Potentially Curative Surgery for Pancreatic Cancer
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 typically only done when complete removal of the cancer will be possible.
There are three procedures 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 involves removing the head of the pancreas and sometimes the body of the pancreas as well. At times, 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. Removal of tissue called the mesopancreas (RMP) may also be combined with the Whipple procedure. This tissue which contains cancer cells or cells that secrete compounds that may help the cancer grow, prevent it from dying or inhibit some chemotherapy. The addition of mesopancreatic resection appears in eary studies to help prolong survivival and may reduce the need for radiation.
This is a long and complex operation, often taking 6-8 hours, that requires much skill and experience. It carries a relatively high risk of complications and 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. At the OHSU Knight Cancer Institute, our surgeons specialize in pancreatic and intestinal cancers, and have the training and experience to perform this surgery successfully. Still, even in the best hands, many patients have complications from the surgery. These can include:
- Leaking from the various connections that the surgeon has to make
- Trouble with the stomach emptying after eating
For you to have the best outcome, you should be treated by a surgeon who does many of these operations. In general, people having this type of surgery do better when it is performed at a hospital that does at least 20 pancreas surgeries per year. At the OHSU Knight Cancer Institute, 90% of our Whipple surgeries are successful and lead to complete resection, due in part to our advanced techniques in vascular reconstruction.
At the time of diagnosis, only about 10 percent of pancreatic cancers have not spread outside the pancreas. Only 10 percent of these can potentially be completely removed with surgery. Even if surgeons remove all the tumor they can see, some cancer cells may have already spread to other parts of the body. These cells may eventually grow into new tumors, causing problems and even death. Among patients who have surgery to completely remove a cancer of the exocrine pancreas, about 20 percent survive for five years.
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 with islet cell tumor and less often, adenocarcinoma of the pancreas found in the tail and body of the pancreas. Another name for this surgery is radical antegrade pancreatosplenectomy or RAMPS procedure. This operation may sometimes be completed laparoscopically.
Total pancreatectomy: This operation was once used for tumors in the body or head of the pancreas. It removes the entire pancreas and often the spleen. It is now seldom used to treat exocrine cancers of the pancreas because there does not seem to be any advantage to 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 become totally dependent on insulin. Total pancreatectomy is now done primarily for IPMN when the entire duct is at risk. If this is the case, the patient sees an endocrinologist pre-surgery to learn how to manage their diabetes. It is never done for adenocarcinoma unless there are unusual compelling reasons.
Enucleation of pancreatic islet cell tumors: An operation called enucleation is often performed for functional pancreatic islet tumors that are small, usually less than 1 to 2cm. Many of these tumors can be removed laparoscopically from the pancreas without removing any healthy pancreatic tissue. This procedure allows a more rapid recovery, early discharge from hospital and early return to work.
Minimally invasive pancreatic surgery: Laparoscopic pancreticosplenectomy are common and laparoscopic whipples are being developed, either may be offered by your surgeon.
Exploratory laparoscopic surgery: Sometimes it is difficult for doctors to tell whether the tumor has spread to other organs in the body. An exploratory laparoscopy surgery may be recommended to see if the tumor is located around the pancreas and in other organs, and to determine if the tumor has spread before making a big incision. Laparoscopic surgeries are performed on the abdomen through small incisions using very special instruments. The benefits of laparoscopic surgery include:
- Reduced blood loss
- Smaller incisions which reduce recovery time
- Shorter hospital stays
- Reduced chance of wound infection