• Reference Number: HEY-941/2018
• Departments: Upper GI
• Last Updated: 12 July 2018

Introduction

This leaflet has been produced to give you general information about your operation. It explains what is involved and what the risks are. It is not meant to replace the discussion between you and your doctor, but may act as a starting point for discussion. If after reading it you have any concerns or require further explanation, please discuss your concerns with a member of your healthcare team.

If the suspected cancer is at an early stage, then there is a modest chance that surgery can be curative.  An early stage means a small tumour, which is confined within the pancreas and has not spread to the lymph nodes or other areas of the body.

Removal of the Suspected Cancer (Resection)

Depending on where the suspected cancer is, and how much of the pancreas is involved, all, or part of the pancreas may need to be removed during surgery.

• Removal of the whole pancreas is called a Pancreatectomy.
• Removal of the pancreatic tail is called a Distal Pancreatectomy.
• Removal of the head of the pancreas, part of the stomach, small bowel (duodenum), the common bile duct, gall bladder and the surrounding lymph nodes is called a Whipple’s procedure.  The aim of this surgery is to reduce the risk of the cancer coming back. This operation may also be performed for cancer of the bile duct or duodenum. A small number of patients who have part of their pancreas removed go on to develop diabetes. This will be discussed in more detail if this affects you.
• The area that has been removed will be sent away to be looked at under the microscope, this is called a biopsy. This helps to decide whether you will require any further treatment after your surgical procedure.

The precise details of your own operation will be discussed with you by the consultant surgeon who is looking after you. This operation is major surgery. Occasionally, during a planned operation, your surgeon may find the disease is not suitable for surgery, perhaps because the suspected cancer cannot be removed as it is more advanced or has spread to other organs. If this is what happens in your case, a biopsy will be taken and other treatment options will be discussed with you.

Are there any alternative treatments?

Surgical removal of the pancreas is currently the only known way of curing suspected pancreatic cancer. It is often used in addition to other treatments such as chemotherapy or radiotherapy.  Some patients go on to have further chemotherapy after surgery. This is known as ‘adjuvant chemotherapy’ and its aim is to ensure that any remaining cancer cells are treated. Not everyone is suitable for or needs this treatment, so do not worry if this is not part of your treatment plan.

Alternatives to surgery are:

• Chemotherapy and / or Radiotherapy
• Biliary stenting
• Palliative care

If surgery is not an option, the alternative treatments will be discussed further with you in more detail, along with an information leaflet.

What happens before the operation?

Before your operation, it is important that you stay as fit and well as you can. If you smoke cigarettes, it is vital that you try to stop smoking as soon as you can. This will help reduce your risk of getting a chest infection after surgery.  You will receive an appointment or phone call asking you to attend for a pre-assessment. This is to assess your general health and fitness for the operation. You may be asked some medical questions and a number of routine tests may be performed. For example, blood tests, electrocardiogram (otherwise known as an ECG or heart tracing), chest X-ray and lung function tests.

It is very important that you bring any medicines, tablets or inhalers that you are taking to this appointment.

Preparing for your operation

You will usually be admitted to the ward the day before your operation and be seen by a member of the surgical team. If there is anything that you have not understood, have forgotten or are particularly worried about, now is the time to ask before you sign the consent form. You can withdraw consent at any time before having surgery.

• A general anaesthetic is used for this operation, which means you will be asleep during the operation. The doctor who gives you the anaesthetic is called an anaesthetist. They will visit you prior to your surgery to discuss the type of anaesthetic to be used and answer any questions you may have.
• Anti-embolic stockings will be applied to help reduce the risk of a deep vein thrombosis (otherwise known as a DVT or blood clots in the legs). You may be given a small injection in your stomach to help prevent a blood clot. You may also be given a drug in the form of a drip and an injection to prepare your body for surgery.
• You will not be allowed to eat or drink anything for between 4 – 6 hours before surgery. Because this surgery involves removing part of your small bowel, you may also be given something to prepare your bowels to ensure that they are empty.
• A porter and a ward nurse will take you to theatre, and a relative may go with you and wait until the anaesthetist is ready.

What is involved in a whipple’s operation?

This operation involves a ‘rooftop’ incision in the abdomen above the belly button, horizontally from one side of the body to the other. This is so the surgeon can see all the organs involved in the surgery.  Along with the head of the pancreas, part of the stomach, small bowel (duodenum), the common bile duct, gall bladder and the surrounding lymph nodes are removed to reduce the risk of the suspected cancer coming back. The remaining structures are joined back together (See Fig A). The surgery can take between 3 – 6 hours.

Fig A – Whipple’s Procedure

The area that has been removed will be sent away to be looked at under the microscope. This helps to decide whether you will require any further treatment.

The precise details of your own operation will be discussed with you by the consultant surgeon who is looking after you. This operation is major surgery. Unfortunately, sometimes during a planned operation on the pancreas, your surgeon may find the disease is not suitable for surgery, perhaps because the suspected cancer cannot be removed as it is more advanced or has spread to other organs. If this is what happens in your case, then a surgical bypass may be performed instead. This means that the suspected cancer has not been removed, but in order to relieve existing symptoms such as jaundice or vomiting, the blockages caused by the suspected cancer have been bypassed. If this is the case, it will be explained to you in further detail by the surgeon once you have recovered. He will also discuss other treatment options with you and may refer you to an oncologist (cancer specialist).

How long will I be in hospital?

It is important that you and your family, together with your nurses, make plans as early as possible for going home. This helps to ensure that you do not have to stay in hospital longer than necessary.  You should expect to stay in hospital for around 10 days to 3 weeks. However, rates of recovery from this surgery vary from person to person, and are dependent on several things. Up to half the people having this operation can develop a “complication”, which may make their stay in hospital longer. Your risk of developing a complication will be explained to you in more detail by your surgeon and clinical nurse specialist.  Briefly, they can include:

• Chest infections and other respiratory (lung) problems
• Bleeding during or after the operation
• Wound infections
• Anastomotic leak (delayed healing of the new “Join” between the stomach, bowel and bile ducts)
• Delayed emptying of the stomach
• Deep vein thrombosis (blood clot in the veins of the leg)

What will happen after my operation?

It is usual to spend at least one night on the intensive care unit, after your operation. You will then be cared for on Ward 14.

You should be awake and able to talk on arrival to the intensive care unit but will probably be quite sleepy. You are likely to have hazy memories of this time and some patients experience vivid dreams and hallucinations. Some people can find these disturbing, but they are only temporary. You will be attached to various tubes and monitors, which allow regular recordings of your observations. This can seem a little frightening but it may help you to know what they are all for, this will allow you to be prepared. They may include:

• An oxygen mask that fits over your nose and mouth, and ensures you receive sufficient oxygen to help you recover from the anaesthetic.
• Intravenous fluids (drip) are usually given by a thin tube that is placed in the vein at the side of your neck (central line). This prevents you from becoming dehydrated while you are ‘nil by mouth’. Antibiotics may be given in the same way. These will be stopped when you are drinking normally.
• A catheter (tube into your bladder) will allow the nurses to accurately record your urine output and means you will not have to get out of bed to pass urine. This will be removed once you are mobile.
• A naso-gastric tube (NG tube) which goes up a nostril, down the back of the throat and into the stomach will be used to help relieve sickness and also to aid the area of the operation to heal. It usually only stays in for a few days and will be removed once your consultant feels that it is no longer required.
• A T-Tube may be inserted into your bile duct to drain the bile produced in the liver and allow the join in the bile duct to heal. This stays in for about 4 weeks. You will go home with this in, and it is usually taken out after a dye test at your out patients appointment.
• Abdominal drains (Robinson’s drains) may be inserted through the abdominal wall. It helps you to heal by draining fluid away from the area of the operation. These stay in for a few days.
• A feeding tube (jejunostomy tube) may be inserted into your small bowel at the time of surgery to allow feeding directly into the bowel. This is to allow the join between your stomach, bowel and bile ducts to heal.
• An epidural may be inserted through your back for pain relief to be delivered.
• A PCAS (patient controlled analgesic system) may be used to give your strong painkillers either through your epidural or intravenous drip.
• You will be allowed small sips of water at first which will be increased slowly, this usually happens over a number of days, but may take longer. Once you are tolerating drinks you will be able to eat.
• You may wake to find flotron boots around your lower leg. These pump up and down to encourage blood flow and prevent blood clots in the leg.
• There will be a long wound across the middle of your abdomen. Staples are usually used to close the wound and are removed before you go home.

How quickly will I recover?

Recovery from a major operation involving the digestive organs is not fast. It can take months for the digestive system to adapt after surgery, although some patients are quicker than others.  Your food and drink intake will be closely monitored by a dietitian, and advice will be given to help you eat well.

A physiotherapist will teach you important coughing and breathing exercises which you will be encouraged to do after your operation. These exercises will help your lungs re-expand and prevent serious chest infections. They will also advise you regarding mobility, which will help prevent the formation of clots in your leg.

During this recovery period you will have regular visits from your clinical nurse specialist. This is to ensure you and your family continues to have their support.

What can I expect when I go home?

• Thinking about going home can be quite an anxious time. It is likely that you and your family will have concerns about how you will manage and what to do if problems arise.  You should already have the contact details of your clinical nurse specialist, whom you should contact with any queries or concerns.
• Your consultant will arrange to see you in the outpatients department a few weeks after discharge. Sometimes this is to see the consultant who did your operation followed by an appointment with an oncologist (cancer specialist). If you do not receive this appointment, contact your clinical nurse specialist who will arrange one for you. This appointment is to review your progress. They will also discuss the pathology findings from the tumour and lymph glands which were removed at the time of the operation. Further treatment options, if necessary will also be discussed.
• If you go home with your T-Tube in you may have a district nurse organised by the ward to help look after this. You will have a dye X-ray test around 4-6 weeks following your operation and if this shows that the join has healed adequately, then your t-tube will be removed. This may happen in out-patients or you may be asked to go to the ward to have it removed. The wound which is left will gradually heal.
• Your other wounds will be healing by the time you leave hospital. You may still have some bruising, swelling and numbness, but this is quite normal and may take some weeks to improve.
• You may take a bath or shower as normal, using unperfumed soap and ensure to gently pat your wounds dry, do not rub them.
• You may continue to feel tender around your wounds for some time after you go home. The amount of discomfort experienced varies between individuals, but you can expect to feel some discomfort for up to 3 months after your operation. You will be given painkillers to take home and you will need to see your GP for further supplies. Continue to take your painkillers on a regular basis, especially in the first week after discharge. When you feel ready, reduce them gradually over a number of days.
• You may already take a tablet called Creon. This helps you digest your food because your pancreas is not working properly. You will need to keep taking this tablet now because part of the pancreas has been removed. If you have not been taking Creon before, then it may be started after your surgery. How and when you take it will be discussed with you.
• It is important to continue the exercises, taught by the physiotherapist, regularly once you are at home. You must avoid heavy lifting or strenuous exercise for at least 8 weeks. This allows the wounds to heal properly. It is however, important to try and develop a routine and take gentle exercise like short walks. It takes up to 6 months to recover fully from this operation, so build up to normal activities in your own time.
• After a major operation it is not unusual to feel low in mood. This may be related to a number of factors such as lack of energy and the frustration of the impact an operation can have temporarily on jobs, hobbies, relationships and sex drive.
• It is important to remember that it can take a few months until you feel you have regained some or most of the strength and energy that you are used to. Getting plenty of rest in the early days of being at home is important. Having an afternoon nap for the first few weeks is recommended, and will prevent you from becoming overtired.
• You may plan a holiday as soon as you feel ready to travel. Holidays which involving flying should not be taken for approximately 6 – 8 weeks after surgery. Check with your consultant and insurance company prior to flying.
• You may be able to start driving approximately 6 – 8 weeks after surgery, once you are able to perform an emergency stop, without pain or hesitation. Check with your consultant and with your insurance company prior to driving.

Will I be able to eat normally?

In the weeks following surgery, you might lose weight, but things will slowly improve as your appetite and confidence improves. Although initially you may not feel like eating, it is very important that you try.  Starting to eat normal foods can feel strange at first, you are likely to feel full very quickly and have a loss of appetite. A dietitian will visit you on the ward prior to going home to advise you on how to overcome some of these problems.  You will also be provided with nutritional supplements, if necessary, to ensure sufficient calorie intake.  Eat little and often as you will feel full quicker than normal. It is important to eat several small meals and snacks throughout the day, rather than rely on 3 small meals a day. To help with loss of appetite, concentrate on eating the foods and snacks you enjoy. You should not need to avoid any particular food, however you may find certain foods upset you in the early days. It may be helpful to keep a food diary and discuss this with your dietitian if this occurs.

The timing of a return to work depends on many factors: age, type of work and whether you have returned to your previous level of fitness. In any event, it may be some months before you do. Heavy work makes more demands and might not be suitable, especially if much bending or lifting is involved. Hopefully your employer may be able to help, by using your skills and knowledge for lighter work, or arranging for you to start with a few hours a day (phased return). Remember to plan time into your day to take nourishment when you need it – little and often.

How often will I have a check up?

After your initial 4-6 week post discharge appointment, you will be seen regularly by your surgeon for the next 5 years. Meanwhile, if you are concerned about any aspect of your recovery, you can contact your clinical nurse specialist.

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the Upper GI Clinical Nurse Specialists on 01482 624349 or (01482) 624350

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

• you must be able to give your consent
• you must be given enough information to enable you to make a decision
• you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.