Hepatobiliary and Pancreatic Surgery

Our specialist consultation service advises patients with diseases of the liver, gallbladder, bile ducts, and pancreas.

These organs work together as a functional unit (hepato-pancreato-biliary unit) in the digestive system.

The liver is the largest internal organ in the human body. It metabolizes the sugars, proteins, and fats ingested with food and immediately converts them into energy or stores them for later use. It detoxifies harmful substances, including drugs and toxins, so that they are less harmful and can be more easily excreted from the body. It also synthesizes important proteins such as albumin and clotting factors, and produces bile, a digestive fluid that aids in the digestion and absorption of fats.

The bile ducts consist of the bile ducts and the gallbladder. The bile ducts are a duct system within the liver whose main function is to transport bile produced by the liver to the small intestine. The gallbladder serves as a storage facility. It concentrates the bile produced by the liver and releases it into the small intestine when it is needed for digestion.

The pancreas is an organ with two main functions: enzyme and hormone production. Digestive enzymes are released into the small intestine and help break down nutrients (sugars, fats, and proteins). The hormones insulin and glucagon are produced by the pancreas, placing the organ at the center of blood sugar and metabolism regulation. Together, these organs play an essential role in digestion, metabolism, and the regulation of nutrients in the body, thus forming a coherent functional unit within the digestive system. Our Hepato-Pancreato-Biliary Surgery (HPB Surgery) working group consists of a highly specialized surgical team that deals with the treatment of diseases affecting the liver, bile ducts, gallbladder, and pancreas. This field encompasses a wide range of surgical procedures aimed at the diagnosis, treatment, and management of various diseases of these organs.

The most important aspects of the specialty include

– liver surgery, both for benign and malignant tumors, including partial liver resections (partial removal of the liver), liver transplants, and other local liver treatments

– surgery on the bile ducts and gallbladder, ranging from cholecystectomy (removal of the gallbladder) as the most common operation to bile duct resections and reconstructions for benign and malignant diseases

– pancreatic surgery for cysts, pancreatitis, and tumors, including pancreatic cancer, involving partial (e.g., pancreatic head or left pancreatectomy) and complete removal of the pancreas

– minimally invasive surgery, including laparoscopic and robotic-assisted surgery, which results in shorter recovery times, less pain, and shorter hospital stays compared to traditional open surgery

– the multidisciplinary approach, thanks to which modern treatment concepts for complex diseases are developed in accordance with the latest scientific findings in collaboration with experts from the fields of hepatology, oncology, radiology, and pathology.

We treat patients with long-standing complaints (e.g., gallstones), specific symptoms (yellowing of the skin = jaundice, increased itching = pruritus, right upper abdominal pain), abnormal laboratory values, or imaging findings (e.g., ultrasound examination) that were performed as part of a preventive medical checkup and require further clarification. All complex clinical pictures as well as all malignant tumors of the liver, gallbladder, and pancreas, and metastatic diseases of the liver are discussed in a multidisciplinary conference.

The monitoring and regular examination of conditions such as cysts or chronic inflammatory diseases, which carry a certain risk of degeneration, is also carried out in collaboration with our colleagues in internal medicine.

We also offer individual post-operative care and oncological follow-up care after resection of malignant diseases in our special outpatient clinic. Oncological follow-up care lasts a total of 5 years, with the first appointment due just 3 months after discharge. Depending on the clinical picture, oncological follow-up care can also take place in the Department of Internal Medicine, while surgical issues continue to be treated in our surgical department.

The typical examination procedure in our outpatient clinic includes a detailed medical history (anamnesis) with a corresponding clinical examination and blood test. Depending on the individual case, imaging examinations are then arranged either immediately or by appointment. A thorough examination usually includes at least one imaging examination. Very often, the first examination is a computed tomography (CT) scan, often supplemented by magnetic resonance imaging (MRI). In some cases, a special ultrasound examination with contrast medium, an endoscopic X-ray examination of the bile ducts (ERCP), or an endoscopic ultrasound examination (endosonography) may also be necessary. In many cases, some of these examinations have already been performed beforehand in a doctor’s office or at another clinic. If this is the case, we ask patients to send us the images and findings in advance so that they are available at the initial consultation and further diagnostic or therapeutic steps can be taken immediately. In some cases, special examinations are necessary for an accurate diagnosis, which are often only available at our clinic.

Patients can consult us independently or by referral for a second opinion. These cases, which are usually complex, are discussed in our multidisciplinary conference and a recommendation on treatment options is made.

For planned, complex resections, we offer a prehabilitation program involving experts in physical medicine and rehabilitation, nutritionists, anesthesiologists, psychologists, and specially trained nursing staff (Innsbruck Perioperative Patient Pathway). The aim of this program is to prepare patients for surgery both physically and mentally, thereby achieving a faster recovery. physically and mentally for surgery in order to achieve a faster recovery.
Careful collection of medical history in conjunction with state-of-the-art and innovative diagnostic and treatment methods form the foundation on which we build to provide the best possible care for patients with liver, biliary tract, or pancreatic diseases.

Liver

The liver is the second largest organ in the human body after the skin and, weighing approximately 1,500 g, the heaviest. It is located in the upper right abdomen on the underside of the diaphragm and is almost completely covered by the right rib cage. The anatomical division into a total of 8 liver segments (left lobe segments I-IV, right lobe segments V-VIII) according to the blood supply is clinically important. As the only solid organ in the human body, the liver has a remarkable ability to regenerate, meaning that up to 80 % of the liver can be removed without causing any damage to the remaining liver tissue. Another special feature is the liver’s dual blood supply. Nutrient-rich blood from the gastrointestinal tract flows through the portal vein (vena portae) to the liver, the central metabolic organ. Arterial blood flows into the liver via the hepatic artery (arteria hepatica). This has a significant influence on susceptibility to diseases or tumors, as well as on the corresponding treatment options, as explained below.

Benign liver tumors

There are a number of benign tumor-like changes (tumors) in the liver. This means that these benign tumors cannot form metastases. Benign liver tumors typically only cause symptoms in patients at a late stage due to their size. Therefore, the diagnosis is often made incidentally during an imaging procedure such as an ultrasound examination or computed tomography. Even benign tumors may need to be surgically removed if they exceed a certain size and compress or constrict surrounding structures such as bile ducts or vessels, or—in rare cases—could develop into a malignant tumor.
Liver hemangiomas (“blood sponges”) are the most common benign liver tumors. Women are affected approximately 2-6 times more often than men. In most cases, a clear diagnosis can be made using ultrasound or contrast-enhanced imaging (ultrasound, computed tomography, or magnetic resonance imaging). While most hemangiomas are less than 5 cm in size, they can occasionally grow considerably larger and cause nonspecific symptoms (e.g., a feeling of pressure in the upper right abdomen). In rare cases, hemangiomas can show significant growth in size. A hormonal influence is being discussed, as growth in size has been described during pregnancy and under the influence of estrogen and progestogen. However, these lesions usually remain relatively constant in size, so that surgical removal is only necessary in cases of pain, growth, or the presence of Kasabach-Merritt syndrome.
Regular check-ups are not necessary for typical hemangiomas without imaging abnormalities and without growth.

Focal nodular hyperplasia (FNH) is the second most common benign liver tumor and predominantly affects women (approx. 90%). Contrast-enhanced magnetic resonance imaging is the best method for diagnosis, as it reveals a central scar that is typical for this tumor. FNH is usually asymptomatic and non-progressive, except for its size. Furthermore, unlike adenomas (see below), there is no risk of degeneration, so typical FNHs do not require further monitoring.

Hepatocellular adenomas are benign liver tumors that occur almost exclusively (approx. 90 %) in younger women (aged 35 – 40). There is a clear association with the use of oral contraceptives (birth control pills). Associations with androgens or the use of anabolic steroids and severe obesity have also been described. Magnetic resonance imaging is the method of choice for diagnosis. Hepatocellular adenomas carry a certain risk of malignant transformation. This means that a benign tumor can become malignant. In male patients, a hepatocellular adenoma is therefore always an indication for surgical removal. In women, the further course of action depends on the size of the adenoma. Adenomas smaller than 5 cm can be monitored. Oral contraceptives should be discontinued during this time and, if necessary, body weight should be reduced. Adenomas larger than 5 cm, or those that show growth in size during follow-up examinations, should be surgically removed. In cases of uncertainty, a biopsy of the adenoma and a subsequent molecular biological examination may be useful. In rare cases, a liver transplant may also be necessary.

Tapeworm infection of the liver (Echinococcus) is a typical parasitic disease in humans and is one of the oldest known diseases in humans and animals (mentioned as early as in the Talmud / by Hippocrates). Humans are only an “accidental” intermediate host for all tapeworms, becoming infected through the accidental ingestion of worm eggs. While 16 species of Echinococcus were originally known, four are clinically relevant to humans and, in our latitudes, mainly two species:
– Echinococcus granulosus (cysticus) – dog tapeworm (worldwide)
– Echinococcus multilocularis (alveolaris) – fox tapeworm (Northern Hemisphere)
After the often asymptomatic ingestion of worm eggs (occasionally accompanied by diarrhea-like symptoms), there is often a symptom-free interval lasting several years, during which the cysts grow slowly in the liver. While the cysts usually grow larger and exert pressure on surrounding tissue, only those caused by Echinococcus multilocularis (alveolaris) exhibit aggressive growth that infiltrates the tissue (similar to a malignant tumor). Symptoms occur on the one hand due to growth (compression or capsule tension pain) and on the other hand due to infection of the cysts. An often dramatic event is an allergic reaction to the worm components caused by a cyst rupture. Such a rupture also carries the risk of the worm components spreading into the free abdominal cavity.
Without treatment, all of these tapeworm diseases are progressive, with the 10-year survival rate for Echinococcus multilocularis (alveolaris) in particular being only 6-25%. The diagnosis is made on the one hand by imaging (ultrasound/CT scan/MRI) and on the other hand by a blood test (which, however, may be negative despite worm infestation).
In all cases, drug therapy (e.g., albendazole) will be recommended. Echinococcus multilocularis (alveolaris) foci also require removal from healthy liver tissue through partial liver resection. This should be followed by several years of drug therapy with annual follow-up examinations.
Lesions caused by Echinococcus granulosus (cysticus) can also be treated less invasively, depending on their location and size, by chemically killing the worm and then draining the cyst using a needle inserted through the skin. If surgery is necessary, the cyst can usually be removed from the liver (= pericystectomy). In all cases, it is particularly important not to damage the cyst in order to avoid spreading the infection in the abdominal cavity. However, completely calcified (= most likely dead worms) foci can be observed in this worm.
In rare cases, echinococcus infestation of the liver may occur that is not amenable to surgery or is not possible due to the patient’s fitness. In such cases, we begin drug therapy and offer regular follow-up checks in collaboration with our colleagues in internal medicine.

Malignant liver tumors

Malignant tumors (malignancies) that originate in the liver tissue itself are referred to as primary liver malignancies.
The most common primary liver malignancy is hepatocellular carcinoma (HCC). Due to its frequent occurrence in livers already damaged by viral hepatitis, HCC is one of the most common tumors of a solid organ worldwide. These tumors rarely occur in otherwise healthy livers. They occur much more frequently in damaged (cirrhotic) livers. In addition to the aforementioned viral hepatitis, the main causes of liver cirrhosis in Central Europe are alcohol consumption, obesity, and liver damage caused by metabolic diseases (e.g., Wilson’s disease, hemochromatosis).
HCC often grows slowly over a long period of time before it is diagnosed. Patients frequently complain of general and nonspecific symptoms such as weakness, fatigue, weight loss, and unexplained fever. In most cases, the diagnosis is made based on a combination of imaging findings and laboratory values. In blood tests, the most important tumor marker is alpha-fetoprotein (AFP), which may be elevated in HCC. Imaging often provides a typical representation of these tumors in two separate procedures (e.g., CT with contrast medium and MRI); confirmation by biopsy is usually not necessary. Like all malignant tumors, HCC can spread throughout the body. In most cases, the lymph nodes near the liver, the lungs, the bones, and the abdominal cavity are the first to be affected.
Treatment with the aim of a cure (curative surgery) is only possible as long as the tumor is confined to the liver and can be completely removed. Very small lesions can be removed using minimally invasive surgery (laparoscopy), whereby the liver function of the usually pre-damaged, cirrhotic liver also plays a decisive role in treatment planning. If certain criteria are met, a liver transplant may be a curative treatment option. In this procedure, both the diseased, cirrhotic liver and the tumor are completely removed. If neither surgical resection nor transplantation is possible due to advanced tumor disease, so-called locoregional therapy methods such as stereotactic radiofrequency ablation (sRFA) or transarterial chemoembolization (TACE) are available. Immunotherapy is also playing an increasingly important role in the treatment of advanced HCC. A combination of different therapeutic approaches may also prove effective. Through the use of locoregional therapies and, in individual cases, immunotherapies, advanced tumor stages can be converted into transplantable or operable tumor stages, so that even in cases of advanced tumor disease, there may still be a chance of cure.

The second most common primary liver malignancy is intrahepatic cholangiocellular carcinoma (iCCC). Similar to how malignant tumors can form from liver cells, carcinomas can also develop from the cells of the bile ducts that run through the liver.
Since the location and size of the tumor as well as liver function are important parameters for deciding on further treatment, careful imaging using CT, MRI, and possibly PET is necessary. More than half of iCCCs are diagnosed late due to the mild and often nonspecific symptoms and are already advanced at the time of diagnosis. While in about half of the cases, metastases outside the liver are already present at the time of initial diagnosis, leaving a very low chance of cure, patients with tumors confined to the liver have various options. The available treatment options include surgical resection, immunotherapy, chemotherapy, and transplantation. If these tumors are initially inaccessible for surgical resection due to their size and location, systemic therapy (chemotherapy) can be attempted first. If the tumor remains stable or shrinks under this therapy, resection of the tumor can be performed. In individual cases, a liver transplant may also be considered.
In extensive liver resections, the planned future liver remnant may be too small to take on the entire workload of the entire liver and may cause liver failure after surgery. To avoid this serious complication, it is essential to accurately measure the planned residual liver volume. If it is too small, targeted occlusion of individual portal vein branches and possibly also a hepatic vein can stimulate increased growth in this non-tumor-affected part of the liver. Various surgical or radiological-interventional methods are available to ultimately reduce the risk of liver failure after surgery.

Liver metastases (= secondary liver malignancies) are malignant tumors in the liver that do not originate primarily in this organ. Since the liver receives blood from the gastrointestinal tract, tumor cells from these regions can enter the liver via the bloodstream, settle there, and form metastases. However, this also means that liver metastasis represents an advanced stage of tumor development with tumor cells already spread throughout the body. Liver metastases are much more common than primary liver malignancies. Because the metastases are often very small and occur in both lobes of the liver (bilobar), precise imaging (CT/MRI/ultrasound/PET) is necessary before the planned surgery. In some cases, a biopsy of the tumor may also be necessary.
Particularly in the case of colorectal metastases, there are modern treatment concepts consisting of combinations of systemic therapy together with surgical resection, sRFA, or transplantation. Therefore, modern treatment of liver metastases also takes the form of a multidisciplinary approach, in which a variety of other specialist disciplines are involved in addition to surgery. Through a coordinated sequence of chemotherapy and, in some cases, successive resections and/or sRFA, complete removal can be achieved even in cases of liver metastases that affect the entire liver and thus appear incurable.
In addition to the chemotherapy protocols and targeted enlargement of non-tumor-affected parts of the liver already mentioned, a precisely coordinated combination of surgery and sRFA offers possibilities for improving operability in such multiple metastases. Another approach for extensive bilobar colorectal liver metastases that are not amenable to surgical resection is liver transplantation. Although this therapy is only suitable for a small group of patients, the results are promising.
With the help of these multimodal approaches, potentially curative therapy is now possible in many cases for patients who, until a few years ago, would have been considered inoperable.

If you have been diagnosed with any of the conditions mentioned above or other changes in your liver, we are here to help. Thanks to our high concentration of specialists in surgery and other disciplines such as hematology-oncology, radiation therapy, radiology, and gastroenterology, we can offer you a wide range of established treatment methods.

Bile ducts and gallbladder

The bile ducts comprise all structures involved in the transport and storage of bile, including the small bile ducts within the liver, the right and left bile ducts, the common bile duct (ductus hepaticus), the main bile duct (ductus choledochus), and the gallbladder.
Bile is produced by the liver cells and flows through the small bile ducts within the liver into increasingly larger bile ducts. Finally, all these ducts flow into the right and left bile ducts, which merge to form the common bile duct and, after joining the cystic duct, the main bile duct (ductus choledochus), which flows into the duodenum. In the last section, before flowing into the duodenum, the main bile duct passes through the pancreas.
The gallbladder is a hollow organ attached to the lower edge of the liver and connected to the main bile duct via the cystic duct. It is approximately 8 – 12 cm long and 4 – 5 cm wide and serves exclusively as a storage site for bile. The bile stored in the gallbladder is concentrated and released into the duodenum via the bile duct when fatty foods are consumed.
Bile consists of cholesterol, bile salts, and water. A balance between these three components is necessary to keep the bile liquid. An imbalance between these components can lead to the formation of gallstones.
The gallbladder and bile ducts can initially be examined by means of a clinical examination, a blood test (including determination of liver values), and an ultrasound. First and foremost, the blood values obtained in this way can indicate whether there is bile congestion and, if necessary, whether liver function is impaired as a result.
A CT or MRI scan may be performed to further clarify the underlying cause. In certain cases – especially if the findings are unclear or tumors are suspected – imaging of the bile ducts may be necessary. This can be done non-invasively using MRI-guided imaging (MRCP).

Benign diseases

Gallstones are particularly visible on ultrasound. The thickening of bile occurs in stages, and it is not uncommon for intermediate stages such as “bile sand” or “grit” to develop before actual stones form. The mere presence of gallstones in the gallbladder is not a reason for intervention. Treatment should only be considered if the gallstones cause symptoms (e.g., recurring upper abdominal pain). Unlike kidney stones, dissolving gallstones with medication or breaking them up with ultrasound is no longer recommended due to the low chances of success.
The treatment of choice is therefore surgical removal of the gallbladder. In 90 – 95% of cases, the procedure is performed as a minimally invasive operation via several (usually four) incisions in the abdominal wall (laparoscopic surgery). The advantage of this technique is that it leaves a smaller scar, causes less postoperative pain, and requires a shorter hospital stay. In rare cases, e.g., severe inflammation of the gallbladder, the operation must be performed through an incision below the right rib cage.
Gallstones and bile sand can occur not only in the gallbladder, but also in the bile ducts. Unlike gallbladder stones, concretions in the bile ducts—especially in the common bile duct—always represent a pathological finding. As a rule, stones in the common bile duct are caused by gallbladder stones that migrate from the gallbladder into the bile duct. This can lead to a blockage of the duct and thus to bile congestion. This usually manifests itself as jaundice accompanied by severe, wave-like pain. The dreaded complication of bile congestion is a bile duct infection, known as cholangitis, which is characterized by jaundice and pain as well as fever and/or chills. In such cases, the bile duct should be quickly relieved by means of a special endoscopic treatment (endoscopic retrograde cholangiopancreatography, ERCP) in order to prevent further consequences, such as blood poisoning.

Gallbladder polyps are benign thickening of the gallbladder wall that usually cause no symptoms. The diagnosis is almost always made incidentally during an ultrasound examination. In this case, removal of the gallbladder is only indicated if the polyps are larger than 1 cm, as they can become malignant, similar to colon polyps. Smaller polyps should be monitored at regular intervals using ultrasound.

Cysts of the bile ducts are caused by dilations or bulges in the bile ducts and can be congenital or acquired. These cysts can occur individually or diffusely and be distributed in several locations—both inside and outside the liver. Removal of isolated cysts is indicated if they lead to bile congestion or recurrent infections, especially in the area of the common bile duct. Certain cysts can develop into malignant disease. Accurate imaging using MRCP is the method of choice for precisely describing these cysts and the potential risk of degeneration.
Diffuse cystic changes in the bile ducts inside and outside the liver are often genetic and usually affect pediatric patients. This can lead to diffuse bile congestion in the liver, which initially causes cirrhosis and ultimately liver failure. These special cases can become apparent in the first months of life, and treatment is carried out in cooperation with colleagues in pediatrics. These patients often require a liver transplant for a definitive cure.

Malignant diseases

As already explained in the “Anatomy” section, the bile ducts are a complex system. Malignant neoplasms can occur in any of the associated parts, which can be summarized under the collective term “bile duct cancer” or “cholangiocellular carcinoma (CCC)”. Cholangiocellular carcinoma is a rare type of tumor (approx. 1% of all malignant tumors) with 1-2 new cases per 100,000 inhabitants per year. In most cases, there are no specific causes for the occurrence of such tumors, although chronic inflammation of the bile ducts—e.g., autoimmune diseases such as primary sclerosing cholangitis—can be a significant risk factor. A special case is CCC of the gallbladder, which is associated with the presence of gallstones and has become increasingly rare in recent years due to the frequent performance of gallbladder surgery.
Depending on its location, CCC covers tumors of the gallbladder (gCCC), the bile ducts within the liver (iCCC), the bile ducts around the bile duct bifurcation (pCCC), and the deep bile ducts in the area of the pancreas (dCCC). This classification is relevant because treatment depends heavily on the location of the CCC.
Regardless of their location, CCCs are often detected late because patients usually have no symptoms until the bile flow becomes increasingly blocked. In fact, these patients are notable for their painless jaundice. Furthermore, there are no specific laboratory values for diagnosing CCC; instead, these tumors are detected through imaging (CT/MRCP) or by taking a sample using ERCP. The tumor marker CA19-9 in the blood may play a role, but is only diagnostically relevant in cases where a tumor mass has been detected by imaging.
In cases of severe obstruction of the common bile duct or the main bile duct, it is often necessary to relieve the pressure by draining the bile in order to alleviate the resulting itching and fatigue and reduce the risk of infection. Relief can be provided by internal drainage into the intestine using ERCP-guided stenting. Alternatively, bile can be drained externally by performing an ultrasound-guided puncture through the skin into an enlarged bile duct in the liver, thereby draining the bile to the outsi

For intrahepatic cholangiocellular carcinomas (iCCC), please refer to the chapter on „liver“.

The treatment of cholangiocellular carcinomas of the bile duct bifurcation (pCCC) still poses a particular challenge today due to late diagnosis and the often necessary preoperative bile duct drainage. Even today, complete surgical removal of such a tumor is the only curative treatment. The chances of a cure vary depending on the pattern of involvement.
The treatment of pCCCs, also known as Klatskin tumors, depends on the location of the tumor. Based on the Bismuth-Corlette classification, they are divided into four subtypes:

Type I: The tumor is located only in the main bile duct and does not reach the bifurcation of the right and left branches.

Type II: The tumor also reaches the fork, but does not extend into the intrahepatic bile ducts.
– These tumors can be treated by removing the main bile duct and gallbladder.

Type III: The tumor infiltrates the entire bile duct on one side (type IIIa on the right, type IIIb on the left) and reaches the segmental inflows there.

– Type IIIa requires partial removal of the liver. Due to the longer bile duct on the left side, the right half or 2/3 of the liver—an extended right hemihepatectomy—can be removed, provided that the remaining left liver has sufficient volume. Here, too, the aforementioned enlargement procedures for the non-tumor-bearing part of the liver can be applied.
– If the tumor grows very deep into the left half of the liver (type IIIb), an extended left hemihepatectomy is preferable. Although this procedure is more complex than the right variant, it does not usually require preoperative enlargement of the remaining right liver, as this normally has sufficient volume.

Typ IV: The tumor extends to the segmental bile ducts in both lobes of the liver.
In the case of a type IV tumor that penetrates deeply into the bile ducts of both halves of the liver, surgical removal is usually not possible. Nevertheless, in the absence of distant metastases, a multimodal therapy concept with the aim of a cure can be considered. In individual patients who respond appropriately, chemotherapy and radiation can be followed by a liver transplant to completely remove the tumor.

Cholangiocellular carcinomas of the gallbladder (gCCC) can sometimes only be detected incidentally during a routine gallbladder removal. Only in the case of very small tumors is the operation already performed sufficient. In more advanced cancer, patients must undergo a second procedure in which an additional portion of the adjacent liver tissue is removed.
Occasionally, gCCC are diagnosed only at a late stage. In these cases, the tumor’s pattern of spread may be so extensive that it cannot be distinguished from a perihilar CCC (pCCA) or an intrahepatic CCA (iCCC). In such situations, the management approach is similar to that used for other tumors of the central bile ducts, and removal of the right liver lobe or up to two‑thirds of the liver may be required. If any of the above-mentioned diagnoses or other abnormalities of the bile ducts have been identified in your case, we are here to support you. With a strong team of specialists in surgery and in related disciplines such as hematology/oncology, radiation oncology, radiology, and gastroenterology, we are able to offer you a broad range of established and evidence-based treatment options.

Bauchspeicheldrüse (Pankreas)

The pancreas is located behind the abdominal cavity, directly in front of the spine at the level of the first and second lumbar vertebrae. It extends from the midline of the body, running behind the stomach, to the spleen in the upper left abdomen. Due to its club‑like shape, the pancreas is divided into three sections: the head, the body, and the tail. The pancreas performs two essential functions in the body:
On the one hand, most of the organ produces digestive enzymes (pancreatic juice), which are released into the intestine during food intake and help break down nutrients (= exocrine function).
On the other hand, the pancreas contains specialized clusters of cells (islet cells) that regulate blood sugar levels via two hormones: insulin (lowers blood sugar) and glucagon (raises blood sugar).
Therefore, impaired pancreatic function can lead to a deficiency of digestive enzymes and also to disturbances in blood sugar regulation (diabetes mellitus). Diseases of the pancreas—especially those requiring surgical intervention—are often challenging due to the organ’s location and its delicate structure. Close collaboration with other medical specialties is crucial to ensure optimal patient care.

Benign diseases

Inflammation of the pancreas (pancreatitis) can occur acutely and may resolve once the underlying cause has been addressed. Alternatively, it can take a chronic course, leading to scarring and the formation of fluid-filled cavities (pseudocysts) within the organ. The most common causes of pancreatitis are gallstone disease and excessive alcohol consumption.
Every acute inflammation of the pancreas is a serious condition and requires thorough evaluation and treatment. Typically, patients experience abdominal pain that radiates in a belt-like pattern to the back. In addition to the clinical examination, blood tests and an ultrasound or CT scan are usually decisive for establishing the diagnosis. Depending on the specific question, an MRI may also be performed. In most cases, an acute inflammation can be healed with non‑surgical therapy. In certain cases, however, when the inflammation is caused by a gallstone that has slipped out of the gallbladder (biliary pancreatitis), it may be necessary to perform a special endoscopic procedure with stone removal (ERCP), followed by surgical removal of the gallbladder in a second step.

In cases of severe acute inflammation of any cause, parts of the pancreas may die off and transform into a fluid-filled cyst that needs to be drained. This can usually be done through a percutaneous puncture from the outside or through the stomach using an endoscopic procedure. Surgery is rarely required and is only performed when all other treatment options have been exhausted.
Repeated inflammation (chronic pancreatitis) leads to progressive scarring and calcification of the pancreas, which can cause the organ to slowly fail. The symptoms of chronic inflammation include unclear upper abdominal and back pain, weight loss, changes in bowel habits (diarrhea), or diabetes mellitus. Here as well, imaging examinations of the pancreas (computed tomography, magnetic resonance imaging, or ultrasound) and a blood test are essential for an accurate diagnosis and further treatment.
Medication is usually sufficient to replace the functions of the pancreas (digestive enzymes in tablet form, insulin) and to treat the pain. However, calcifications can lead to a blockage of the pancreatic duct. These can then be resolved by an ERCP with stone removal or bridging of the narrowing, or by surgery (partial removal of the pancreas or restoration of pancreatic drainage).

Benign tumors

Changes in the pancreas that lead to an increase in cell proliferation are referred to as tumors. A distinction is made between tumors that proliferate uncontrollably within the organ and spread to other organs (malignant tumors), and those that grow slowly, do not destroy the organ, and do not form metastases in other organs (benign tumors). Benign tumors of the pancreas are generally rare. The most common of these tumors arise either from neuroendocrine cells or from the ductal system (usually forming cavities, i.e., cystic tumors). The challenge in managing these benign tumors is identifying those that may develop into malignant tumors over time.

Cystic tumors of the pancreas are very slowly growing, fluid-filled lesions that usually cause little or no symptoms for patients. Cystic tumors with a higher risk of malignant transformation include the mucin-producing lesions mucinous cystic neoplasia (MCN) and intraductal papillary mucinous neoplasms (IPMN). Both are defined as precursor lesions and should be monitored at regular intervals by magnetic resonance imaging or a specialized endoscopic examination for possible changes (e.g., nodule formation, increase in size). Assessing the probability of malignant transformation of these tumors requires particular expertise with this condition, which is why patients with cystic tumors are discussed in a multidisciplinary conference. If the overall picture indicates an increased risk of malignant transformation, part of the pancreas—or in rare cases the entire pancreas—must be removed.
If carcinoma is detected in this cyst during postoperative histopathological examination, chemotherapy must be considered.
Solid pseudopapillary neoplasia (Frantz tumor) is also classified among the benign cystic tumors, although surgery in the form of partial pancreatic resection is indicated due to the solid components of the tumor. Recurrence of these cystic tumors is very unlikely after complete removal. Regular follow‑up during the first 5 years after surgery is recommended.

Another rare cystic lesion of the pancreas is the so‑called serous cystic neoplasm (SCN – serous cystic neoplasm), which only rarely requires surgical removal. Patients with SCN are usually asymptomatic. Since SCN is benign and carries no potential for malignant transformation, surgical resection is only necessary if there are compression effects on vital structures. Regular follow‑up examinations in our specialized outpatient clinic are not required for this lesion.

Neuroendocrine neoplasms (NEN) of the pancreas

arise from hormone‑producing cells of the pancreas and, depending on hormone production and size, can be monitored regularly or removed by surgery. These tumors vary greatly in their location and size, but are overall rare.
Hormone‑producing NEN are usually small and, due to the overproduction of the corresponding hormone, cause symptoms. The most common hormone‑producing NEN are insulinomas. Because of the excess insulin, patients experience repeated drops in blood sugar levels, which can lead to potentially life‑threatening situations. In addition to a detailed medical history and blood tests, a computed tomography scan and special nuclear medicine examinations, which our university hospital offers, are crucial for an accurate diagnosis. The treatment of choice in such cases is the removal of the hormone‑producing tumor – either by removing part of the pancreas or often by selectively removing (enucleating) the tumor itself.
Non‑hormone‑producing NEN usually do not cause symptoms and therefore are often detected in imaging (ultrasound or computed tomography) that was performed for another reason, as an incidental finding. For tumors up to almost 2 cm in size with a low‑aggressiveness tumor profile, current guidelines allow a so‑called watch‑and‑wait strategy, in which no surgical removal of the tumor is performed at first, but instead the tumor is monitored at regular intervals using imaging and various laboratory tests. Thus, if the tumor changes, timely action can be taken without the upfront risk of an operation, which is often not necessary for a low‑aggressiveness tumor. Here as well, if surgery becomes necessary, partial removal or simple enucleation of the tumor is possible.
In special cases, NEN can also be operated on even when metastases in the liver are already present, in order to reduce the overall tumor mass. The goal of such surgery is not necessarily the complete removal of all tumor sites, but rather to achieve a better effect of systemic therapy by reducing the total tumor burden.

Malignant tumors

malignant tumors of the pancreas originate for the vast majority (> 95 %) from the exocrine glandular portion (= ductal adenocarcinoma), and less frequently from the hormone‑producing cells (1–2%) or other cell types.after colorectal and gastric cancer, pancreatic cancer is the third most common type of gastrointestinal tumor. Men are affected slightly more often than women (1.5 : 1). A major problem in the treatment of pancreatic cancer is, on the one hand, the fact that this tumor type remains painless for a long time and usually causes symptoms only when surrounding structures (nerves, bile duct) are affected, or when metastases develop in other organs, and is therefore often diagnosed very late. On the other hand, pancreatic cancer unfortunately tends to spread early, with involvement of the lymph nodes around the pancreas and subsequently the liver and the peritoneum. an operative removal of the tumor is usually possible as long as the tumor has not spread beyond the lymph nodes adjacent to the pancreas and has not invaded the arteries running around the pancreas. In locally advanced cases, a multimodal treatment approach can still achieve a cure. In these patients, chemotherapy is used beforehand in an attempt to shrink the tumor. If the response is good, surgery can be planned, provided that complete removal of the tumor is surgically feasible. In contrast to NEN, the presence of liver metastases represents a contraindication for surgery.
a thorough evaluation of any changes in the pancreas is therefore crucial for the success of therapy, in order to reliably rule out a carcinoma. Such an evaluation includes, in addition to clinical assessment, blood tests for specific parameters, computed tomography, magnetic resonance imaging, and – if necessary – endoscopic ultrasonography with biopsy or examination of the bile and pancreatic ducts (ERCP).
due to the complex tumor biology and anatomy of the pancreas, all patients at our center are discussed in a multidisciplinary oncological meeting. This allows us to always provide a patient‑tailored therapy that corresponds to the most current state of knowledge.
Secondary pancreatic tumors (metastases) in the pancreas arising from tumors of other organs are very rare. Normally, these are diagnosed during follow‑up of other tumor diseases. Typical primary tumor types include renal cell carcinoma (RCC), melanoma, breast cancer (particularly in the case of a BRCA1 mutation), lung cancer, gastric cancer (in which a direct invasion of the tumor is also possible due to the close relationship of the two organs), as well as colorectal carcinoma. In individual cases, such a metastasis can be removed. Since metastases are generally a sign of an advanced tumor disease, the decision to surgically remove them is always made together with the physicians treating the underlying tumor.
Other rare malignant pancreatic tumors include both sarcomas (arising from various connective‑ and soft‑tissue cell types) as well as rare mixed carcinoma forms, such as adenosquamous carcinoma, acinar cell carcinoma, or pancreatoblastomas, which are very rare and occur almost exclusively in childhood. Because the pancreas also contains numerous immunologically active cells, manifestations of lymphomas in the pancreas are also possible.
if any of the diagnoses mentioned above or other changes of the pancreas have been diagnosed in your case, we are at your disposal. Due to the high density of specialists both in surgery and in other disciplines such as hematology‑oncology, radiation oncology, radiology, and gastroenterology, we can offer you a wide range of established methods.