Surgery for cancer of the pancreas is performed in order to remove the cancer and learn additional information about the cancer. Surgery is an important treatment for patients with pancreatic cancer. However, optimal treatment of patients with pancreatic cancer often requires more than one therapeutic approach. Thus, it is important for patients to be treated at a medical center that can offer multi-modality treatment involving surgeons, medical oncologists, radiation oncologists, medical gastroenterologists, and nutritionists.
Surgery can be performed with curative intent for some patients with cancer localized to the pancreas. Patients with more-advanced cancer may undergo surgery for reduction of symptoms and prevention of obstruction of the bile duct. Obstruction of the bile duct is a common complication of pancreatic cancer that may lead to jaundice (a yellow discoloration of the skin). Less frequently, surgery is performed to treat or prevent obstruction of the stomach outlet.
It is important that a portion of the cancer removed during surgery be made available for biomarker testing to determine whether any precision cancer medicines are available for treatment. Patients should discuss this with their surgeon prior to surgery to ensure it is performed.
Surgery for pancreatic cancer is difficult in part because of the location of the pancreas. The pancreas is located in the middle of the abdomen between the liver and the spleen, just below and behind the stomach. The pancreas is a “retro-peritoneal” organ, meaning it is located behind and outside the abdominal cavity. The pancreas consists of a head and a tail. The head of the pancreas is connected to the last part of the stomach (the pylorus) and the first portion of the small intestine (the duodenum). The pancreas has a duct that carries digestive enzymes into the duodenum at the same location where the bile duct empties bile from the liver. Cancer in the head of the pancreas can block the bile duct and the outlet from the stomach. In all operations for pancreatic cancer, the bile duct has to be relocated to the middle section of the small intestine, called the jejunum, or less commonly, into the stomach. In some operations the bile duct is kept open with an artificial tube called a stent.
Choosing a Surgeon
Most clinical studies suggest that hospitals that treat a relatively large number of patients with cancer (high-volume hospitals) report lower surgical in-hospital death rates than hospitals that treat a small number of patients (low-volume hospitals). This is thought to be due to experience of the surgeon and to the presence of surgical teams with sub-specialty expertise. For example, in one clinical study involving more than 5,000 patients, the risk of dying following pancreatectomy and other major cancer surgeries was 6% in the 30 days following surgery compared to 13% for low-volume hospitals.1 However, in another clinical study reported from the City of Hope Medical Center (Duarte, CA), there were no post-operative deaths in 54 patients undergoing pancreatectomy during an 11-year period. In this clinical setting, nine different surgical oncologists performed an average of six pancreatectomies during 11 years.2 These doctors concluded that in the setting of an exclusive oncology practice, operative mortality rates following pancreatectomy could remain low despite small numbers of treated patients. In order to receive the best treatment, patients should specifically inquire about the experience of the surgeons and the hospital, and ask to be informed about the risk of major complications by the surgeons performing the operation.
Pancreaticoduodenectomy (Whipple Resection): The usual operation for pancreatic cancer consists of removing the pancreas with the first part of the small intestine (duodenum) and the pylorus, or last part of the stomach. The stomach is then connected back to the middle of the small intestine (the jejunum) in a procedure called a gastrojejunostomy. The bile duct is rerouted into the jejunum. Recent clinical studies suggest that connections of the bile duct and pancreatic duct to the stomach (pancreaticogastrostomy) may be preferable to connection to the jejunum (pancreaticojejunostomy).
Partial Pancreatectomy: When cancer involves only the first part or head of the pancreas, the tail, which is uninvolved with cancer, can be preserved. This is called a partial pancreatectomy and requires that the pancreatic duct be rerouted to the stomach or jejunum. This is an important consideration as digestive juices from the remaining pancreas help in digestion, nutrition, and general well-being.
Pylorus-preserving procedure: In standard pancreatic surgery, the pylorus, or “valve” that controls emptying of the stomach, is removed. Rapid entry of food from the stomach to the small intestine can result in discomforting symptoms and leads to poor absorption of nutrients. This is referred to as the “dumping syndrome” and is caused by the removal of the pylorus. By preserving the pylorus, rapid emptying or dumping of food into the small intestine can probably be reduced; however, it is important that adequate removal of the cancer is not compromised by this procedure. Many surgeons, especially in Japan, are using pylorus-sparing surgery, although absolute documentation of benefit is currently lacking.
Complications of Surgery for Pancreatic Cancer
The most frequent early complications of surgery include infections in the abdomen, bleeding in the abdomen, leakage of bile and/or digestive juices from the rerouted bile and pancreatic ducts into the abdomen, inflammation of the bile ducts, and rapid emptying of the stomach (dumping syndrome). The most frequent late complications include: diabetes, diarrhea, and malnutrition.
If the cancer has spread and cannot be removed, the following surgeries may be done to relieve symptoms and improve quality of life.
- Surgical biliary bypass: If cancer is blocking the small intestine and bile is building up in the gallbladder a surgeon can cut the gallbladder or bile duct and sew it to the small intestine to create a new pathway or “bypass” around the blocked area.
- Endoscopic stent: If the cancer is blocking the bile duct, surgery may be done to insert a stent (a thin tube) to drain bile that has built up in the area. The stent can either that drain the bile to the outside of the body or internally into the small intestine.
- Gastric bypass: If the cancer is blocking the flow of food from the stomach, the stomach may be sewn directly to the small intestine so the patient can continue to eat normally.
1 Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of Hospital Volume on Operative Mortality for Major Cancer Surgery. JAMA. 1998;280:1747-1751.
2 Schwarz RE, Ellenhorn JDI. Influence of Hospital Volume on Mortality Following Major Cancer Surgery [Letter]. JAMA. 1999;281: 1374.
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