The pancreas produces important enzymes. It produces 1.5–3 L of enzyme-containing secretion daily. This digestive secretion is produced by specialized cells throughout the gland and is directed through a widely branched ductal system where it finally collects in a main duct called the “ductus pancreaticus”. Just before entering the duodenum, the pancreatic secretion is joined by bile from the liver. These secretions are passed into the duodenum, through the papilla Vateri. In the duodenum, the pancreatic enzymes are activated, allowing food coming from the stomach to be digested.

The pancreas produces more than 20 different digestive enzymes that break down food into its smallest building blocks. The three most important enzymes of the pancreas are:

• Amylase, which digests carbohydrates
• Trypsin, which digests proteins
• Lipase, which digests fats.

Food components need to be broken down into smaller pieces so the body can absorb them through the intestines. If the pancreatic enzymes are missing, the carbohydrates, proteins and fats are not broken down properly and the intestine is not able to transport the nutrients to the blood. The undigested food is then transported through the intestines, leading to diarrhea, flatulence, and abdominal cramps.

In addition to digestive enzymes, the pancreas produces an important hormone, insulin. Insulin is released directly from the pancreas into the blood. This hormone controls blood sugar levels. In a sense, it opens the doors of all the body’s cells to allow sugar in. Glucose is the most important sugar molecule and all cells depend on glucose. Insulin enables glucose to pass from the blood into the body’s cells. If there is too little or no insulin, glucose cannot pass from the blood into the body’s cells. This causes blood glucose to rise, which has life-threatening consequences for humans. Diabetics do not produce enough insulin so have sustained high blood sugar levels.

The pancreas produces another important hormone, glucagon. When low blood sugar threatens the function of cells, glucagon releases glucose from reserves in the body, especially in the liver, and blood sugar rises. If the pancreas is absent, this important hormone cannot be produced. This must be taken into account when treating pancreas-operated patients.

 

Pain or discomfort in the upper and middle of the abdomen is the most common complaint in pancreatic diseases. Typically, abdominal pain is belt-shaped or radiates to the back (the pancreas is located in the back of the abdomen, which explains the back pain). The pain may be quite sudden and severe (acute pancreatitis), recurrent (chronic pancreatitis), or slowly increasing (pancreatic tumor). Jaundice is also a prevalent manifestation of pancreatic diseases, especially pancreatic tumors, and is caused by occlusion of the bile duct by tumors in the pancreas head. Other symptoms of pancreatic disease include diarrhea, bloating, flatulence, or diabetes. Other signs and disorders are due to the reaction of the immune system to the cancerous tumor, known as a “paraneoplastic syndrome”. These signs include weight loss, skin lesions, and fatigue.

 

Cancer of the pancreas is a very serious disease that needs to be treated very quickly. The sooner you catch the disease, the better your chances of survival. In addition to a consultation with your physician and a physical examination, other methods can be used to diagnose pancreatic cancer, including laboratory tests, ultrasound, computed tomography scan, magnetic resonance imaging, and endoscopic examination of the duodenum with X-ray imaging of the bile and pancreatic ducts. If these methods do not give a clear diagnosis, diagnostic laparoscopy or trial surgery must be performed.

 

A carcinoma can only be cured surgically by removing it. This is accompanied by treatment of the symptoms and the consequences of the disease (pain management, improvement of digestion, insulin therapy, etc.) Chemotherapy and radiation treatment alone do not cure the disease, but prolong and improve the quality of life. Nowadays, an individualized multimodal therapy, comprising a combination of modern chemotherapy (before and/or after surgery) and curative surgery, has improved the prognosis and increased the life expectancy of patients with pancreatic cancer. This holistic treatment can also improve the patient’s quality of life and can increase their mobility and autonomy, allowing them to return more quickly to normal physical activity.

Pancreatitis is the inflammation of the pancreas and can be acute or chronic.

Acute pancreatitis is an acute inflammation of the pancreas, often caused by gallstones blocking the pancreatic duct or by too much alcohol damaging the cells of the pancreas. Acute pancreatitis is dangerous and should be treated in hospital. Inflammation causes the pancreas to swell, bleed, and self-digest and may affect other organs. In 85% of cases, acute pancreatitis is mild whereas in 15% of cases it is life-threatening. Acute pancreatitis is usually treated medically or interventionally (such as endoscopic treatments) and surgery is only needed in case of complications, such as abscess formation or extensive tissue damage.

Chronic pancreatitis is an inflammation of the pancreas that usually progresses over years and causes severe pain. It is triggered by alcohol in 80% of cases. Repeated episodes of inflammation lead to an increasing loss of function and deficiency of digestive enzymes, vitamins, and insulin. The pancreas is severely altered over the years, hardening and even calcifying. Chronic pancreatitis can lead to cancer, so patients with chronic pancreatitis need regular check-ups by a specialist. One in two patients with chronic pancreatitis will require surgery during the course of their disease. This must be performed very carefully and in specialized hospitals. Surgery may be necessary for the following reasons:

1. If the pain cannot be controlled with conservative or interventional methods.
2. If chronic inflammation of the pancreas has blocked the duodenum, bile duct, main pancreatic duct, or vessels behind the pancreas.
3. If it is unclear whether a tumor has developed.

The best time for surgery must be discussed with an experienced pancreatic surgeon. Early removal of the inflamed area can help preserve important pancreatic functions such as digestion and blood sugar control.

 

There are several indications for pancreatic surgery, including pancreatitis, suspicious precancerous changes, and cancer. The most common indication for pancreatic surgery is the presence of a malignant or premalignant neoplasm in the pancreas or adjacent structures, such as the bile duct or duodenum. In acute pancreatitis, surgery is only needed if there are complications. In chronic pancreatitis, surgery is usually necessary in later stages of the disease (after 3 to 5 years).

There are different options for performing pancreatic surgery, including open and minimally invasive (laparoscopic or robot-assisted) operations. Minimally invasive surgery is done using small incisions, with light and a camera, instead of making a big abdominal incision. Recently, robot-assisted surgery has been used for pancreatic operations. The surgical method should be decided on an individual basis, based on the type and progression of the disease and the patient’s medical and surgical history.

Possible risks of pancreatic surgery include:

• Internal infection or abscess and fluid collection, which can be treated by draining the abscess and antibiotic therapy.
• An abnormal opening (fistula) of the pancreatic or bile duct, which can leak into the abdomen. This can usually be treated by drainage or stenting and rarely needs a second surgery.
• Bleeding, which can be treated by blood transfusion or radiologic interventions or sometimes even by surgery.
• Blood clots, which can be treated with anticoagulant medications.
• Lung infection and heart problems.

The risks of surgery are low if the surgery is done in a center with high experience. The risks are higher if the surgery is done in a hospital with less experience of pancreas surgery.

You can live without your pancreas, but you will have to take medication to replace pancreatic digestive enzymes and insulin. Because your body will no longer produce insulin to control your blood sugar, you will have diabetes and you will need to monitor your blood sugar and take insulin at regular intervals. You will also need interdisciplinary follow-up with surgeons, endocrinologists, gastroenterologists, and nutritionists to regulate your blood sugar and diet and control your general condition.

Patients who have had part or even all of their pancreas removed may experience functional impairment of the pancreas, depending on the extent of the removal. There are two main problems:

• too few pancreatic enzymes (leads to digestive problems)
• too little insulin (leads to high blood sugar and diabetes)

These deficiencies can be substituted with appropriate medications.

1. Pancreatic enzyme substitution

Today, there are preparations on the market that replace the function of pancreatic enzymes (e.g., Kreon). These enzyme preparations must be taken with all meals and snacks. The dosage varies from patient to patient and depends on the type of food being eaten and the patient’s symptoms. Typically, higher dosages need to be taken with main meals than with snacks in between. As a rule, you can eat normally, but you should eat more than 3, preferably 5–6 meals a day. After major pancreatic surgery, you have to limit fat consumption or adjust it to your tolerance. However, the quality of life remains good after pancreas surgery.

2. Insulin substitution

If pancreatic disease or pancreatic surgery causes high blood sugar levels, appropriate blood sugar therapy is needed. Diabetes only develops if 60–90% of the pancreas is removed, or if the gland is already damaged by chronic inflammation. If blood glucose levels are not highly elevated, they can be controlled by adjusting food intake and taking tablets that regulate glucose levels. However, the loss of insulin-producing cells often means insulin treatment is needed. This treatment needs to be closely supervised by the family doctor or specialist, especially during the initial phase.

Nowadays, with improved multidrug chemotherapy regimens and surgical approaches, patients with advanced pancreatic cancer might receive curative treatment in specialized cancer centers. However, if curative resection is not possible because of tumor progression or metastasis, other multimodal therapy options can increase survival of patients or decrease symptoms of cancer. These treatments include chemotherapy or surgical removal of distant metastasis (e.g., in liver or lung) or palliative surgeries (e.g., bypassing the intestinal or bile duct obstructions), and can significantly improve the survival or the quality of life of patients.

The spleen may have to be removed as part of a pancreas operation.

It is possible to live without a spleen. The spleen plays a role in the immune system, so without it you are more susceptible to bacterial infections. These can become life-threatening diseases, so you should receive an appropriate vaccinations after surgery, such as the vaccination against pneumococcal infection. According to current guidelines, these vaccinations must be repeated after 3–5 years. When an infectious disease occurs, the patient should visit the family doctor and tell them that they no longer have a spleen. The doctor will then decide whether antibiotic therapy is necessary.

After splenectomy, there may also be an increase in blood platelets (thrombocytes). It is important to check this regularly. If the increase gets too high, the risk of thrombosis increases and your doctor should temporarily prescribe medication such as aspirin to reduce this risk.

The pancreas develops from two parts that normally merge during embryo growth. These two parts and the separate ducts merge into one organ, as the part located further forward (ventrally) migrates to the rear. During embryonic development, the merging of the pancreas may be disturbed, which may lead to disease.

1. Anulare pancreas

During the early phase of development, the migration of the ventral pancreas causes a part of the duodenum to be wrapped above the papilla, thus obstructing the passage of the food.

2. Pancreas divisum

In this anomaly, the two ductal systems of the pancreas do not fuse together, while the actual tissue does. Thus, two ducts opening into the small intestine remain. Secretions from the larger posterior (dorsal) portion are drained through the ductus Santorini via a “minor papilla”. The anterior smaller (ventral) section empties its secretion into the ductus Wirsungianus via the “major papilla”. As a rule, this is not important and only obstructs pancreatic outflow if the minor papilla has an excessively narrow outflow duct in the papillary region. This can cause acute or chronic pancreatitis.