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buton Transplant Surgery
buton Liver Surgery
buton Pancreas Surgery
buton Gall bladder & Bile Duct Surgery
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Dr Ravi Shankar Dr. Ravishankar
Liver & Transplant Surgeon

Cell: 0065-91817293
Ph: +65-64790608
24hr Svc : +65-65358833
Fax : +65 64797608

Email: diddapur@yahoo.com.sg

Specialist Surgery Singapore Pte Ltd
#02-35, Gleneagles Hospital
6 Napier Road, SINGAPORE 258500
Pancreas Surgery
The pancreas is a small, organ which lies just behind the stomach and deep within the abdomen. It produces enzymes which are useful for the digestion of food and it secretes hormones which, among other things, help maintain and regulate body sugar levels.
How does Pancreatic Cancer manifest itself?
  Generally, the most common symptoms of cancer of the pancreas include loss-of-appetite, weight loss, abdominal discomfort and nausea. As these are all fairly non-specific symptoms, there is often delay in getting to the final diagnosis. The most common physical sign of pancreatic cancer is jaundice, with or without associated itching.
How is Pancreatic Cancer Diagnosed?
  It is usually detected on a US/CT/MR scan.
Often blood tests show a high bilirubin (bile pigment found in the serum) and elevated liver function enzymes. The CA 19-9 marker, a Lewis blood group-related mucin, is frequently elevated in adenocarcinoma of the pancreas.
How do you assess the extent of pancreas cancer?
Staging Studies
Dynamic Spiral CT scan with contrast
MRI Scan
Endoscopy/ERCP/Endoscopic ultrasound
Staging Laparoscopy/Laparoscopic ultrasound
What are the steps in the work up and treatment of the tumor in the pancreas?
  The following questions are sequentially addressed when a patient is seen with a pancreas tumor:
Where is the tumor in the pancreas and has it spread
What is the likely type of the tumor (adenocarcinoma or a less aggressive tumor type)
Is the tumor surgically removable or what other approaches to follow
Is laparoscopic approach possible for your tumor type
Is chemotherapy and/or radiation therapy indicated
What is the surgical treatment of pancreatic cancer?
  The most common (85%) type of cancer of the pancreas is an adenocarcinoma. Surgery is a treatment of choice for patients who have adenocarcinoma of the pancreas that is surgically removable. Appropriate diagnostic testing and careful selection of patients is important to avoid unnecessary surgeries in patients whose tumors are too advanced for surgical removal.We also do scans for heart and lungs to make sure the patient is fit for surgery, as most of the patients are elderly.

The surgical procedure that is done depends on the location of the tumor in the pancreas. For tumors that occur in the head (which is the first part) of the pancreas, the Whipple operation is usually performed to remove the first half of the pancreas and adjacent structures. For tumors that are located in the body and tail of the pancreas a distal pancreatectomy is done to remove the later half of the pancreas. The results of surgery have dramatically improved in the last two decades such that today the mortality (death) rate from surgery is less than 5% in experienced hands. Dr Ravishankar has done Whipple’s operation on patients upto 78 years age and would offer the operations to those 80 years and beyond if they are fit. He has maintained a zero 30 day mortality for all his Whipple’s operation at NUH over the last 4 years.

Many patients will require chemotherapy and radiation therapy after the surgery based on lymphnode status and microscopic margins of clearance.
What is the treatment of advanced pancreatic cancer?
  Patients with unresectable tumors are often treated with chemotherapy and radiation therapy, and in some patients response to the treatment may allow subsequent surgical removal of the tumor.
What are the other tumors in the pancreas?
  15% of tumors that develop in the pancreas are not adenocarcinomas and these tumors often have a far better prognosis. Since many patients with these tumors are often cured after surgery, identification and aggressive treatment of these tumors is important.The tumor types that are found in this group include:
ystic tumors or neoplasms including mucinous cystadenoma and serous cyst adenoma
islet cell tumors also called neuroendocrine tumors
papillary cystic neoplasms
acinar cell tumors of the pancreas
  The majority of these tumors are non-malignant or benign, however even malignant tumors have five year survival rates in the order of 40 to 80% depending on the tumor type. In view of the excellent outcome, aggressive surgical therapy is indicated for these tumors, and the part of the pancreas that is affected by the tumor is removed.

Dr Ravishankar's emphasis has been to preserve as much of the pancreas as possible when removing benign and precancerous tumors to minimize the consequences of removal of large amounts of the pancreas such as diabetes and malabsorption (inability to digest food). He offers procedures like central pancreatectomy where only the central portion of the pancreas is removed for tumors in this location preserving the head and body and tail of the pancreas. He also offers laparoscopic procedures that emphasize minimal access surgical technique for more rapid recovery like laparoscopic distal pancreatectomy for benign tumors of the pancreas.
What is Pancreas Preserving Surgery?
  The pancreas plays an important role in the digestion of food and in regulation of blood sugar. Loss of pancreatic tissue after surgical removal increases the risks for the development of diabetes mellitus and mal-absorption of food.

Preservation of pancreatic tissue is an important goal during surgery for pancreatic and biliary diseases to reduce the risks of loss of pancreatic tissue.

The procedures we offer as an alternative to massive pancreas removal include:

Central pancreatectomy
This procedure is indicated for patients who have low-grade malignant or benign tumors in the neck (in the middle of the pancreas). Removal of tumors in this area often require removing a large portion of the normal pancreas by surgical procedures such as either an extended Whipple operation or a subtotal pancreatectomy (removal of 80% of the pancreas).

We offer a highly specialized surgical procedure that removes only the tumorous portion of the neck of the pancreas. We therefore preserve the head of the pancreas avoiding the Whipple operation and also the body and tail of the pancreas.

Spleen preserving distal pancreatectomy
This procedure is indicated for patients with low-grade malignancy or benign disorders of the tail of the pancreas. The spleen is often removed with a standard distal pancreatectomy, however, in patients with low-grade malignancy or benign disorders of the tail of the pancreas there is often no indication for a splenectomy. We offer a procedure that would remove only the pancreas while preserving the spleen.

Enucleation of pancreatic islet cell tumors
Many functional pancreatic islet tumors such as insulinoma and gastrinoma are small and often on the surface of the pancreas. An operation called enucleation is done to remove only the tumor from the pancreas without removing any pancreatic tissue. We also offer Laparoscopic enucleation of a pancreatic islet cell tumor. This allows rapid recovery, early discharge from hospital and early return to work.

Wide resection of Ampulla Vater
This procedure is offered to patients with ampullary polyps or other benign disorders of the ampulla . Patients usually present with pancreatitis or jaundice. The Whipple operation is usually offered for these benign conditions. We prefer local resection of the ampulla vater for villous adenomas since the pancreas and duodenum are preserved. We widely remove the ampulla and then re-implant the cut ends of the bile duct and the pancreatic duct into the duodenum.

Isolated resection of the third and fourth portion of the duodenum
This procedure is an option for patients with tumors in the third and fourth portions of the duodenum. This procedure is performed to avoid a Whipple operation. In this surgical procedure only the third and the fourth portion of the duodenum is removed and the cut end of the intestine are then sutured together.

What about Neuroendocrine (islet cell) tumors?
  Neuroendocrine tumors of the pancreas (islet cell tumors) are much less common than tumors arising from the exocrine pancreas. About 75% of these tumors are "functioning." That is they are found to be producing symptoms related to one or more of the hormone peptides that they secrete
Except for insulinomas, very roughly about 60% of islet cell tumors are malignant. This rate contrasts with about 10% of insulinomas which are eventually found to be malignant. The sites of metastasis of islet cell tumors most commonly are the liver and the lymph nodes in the vicinity of the pancreas.

Carcinoid cancer is the most common of the neuroendocrine tumors. The symptoms and signs of carcinoid tumors range widely, and depend on the location and size of the tumor, on the presence of metastases, and secretions. They can appear to the surgeon as firm nodules bulging into the intestinal lumen (can originate from pancreas, lungs, thymus, appendix, and ovaries, etc.), with possible local expansion, and possible metastases to mesenteric lymph nodes, liver, ovaries, peritoneum, testes, prostate, spleen and other anatomic locations. Carcinoid tumors can secrete any number of hormonal, growth and other factors. The treatment of choice for localized islet cell tumors is generally curative surgery.
What is Acute pancreatitis?
  Acute pancreatitis is a condition that develops when the pancreas is damaged by an inflammation that leads to swelling and sometimes to necrosis (death) of parts of the pancreas. In about 85% of patients, acute pancreatitis is a mild disease and is associated with a rapid recovery within a few days of onset of the illness.

In about 15-20% of patients, acute pancreatitis can lead to severe damage of the pancreas associated with the development of pancreatic necrosis (parts of the pancreas becomes dead).

Development of pancreatic necrosis often lead to a severe illness associated with an extended hospital stay, multiple surgical procedures and deaths have been reported in some 20% to 50% in this group of patients with pancreatitis.

Patients with severe acute pancreatitis are at risk for developing the following complications:
Failure of multiple body organ systems such as the heart, lungs, liver and kidney.
Pancreatic necrosis (parts of the pancreas becomes dead)
Infected pancreatic necrosis (infection of the dead pancreas)
Pancreatic abscess
Pancreatic fistula
Damage to surrounding organs such as small bowel, colon and duodenum by the inflammat
  Specialty treatments offered at Specialist Surgery Singapore for acute pancreatitis and other Pancreatic and Biliary Diseases:
Team of pancreatic specialists from different subspecialties provide optimal care to patients with acute pancreatitis
Specialized ICU care
Laparoscopic surgery for pancreatic abscess, pancreatic necrosis and pseudocyst. This is one of the few centers in Singapore to offer these complex surgical procedures; our preferred approach for these condition is by laparoscopic surgery.
Experience in open surgical drainage of pancreatic infection and necrosis
Specialized endoscopic procedures for treatment of pseudocyst
What is Chronic pancreatitis?
  Chronic pancreatitis is a condition associated with widespread scarring and destruction of pancreatic tissue. This condition is most frequently associated with alcohol abuse and excessive smoking. The scarring and destruction of pancreatic tissue develops from inflammatory damage of the pancreas over many years due to the effects of alcohol. In many patients this condition may develop without any apparent cause. Chronic pancreatitis is a slowly progressive disease that takes many years to develop.
What is problems can be expected in Chronic pancreatitis?
  Patients with chronic pancreatitis are at risk for developing the following problems:

severe chronic pain

diabetes mellitus
poor absorption of nutrients from the digestive tract especially fats
cancer of the pancreas
blockage of bile ducts
bleeding from the stomach due to splenic vein thrombosis
What are the surgical options in Chronic pancreatitis?
  Surgical operations offered for chronic pancreatitis are:

Pancreatic and Biliary Diseases

Peustow/Frey procedure of pancreatic duct drainage
Laparoscopic surgery for pancreatic pseudocyst
Laparoscopic distal pancreatectomy
Pancreas head coring operation
Whipple surgery

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