Pancreatic Cancer Surgery: For Patients

When considering surgery for pancreatic cancer it is important to understand the difference between curative and palliative surgery. Surgery that is potentially curative aims to remove all the cancer. Tests and examinations will determine whether pancreatic cancer can be cut out in a procedure called pancreatic tumor resection. If a tumor is resectable it means that it is possible to cut out all the cancer and that surgery offers a potential cure. If tests show that pancreatic cancer has spread too much for it to be completely removed, it is unresectable. Palliative surgery may be performed with the goal of relieving symptoms. The purpose of palliative surgery is not to cure pancreatic cancer, but this type of surgery can prevent complications such as blockage of the bile duct or intestine.

Laparoscopy

The stage of pancreatic cancer is an important part of determining which surgery option is best. In addition to imaging tests, laparoscopy is also done to understand the stage or extent of cancer progression. For laparoscopy, the surgeon makes a few small incisions in the abdomen and inserts instruments including a camera to view the pancreas and other organs. The surgeon may also collect biopsies, which are small samples of tumors and other areas inside the abdomen if they look abnormal. Analysis of biopsies will provide information about how far the pancreatic cancer has spread.

Curative Surgery

Pancreatic cancer surgery can be curative, but only if the cancer is resectable. This usually means the cancer is confined to the pancreas. The pancreas is shaped like a tadpole. Pancreatic cancers at the head of the pancreas are more likely to be found early enough for curative surgery. This is because cancers at the head of the pancreas can cause the symptoms of jaundice, yellow appearance of the skin, and the whites of the eyes due to blockage of the liver’s bile duct.

Fewer than 1 in 5 pancreatic cancers appear to be confined to the pancreas. Surgery in these cases does not always lead to a cure because the removal of all visible cancer may still leave behind cancer cells that spread to other parts of the body. Sometimes it is not known until after the operation begins that the cancer has grown too far and is not resectable. Because removing part of the pancreas does not help patients live longer, the surgeon may decide to stop the operation or switch from curative to palliative surgery. Palliative surgery is a smaller operation done to relieve or prevent some symptoms of pancreatic cancer.

Potentially curative pancreatic surgery is a complex surgery that can cause complications and may take weeks to months for the patient to fully recover. That is why it is important to weigh the potential benefits and risks. If the surgeon discovers that pancreatic cancer has spread too far and surgery is not likely to cure the cancer, the benefits may no longer outweigh the risks, side effects, and long recovery time from surgery. A long recovery time from surgery could delay other pancreatic cancer treatments such as chemotherapy and targeted therapy.

Whipple Procedure

The Whipple procedure, also called pancreaticoduodenectomy, is the most common surgical procedure for pancreatic cancer that is done to remove cancer in the head of the pancreas. Sometimes removal of the body of the pancreas is included in the Whipple procedure. In addition, parts of other organs nearby such as the bile duct, gallbladder, lymph nodes, and stomach are removed. The parts of the bile duct and pancreas that remain are attached to the small intestine, allowing bile and digestive enzymes to go into the small intestine. The surgeon will reattach the small intestine (or small intestine and stomach) so that food will pass through the digestive tract or gut. The Whipple procedure is most often performed through a large incision in the middle of the belly but at major cancer centers, it may be done laparoscopically. Laparoscopic surgery, sometimes called keyhole surgery, uses smaller incisions as the surgeon performs the operation with narrow instruments and a video camera.

A Whipple procedure is very complex and requires a lot of skill and surgical experience. There is a relatively high risk of life-threatening complications with a Whipple procedure and the risk can vary depending on the hospital. Up to 15% of patients die of surgical complications when performed in small hospitals that have less experienced surgeons compared with 5% when performed in cancer centers. People tend to do better with a Whipple procedure when the hospital performs at least 15 to 20 of these procedures a year.

Complications can occur after a Whipple procedure even under the best circumstances. Some of these complications include leaky connections, infections, bleeding, trouble with stomach emptying, digestion, weight loss, changes in bowel habits, and diabetes.

The Tail of the Pancreas – Distal Pancreatectomy

A distal pancreatectomy removes the tail of the pancreas or the tail together with part of the body of the pancreas. Unfortunately, when cancer is found in the tail and body of the pancreas it has usually spread to the point where surgery is not an option. In cases where distal pancreatectomy is performed, the spleen is often removed, which causes patients to have an increased risk of infection with certain bacteria. That is why certain vaccines may be recommended prior to surgery to decrease the risk of infection.

Total Pancreatectomy

A total pancreatectomy is the removal of the entire pancreas, gallbladder, part of the stomach small intestine and spleen. If cancer has spread throughout the pancreas but can still be removed, total pancreatectomy may be an option. However, the major side effects of living without a pancreas make this surgical option less common. Remember that the pancreas produces insulin, which moves sugar out of the bloodstream and into cells where it is used for energy. Without a pancreas, people develop diabetes and are completely dependent on insulin shots. The pancreas also produces enzymes to break down food. People who have had a pancreatectomy need to take pancreatic enzyme pills to digest certain foods.

Palliative Surgery

Whenever pancreatic cancer has spread too far to be completely removed, palliative surgery is considered rather than curative surgery. Most doctors do not advise major surgery for the relief of symptoms in people who are in poor health. If a surgeon discovers during surgery that the cancer is not resectable, they may switch to a palliative operation known as bypass surgery which can help relieve symptoms.

If pancreatic cancer reaches the nerves, it can cause pain. Cutting the nerves around the pancreas or injecting them with alcohol can be done during surgery to relieve pain. The placement of a stent is another palliative procedure that can relieve pain and digestive problems caused by pancreatic cancer.

Stent Placement

Cancers in the head of the pancreas can block the common bile duct which passes through the pancreas. To relieve pain and digestive problems caused by bile being blocked from entering the intestine and building up in the body, a stent may be inserted into the bile duct to keep it open. A stent is a small tube, usually made of metal. Stent placement may be done as a palliative procedure or prior to curative surgery to help lower the risk of surgery-related complications.

Stent placement does not involve surgery and can be performed through a tube called an endoscope under sedation and may be part of a procedure called endoscopic retrograde cholangiopancreatography (ERCP). In ERCP, endoscopy is used along with X-rays to examine and treat problems in the pancreas and bile ducts. The light and camera at the end of the endoscope help the doctor insert the stent. Another method of placing a stent is via a needle inserted through the skin and into the liver. This procedure, called percutaneous transhepatic cholangiography, uses a dye to visualize the bile duct.

Bypass Surgery

A blocked bile duct in the pancreas can be relieved by bypass surgery to reroute the flow of bile from the common bile duct directly into the small intestine. Bypass surgery may involve a large incision and weeks to recover or may be performed by laparoscopic surgery involving smaller incisions. While a stent is often an easier method of relieving symptoms of a blocked bile duct, with less recovery time, bypass surgery offers a longer-lasting effect. Stents may require subsequent procedures to be cleaned out or replaced.

Pancreatic cancer can grow large enough to block the duodenum, which is the first part of the small intestine. If this happens, it causes pain and vomiting and must be treated with urgent surgery. Gastric bypass is one way to prevent this situation from occurring. The gastric bypass procedure disconnects the stomach from the duodenum and attaches it farther down the small intestine. Since bypass surgery is a major operation, it is important to be healthy enough to tolerate the procedure.

Pancreatic tumor removal through surgery can potentially cure pancreatic cancer or pancreatic surgery may aim to relieve symptoms. Patients with pancreatic cancer should be aware of the potential benefits of various surgical options and also their limitations. The risks and benefits will be different for each patient depending on their health and on the location and stage of their cancer.

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