often necessary to confirm the exclusion or not of the tumor and possible invisible metastases. The only hope for healing is the surgical exclusion of the affected part of the organ, along with the lymph nodes in the area and any neighboring organs involved: duodenum, spleen, large intestine, stomach.
Tumors located in the head of the pancreas to be excised require excision of this part of the pancreas as well as part of the stomach, duodenum, gallbladder and part of the gallbladder. This operation is more commonly known as Whipple surgery, and is one of the most demanding technical surgeries. For tumors located in the body and tail of the pancreas, excision of the corresponding part of the organ as well as splenectomy is required. Complementary therapy (chemotherapy and / or radiotherapy) is often necessary.
Treatment
“Apart from the classic open surgery (with incisions), Robotic Surgery using the Da Vinci system is a special object of interest. “Specifically, all surgical diseases of the pancreas, benign and malignant, are performed robotically with maximum safety and efficiency”, concludes Mr. Kozadinos.
Writes:
Dr. Ioannis K. Kozadinos, Director of the 1st Robotic Surgery Clinic of the Metropolitan Hospital
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