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 imaging 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 completely removed. This is done to relieve symptoms or to prevent certain complications like a blocked bile duct or intestinal tract.

Several studies have shown that removing only part of the cancer does not help patients live longer. Pancreatic cancer surgery is one of the most difficult operations a surgeon can do. It is also one of hardest for patients. There may be complications and it may take several weeks for patients to recover. Patients need to weigh the potential benefits and risks of such surgery carefully.

Potentially curative surgery

Most curative surgery is designed to treat cancers at the head of the pancreas. Because these cancers are near the bile duct, some of them cause jaundice and are 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 are used to remove tumors of the pancreas:

Pancreaticoduodenectomy (Whipple procedure): This is the most common operation to remove a cancer of the exocrine pancreas and it is also sometimes used to treat cancers of the endocrine pancreas. It removes the head of the pancreas and sometimes the body of the pancreas as well. Part of the stomach, small intestine, and lymph nodes near the pancreas are also removed. The gallbladder and part of the common bile duct are removed and the remaining bile duct is attached to the small intestine so that bile from the liver can continue to enter the small intestine.

This is a complex operation that requires much skill and experience. It carries a relatively high risk of complications that may even be fatal. When the operation is done in small hospitals or by doctors with less experience, more than 15% of patients may die as a result of surgical complications. In contrast, when this operation is performed in cancer centers by surgeons experienced in the procedure, less than 5% of patients die as a direct result of complications from surgery. Still, even in the best of hands, many patients suffer complications from the surgery. These can include:

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

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

At the time of diagnosis, only about 10% of cancers of the pancreas appear to be contained entirely within the pancreas. Only about half of these turn out to be truly resectable once the surgery is started. Although surgery offers the only real chance to cure exocrine pancreatic cancer, it doesn’t always lead to a cure. Even if all visible tumor is removed, often some cancer cells have already spread to other parts of the body. These cells eventually grow into new tumors and cause many problems — even death. This is why the cancer comes back later in most patients who had surgery that appeared to completely remove a cancer of the exocrine pancreas.

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

The spleen helps the body fight infections, so having it removed means an increased risk of infection with certain bacteria. To help with this, doctors recommend that patients get certain vaccines before a Whipple procedure.

Distal pancreatectomy: This operation 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.

Your doctor might recommend certain vaccines before this operation because the spleen will be removed.

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. These people develop diabetes, which can be hard to manage because they are totally dependent on insulin shots and because the islet cells also make other hormones that help maintain blood sugar levels.

Palliative surgery

If the cancer has spread too far to be completely removed, any surgery being considered would be palliative (intended to relieve or prevent symptoms). Because pancreatic cancer can progress quickly, most doctors do not advise surgery for palliation. Sometimes surgery may begin with the hope it will cure the patient, but the surgeon discovers this is not possible. In this case, the surgeon may continue the operation as a palliative procedure 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 build up in the body. There are 2 options for relieving bile duct blockage.

Surgery can reroute the flow of bile from the common bile duct directly into the small intestine, bypassing the pancreas. This requires a large incision in the abdomen, and it may take weeks to completely recover. One advantage is that during this procedure, 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 that may be caused by the cancer.

Sometimes, the stomach connection to the duodenum (the first part of the small intestine) is rerouted at this time as well. 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 help avoid a second operation.

A second approach to relieving a blocked bile duct does not involve surgery. Instead, a stent (small tube) is placed in the duct to keep it open. This is usually done through an endoscope (a long, flexible tube) while the patient is sedated. The doctor passes the endoscope down the patient's 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, which is usually made of metal, 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. Larger stents are also used to keep the duodenum (or other parts of the small intestine) open if it is in danger of being blocked.

In general, the use of endoscopically placed stents has replaced surgery to relieve bile duct obstruction. Stents can also be placed before surgery to relieve jaundice before the pancreas is removed.

Surgery to treat pancreatic neuroendocrine tumors and cancers

In addition to the procedures described above, some less extensive procedures may be used to remove PNETs. Often laparoscopy is done first to better locate the tumor and see how far it has spread.

Sometimes if the 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 (2 inches or less) may also be treated with enucleation, but sometimes the duodenum (the first part of the small intestine) is removed as well. Larger gastrinomas may require a pancreaticoduodenectomy 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 PNET has spread. This can be used when it has spread to the liver (the most common site of spread) and the lungs. Removing metastases can improve symptoms and prolong life in patients with PNETs. In rare cases, liver transplantation might be used to treat PNETs that have spread to the liver.

Last Medical Review: 01/28/2013
Last Revised: 02/05/2014