Surgery Options For Pancreatic Cancer

Introduction

Brief overview of pancreatic cancer

Pancreatic cancer starts in the tissue of the pancreas. This small organ is key for breaking down food and controlling sugar levels. It splits into two main types: 

Exocrine tumours: These form about 95% of all pancreatic cancers. The most common kind is called pancreatic ductal adenocarcinoma (PDAC). It starts in the ducts that transport enzymes for digestion. 

Pancreatic Neuroendocrine Tumours (PanNETs): These are rarer and grow from cells that produce hormones in the pancreas. PanNETs can either be "functioning," which means they send out hormones like insulin or gastrin, or "non-functioning," where they don’t produce any key hormones.

Symptoms

Pancreatic cancer may not show signs at first and is often discovered late. When symptoms do appear, they may include jaundice, abdominal pain radiating to the back, unexplained weight loss, nausea, vomiting, and loss of appetite.¹

Importance of surgery in treatment

Surgery is crucial in treating pancreatic cancer as it might be the only way to try for a cure, especially if found early and the tumour has not spread much. Yet, not all people with pancreatic cancer can have surgery. Only 15-20% of people can undergo surgery because the cancer is usually reached a late stage when found.² 

Factors determining surgical eligibility

To determine if a person can undergo surgery for pancreatic cancer, a few factors are reviewed. Only 15-20% of people can have the surgery when they first determine they have cancer.³ The features that doctors look for include:⁴ 

• Where the tumour is and how big it is 
• If blood vessels near it are involved 
• If it can be cut out
• What the tumour is made of and its type 
• What the patient wants

Types of surgery for pancreatic cancer

Surgery for pancreatic cancer is based on the location of the tumour and how far it has spread. There are two key types: curative and palliative surgeries.

Potentially curative surgery 

For pancreatic cancer that can be cut out, surgery may be the only method to get rid of it. The type of surgery depends on where the tumour is within the pancreas.

Whipple procedure (pancreaticoduodenectomy)

Whipple surgery is the top contender for treating cancer that can be cut out from the head of the pancreas. It's a tricky and risky surgery, yet it gives the best odds of a longer life for some people.

Indications for the whipple procedure

The Whipple procedure is performed for:

• Cancer in the head of the pancreas 
• Cancer at the ampulla 
• Cancer in the far end of the bile duct or near the start of the small intestine 
• Some very severe cases of chronic pancreatitis

Types of whipple procedures

There are two main variations:

• Standard (Classic) Whipple: takes out part of the belly along with the pancreas 
• Pylorus-Preserving Whipple: keeps the stomach and pylorus as is

 Recovery and life after whipple surgery

• Time in hospital: About 7 to 14 days 
• Full recovery: Many months 
• Food changes: Small meals often, enzymes, and sometimes a need for insulin 
• Follow-up care: Checks, imaging and chemotherapy

Distal pancreatectomy

Distal pancreatectomy is a surgical procedure used to remove tumours located in the body or tail of the pancreas. It is dissimilar to the Whipple method, which targets growths in the head of the pancreas. A distal pancreatectomy is less arduous, yet still a big surgery.

Indications for distal pancreatectomy

This procedure is performed for:

• Cancer in the main part or end of the pancreas 
• Tumours in the pancreas that start from nerve cells 
• Cysts that have grown inside (like those full of mucus)
• Chronic pancreatitisoccurs when the tail is damaged

Recovery and life after distal pancreatectomy

• Time in hospital: around 5-7 days 
• Full recovery: 4-8 weeks, changes in health
• Dietary changes: Patients may need enzyme supplements if digestion is impaired
• Long-term care: Regular follow-ups to monitor cancer recurrence

Total pancreatectomy

A total pancreatectomy is a surgery where the full pancreas and some nearby organs are taken out. It is conducted when a tumour or sickness has spread throughout the pancreas, so taking only a part of it out (Whipple or distal pancreatectomy) isn't possible. As the full pancreas is removed, people who have undergone it will then face lifelong diabetes and require permanent enzyme supplementation for digestion.

Indications for total pancreatectomy

A total pancreatectomy is recommended for:

• ​​Cancer that takes over the whole pancreas 
• Multiple tumours in the pancreas 
• Widespread  intraductal papillary mucinous neoplasm (IPMN) with a high chance of cancer
• Genetic syndromes (e.g., BRCA mutation) in high-risk patients

Recovery and long-term management

Time in hospital: 7–14 days
Time for full recovery: many months
Lifestyle changes:⁵

• Must keep blood sugar low with insulin throughout your life  
• Need to take enzyme pills to help break down food 
• Eat small meals often to help with stomach work 
• Keep seeing the doctor to check for signs of cancer 
• Chance of living for 5 more years

Palliative surgery 

Palliative surgery is not executed to cure pancreatic cancer, but to ease pain, improve quality of life, and prevent issues in people who have pancreatic cancer that has spread or cannot be removed. Since only 15–20% of pancreatic cancer cases can be removed surgically at diagnosis, palliative care is an essential part of treatment for most patients.

Biliary bypass

A biliary bypass is a simple surgery to help with bile duct blockage from pancreatic cancer that is difficult to remove. When a pancreatic tumour obstructs the bile duct, bile can't enter the gut, which leads to jaundice, itching, nausea, and may even lead to an infection. 

This surgery does not cure cancer but improves a person’s life by letting bile travel as it normally should.

Indications for biliary bypass

• The pancreatic tumour stops the bile duct, causing jaundice
• Endoscopic stenting can't be done or did not work
• The person has symptoms such as itching, weight loss, or a defunctioning liver.

Gastric bypass

Gastric bypass is a palliative surgery performed when a pancreatic tumour blocks the duodenum (first part of the small intestine connected to the stomach), preventing food from passing from the stomach into the intestines. This condition is called gastric outlet obstruction and leads to severe symptoms like nausea, vomiting, and malnutrition.

This is not a cure for cancer, but it improves quality of life by restoring normal eating and digestion processes.

Indications for gastric bypass surgery

• The cancer in the pancreas obstructs the duodenum, so food can't move to the lower gut
• The afflicted person will experience sickness, frequent vomiting, and weight loss
• Endoscopic stent placement has not worked or can't be done 
• The afflicted person is also undergoing other surgical procedures, like a bile duct bypass

Recovery and life after palliative surgery

• Hospital stay: ~5–10 days
• Full recovery time: Several weeks
• Follow-up care: Regular monitoring for complications
• Food changes: they may need to eat less fatty foods and take pills to help digest food

Stent placement

Stent placement is a less invasive procedure used to relieve blockages caused by pancreatic cancer, particularly in the bile duct or duodenum. This helps manage symptoms like jaundice, nausea, and vomiting, improving the patient’s quality of life without requiring major surgery.

Stents are tiny, hollow tubes made of metal or plastic. They are inserted into the bile tube or upper gut to prevent them from closing shut.

Indications for stent placement

A stent is recommended for patients with:

• Blocked bile ducts 
• Blocked upper intestine 
• Tumours that can't be removed through surgery

Life after stent placement⁶

• Bile duct stents: must watch out for skin turning yellow, high body heat, or belly pain 
• Duodenal stents: should eat small, soft meals, which will cause less pain 
• Regular follow-ups are needed to check for stent function and possible replacements 

Debulking surgery

Debulking surgery is a method focused on eliminating as much of the tumour as possible when total removal is not achievable. Unlike curative surgery, debulking does not attempt to dispose of all the cancer cells, but it cuts down the size of the tumour to help ease symptoms or improve the outcome of other treatments, like chemotherapy and radiation.⁷

Risks and recovery

Pancreatic cancer surgeries are complex procedures with potential complications. The risks depend on the patient’s overall health, tumour location, and type of surgery performed.

Common risks and complications⁸

• Infection
• Haemorrhage
• Gastroparesis
• Leakage from Surgical Connections
• Bowel Obstruction
• Diabetes
• Nutritional Deficiencies
• Weight Loss

Recovery process after pancreatic cancer surgery

Hospital stay (immediate post-surgery recovery)

First few days:

• IV meds for pain
• IV fluids and feed tubes (till eating is recovered to normal)
• Drain tubes may be placed to prevent fluid buildup and infection
• Early mobilisation

Home recovery (first few weeks to months)⁹

• Week 1–2: Tiredness, pain, difficulty in  eating 
• Week 3–6: Slowly improving condition, but still some weakness, change in type of food 
• Months 2–3: Most people recover their strength, but might still face stomach problems

Alternative and complementary treatments

Though surgery, chemotherapy, and radiation are the main ways to treat pancreatic cancer, there are other options available:¹⁰

• Acupuncture
• Massage
• Relaxation therapies
• Visualisation
• Art and music therapy
• Pet therapy
• Virtual reality headsets

Summary

Pancreatic cancer has two main types: exocrine and neuroendocrine tumours. They are often discovered in the late stages. Surgical procedures are the most advised method of treatment and may potentially prove to be a cure in some cases. Palliative care helps ease pain, using bypasses and stents, which enhances quality of life. Recovery varies, and some require long-term dietary and medical management.