Pancreatic Cancer

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Treating Pancreatic Cancer TOPICS

Surgery for pancreatic cancer

There are 2 general types of surgery used for pancreatic cancer:

  • Potentially curative surgery is used when the results of exams and tests suggest that it is possible to remove all the cancer.
  • Palliative surgery may be done if imaging tests show that the tumor 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 it is not meant to try to cure the cancer.

Several studies have shown that removing only part of the cancer does not help patients live longer, so potentially curative surgery is only done if the surgeon thinks all of the cancer can be removed. Even then, this is one of the most difficult operations a surgeon can do. It is also one of the hardest for patients. It can cause complications and take several weeks to recover from. Patients need to weigh the potential benefits and risks of such surgery carefully.

Potentially curative surgery

Fewer than 1 in 5 pancreatic cancers appear to be confined to the pancreas at the time of diagnosis. Even then, not all of these cancers turn out to be truly resectable once the surgery is started. Sometimes once the surgeon starts the operation it becomes clear that the cancer has grown too far to be removed completely. 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 exocrine 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 eventually grow into new tumors, which can be very hard to treat.

Long-term success rates for surgery on pancreatic neuroendocrine tumors (NETs) are often much better. These tumors are more likely to be cured with surgery.

Curative surgery is done mainly to treat cancers in the head of the pancreas. Because these cancers are near the bile duct, they often cause jaundice, which allows them to be found early enough to be removed. Surgeries for other parts of the pancreas are mentioned below, but these are only done when it’s possible to remove all of the cancer.

Three procedures can be used to remove tumors of the pancreas:

Pancreaticoduodenectomy (Whipple procedure): This is the most common operation to remove a cancer of the exocrine pancreas. It is also sometimes used to treat pancreatic NETs.

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 enter the small intestine. The pieces of the small intestine (or the stomach and small intestine) are then reattached as well so that food can pass through the digestive tract.

Most often, this operation is done through a large incision (cut) down the middle of the belly. Some doctors at major cancer centers also do the operation laparoscopically, which is sometimes known as “keyhole surgery” (see “What’s new in pancreatic cancer research and treatment?”).

A Whipple procedure is a complex operation that requires a lot of skill and experience. It carries a relatively high risk of complications that can sometimes 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 as a result of surgical complications. In contrast, when the operation is done in cancer centers by surgeons experienced in the procedure, less than 5% of patients die as a direct result of surgery.

For patients to have the best outcomes, they should be treated by a surgeon who does many of these operations and have the surgery at a hospital where many of them are done. In general, people having this type of surgery do better when it is done at a hospital that does at least 15 to 20 Whipple procedures per year.

Still, even in the best of hands, many patients suffer complications from the surgery. These can include:

  • Leaking from the various connections among organs that the surgeon has to make
  • Infections
  • Bleeding
  • Trouble with the stomach emptying itself after eating

Other, longer-term complications can include weight loss, trouble digesting some foods, changes in bowel habits, and diabetes in some people.

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. This operation is used more often to treat PNETs found in the tail and body of the pancreas. It is seldom used to treat cancers of the exocrine pancreas because these tumors have usually already spread by the time they are found.

The spleen helps the body fight infections, so if it’s removed you’ll be at increased risk of infection with certain bacteria. To help with this, doctors recommend that patients get certain vaccines before this surgery.

Total pancreatectomy: This operation was once used for tumors in the body or head of the pancreas. It removes the entire pancreas and the spleen. It is now seldom used to treat exocrine cancers of the pancreas because there doesn’t seem to be an advantage in removing the whole pancreas.

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

Your doctor will recommend certain vaccines before this operation because the spleen 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 or prevent symptoms). Because pancreatic cancer can progress quickly, most doctors do not advise major surgery for palliation, especially for people who are in poor health.

Sometimes surgery might begin with the hope it will cure the patient, but the surgeon discovers this is not possible. In this case, the surgeon might continue the operation as a palliative procedure (bypass surgery) to relieve or prevent symptoms.

Cancers growing in the head of the pancreas can block the common bile duct as it passes through this part of 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. This can cause jaundice, nausea, vomiting, and other problems.

There are 2 main options for relieving bile duct blockage.

Stent placement: The most common approach to relieving a blocked bile duct does not involve actual surgery. Instead, a stent (small tube, usually made of metal) is placed 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. The doctor can then insert the stent into the bile duct through the endoscope. The stent can also be placed through the skin during a percutaneous transhepatic cholangiography (PTC). (These tests are described in the section “How is pancreatic cancer diagnosed?”)

The stent helps keep the bile duct open and resists compression from the surrounding cancer. After several months, the stent may become clogged and may need to be cleared or replaced. Larger stents can also be used to keep parts of the small intestine open if they are in danger of being blocked from the cancer.

Stents can also be placed to help relieve jaundice before curative surgery is done (typically a couple of weeks later). This helps lower the risk of complications from the surgery.

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 in the abdomen, from which it can take weeks to recover. Sometimes it can be done through several small cuts made 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 the nerves leading to the pancreas or inject them with alcohol. This may reduce or get rid of any pain caused by the cancer. (Pancreatic cancer often causes pain if it reaches these nerves.)

Still, a biliary bypass can be a major operation, so it is important that you are healthy enough to withstand it and that you talk with your doctor about the possible benefits and risks before you have the surgery.

Sometimes, the end of the stomach is disconnected from the duodenum (the first part of the small intestine) and attached farther down the small intestine during this surgery as well. (This is known as a gastric bypass.) Often, late in the course of pancreatic cancer, the duodenum becomes blocked by cancer, which can cause pain and vomiting that requires surgery. Bypassing the duodenum before this happens can sometimes help avoid a second operation.

Surgery to treat pancreatic neuroendocrine tumors

Along with the surgeries described above, some less extensive procedures may be used to remove pancreatic NETs.

Often laparoscopy is done first to better locate the tumor and see how far it has spread. For this procedure, the surgeon makes a few small incisions (cuts) in the abdomen and inserts thin, telescope-like instruments. One of these has a small video camera on the end to let the surgeon see inside the abdomen. The surgeon can look at the pancreas and other organs for tumors and take biopsy samples of abnormal areas.

Sometimes if the pancreatic tumor is small, just the tumor itself is removed. This is called enucleation. This operation may be done using a laparoscope, so that only a few small incisions are needed. This operation may be all that is needed to treat an insulinoma, since this type of tumor is often benign.

Small gastrinomas and some other pancreatic NETs may also be treated with enucleation, but sometimes the duodenum (the first part of the small intestine) is removed as well. Larger gastrinomas and other types of pancreatic NETs often require a pancreaticoduodenectomy (Whipple procedure) or a distal pancreatectomy, depending on the location of the tumor.

The lymph nodes around the pancreas are also removed in some cases so that they can be checked for signs of cancer spread.

Surgery may be used to remove metastases if a pancreatic NET has spread to the liver (the most common site of spread) or the lungs. Removing metastases can improve symptoms and prolong life in patients with pancreatic NETs. In rare cases, a liver transplant might be used to treat pancreatic NETs that have spread to the liver.

For more general information about surgery as a treatment for cancer, see our document Understanding Cancer Surgery: A Guide for Patients and Families.

Last Medical Review: 06/11/2014
Last Revised: 01/09/2015