Pancreatic and upper GI surgery covers operations on the pancreas, esophagus, stomach, and small intestine. These organs sit at the upper end of the digestive tract and handle every meal a person eats. Cancer surgery and complex non-cancer surgery in this region tend to be technically demanding, because the anatomy is unforgiving and major blood vessels run close to the operative field. Most of the operations on this page can be performed robotically when the disease and anatomy allow.
This page describes the conditions Dr. Jabbar treats and the operations he performs, written for patients and families who want to understand what their diagnosis means and what surgery actually involves.
The conditions below are the most common reasons patients are referred to Dr. Jabbar’s practice for pancreatic and foregut surgery. Each is covered briefly, focusing on the patterns that come up most often in the clinic.
Pancreatic adenocarcinoma is the most common cancer that starts in the pancreas, the gland that sits behind the stomach and makes both digestive enzymes and the hormones that regulate blood sugar. It begins in the cells that line the pancreatic ducts and tends to grow quietly until it has spread.
Symptoms are often vague and late. They can include upper abdominal pain that radiates to the back, yellowing of the skin and eyes (jaundice), unexplained weight loss, loss of appetite, persistent fatigue, and new-onset diabetes in someone without a family history.
The most important risk factors are smoking, chronic pancreatitis, long-standing type 2 diabetes, obesity, and inherited genetic syndromes (BRCA2 mutations, Lynch syndrome, FAMMM, hereditary pancreatitis). A significant share of cases occur without any clear risk factor.
Diagnosis usually starts with cross-sectional imaging (CT or MRI of the abdomen). EUS-guided tissue sampling is often used when it will guide treatment; selected patients with a clearly resectable lesion may proceed without a preoperative biopsy after multidisciplinary review. The CA 19-9 blood test is used as a baseline tumor marker. Staging looks for spread to the liver, lung, peritoneum, and lymph nodes.
Surgery offers the best chance for long-term survival when the cancer can be removed safely and has not spread to distant organs. Limited involvement of certain veins may still be resectable with vascular reconstruction at experienced centers. Depending on tumor location, the operation is a Whipple procedure (for tumors in the head of the pancreas) or a distal pancreatectomy (for tumors in the body or tail). Chemotherapy is given before surgery, after it, or both, depending on the stage. Radiation has a role in select cases. For tumors that cannot be removed, chemotherapy and targeted therapy are the mainstays.
Pancreatic neuroendocrine tumors (often shortened to PNETs, and sometimes called islet cell tumors) are uncommon growths that arise from the hormone-producing cells of the pancreas. They behave very differently from pancreatic adenocarcinoma. They often grow slowly and can be either functional (releasing hormones that produce symptoms) or nonfunctional (silent until they cause a mass effect or are found incidentally).
Symptoms depend on whether the tumor releases a hormone. Insulinomas cause episodes of low blood sugar. Gastrinomas cause stubborn peptic ulcers and diarrhea. Other tumors release glucagon, somatostatin, or VIP. Nonfunctional PNETs typically present with vague abdominal pain, weight loss, or jaundice once they grow large enough to compress nearby structures.
Most PNETs are sporadic. About 10 percent are part of an inherited syndrome (MEN1, von Hippel-Lindau, neurofibromatosis type 1, tuberous sclerosis). Patients with these syndromes are screened with imaging and hormone panels at intervals.
Workup includes cross-sectional imaging (CT or MRI), endoscopic ultrasound, and a specialized nuclear medicine scan called Ga-68 DOTATATE PET that highlights neuroendocrine cells. Blood and urine hormone panels help characterize functional tumors.
Surgery is the main treatment when the tumor can be removed, and the specific operation depends on location and size. Small, benign-appearing tumors can be enucleated (shelled out) to preserve as much pancreas as possible. Tumors in the body or tail are treated with distal pancreatectomy or central pancreatectomy. Tumors in the head are treated with a Whipple procedure. For tumors that cannot be removed or have spread, options include somatostatin analogs (octreotide, lanreotide), targeted therapy, peptide receptor radionuclide therapy (PRRT), and liver-directed treatments.
Pancreatic cysts are fluid-filled pockets on or inside the pancreas. Most are discovered by accident, on a CT or MRI done for some unrelated reason. The clinical question is almost always the same: is this cyst dangerous, and does it need to come out?
Most pancreatic cysts are benign. Some are precancerous. The most important precancerous type is intraductal papillary mucinous neoplasm, or IPMN. IPMN comes in two main forms. Main-duct IPMN involves the main pancreatic duct and has a high risk of progressing to cancer. Branch-duct IPMN involves the side branches and has a much lower risk. Other mucinous cysts (mucinous cystic neoplasms, or MCNs) are also potentially precancerous.
Symptoms are uncommon. When they occur, they include upper abdominal pain that radiates to the back, nausea, early fullness with meals, and unexplained weight loss. A cyst that obstructs the pancreatic duct can cause pancreatitis.
Workup combines high-resolution imaging (MRI with MRCP is preferred) with endoscopic ultrasound and fluid sampling (EUS-FNA). The fluid is tested for amylase, mucin, CEA, and molecular markers that indicate a mucinous or precancerous cyst.
The decision to operate is based on the cyst type, size, and location, and on a list of “high-risk” or “worrisome” features (solid components, a thickened cyst wall, main-duct dilation, jaundice, rapid growth, positive cytology). Main-duct or mixed-type IPMN generally warrants multidisciplinary evaluation for surgery, with the decision based on high-risk features, duct findings, operative risk, and patient preferences. High-risk branch-duct IPMN is removed surgically. Low-risk branch-duct IPMN is watched with imaging. The operation depends on the cyst’s location, ranging from enucleation for small benign cysts to a Whipple procedure or distal pancreatectomy for high-risk lesions.
The ampulla of Vater is the small opening where the bile and pancreatic ducts drain into the first part of the small intestine (the duodenum). Cancer that starts at the ampulla is called ampullary cancer; cancer that starts in the duodenum itself is called duodenal cancer. They sit in the same neighborhood and are often discussed together because their presentations, workups, and surgical treatments overlap.
The most common early sign is painless jaundice, because the tumor sits right at the spot where the bile duct empties into the gut and obstructs bile drainage. Other symptoms include itching, dark urine, pale stools, abdominal pain, nausea, vomiting, unintended weight loss, and gastrointestinal bleeding (which can show up as iron-deficiency anemia on routine labs).
Risk factors include familial adenomatous polyposis (FAP), Lynch syndrome, Crohn’s disease, celiac disease, smoking, and age over 50.
Workup starts with upper endoscopy. A side-viewing endoscope (or ERCP) is often needed to reach the ampulla and biopsy it directly. CT or MRI characterizes the local extent and looks for spread. Endoscopic ultrasound assesses depth and lymph nodes. CA 19-9 and liver function tests are added.
Surgery is the primary curative treatment. Most ampullary and proximal duodenal cancers are treated with a Whipple procedure. Very early ampullary lesions can sometimes be removed endoscopically, and cancers further down the duodenum may be treated with segmental resection. Chemotherapy or radiation is added based on stage and pathology.
Gastric cancer is a malignancy that starts in the lining of the stomach. Most cases are adenocarcinoma.
Symptoms tend to appear at a later stage, because the stomach has room to accommodate a growing tumor before it interferes with eating. They include trouble swallowing, persistent stomach pain or burning above the navel, feeling full after only a small amount of food, nausea, heartburn that has changed in character or worsened, unintended weight loss, fatigue from anemia, and — in advanced cases — vomiting blood or passing black, tarry stools.
The biggest risk factor worldwide is long-standing infection with Helicobacter pylori. Other risk factors include a diet high in smoked, salted, or pickled foods and low in fruits and vegetables, smoking, heavy alcohol use, obesity, chronic atrophic gastritis, and inherited syndromes such as hereditary diffuse gastric cancer, Lynch syndrome, FAP, Peutz-Jeghers, and juvenile polyposis.
Diagnosis is made by upper endoscopy with biopsy. Staging combines CT, endoscopic ultrasound (which measures depth of invasion and lymph node involvement), and PET/CT. Diagnostic laparoscopy is sometimes used to detect peritoneal spread that imaging cannot see.
Treatment is staged by depth of invasion and extent of spread. Very early lesions confined to the mucosa can be removed endoscopically. Invasive cancers are treated with gastrectomy (subtotal or total, depending on tumor location) combined with lymph node dissection. Chemotherapy is typically given before and after surgery. Radiation, immunotherapy, and targeted therapy (HER2, PD-L1) are used in selected patients.
Gastric neuroendocrine tumors, sometimes called gastric carcinoids, are uncommon growths that arise from the hormone-producing cells in the stomach lining. They are classified into Types 1 through 4 based on the underlying cause and biology, which dictate how aggressive they are and how they are treated.
Type 1 tumors are the most common and the least aggressive. They develop in patients with chronic atrophic gastritis, which reduces stomach acid secretion. Lower acid drives a hormonal feedback loop that stimulates the growth of small, often multiple, low-grade tumors. Type 2 tumors are associated with Zollinger-Ellison syndrome and Multiple Endocrine Neoplasia type 1. Type 3 tumors arise sporadically, without any background condition, and behave more aggressively. Type 4 tumors are poorly differentiated neuroendocrine carcinomas and behave like aggressive cancer.
Symptoms are often absent, and many of these tumors are found incidentally during an upper endoscopy done for other reasons. When symptoms occur, they include upper abdominal discomfort, nausea, iron-deficiency anemia or GI bleeding, and — rarely, in advanced disease — carcinoid syndrome with flushing, wheezing, or diarrhea.
Workup includes upper endoscopy with biopsy, blood tests for serum gastrin and chromogranin A, and Ga-68 DOTATATE PET for staging.
Treatment depends on the type. Small, low-grade Type 1 and 2 tumors are usually watched or removed endoscopically. Larger or recurrent Type 1 tumors may require surgical antrectomy to remove the part of the stomach driving the hormonal stimulation. Type 3 and Type 4 tumors are treated like adenocarcinoma, with partial or total gastrectomy and lymph node dissection, plus systemic therapy for advanced disease.
Esophageal cancer is a malignancy that starts in the esophagus, the muscular tube that carries food from the throat to the stomach. There are two main types. Adenocarcinoma arises in the lower esophagus and is most often associated with long-standing acid reflux and Barrett’s esophagus. Squamous cell carcinoma arises in the upper and middle esophagus and is more often associated with smoking and heavy alcohol use.
The most common symptom is difficulty swallowing, which is usually progressive — starting with solid foods and eventually involving liquids. Other symptoms include unintended weight loss, chest pain or burning behind the breastbone, worsening heartburn, coughing or hoarseness, and regurgitation of food.
Risk factors include long-standing GERD and Barrett’s esophagus (for adenocarcinoma), smoking and heavy alcohol use (for squamous cell carcinoma), obesity (for adenocarcinoma), a diet low in fruits and vegetables, and a history of drinking very hot liquids.
Workup starts with upper endoscopy and biopsy. Endoscopic ultrasound assesses depth and local lymph nodes. CT and PET imaging are used to detect spread.
Treatment is stage-driven. Very early cancers confined to the inner lining (and high-grade dysplasia in Barrett’s esophagus) can be treated endoscopically with mucosal resection and ablation. Invasive cancers are treated with esophagectomy — the surgical removal of the affected part of the esophagus — combined with reconstruction, usually by pulling the stomach up into the chest. Chemotherapy and radiation are usually given before surgery to shrink the tumor. Immunotherapy and targeted therapy are used in selected advanced cases.
Gastrointestinal stromal tumors, or GISTs, are uncommon tumors that grow from specialized cells in the wall of the digestive tract called interstitial cells of Cajal. These cells normally help coordinate the wave-like contractions that move food through the gut. GISTs most often arise in the stomach, with the small intestine as the second most common site.
GISTs span a wide range of biology, from small, indolent tumors found incidentally to aggressive cancers that recur and spread. The risk of recurrence is predicted by tumor size, mitotic rate, and location. Small gastric GISTs under 2 centimeters with a low mitotic rate carry very low risk and are often watched. Larger tumors and those in the small intestine carry higher risk.
Symptoms, when present, include gastrointestinal bleeding (the most common presenting sign, often showing up as fatigue or anemia from slow blood loss), upper abdominal pain, a palpable mass, nausea, and early fullness with meals.
Most GISTs are sporadic and carry mutations in the KIT or PDGFRA genes that drive the tumor’s growth. Rare inherited syndromes (familial GIST, neurofibromatosis type 1, Carney triad) account for a small share. There are no major lifestyle risk factors.
Workup combines CT or MRI, upper endoscopy, endoscopic ultrasound, and biopsy. Molecular testing for KIT and PDGFRA mutations guides decisions about targeted therapy.
Surgery is the main treatment, and the goal is complete removal of the tumor with negative margins. Because GISTs rarely spread to lymph nodes, large lymph node dissections are not usually needed — which is why a wedge resection of the stomach is the standard operation for most gastric GISTs. Targeted therapy with imatinib is used before surgery to shrink larger tumors, after surgery to reduce recurrence risk in high-risk tumors, and as the main treatment for metastatic disease.
Cancer of the small intestine is uncommon. Despite being about 20 feet long, the small intestine has a relatively low rate of malignancy compared with the colon or the stomach. The main types include adenocarcinoma, neuroendocrine tumors (carcinoid), lymphoma, and sarcoma (including GIST).
Symptoms tend to be vague and intermittent. They can include crampy abdominal pain, unintended weight loss, nausea and vomiting, fatigue or weakness from chronic anemia, blood in the stool or black tarry stools, and signs of bowel obstruction when the tumor grows large enough to block the passage of food.
Risk factors include Crohn’s disease (especially in the duodenum), celiac disease, inherited polyposis syndromes (FAP, Lynch syndrome, Peutz-Jeghers), smoking, and heavy alcohol use.
Diagnosis is more challenging than for other GI cancers, because most of the small intestine is beyond the reach of standard endoscopy. Imaging includes CT enterography and MRI. Diagnostic tools include capsule endoscopy (a small camera the patient swallows), push enteroscopy, and balloon-assisted enteroscopy. Blood work checks for anemia and tumor markers.
Surgery is the primary treatment. The operation is a segmental resection of the affected portion of the small intestine, with removal of the surrounding lymph nodes. Tumors of the duodenum near the ampulla often require a Whipple procedure rather than a simple segmental resection. Chemotherapy, targeted therapy, or immunotherapy is added based on the tumor type and stage.
The operations below are the most common procedures Dr. Jabbar performs for the conditions described above. Whenever the disease and anatomy allow, they are performed robotically through small incisions. When the case requires it, the same operations are performed open.
The Whipple procedure (also known as pancreaticoduodenectomy) is one of the most complex operations in general surgery. It removes the head of the pancreas, the duodenum (the first portion of the small intestine), the gallbladder, the lower part of the bile duct, and sometimes a small portion of the stomach. The remaining pancreas, bile duct, and small intestine are then reconnected so that bile, pancreatic juice, and food can flow into the gut again.
The Whipple is the standard operation for tumors in the head of the pancreas, ampullary cancer, distal cholangiocarcinoma, certain duodenal cancers, some pancreatic neuroendocrine tumors, and high-risk IPMN or other precancerous cysts in the pancreatic head.
Historically, the Whipple was done open, through a long upper abdominal incision. Today it can also be performed laparoscopically or robotically at experienced centers. At experienced centers, a robotic approach can be used for selected patients and provides magnified visualization and wristed instruments for dissection and reconstruction. Approach selection depends on tumor size, vascular involvement, the patient’s prior abdominal surgery, and the surgeon’s experience.
The operation commonly takes several hours. After an uncomplicated Whipple procedure, hospital stay and full recovery are measured in days and weeks, respectively, but vary substantially with the patient, approach, and postoperative course.
Pancreatectomy is the surgical removal of all or part of the pancreas. The specific operation depends on where the tumor sits and how much surrounding tissue must be removed with it.
Distal pancreatectomy removes the body and tail of the pancreas (the left side). The spleen is often removed at the same time, because it shares its blood supply with this part of the pancreas. Distal pancreatectomy is used for tumors in the body or tail, including adenocarcinoma, neuroendocrine tumors, and mucinous cysts.
Total pancreatectomy removes the entire pancreas, often with the spleen, gallbladder, part of the stomach, and the duodenum. It is used for diffuse disease throughout the pancreas, multifocal IPMN involving the entire gland, or hereditary cancer syndromes. Patients who undergo a total pancreatectomy require lifelong insulin and pancreatic enzyme replacement therapy.
Central pancreatectomy removes the middle portion of the pancreas (the neck and proximal body) while preserving the head and tail. It is chosen for small, benign or low-grade tumors in the middle of the pancreas, when the goal is to preserve as much normal pancreatic tissue and endocrine function as possible.
Enucleation removes the tumor itself without removing surrounding pancreatic tissue. It is reserved for small, benign, or low-grade lesions that sit away from the main pancreatic duct.
Distal pancreatectomy, central pancreatectomy, and enucleation are commonly performed robotically when the anatomy allows. Total pancreatectomy can also be done robotically at high-volume centers.
Hospital stay generally ranges from five to ten days for a distal pancreatectomy, and longer for a total pancreatectomy. Full recovery typically takes one to two months.
The operation for a pancreatic cyst depends on what kind of cyst it is and where it sits in the pancreas. There is no single “cyst surgery” — most operations are one of the pancreatectomies described above, chosen to remove the cyst with a clean margin.
The decision to operate is based on the type of cyst, its size, its location, and whether it has “high-risk” or “worrisome” features. High-risk features include solid components inside the cyst, thickening of the cyst wall, dilation of the main pancreatic duct, jaundice, rapid growth on serial imaging, and positive cytology from fluid sampling.
Main-duct or mixed-type IPMN generally warrants multidisciplinary evaluation for surgery because of its higher cancer risk; the decision depends on high-risk features, duct findings, operative risk, and patient preferences. Mucinous cystic neoplasms are also generally removed, as is high-risk branch-duct IPMN. Low-risk branch-duct IPMN and small, benign-appearing cysts without worrisome features are watched with serial imaging.
The operation depends on the cyst’s location. A cyst in the head of the pancreas typically requires a Whipple procedure. A cyst in the body or tail is removed with a distal pancreatectomy. A small, benign-appearing cyst in the central pancreas can sometimes be removed with central pancreatectomy or enucleation. Pseudocysts (which form after pancreatitis) are drained rather than resected when possible.
Gastrectomy is the surgical removal of part or all of the stomach. The remaining digestive tract is then reconnected so that food can move from the esophagus into the intestine.
Subtotal (also called partial) gastrectomy removes a portion of the stomach — most often the lower two-thirds, where most gastric cancers arise. The remaining upper portion of the stomach is then reconnected to the small intestine, either directly or with a small loop of jejunum.
Total gastrectomy removes the entire stomach. The esophagus is then connected directly to the small intestine, using a loop of jejunum brought up to take the place of the missing stomach.
The most common indication for gastrectomy is gastric cancer. Other indications include large or perforated stomach ulcers, large gastric GISTs that cannot be safely removed with a wedge resection, severe non-cancerous diseases, and prophylactic surgery for hereditary diffuse gastric cancer syndrome.
Today, gastrectomy is most often performed robotically or laparoscopically, particularly subtotal gastrectomy. Total gastrectomy is also increasingly done robotically at experienced centers. In the published literature, the minimally invasive approach is associated with shorter hospital stays, less blood loss, less pain, and an earlier return to eating compared with open surgery. Open surgery is used when the tumor is very large, when the anatomy is hostile from prior surgery, or when conversion is needed mid-operation.
After a gastrectomy, patients work with a dietitian to adjust how they eat; smaller, more frequent meals are the rule. Some patients develop “dumping syndrome,” a set of symptoms after eating that improves with dietary adjustments over time.
A wedge resection of the stomach removes the tumor and a small surrounding margin of normal stomach wall, leaving the rest of the stomach intact. It is the standard of care for most gastric GISTs, because GISTs almost never spread to lymph nodes and a clean margin is generally sufficient.
Wedge resection is suitable when the tumor sits in a part of the stomach that allows safe removal without compromising the gastric inlet or outlet. Tumors near the gastroesophageal junction, near the pylorus, or on the lesser curvature can be more difficult and sometimes require a different operation.
The robotic approach is well suited to wedge resection, particularly for tumors in awkward locations, where extra dexterity during dissection and suturing helps preserve the stomach’s normal anatomy. Laparoscopic wedge resection with a surgical stapler is the standard for tumors in straightforward locations. Open surgery is reserved for very large tumors, scarred anatomy from prior surgery, or when conversion is needed.
Hospital stay is typically two to four days for an uncomplicated laparoscopic or robotic wedge resection.
Esophagectomy is the surgical removal of part or all of the esophagus, along with the surrounding lymph nodes. The swallowing tract is then rebuilt, most often by mobilizing the stomach, pulling it up into the chest, and connecting it to the remaining esophagus.
The main indication is esophageal cancer that has invaded beyond the most superficial layers of the esophageal wall. Other indications include high-grade dysplasia in Barrett’s esophagus that cannot be controlled endoscopically and, rarely, severe end-stage achalasia or large benign tumors of the esophagus.
There are several established approaches. The transthoracic (Ivor Lewis) approach uses an abdominal incision and a right chest incision. The McKeown three-incision approach adds a neck incision. The transhiatal approach avoids the chest by working only through the abdomen and neck. Each version can be performed open, laparoscopically, thoracoscopically, or robotically. The choice depends on tumor location, the patient’s anatomy, prior treatment, and the surgeon’s experience. Robotic-assisted esophagectomy is increasingly used because it provides precise visualization in the chest, where the operative field is deep and narrow.
Esophagectomy is a major operation with a meaningful recovery curve. Hospital stay typically lasts 7 to 11 days, including two to three days in the intensive care unit. Many patients go home with a temporary feeding (J) tube placed at the time of surgery, used while the new connection between the esophagus and stomach heals over the following weeks.
