Surgery for Cancer of the Pancreas
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Understanding of pancreatic cancer has expanded, and specialists have made improvements in caring for it. Though this type of cancer remains challenging to treat, the type of intervention recommended for each patient depends on many factors, including the patient's age and general health. Symptoms of pancreatic cancer include pancreatitis, abdominal pain that can radiate, and jaundice.
Surgery remains the primary form of treatment for pancreatic cancer, although only a small portion of patients with this disease will be candidates for curative operations, in part because the cancer tends to be well advanced when diagnosed. Some of these patients will require only surgery, while some will also undergo chemotherapy or
radiation therapy before or after surgery. Recent progress in treating cancer is partly a result of such combined treatments.
Available techniques permit surgery designed for the specific status of the patient's pancreatic cancer. The type of surgery performed will depend partly on the location and size of the tumor (in areas of the organ referred to as the head, body, or tail) and on the patient's symptoms and health. Surgery is potentially curative if imaging studies indicate that it is possible to remove the all of the cancer.
To accomplish this and retain digestive function, the surgeon may remove all or part of the pancreas, as well as the gallbladder, at least a portion of the stomach and small intestine, and sometimes other organs or tissue, and then perform a reconstruction of this portion of the gastrointestinal tract. Improvements in survival for these major operations, and decreases in complications - along with increases in five-year survival rates after the operations - gives reason for cautious optimism about progress against pancreatic cancer.
The Whipple is directed at pancreatic cancer in the head of the pancreas, which is the widest part of the organ and the end of the organ that attaches to the rest of the digestive tract. When the pancreatic tumor is confined to this area, the standard surgical strategy is to remove this portion of the pancreas, as well as the gall bladder and part of the small intestine, bile duct, and stomach. The surgeon then reconnects the remaining portion of the pancreas, stomach, bile duct, and small intestine. Enough of the pancreas is left to produce digestive juices and insulin.
Also called pancreaticoduodenectomy, this is the most common surgical procedure for operable cancer of the pancreas. With a portion of the pancreas remaining after the operation, patients are unlikely to need to take insulin after undergoing this operation.
If the tumor is located in the body or tail of the pancreas, the surgical approach is to remove just these sections of the organ. Typically, the surgeon will also remove the spleen because of its proximity and tissue connections to the tail of the pancreas. Partly because the surgeon is removing the area that is distal to the connection of the pancreas with the other portions of the digestive system, no reconstructive surgery is necessary. Again, with a portion of the pancreas remaining after the operation, patients are unlikely to need to take insulin after undergoing this operation. Only a small percentage of pancreatic cancer patients have tumor that is isolated in this portion of the organ.
When the extent of the cancer dictates that the entire pancreas must be removed, the surgeon will sometimes remove the whole of the organ, as well as part of the small intestine and stomach, the common bile duct, the spleen, the gallbladder, and some lymph notes. The surgeon then reconnects the remaining portion of the stomach, bile duct, and small intestine.
This operation is less commonly performed, partly because patients must be fit to survive this very major procedure, and recovery time is extensive. In addition, patients undergoing a total pancreatectomy will:
- have to take enzymes to digest food, as a result of the total loss of the pancreas;
- have to carefully monitor their blood sugar and receive insulin injections because of becoming diabetic as a result of the total loss of the pancreas;
- and have to take a variety of steps to protect themselves immunologically, due to loss of the spleen.
Sometimes when imaging studies reveal that the tumor is too advanced or the cancer too widespread to be completely removed, and that curative surgery is thus not possible, surgical treatment can still be beneficial in addressing and reducing symptoms. Pancreatic cancers can cause pain or obstruction of the digestive tract.
Cancers in the head of the pancreas can block the nearby bile duct. In one type of operation, the surgeon will reroute the flow of bile from the common bile duct past the pancreas and into the small intestine, also cutting nerves to the pancreas to decrease pain. Another option is to reconnect the stomach to the small intestine if the intestine becomes blocked, to allow the patient to continue to eat normally.
Endoscopic procedures are also possible, to place stents (tubes) to keep the bile duct open. The stent may drain to the outside of the body or into the small intestine. These procedures are more common for patients with extensive disease or who are too weakened to be candidates for an open surgical operation to relieve bile obstruction.
Another type of palliative surgery is tumor resection for patients whose cancer has already spread to other parts of the body at the time of initial diagnosis. The step can help reduce later bleeding, blockages, pain, and other symptoms caused by masses and by tumor invasion of nearby organs.
Surgeons may initially undertake a curative operation but perform a palliative procedure instead, if they determine that the cancer is inoperable during the open procedure.
Download this discussion on pancreatic cancer and its treatment, by Jeffrey T. Brodsky, Chief of Surgical Oncology at Aria Health: Download file (Adobe PDF).