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Pancreatectomy: Indications, Types, and Consequences

A pancreatectomy is surgical removal of part or all of the pancreas. It is a major operation with lifelong metabolic consequences, reserved for specific indications.

Indications

1. Pancreatic Cancer

Whipple procedure (pancreaticoduodenectomy): Head/neck tumors. Removes pancreatic head, duodenum, gallbladder, distal bile duct, ± distal stomach; reconstruction with pancreaticojejunostomy, hepaticojejunostomy, gastrojejunostomy.
Distal pancreatectomy: Body/tail tumors. ± splenectomy.
Total pancreatectomy: Multifocal, centrally located, or positive margins after partial resection.

2. Chronic Pancreatitis

Refractory pain despite endoscopic/medical therapy
Distal pancreatectomy (if disease distal) or total pancreatectomy (diffuse)
Autologous islet transplantation (AIT) may preserve endocrine function

3. Trauma

Grade III–V pancreatic injuries (AAST): distal pancreatectomy for body/tail transection; Whipple for head destruction.

4. Neuroendocrine Tumors (NETs)

Insulinoma (enucleation or distal pancreatectomy)
Non-functional NETs >2 cm or growing

5. Premalignant Cysts (IPMN, MCN)

High-risk features: main duct dilation >10 mm, mural nodule, cytology, symptoms

Consequences of Resection

Postoperative Management

Pancreatic enzyme replacement therapy (PERT): Enteric-coated lipase with meals/snacks; titrate to symptoms.
Diabetes management: Insulin therapy (brittle if total); CGM recommended. Glucagon absent after total pancreatectomy → hypoglycemia risk.
Nutrition: Small, frequent, low-fat meals; fat-soluble vitamin supplementation (A, D, E, K).
Surveillance: Imaging for recurrence (cancer); metabolic monitoring.

Multidisciplinary Decision

Pancreatectomy requires a team: HPB surgeon, medical oncologist, gastroenterologist, endocrinologist, nutritionist, anesthesiologist. Goals: oncologic clearance, symptom relief, quality of life.

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Extent	Exocrine Insufficiency	Endocrine Insufficiency
Distal (≤50%)	Uncommon	Uncommon (diabetes ~10-30%)
Distal + spleen	Uncommon	Higher diabetes risk; asplenia (vaccines, antibiotic prophylaxis)
Whipple	~30-50% (PEI)	~20-40% diabetes
Total	Universal (severe)	Universal (brittle diabetes)