Pankreasoperation
Der Pankreas oder die Bauchspeicheldrüse ist eine Drüse, die sich im zentralen Teil des Bauchs befindet. Sie ist in unmittelbarem Kontakt mit der großen Mehrheit der Bauchorgane. Mit ihrer Vorderseite grenzt sie an die Hinterseite des Magens. Der Pankreaskopf ist in der Einbuchtung des Zwölffingerdarms verwurzelt, und mit seinem Schwanz kommt der Pankreas in Kontakt mit der Milz. Auf der Hinterseite des Pankreas befinden sich in unmittelbarem Kontakt die großen Blutgefäße dieser Region, wie der Anfang der Pfortader und die ein bisschen tiefer gelegene obere Eingeweidearterie, die mit der Aorta die aortomesenterische Zange bildet, durch die die linkste Nierenvene durchgeht.
Bild.1
Auf diesem Bild sieht man den Pankreas, die Milz, den Zwölffingerdarm und die magistralen Blutgefäße, sowie von hinten betrachtend den Hauptgallengang..
Der Pankreas ist sowohl eine endokrine als auch eine exokrine Drüse. Das bedeutet, dass sie ihre Sekrete direkt ins Blut (endokrin), aber auch in den Darm (exokrine Funktion) absondert. Das Pankreasgewebe besteht aus mehreren Zelltypen: 1. die Alfa-Zellen, Zellen, die das Glukagon, ein Hormon, das den Blutzuckerspiegel im Blut im Falle von niedrigen Blutzuckerwerten reguliert, absondern, 2. die Beta-Zellen, die das Insulin, ein Hormon, das auch regulatorisch reagiert, indem es den Blutzuckerspiegel senkt, bilden, 3. die D-Zellen, die das Somatostatin, ein Hormon, das regulatorisch auf die Bildung von Insulin und Glukagon wirkt, bilden und 4. die PP-Zellen, die auch selbstregulatorisch auf die Bildung von Hormonen wirken.
Der Pankreas ist ein Teil des menschlichen Organismus, ohne dessen man nicht leben kann.
Wegen der Lage sowie der komplizierten Anatomie und Vaskularisation gehören die Operationen an der Pankreas zu den schwierigsten und größten Operationen der abdominalen Chirurgie. Die meisten Indikationen für die operative Behandlung der Pankreas sind Tumoren und Zysten an der Pankreas. Pankreastumoren sind meistens maligne und am Pankreaskopf lokalisiert. Dem hystologischem Typ zufolge geht es meistens um Adenokarzinome. Dieser Tumortyp ist sehr tückisch, da, wenn sich die Patienten meistens aufgrund dessen, dass sie eine gelbe Farbe bekommen und einen Juckreiz haben, melden, der Tumor bereits ziemlich gewachsen ist und eine Obstruktion am Niveau der Vaterschen Papille, in die die Pankreas-, aber auch Galleninhalte fließen, ausübt.
Bei Patienten, bei denen diese Erkrankung in diesem Stadium diagnostiziert wurde, ist die einzige Lösung eine Operation. Diese Operation heißt „Duodenopankreatektomie“. Ich habe diese drei Wörter absichtlich aufgeteilt. Wir beginnen mit dem letzten. Ektomie bedeutet Herausschneiden. Das Duodenum ist der Zwölffingerdarm und der Pankreas ist die Bauchspeicheldrüse. Also das Herausschneiden der Bauchspeicheldrüse und des Zwölffingerdarms mit folgender Verbindung zweier anatomischer Strukturen beziehungsweise das Verbinden des Magens mit dem Dünndarm, des Gallengangs mit dem Dünndarm sowie des restlichen Pankreasteils mit dem Dünndarm.
Der erste Akt der Operation ist das Öffnen des Abdomens, das meistens nach Orr abläuft und ein bogenartiges Öffnen unter den beiden Rippenbogen, die sich in der mittleren Linie aufholen, versteht. Manche erfahrene Chirurgen wenden, abhängig von der Konstitution des Patienten, auch den mittleren vertikalen Schnitt, an.
Nach dem Öffnen des Bauchs und seiner Untersuchung, beginnt man mit der Verschiebung der Organe, um zum Pankreas zu kommen. Die Verschiebung der benachbarten Organe ist ein sehr mildes Wort, da sehr oft Instrumente, wie die Schere oder das Elektrokauter-Messer, verwendet werden. Genauso wie der Automechaniker einiges entfernen muss bis er dorthin gelangt ist wo er will, so müssen auch die Chirurgen einiges „verschieben“. Man seziert das Gallenbläschen aus der Rebe, legiert die Ballenblasenarterie und der Gallenblasengang gehemmt. Danach beginnt man mit dem Herablassen der rechten Flexur des Dickdarms, um zum unteren Zwölffingerdarmabschnitt. Wenn man zum Zwölffingerdarm kommt, beginnt man mit der Koherisation des Zwölffingerdarms, wo man durch das Heraufheben zur unteren Hohlvene kommt. Nach der beendeten Koherisation des Zwölffingerdarms, nähert man sich der Vorderseite der Pankreas über die Bursa Omentalis und die Hinterseite des Magens. Danach wird die Disektion des Ligaments hepatoduodenale gemacht, worin alle Strukturen identifiziert werden müssen. Auf dieser Stelle bestehen viele Modifikationen des arteriellen Stammes, der meistens von Gallenveränderungen begleitet wird.
Der gemeinsame Lebergang wird durchgeschnitten und hier beginnt in der Tat die Behandlung des Patienten. Danach geht man am Pankreas von seiner Unterseite über die Mesoa kolona transversuma ran, wo die Chirurgen nicht selten die rechte Kolikarterie ligieren und durchschneiden. Wenn die Bedingungen gegeben sind, wird auch der Pankreas im Niveau des Körpers distal über den Processus unciatus durchgeschnitten.
Danach wird der Magen durchgeschnitten, wenn er so durchgeschnitten wird, dass der Pilorus behaltet wird, dann heißt die Operation PPD (Pilorus-präservative Duodenopankreatektomie), und wenn nicht, dann ist sie nach Whippl. Danach werden Verbindungen zwischen dem übriggebliebenen Pankreasteil mit dem Leerdarm, und danach eine Verbindung zwischen dem gemeinsamen Lebergang und dem Leerdarm und am Ende das Verbinden des Magens mit dem Leerdarm. Nach der Herstellung der Verbindungen, werden dem Patienten Drainagen ins Abdomen gestellt.
Falls postoperativ alles gut verläuft, werden diese Patienten nach 12–13 Tagen nach Hause entlassen.
Diese Operationen sind mutilante Operationen, sie dauern lange und sind bis zum Ende ungewiss. Aber ich war an einem großen Teil von Fällen präsent, als diese Verfahren Leben gerettet und bedeutend verlängert haben.
STARVATION
I started with starvation on 14th of April, 2012, after the last meal which was somewhere around 08: 45 pm. In the morning, on 15th of April, 2012, I drank sweetened coffee and smoked 2-3 cigarettes. That day, on Easter, Nebojsa and Katarina came to Sjenica to visit us and they brought food with them in addition to the pile of already brought and present food. Given that starvation is about living only on water, without anything else, I had to give up the bad habit of smoking. That day, my cigarettes were the biggest challenge, bigger than Easter food. Then we went to "Bagic’s", where, if it hadn’t been for my uncle, I would have given in to the temptation. However my uncle's charisma deterred me from taking the cigarettes and alcohol, even though I was on vacation. I slept very well. The first day passed. I didn’t have a headache, as described in books about starvation.
I spent the second day mostly walking, but because of an unnecessary, great fear of wolves, I always carry with me, "teak" – thick stick. That day I walked about 6-7 km and I felt really good after the walking. I felt a desire for food, but not excessive. I was warmed chakras and various parts of the body and the face with stones that I had warmed on the hot stove, which we stoke with juniper and beechwood. We lit the fire with tinder. I went to bed. During the night I woke up at some point and for the first time in my life I didn’t know who I was or where I was and even what I was. Darkness all around me, ‘’neverland’’ at altitude of 1500 m, the wind was whistling, it was pouring down with rain. As if, God forbid, I was in a coffin, but not for the living.
The third day was marked by the beginning of production of a larger than normal amount of stomach acid. I kept spitting. I walked on the third day, too,, about the same as on the second day. I had already felt a little tired, and the walking didn’t feel good. By the way, I am an athlete and my pulse is constantly below 60, but then my heart rate didn’t go under 80. That was very likely due to the adaptation to the altitude, where a temperature from the beginning was 10 degrees lower than the level of the sea, and don’t even let me start about oxygen concentration. I still didn’t feel the lack of air. I continued with warming my body with hot stones. I didn’t sleep well; I woke up several times to urinate.
The fourth day was the calmest from all the rest, until night. However, I think I made a mistake that day because I walked around 12-13 km. I did not feel extremely tired, but I started feeling the lack of air. When I arrived after walking at the cottage I could not relax, nor did my pulse go under 93. I slept poorly, and on top of that I had even more stomach acid than before. I continued warming my body, but I did not have the will because of the stomach acid. Every time I turned in bed, either to the left or right, I had to burp and spit acid in a glass. I fell asleep, I didn’t sleep very well.
The fifth day from the very beginning was somehow "flabby" with the continuation of the acid. I didn’t walk a lot. Everything that had not annoyed me till that moment started annoying me. Smoke in the cottage, my thoughts, my uncle, the starvation, all ... I ran out of the cottage to throw up, but I didn’t succeed. Instead I yelled three times so loud that wolves in the mountains heard me and responded. I felt good, I felt like a primal man. But what was the meaning of a “primal scream" when the acid didn’t stop. When I went to sleep, as soon as I lay down I felt the acid and started spitting. Again: smoke, thoughts, uncle. For a second, I ran to the south terrace of the cottage and started vomiting. I could not believe what a person could throw up when he had nothing but acid and water that he drinks every day in his stomach. During vomitus I got afraid for a moment, but did not ask anything. Vomiting continued. Three jets of vomit and smaller square parts fell on my uncle's wood, which he had prepared to make a cottage. I lay down again, I was afraid to burp again, thinking that the scenario from earlier would be repeated. I ventured, but nothing happened. I had been burping with pleasure until late into the night, until I fell asleep.
The sixth day passed well, the acid was getting weaker. I didn’t walk a lot, about 2-3 km. During all those days of starvation I urinated normally, maybe even easier than in Vrbas. Urine was sometimes yellow, sometimes transparent like water. I slept badly. The sixth day passed.
On the seventh day I remembered Malahov, a top Russian expert in the field of starving, who recommends the use of mild lemonade, of course sugar free. I told my uncle to bring me a lemon from Njegovudj, but he objected because he was my guru. The man who for the last 25-30 years have been starving himself for 12 days every year gave in and brought me a lemon. I squeezed half of a lemon in 2.5 ml of water and drank the sweetest and most beautiful drink in my life. I woke up several times during the night. The seventh day passed.
The eighth day was excellent, whether because of lemonade, whether due to the cessation of the stomach acid, I do not know. In the morning I felt the strength and enthusiasm. The uncle went into the forest to gather firewood, and I even cut them, and I felt good. I bathed approximately every other day, but what was interesting is that the feet had no odour, not even shirts nor underpants. Wonderful, almost divine. On that day, I walked a little. That day I devoured two little lemons into the water. My uncle brought only small lemons, because, as he said, those were male and juicer lemons. Though I didn’t agree with him on that, I wanted the biggest lemons from sea coasts. The pulse slowly began to drop to around 72. I woke up once during the night. The eight day also passed.
The ninth day was filled with even more strength and more work. Again, I chopped firewood, but soon I got tired so I stopped. I went for a walk to get water, about 2 km, and after that I had a bath. We listened to songs on the laptop, I enjoyed every day in conversations with my uncle. He expanded my horizons and gave me the strength to get rid of slavery in which I was living. Slavery of society, slavery of thoughts, behaviours, attitudes, everything ... What was interesting was that I started to realize all my thoughts and I noticed that they were worse than snake venom. This didn’t happen exactly on the ninth day but somewhere around 4-5th day. If only I could turn down, i.e. select those thoughts, I think I would be the happiest and the most successful man in the world. The discipline is the key; I came to that conclusion after I had left the elite 63rd Parachute Brigade, 7 years before. In that 2005 I brought from the army cardiac arrhythmia of so called ventricular extrasystoles. I was very much afraid of it, so I stopped consuming alcohol, coffee, soda, and stopped excessive physical activity. After 6 months, extrasystoles retreated. I went to sleep on the ninth day of the starvation, and I felt one extrasystole. I said to myself that one or two a day weren’t bad. Soon another one appeared. For half an hour other 10-15 appeared. The first thought that occurred to me was to stop starvation. However, I said to myself: ’’We'll see tomorrow.’’ I fell asleep; I woke up once that night.
The tenth day started slowly, I felt a slight fatigue, I had 2-3 extrasystoles. I woke up, washed my teeth, drank lemonade, and now I am drinking water and writing my observation of myself to You. I decided to continue with starvation. At around 11 am my pulse was around 68, which made me happy. In the last 1,5 -2 hours I haven’t had any extrasystoles, which gives me the strength to continue. I'm going to spend this day in silence, in agreement with my uncle, so that my thoughts could become calmer and so that the return to myself could be possible.
Silence suits me. As for the physical changes, I lost weight. Understandable, right? Laughter ... During these ten days, in my estimation, I have lost about 10 kg and now I weight 79-80kg. Lipomas, or popularly called fatty lumps, which I have a lot on my body, on average have declined by one-third from their original volumes. Some have declined more and some less. It seems to me that the bigger the lipoma the faster it disappears. The biggest, which was about 2cm in diameter, is now about 1 cm. I get the impression that all would disappeared after twenty -day long starvation, but this is not recommended by, really precious to me, Gayton. Gayton, a top medical scientist in the field of physiology, says that 14-15 days long starvation is not detrimental to the health. Malakhov has withstood it for 27 or 29 days, and he is still healthy, treating people with starvation for the worst diseases. Well, there are people who do not eat anything, and they are fed with solar energy, the so-called solar yoga, for me the great unknown for now, although I succeeded in looking at the sun setting or rising for nearly seven minutes. My skin has cleansed, I grew beard, my eyes have come into focus, and now I really look like an image of a soldier from Erica Jong’s books, which immediately evokes fond memories of my bachelor life. At around 14:30 my pulse was 66. I feel good, despite negative thoughts that are with me every day. Mainly the fight against the people who annoy me or who annoyed me. A thought starts with something simple, but in the end it finishes with the story where I am in conflict with someone. They are mostly people who are "authorities" when it comes to attitude and talk. I still drink lemonade, I started the second lemon. My uncle thinks that there are no more lemons, but I "stole" one from his backpack while he was changing clothes in a small cottage. I realized that the cause of these mental conflicts is a thinker, in this case-I. I am in conflict with myself, not with those people, who I presented to myself mentally in that way. On the other hand, I'm not the one who decided to interpret things in that way because they have been rooted from my birth, when Learning begins. Wrong or right? I'd say destiny like. The proof that all that has been related to destiny is my own name, which I was given after a top Russian chess players (Boris Spaski (in the Serbian language the word ‘’spasiti’’ means’’ to save’’)). It is just that he saved himself, and I...well, we'll see what means the second i.e. the first part of the surname, Banovic. In that way a man is left at the mercy of those thoughts, or fate. Buddhist teachings say that one should not identify with those thoughts, nor ’’hook’’ on them, and then creates stories with conflicting endings like I do, which consume precious life energy; instead, they should only be seen without emotion and self-identification. The sole feeling and thought of that makes me joyous, because that kind of objectivity in life leads to happiness and life without suffering. It also allows one to get rid of one’s pride and one’s great ’’I.’’ Observation, observation, observation ... My silence suddenly came to an end. At the door of the cottage appeared an old woman, which at the moment reminded me of the old people from Memedovic’s program, which he recorded in the north of the planet. She smiled, I smiled, but I didn’t talk. I thought I would be able to stick to silence. She asked me how my family was and a few more questions which I answered with a polite nod and a smile. I took an apparatus for measuring blood pressure and stethoscope, sat down beside her, and she understood. I took some bags of drugs to tell her what they were used for. I measured her blood pressure that was like in a young man, normal, 120/80. I continued to smile without talking. She asked me what the drugs were for, and I again responded with just a smile. I couldn’t continue it any longer, and then an eruption happened. My voice was strong, full of self-confidence and faith in what I was saying. Then I told her about the drugs and we finished that theme with her satisfaction, and even mine. She told me that her heart was skipping, so I performed ascuIation. I told her she would live for 110 years. The continuation of our story was remarkable. From that old lady I heard the recipe for "vodnjika," a divine drink. First you have to get a barrel of 50 l , with a tap or without it. Then you have to get wild apples- really sour apples, cornelian cherries and dog-roses. I did not ask her what amount went with 50 l of water, but I will make it before I get back to my home town. You put all that into the barrel, and add water almost to the top and tightly close the barrel. It is kept in a dark, cool place (cellar), and is ready for consumption when all these fruits fall to the bottom of the barrel. I have not heard of a healthier recipe for juice than “vodnjika" from Durmitor in my whole life. Dog-roses, Cornelian cherries, wild apples, pinemat manzanita, St. John's worts and many other plants that grow here, at 1500m altitude, are absolutely unpolluted and healthy. Then we talked about how Cornelian cherries could be eaten and dog-roses not so much. But she corrected herself after that and said that they could be eaten when they start to rotten and that she had eaten them before. The old lady doesn’t know what vitamin C is and that dog-rose is famous for vitamin C more than any other food in the world. It is good that vitamin C is non-toxic. But because of that her pressure is as in a young boy, and her heart works like a Swiss watch. Soon after, the old woman left, we greeted each other nicely and she invited me to visit her sometimes. I nodded politely in affirmation, smiled and responded to the greeting. I continued to be silent. The uncle went somewhere, I think he went to Njegovudj, maybe Kolasin, it’s possible even Talin, who knows ... Not to jinx it, the starvation is going great. It seems to me that I might go like this forever. I measured my blood pressure today and it was 110/80, almost like in the old woman. Towards the end of the tenth day of starvation, I decided to try an experiment. I had been thinking about what could speed up the removal of fat from the body, as well as lipomas. After some thinking I realized the answer was fat. I remembered that my uncle had oil, and I rose up from the bed and in my assessment I drank about 0.3 ml of sunflower oil. I did that so that the body could, after the consumption of this small amount of oil, start consuming its own fat for energy. This is energetically around 2.8 kcal, which is enough for my body for 3 minutes of basal metabolism ... I was resting the whole day, except when I went out at dusk to catch some air. I saw a crescent moon with its morning star, which looked like a scene from some big-budget Arab film. A little lower from them, towards the west, stretched a scene of a raw wilderness, covered with dark clouds and here and there turned on light in houses of Zabljak. DURMITOR ... Contrasting picture of a beautiful and terrifying showed me that they were both life. I went to bed around 10 pm, however, I couldn’t fall asleep until 04-04: 30 am. Stomach acid tortured me, likely because I had drunk water from a cistern, which was repugnant to me, but when there was no other I had to drink it. I felt an incredible hunger, unrest all over the body, especially around the blades, upper arms and thighs. My thoughts were everything but beautiful. I decided to stop the starvation. At one point sexual thoughts appeared, so I fell asleep. I woke up at around 8 am, but I stayed in bed until almost 11.30 am.
The eleventh day of starvation started with the charge of the energy we get every morning, so I gave up the thought of quitting my starvation. I touched the lipoma on the left upper arm, it decreased by 2/3 of its original size. If I had time, I might continue this for 14 days, but I have to go home in 3 days, and I wouldn’t like to go as an ascetic, who cannot eat anything. I told my wife that my uncle bought lamb and that we stuffed ourselves because of which I gained 5-6 kg. When she sees me, I hope she will not get a heart attack. The kids will recognize my smile, I'm sure of it, but they might not recognize me at first. I do not measure my pulse any more. I decided to stop starvation, but the uncle came from Njegovudj, and after a brief loud discussion he quickly dissuaded me from it. He brought everything from Njegovudj, and a blackberry wine especially caught my eye. Outside, the weather was sunny with a breeze and birds singing. I observed a white cat that sat on a stump and turned towards the sun, and began to collect energy. It seemed to me that it was a statue. I said to myself: ’’You, too, mate, concentrate on moving less and absorb the Sun's energy. So I did it, just, the problem was I turned on every sound the cat made to see what it was doing. It was still like a statue. We both stayed like that until sunset. On the day, 25.04.2012, from the place just a little above my uncle's cottage where I was sitting in an armchair, the sun set behind Durmitor at circa 06:56 pm. I had two more nights to spend there, and then my Uncle and I were going to "pour" the blackberry wine down our throats. So far, yet so close ... I went to bed around 09: 30pm. I slept much calmer, almost without any tension. I remembered a friend, Ana, who practiced yoga who once told me that most people do not know how to breathe. She told me one has to breathe using the stomach. I tried it and at that moment I felt relief in the whole body and fell asleep. That night I slept best of all days I had been there. I slept seven and a half hours, which was fantastic compared to the average of less than four hours each day, except the first. The eleventh day also passed.
The twelfth day started, and I feel like a baby dragon, I am about to fly and spit fire. Why is this so, whether because of two lemons which I gulped yesterday afternoon, or Ana's breathing or yesterday's sun, or today’s sun, or all together, I have no idea. Anyway, this morning was the first morning since I have been here that it was not snowing or raining when I woke up. The weather is great. The uncle will show me where to pick pinemat manzanita (kinnikinnick) and I'll pick one bag of 10-15 kg so we would have in Vojvodina something unsprayed and healthy we can eat throughout the year, when it dries. I picked exactly that amount, but when leaves are dried and separated from their stems it will amount to perhaps only 4-5kg. Pinemat manzanita grows on hills near rocks and in this region there is quite a lot of it. The quality of this pinemat manzanita is not comparable with the other pinemat manzanita originating from Vojvodina. The man, who my uncle picks pinemat manzanita for, won all the gold medals at plant fairs. I returned, rested a bit and after that went to the spring ’’Srndajica’’ to collect water. The water was so good, that words could not explain or describe it. Currently I am resting a little outside, a little inside, because the sun is very strong. I am not hungry, but tomorrow morning I will start with the crust of bread that can only be chewed and rubbed with tongue, and then spit. Then I will suck one half of an orange and I will eat another. After that I will drink sweetened tea from pinemat manzanita, and we will see what afterwards. Again, in the afternoon, as the sun slowly went towards the west, appeared, as it seemed to me, the only friend I had ever had in my life, the white cat. It sat on the stump near the cottage and began to absorb the sun's energy. I did the same. It was nice. The uncle worked really hard on that day, he worked as if he was a young boy, and not a 62 years old man. He prepared dinner for himself, baked bread, whose smell filled whole Durmitor, fried bacon and some salami, and I ... I almost gave in to the temptation. Soon after that I went to my room to sleep. I fell asleep before midnight. I woke up on the thirteenth day of the starvation, and I felt the smell of soup. I went down, washed my face and thanked the uncle because he had been helping me endure this method of health and regeneration. The chewing started; I turned crust of bread in the mouth, rubbed my tongue with the crust and spat all out. I did the same with an orange. Now, just a couple of tablespoons of soup and my breakfast is completed. Ladies and gentlemen, this is it. I have to go sipping my soup.
Pancreatic surgery
The pancreas is a gland that is located in the central part of the stomach. It comes in direct contact with the vast majority of abdominal organs. Its front side comes into contact with the back of the stomach. The head of the pancreas is lodged within the concavity of the duodenum, and with its tail the pancreas comes into contact with the spleen. On the back of the pancreas, in direct contact, there are large blood vessels of the region, and this is the beginning of the portal vein and placed a little deeper is the superior mesenteric artery, which forms the aorto-mesenteric clamp with the aorta through which the left renal vein passes.

sl.1
In this photo can be seen the spleen, pancreas, duodenum and main blood vessels, as well as the common bile duct, seen from behind.
The pancreas is both an endocrine and exocrine gland. This means that it secretes its excreta directly into the bloodstream (endocrine), but also into the intestine (exocrine function). Pancreatic tissue consists of several cell types, namely: 1. The alpha cells, which secrete glucagon, a hormone that regulates the level of glucose in the blood in cases of low blood sugar (increases glucose in the blood), 2 Beta cells that secrete insulin, a hormone that also acts regulatory, lowering the level of glucose in the blood, 3. D cells which secrete somatostatin, a hormone which also regulates the secretion of insulin and glucagon and 4. PP cells, which also act self-regulatory on hormone secretion.
The pancreas is part of the human body without which a person can live.
Because of its location, but also its complicated anatomy and vascularization, surgery on the pancreas belong to the most difficult and biggest operations of abdominal surgery. The most common indications for surgical treatment of the pancreas are pancreatic tumors and cysts. Pancreatic tumors are usually malignant and localized on the head of the pancreas. The most common histological type is usually adenocarcinomas. This type of tumor is very insidious because when patients come to a doctor, usually because their skin becomes yellow and itchy, tumor has already grown quite big so that it causes obstruction on the major duodenal papilla level, which the pancreatic, but also the bile content flows into.
For patients who are diagnosed with this disease, at this stage, the only solution is surgery. This operation is called Duodenopancreatectomy. I deliberately separated these three words. We will start with the last one. Ectomy means elimination. The duodenum is the first portion of the small intestine, from the stomach to the jejunum, and the pancreas is a gland inside the body, near the stomach. So it means the removal of the pancreas and duodenum with the consequent creation of anastomoses, or connecting the stomach to the small intestine, bile duct to the small intestine and the remaining part of the pancreas to the small intestine.
The first act is to open the abdomen, which is usually according to Orr method, which means performing a transverse incision beneath both costal arches which meet in the midline. Some experienced surgeons, depending on the constitution of the patient, use a vertical (midline) incision.
After opening the abdomen and its exploration, the moving of the organs starts in order to come to the pancreas. Moving of the adjacent organs is a very mild term, since usually used instruments are scissors and an electrocautery knife. Just as a car mechanic has to remove a lot in order to get where he wants, surgeons also have a lot to "move". The gall bladder is removed from its lodge, cystic artery is ligated, and cystic duct restrained. Then it is starts with lowering the right colic flexure in order to reach the bottom of the duodenal knee. When the duodenum is reached, starts the mobilization of the duodenum by Kocher’s maneuver, where the inferior vena cava is reached by lifting. With the completion of mobilization of duodenum by Kocher’s maneuver, the front of the pancreas is approached, over the bursa omentalis and back side of the stomach. After that dissection of the hepatoduodenal ligament is performed, where all structures in it must be identified. At this point there are many modifications of the arterial tree, which is usually accompanied by biliary modifications. The ductus hapaticus communis is cut and this is actually where the treatment of a patient begins. Then the pancreas is approached from its underside, through the transverse mesocolon, where surgeons often ligate and cut the right colic artery. When conditions are met the pancreas is cut at body’s level, distal to processus uncinatus.
Then the stomach is also cut, if it is cut in the way to preserve the pylorus, then this operation is called PPD (pylorus preserving duodenopancreatectomy), and if not, then it is the Whipple procedure. Then the anastomoses are created between the remaining part of the pancreas and the jejunum, and then the anastomosis between the ductus hepacticus communis and the jejunum, and finally connection of the stomach with the jejunum. Upon completion of the creation of the anastomoses, drains are placed in the patient’s abdomen.
If all goes well after the surgery, patients are discharged from the hospital after 12-13 days.
Such surgeries are mutilating surgeries; they are long-lasting and uncertain until the very end. However, I attended a number of cases, where these procedures saved and significantly prolonged people’s lives.