Surgery for Pancreatic Cancer

Two general types of surgery can be used for pancreatic cancer:

• Potentially curative surgery is used when the results of exams and tests suggest that it’s possible to remove (resect) all the cancer.
• Palliative surgery may be done if tests show that the cancer is too widespread to be removed completely. This surgery is done to relieve symptoms or to prevent certain complications like a blocked bile duct or intestine, but the goal is not to cure the cancer.

Staging laparoscopy

To determine which type of surgery might be best, it’s important to know the stage (extent) of the cancer. But it can be hard to stage pancreatic cancer accurately just using imaging tests. Sometimes laparoscopy is done first to help determine the extent of the cancer and if it can be resected.

For this procedure, the surgeon makes a few small incisions (cuts) in the abdomen (belly) and inserts long, thin instruments. One of these has a small video camera on the end so the surgeon can see inside the abdomen and look at the pancreas and other organs. Biopsy samples of tumors and other abnormal areas can show how far the cancer has spread.

Potentially curative surgery

Studies have shown that removing only part of a pancreatic cancer doesn’t help patients live longer, so potentially curative surgery is only considered if the surgeon thinks all of the cancer can be removed.

This is a very complex surgery, and it can be very hard for patients. It can cause complications and might take weeks or months to recover from fully. If you’re thinking about having this type of surgery, it’s important to weigh the potential benefits and risks carefully.

Fewer than 1 in 5 pancreatic cancers appear to be confined to the pancreas at the time they are found. Even then, not all of these cancers turn out to be truly resectable (able to be completely removed). Sometimes after the surgeon starts the operation it becomes clear that the cancer has grown too far to be completely taken out. If this happens, the operation may be stopped, or the surgeon might continue with a smaller operation with a goal of relieving or preventing symptoms (see Palliative surgery below). This is because the planned operation would be very unlikely to cure the cancer and could still lead to major side effects. It would also lengthen the recovery time, which could delay other treatments.

Surgery offers the only realistic chance to cure pancreatic cancer, but it doesn’t always lead to a cure. Even if all visible cancer is removed, often some cancer cells have already spread to other parts of the body. These cells can grow into new tumors over time, which can be hard to treat.

Whipple procedure (pancreaticoduodenectomy)

This is the most common operation to remove a cancer in the head of the pancreas.

During this operation, the surgeon removes the head of the pancreas and sometimes the body of the pancreas as well. Nearby structures, such as part of the small intestine, part of the bile duct, the gallbladder, lymph nodes near the pancreas, and sometimes part of the stomach, are also removed. The remaining bile duct and pancreas are then attached to the small intestine so that bile and digestive enzymes can still go into the small intestine. The end pieces of the small intestine (or the stomach and small intestine) are then reattached so that food can pass through the digestive tract (gut).

There are different ways a surgeon may perform the Whipple procedure. Decisions on which approach to use is very patient-specific. Details such as whether a patient has had pancreas surgery in the past, and the position of the tumor in relation to surrounding vessels all play into this decision:

• Open surgery: This is the most common approach. The surgeon makes a cut (incision) down the middle of the belly to reach the pancreas.
• Laparoscopic surgery: This is a type of minimally invasive surgery. The surgeon makes small cuts in the belly to insert surgical tools and a camera. The camera allows the surgeon to view the pancreas and surrounding tissue, as they use the inserted surgical tools to perform the Whipple procedure.
• Robotic surgery: This is another type of minimally invasive surgery. The surgeon makes small cuts in the belly to insert surgical tools and a camera. The surgical tools are then connected to a “robot,” a device that is directed by the surgeon using hand controls. The use of the robot theoretically allows for more precise, smaller cuts during the Whipple procedure.

A Whipple procedure is a very complex operation that requires a surgeon with a lot of skill and experience. It carries a relatively high risk of complications that can be life-threatening. When the operation is done in small hospitals or by doctors with less experience, as many as 15% of patients may die because of surgical complications. In contrast, when the operation is done in cancer centers by surgeons experienced in the procedure, fewer than 5% of patients die as a direct result of surgery.

To have the best outcome, it’s important to be treated by a surgeon who does many of these operations and to have the surgery at a hospital where many of them are done. In general, people having this type of surgery do better when it’s done at a hospital that does at least 15 to 20 Whipple procedures per year.

Still, even under the best circumstances, many patients have complications from the surgery. These can include:

• Leaking from the various connections between organs that the surgeon has to join
• Infections
• Bleeding
• Trouble with the stomach emptying after eating
• Trouble digesting some foods (which might require taking some pills to help with digestion)
• Weight loss
• Changes in bowel habits
• Diabetes

Distal pancreatectomy

In this operation, the surgeon removes only the tail of the pancreas or the tail and a portion of the body of the pancreas. The spleen is usually removed as well, called a splenectomy. The spleen helps the body fight infections, so if it is removed, you’ll be at increased risk of infection with certain bacteria. To help with this, doctors recommend that patients get certain vaccines before the surgery.

A distal pancreatectomy is used to treat cancers found in the tail and body of the pancreas. Unfortunately, many of these tumors have already spread by the time they are found, and surgery is not always an option.

Total pancreatectomy

This operation removes the entire pancreas, the gallbladder and common bile duct, part of the stomach and small intestine, and the spleen. This surgery might be an option if the cancer has spread throughout the pancreas but can still be removed. But this type of surgery is used less often than the other operations because there doesn’t seem to be a major advantage in removing the whole pancreas, and it can have major side effects.

It’s possible to live without a pancreas. But when the entire pancreas is removed, people are left without the cells that make insulin and other hormones that help maintain safe blood sugar levels. These people develop diabetes, which can be hard to manage because they are totally dependent on insulin shots. People who have this surgery also need to take pancreatic enzyme pills to help them digest certain foods.

Before you have this operation, your doctor will recommend that you get certain vaccines because the spleen also will be removed.

Palliative surgery

If the cancer has spread too far to be removed completely, any surgery being considered would be palliative (intended to relieve symptoms, but not to cure the cancer). Because pancreatic cancer can spread quickly, most doctors don’t advise major surgery for palliation, especially for people who are in poor health.

Sometimes surgery might be started with the hope it will cure the patient, but once it begins the surgeon discovers this is not possible. In this case, the surgeon might do a less extensive, palliative operation known as bypass surgery to help relieve symptoms.

Cancers growing in the head of the pancreas can block the common bile duct as it passes through the pancreas. This can cause pain and digestive problems because bile can’t get into the intestine. The bile chemicals will also build up in the body, which can cause jaundice, nausea, vomiting, and other problems. There are two main options to relieve bile duct blockage in this situation:

Biliary stent placement

The most common approach to relieving a blocked bile duct does not involve actual surgery. Instead, a stent (a small tube made of either metal or plastic) is put inside the duct to keep it open. This is usually done through an endoscope (a long, flexible tube) while the patient is sedated. Often this is part of an endoscopic retrograde cholangiopancreatography (ERCP). The doctor passes the endoscope down the throat and all the way into the small intestine. Through the endoscope, the doctor can then put the stent into the bile duct. The stent can also be put in place through the skin during a percutaneous transhepatic cholangiography (PTC). (See Tests for Pancreatic Cancer.)

The biliary stent helps keep the bile duct open even if the surrounding cancer presses on it. But after several months, the stent may become clogged and may need to be cleared or replaced.

A bile duct stent can also be put in to help relieve jaundice before curative surgery is done (which would typically be a couple of weeks later). This can help lower the risk of complications from surgery.

Biliary bypass surgery

In people who are healthy enough, another option for relieving a blocked bile duct is surgery to reroute the flow of bile from the common bile duct directly into the small intestine, bypassing the pancreas. This typically requires a large incision (cut) in the abdomen, and it can take weeks to recover from this. Sometimes surgery can be done through several small cuts in the abdomen using special long surgical tools. (This is known as laparoscopic or keyhole surgery.)

Having a stent placed is often easier and the recovery is much shorter, which is why this is done more often than bypass surgery. But surgery can have some advantages, such as:

• It can often give longer-lasting relief than a stent, which might need to be cleaned out or replaced.
• It might be an option if a stent can’t be placed for some reason.
• During surgery, the surgeon may be able to cut some of the nerves around the pancreas or inject them with alcohol. Because pancreatic cancer often causes pain if it reaches these nerves, this procedure may reduce or get rid of any pain caused by the cancer.

Bypass surgery can also be an option when the pancreatic tumor blocks the duodenum (the first part of the small intestine). During this surgery, the end of the stomach is attached farther down the small intestine to bypass the blockage in the duodenum. This is done to alleviate symptoms of pain and vomiting and allows your stomach to empty into the small intestine.

Bypass surgery can still be a major operation, so it’s important that you are healthy enough to tolerate it and that you talk with your doctor about the possible benefits and risks before you have the surgery.