Professor Mike Ralf Langenbach, M.D., is an outstanding specialist in surgery with expertise in hernia surgery, reflux surgery, and visceral surgery. He has established himself as an experienced surgeon in the treatment of hernias, such as inguinal and umbilical hernias, as well as in the treatment of reflux diseases and pancreatic surgery.
Prof. Dr. Langenbach, who previously served as chief of surgery and medical director at the Helios St. Elisabeth Clinic in Oberhausen, took over as head of the Department of General, Visceral Surgery, and Coloproctology at the Evangelical Hospital in Lippstadt (EVK Lippstadt), one of the largest acute care hospitals in the region. Under his leadership, over 200 hernia surgeries are performed annually, making the EVK Lippstadt one of the leading centers in the region; in December 2024, it merged with the Dreifaltigkeits-Hospital and was renamed Klinik Lippstadt – Christliches Krankenhaus.
In addition to his clinical work, Prof. Dr. Langenbach is also active in research and teaching at Witten/Herdecke University, which underscores his comprehensive expertise. He is a member of the German Hernia Society (DHG) and has contributed significantly to the establishment of the Reflux Center at Klinikum Lippstadt. Working closely with other specialist departments and private practitioners, he ensures optimal, interdisciplinary care for his patients. The editorial team of the Leading Medicine Guide spoke with Prof. Dr. Langenbach and learned about interesting connections related to pancreatic disease.
Lippstadt Hospital – Christian Hospital – Expansion of Care Structures
Lippstadt Hospital was established in December 2024 following the merger of the Evangelical Hospital and Trinity Hospital. With over 700 beds, the new facility is a maximum-care hospital in the region. Visceral surgery, in particular, has been significantly expanded and developed into an independent, high-performing specialty department. Procedures on the pancreas, which are subject to defined minimum volume requirements, are now being performed in significantly higher numbers. This structural expansion noticeably improves medical care and strengthens the Lippstadt Clinic—Christian Hospital as a modern healthcare facility.
The pancreas is a vital organ that plays a central role in both digestion and blood sugar regulation. It produces digestive enzymes that are released into the duodenum via a duct. There, they help break down food components such as fats, proteins, and carbohydrates into their smaller components so that they can be absorbed by the body. At the same time, the pancreas produces important hormones such as insulin and glucagon in specialized groups of cells known as the islets of Langerhans. These hormones regulate blood sugar levels by ensuring that sugar either enters the cells from the blood or is released from the body’s own reserves. In this way, the pancreas plays a key role in maintaining a balanced metabolism and smooth digestion. If its function is impaired, this can therefore have far-reaching consequences—such as digestive disorders or the development of diabetes.
Chronic inflammation of the pancreas, or chronic pancreatitis, is usually caused by long-term damage to the organ, leading to progressive tissue destruction.
“The pancreas is particularly sensitive to certain risk factors, of which chronic or excessive alcohol consumption is considered one of the most serious. It can trigger both acute and chronic inflammation of the gland, known as pancreatitis. Smoking also plays a role, as does a very high-fat diet. Although viral infections can cause pancreatitis in rare cases, this is generally the exception. Another common trigger is gallstones, which can block the common duct connecting the bile ducts and the pancreas. This results in what is known as biliary pancreatitis. The acute form, in particular, is a potentially life-threatening condition in which the mortality rate can be quite high in certain cases. “It is not uncommon for acute inflammation to progress to a chronic form,” explains Prof. Dr. Langenbach, who also comments on the symptoms experienced by patients:
“Typical symptoms of pancreatitis include ring-shaped pain in the upper abdomen, which can sometimes be very severe. However, nonspecific symptoms also occur, such as a pulling or twinging sensation in the abdominal area, sometimes accompanied by diarrhea. These symptoms arise because the pancreas is no longer producing sufficient digestive enzymes or is no longer releasing them properly into the duodenum. In acute cases, patients experience high fever, severe pain, and a significantly deteriorated overall condition—a so-called acute abdomen, which often requires intensive care. The chronic form, on the other hand, develops gradually and can drag on for months or years with recurring symptoms. It can happen that, over time, the pancreas ceases to function almost entirely, resulting in insufficient production of both enzymes and insulin. Since the pancreas is responsible not only for digestion but also for regulating blood sugar levels, inflammation can have an impact here as well. The so-called islets of Langerhans in the pancreas produce insulin. If the gland is diseased, insulin production may be reduced, which ultimately leads to the development of diabetes. The lack of digestive enzymes also disrupts the breakdown and absorption of fats and proteins in the small intestine. This often results in fatty stools and persistent diarrhea. In the long term, this can lead to malnutrition, since not only the major nutrients but also fat-soluble vitamins are no longer absorbed in sufficient quantities.”
When a patient is presented with suspected pancreatic disease, the diagnostic approach initially depends heavily on the clinical presentation. If it is acute pancreatitis and the patient is already in very poor condition—for example, with severe pain and circulatory problems—they are usually brought in by emergency services and immediately undergo a CT scan.
Prof. Dr. Langebach explains: “In these cases, the pancreas begins to partially digest itself, which is visible on imaging as cystic changes and fluid-filled cavities. These patients generally require intensive care. The situation is different with chronic pancreatitis, which usually persists for years and often occurs in people who regularly consume alcohol. Here, the time pressure is less, although the diagnosis must still be carried out carefully. Yet another scenario arises when a patient presents with so-called painless jaundice—that is, yellowing of the skin without accompanying pain. Such a finding is always suggestive of pancreatic cancer, especially if the tumor is compressing the bile duct. In these cases, a high-resolution MRI with and without contrast is performed promptly. At the same time, specific tumor markers are measured in the blood.
In addition, an endosonography may be necessary. This is an ultrasound examination performed from the inside, in which an endoscope is inserted through the duodenum under sedation to specifically visualize the papilla and the excretory ducts. If necessary, a procedure known as ERCP can also be performed through this access—an endoscopic examination of the bile and pancreatic ducts using contrast dye, during which tissue samples can also be taken. However, these samples do not always provide conclusive results. It may happen that only nonspecific inflammatory cells are detected, which does not allow for a definitive conclusion regarding the presence of a tumor. This is due, among other things, to the fact that the sample taken represents only a very small portion of the tissue that may be maliciously altered. For this reason, when cystic changes—so-called cystic lesions in the head, body, or tail of the pancreas—are suspected, surgery is often performed at an early stage, as these changes may represent potential precursors to carcinoma.
In addition to endosonography and MRI, conventional ultrasound examinations and, if necessary, an additional CT scan are also used during the diagnostic process. The results of all imaging procedures and laboratory analyses are ultimately discussed at an interdisciplinary tumor board meeting, which takes place once a week at our facility. There, specialists from radiology, radiation oncology, pathology, oncology, gastroenterology, and surgery come together to jointly determine the best course of treatment for each patient based on current guidelines. This structured approach is an integral part of the care we provide at our hospital.”
Genetic factors play an important role in the development of pancreatic cancer, particularly in the most common form, ductal adenocarcinoma of the pancreas. There are both inherited and acquired genetic changes that increase the risk of the disease and promote tumor growth.
“Genetic factors play a role in pancreatic diseases, particularly when it comes to malignant changes such as pancreatic cancer. A family history of the disease can increase the risk, although the evidence from studies on this topic is not yet conclusive, and clear findings are still lacking. Nevertheless, a genetic predisposition is considered in cases of familial clustering. While the prognosis for other types of cancer—such as colorectal or lung cancer—has improved significantly in recent decades thanks to advanced treatments like targeted chemotherapy or surgical procedures, progress in pancreatic cancer remains comparatively limited. Survival rates have hardly improved, primarily due to late diagnosis. This is because pancreatic cancer causes few specific symptoms for a long time and is therefore often not detected until it has reached an advanced stage. However, there have been advances in the field of diagnostics.
Modern high-resolution MRI techniques now allow for earlier detection of cystic changes in the pancreas, which in some cases are considered precursors to cancer. Such cystic lesions, for example, so-called IPMN (intraductal papillary mucinous neoplasms), are now assessed much more accurately and may indicate a potential early stage of pancreatic cancer. Against this backdrop, there is a growing trend toward considering surgical removal at an early stage in cases of suspicious cystic changes. This is because surgical removal at the earliest possible stage remains the only chance for a cure in this aggressive form of cancer. “The goal is therefore to detect the disease while it is still operable, before the tumor spreads further,” Prof. Dr. Langenbach explains.
The insidious nature of pancreatic cancer lies primarily in the fact that the disease often causes no symptoms—or only nonspecific ones—for a long time. As a result, the tumor is frequently not detected until an advanced stage, when the chances of a cure have significantly decreased. Early signs such as abdominal or back pain, unintentional weight loss, jaundice, or loss of appetite are usually nonspecific and are often not taken seriously until it is too late.
“Pancreatic cancer is one of the most aggressive forms of cancer, and little has changed in this regard in recent years. The prognosis remains extremely poor, especially when the disease is not detected until an advanced stage. When considering all disease courses and stages together, the five-year survival rate remains extremely low—with or without treatment. A decisive factor in the chances of survival is the timing of the diagnosis. Only if pancreatic cancer is detected very early and can be treated with radical surgery is there any realistic chance of a cure. Although there are now treatment approaches modeled after those used for other types of tumors—such as neoadjuvant therapy (chemotherapy prior to potential surgery)—these measures have so far shown only limited effectiveness in pancreatic cancer. The response rate to these forms of chemotherapy is low, so early detection and prompt surgical removal of the tumor remain the only real chances for a cure. “The age distribution shows that people in middle to older age groups are particularly affected,” says Prof. Dr. Langenbach.
Pancreatic cancer is currently one of the five most common cancers and appears to be on the rise overall. The exact cause is not yet clear, but lifestyle changes are among the suspected factors. A high intake of foods high in fat and sugar, regular alcohol consumption, and smoking are considered major risk factors.
“While there are many people who pay attention to a healthy diet and lifestyle, there is also a large segment of the population with poor dietary habits characterized by fast food, a lack of physical activity, and high alcohol consumption. At the same time, it remains a concerning finding that even people who lead very health-conscious lives are not immune to pancreatic cancer. Even in these patients, clear causes often cannot be identified. In addition to known risk factors such as chronic pancreatitis, alcohol abuse, viral infections, or biliary tract diseases, genetic influences are also likely to play a role. “With regard to the microbiome—that is, the totality of microorganisms living in the gut—no definitive link to the development of pancreatic cancer has been established to date. There is currently no scientifically substantiated evidence of any relevant significance,” notes Prof. Dr. Langenbach.
If a patient has had pancreatitis that was not chronic and was successfully treated, there is generally no permanently increased risk of developing cancer.
Prof. Dr. Langenbach explains: “Acute pancreatitis can heal completely without causing lasting damage. The situation is different with chronic pancreatitis: This often leads to permanent functional impairments, such as in insulin production or the exocrine function of the pancreas. If the inflammation remains active over a prolonged period and does not fully subside, the risk of developing cancer also increases. The risk is particularly elevated in people with a long history of alcohol abuse—even if they eventually stop drinking. For example, someone who has lived with heavy alcohol consumption for decades continues to carry the long-term consequences in their tissue, even if the damaging influence ceases later on. In such cases, chronic inflammation may persist, thereby increasing the long-term risk of cancer. As for other diseases or changes in the abdominal cavity—such as a hiatal hernia or certain surgeries that may alter pressure conditions in the upper abdomen—there is no direct link to the pancreas. “There is no evidence that such findings or procedures affect the risk of pancreatitis or even pancreatic cancer.”
Unexplained upper abdominal pain should be taken seriously and evaluated by a doctor—even though this poses a challenge for primary care physicians, as such pain can have many harmless causes, such as stomach problems, stress-related symptoms, gallbladder issues, or colon problems.
“A clear warning sign, however, is yellowing of the skin or eyes, as well as discolored urine. Both indicate impaired excretion of bilirubin, which then accumulates in the skin. Unintentional weight loss—for example, six kilograms in three months without any conscious change in diet—should also be closely monitored. Similarly, the sudden onset of diabetes mellitus in middle age can be a sign of a malignant change in the pancreas and should prompt a targeted visit to the primary care physician. At the same time, it is understandable that not everyone with upper abdominal discomfort can be immediately referred for extensive diagnostic testing. Nevertheless, if the primary care physician is unsure after an ultrasound whether there are changes in the pancreas, further diagnostic testing with an MRI should definitely be performed. In such situations, patients are well advised not to settle for a quick solution but to insist on a thorough evaluation if symptoms persist. “This is precisely why education is so important—to enable people to better interpret their own symptoms and, when in doubt, ask specific questions,” explains Prof. Dr. Langenbach. 
At the Lippstadt Clinic—Christian Hospital, approximately 40 patients per year undergo surgery for pancreatic cancer. Pancreatic cancer is rare compared to many other diseases, but it is serious, so this number attests to a high level of surgical expertise.
“In this context, hospital reform—particularly the centralization of such procedures—also makes sense. For serious diseases such as pancreatic cancer, specialized centers with the appropriate expertise in diagnosis and treatment are absolutely essential. A center must have a modern radiology department, experienced gastroenterologists who are proficient in all necessary diagnostic and interventional procedures—such as endosonography, ERCP (endoscopic retrograde cholangiopancreatography), or specimen collection—even in emergency situations—and a surgical team that performs such procedures regularly. Meanwhile, robotic-assisted surgery is becoming increasingly common, for example using the DaVinci system. This technology enables minimally invasive yet extremely precise surgery, particularly for smaller resections such as the removal of the pancreatic tail—a procedure that previously required opening the entire abdomen.
The Whipple procedure, in which the head of the pancreas, the duodenum, and part of the stomach are removed, also remains part of the treatment spectrum—it is currently still performed predominantly as open surgery but remains one of the most extensive procedures in visceral surgery. These procedures profoundly change patients’ lives, yet they are often the only way to offer a chance at survival. Close interdisciplinary collaboration is also essential. At our hospital, the best course of action for each individual patient is decided jointly during tumor board meetings—by a team comprising specialists in visceral surgery, gastroenterology, oncology, radiology, and other disciplines. Last but not least, psycho-oncological support is an integral part of patient care. The psychological strain is significant, and it is therefore crucial to incorporate this aspect into the care of those affected. Close cooperation within specialized teams and the collaboration of several experienced visceral surgeons creates a high level of expertise that benefits patients—an advancement that is becoming increasingly important in the care of pancreatic diseases,” Prof. Dr. Langenbach concluded.
Thank you very much, Professor Dr. Langenbach, for this helpful and important information!
