By the time a patient is diagnosed with pancreatic cancer, the disease is often already in an advanced stage. For this reason, a large majority of patients are not candidates for surgical treatment. We are making advances in understanding the early stages of this disease that, in time, will help us to detect more pancreatic cancers while they are still operable.
Surgery may be suggested as a potentially curative treatment or as a palliative measure to improve the patient’s quality of life. Before reviewing the surgical procedures, it is important to emphasize that every patient has a unique case that should be discussed in detail with your healthcare providers.
When is surgery possible?
Generally if the cancer is localized, surgical treatment, by resection or removal of the tumor, can be pursued. This means that the cancer has not spread to any blood vessels, distant lymph nodes or other organs, such as the liver or lung. These characteristics are determined through various complimentary diagnostic techniques. If the cancer has spread to nearby lymph nodes that are routinely removed during a given surgical procedure, surgery will usually still be possible. Also, recent developments have allowed for surgical replacement of the portal vein, a major blood vessel that carries blood to the liver.
What excludes surgery as a treatment option?
Generally, if the cancer is found in distant lymph nodes, other organs or blood vessels, surgical resection will not be pursued. If this is the case, the doctors and/or nurses will discuss possible medical treatments and/or palliative procedures. Surgery may still be considered to alleviate some symptoms and make the patient more comfortable but not as a curative measure.
What types of surgical procedures are performed to treat pancreatic cancer?
This depends where the tumor is located within the pancreas.
If it is located in the head of the pancreas, Whipple’s operation is the procedure to treat it. It can be done by both open and laparoscopic approach.
If it is located in the body or tail of the pancreas, distal pancreatectomy with or without splenectomy is the procedure for its treatment.
How can palliative surgery improve quality of life?
Double By-pass- A palliative surgical procedure to alleviate jaundice, nausea and vomiting for patients with advanced tumors in the head of the pancreas. The double bypass involves a bypass to the bile duct and a bypass to the stomach. Often a celiac nerve block is also performed.
Celiac Nerve Block- Can be done during a surgical procedure or as a separate non-surgical procedure. This improves tumor-associated pain and may reduce the need to use pain medications.
Whipple’s operation is done for following cancers- cancer of head of the pancreas, distal bile duct, ampulla and duodenum (collectively also known as the periampullary cancers).
This is a complex surgery which extend life and gives a potential cure. Those who undergo a successful Whipple procedure may have a five-year survival rate of up to 25%.
The classic Whipple procedure is named after Allen Whipple, MD, a Columbia University surgeon who was the first American to perform the operation in 1935. Also known as pancreaticoduodenectomy, the Whipple procedure involves removal of the “head” (wide part) of the pancreas next to the first part of the small intestine (duodenum). It also involves removal of the duodenum, a portion of the common bile duct, gallbladder, and sometimes part of the stomach. Afterward, surgeons reconnect the remaining intestine, bile duct, and pancreas.
Who Is a Candidate for the Whipple Procedure?
Only about 20% of pancreatic cancer patients are eligible for the Whipple procedure and other surgeries. These are usually patients whose tumors are confined to the head of the pancreas and haven’t spread into any nearby major blood vessels, the liver, lungs, or abdominal cavity. Intensive testing is usually necessary to identify possible candidates for the Whipple procedure.
Some patients may be eligible for a minimally invasive (laparoscopic) Whipple procedure, which is performed through several small incisions instead of a single large incision. Compared to the classic procedure, the laparoscopic procedure may result in less blood loss, a shorter hospital stay, a quicker recovery, and fewer complications.
The Whipple procedure isn’t an option for the 40% of newly diagnosed patients whose tumors have spread (metastasized) beyond the pancreas. Only rarely is it an option for the 40% of patients with locally advanced disease that has spread to adjacent areas such as the superior mesenteric vein and artery, or for those whose tumors have spread to the body or tail of the pancreas.
Who Should Perform the Whipple Procedure?
The Whipple procedure can take several hours to perform and requires great surgical skill and experience. The area around the pancreas is complex and surgeons often encounter patients who have a variation in the arrangement of blood vessels and ducts.
After the Whipple procedure was introduced, many surgeons were reluctant to perform it because it had a high death rate. As recently as the 1970s, up to 25% of patients either died during the surgery or shortly thereafter.
Since then, improvements in diagnosis, staging, surgical techniques, anesthesia, and postoperative care have reduced the short-term death rate to less than 4% in patients whose operation is performed at cancer centers by experienced surgeons. At some major centers, the reported death rate is less than 1%. But the rate may still be above 15% in patients who are treated at small hospitals or by less experienced surgeons.
Because the Whipple procedure continues to be one of the most demanding and risky operations for surgeons and patients, it’s best to have the procedure done at a hospital that performs at least 15 to 20 pancreas surgeries per year.
What Are Complications of the Whipple Procedure?
Immediately after the Whipple procedure, serious complications can affect many patients. One of the most common of these include the development of false channels (fistulas) and leakage from the site of the bowel reconnection. Other possible surgical complications include:
- Trouble with the stomach emptying itself after meals
After surgery, patients are usually hospitalized for a week before returning home. Because recovery can be slow and painful, they usually need to take prescription or over-the-counter pain medications.
At first, patients can eat only small amounts of easily digestible food. They may need to take pancreatic enzymes — either short-term or long-term — to assist with digestion. Diarrhea is a common problem during the two or three months it usually takes for the rearranged digestive tract to fully recover.
Other possible complications include:
- Weight loss. Most patients can expect to lose weight after the surgery.
- Diabetes.This condition can develop if too many insulin-producing cells are removed from the pancreas. However, patients who have normal blood sugar before surgery are unlikely to develop diabetes, and those who recently developed diabetes before surgery are even likely to improve.
Prognosis After the Whipple Procedure
Overall, the five-year survival rate after a Whipple procedure is about 20 to 25%. Even if the procedure successfully removes the visible tumor, it’s possible that some cancer cells have already spread elsewhere in the body, where they can form new tumors and eventually cause death.
The five-year survival rate is higher in node-negative patients (their cancer has not spread to nearby lymph nodes) than for node-positive patients.
Regardless of node status, most patients receive chemotherapy, radiation, or both after surgery. However, cancer specialists have differing opinions on the best combination and the best drugs to use.
It’s not yet known if therapy works better before or after surgery. But some research suggests that therapy could allow a few patients who are initially thought to be ineligible for surgery to eventually undergo the Whipple procedure. Studies are ongoing.