Pancreatic Cancer Surgical Options

Doctors recommend surgery for patients with pancreatic cancer when imaging tests show the cancer can be completely removed surgically. Doctors generally consider tumors removable if they have not spread beyond the pancreas and do not involve major arteries.

Palliative surgery can relieve symptoms or prevent complications if surgery can’t fully remove the tumor.

Doctors often mix surgery with other treatments like chemotherapy or radiation.

• Neoadjuvant therapy — given before surgery, involves the use of chemotherapy, radiation, or both, to shrink the tumor. This makes it easier to remove and may improve the chances for a complete removal.
• Adjuvant therapy — given after surgery, uses chemotherapy, radiation, or both to kill any small amounts of cancer cells that spread before surgery or were left behind. The goal is to prevent the reappearance of the cancer.

The goal of surgical treatment for this disease depends on the likelihood of removing the tumor.

• If imaging test results suggest surgeons can excise the entire mass then the goal of surgery is to cure the pancreatic cancer.
• If the imaging test results suggest the tumor is too large or widespread for surgeons to remove then the goal of surgery is to relieve symptoms or prevent complications (palliative surgery).

Imaging tests can't always predict exactly what the surgeon will encounter. He or she may need to switch from curative to palliative surgery based on the situation at hand.

Surgery is often just one part of a complete treatment plan that may also include radiation and medical oncology.

The surgical oncologists at UPMC Hillman Cancer Center are experts in a range of advanced pancreatic cancer surgery techniques.

Minimally invasive and robotic surgical methods — including the robotically assisted Whipple procedure — reduce risks and healing times.

Almost 80 percent of pancreatic cancer patients at UPMC who are surgical candidates have the Whipple procedure. And up to 85 percent of patients slated for the Whipple are candidates for the robotic option.

UPMC is one of only a handful of hospitals in the United States to offer the robotic Whipple method and has more experience than any hospital in the nation. The American Cancer Society recommends undergoing a Whipple at a hospital that performs at least 15 of these surgeries each year; in 2018, UPMC’s surgeons performed more than 60.

Your care team and surgeon will:

• Explain your pancreatic cancer surgical treatment options.
• Suggest the option that considers the type and stage of pancreatic cancer, along with the goals of surgery.
• Discuss the risks and benefits of the procedure and describe the recovery process.

You will also make decisions together about adding radiation or medical oncology to your treatment plan either before or after surgery.

Types of pancreatic cancer surgeries we perform

• Distal pancreatectomy — this is the removal (resection) of the tail and some of the body of the pancreas. Used mainly for neuroendocrine (islet cell) tumors, this open surgery often includes removal of the spleen. Because the spleen helps fight infection, you may need a vaccination before surgery. This operation often requires a hospital stay of six to eight days.
• Laparoscopic pancreatectomy — this minimally invasive surgery removes the tail and body of the pancreas through five or six small “keyhole” cuts. This can reduce risks and shorten hospital stay by a few days.
• Pancreas-sparing tumor resection — in this type of limited resection, the surgeon removes the tumor without removing the pancreas. Contained tumors that haven't invaded nearby structures may be entirely resectable. Sometimes, the surgeon will resect a tumor along with part of a structure (usually the duodenum) that it has invaded.
• Portal vein resection and reconstruction — at the head of the pancreas, the superior mesenteric vein meets the splenic vein. These form the hepatic portal vein, which sends blood to the liver. If a tumor invades this meeting point, the surgeon may resect it and build a new pathway to the liver. Surgeons can do portal vein resection along with the Whipple procedure or on its own.
• Whipple procedure (Pylorus preserving pancreaticoduodenectomy) — this open method used mostly for exocrine pancreatic cancer removes a tumor in the head of the pancreas. Surgeons also remove the attached duodenum and bile duct, the gallbladder, and part of the stomach. The open Whipple requires a large incision and usually means a hospital stay of about 10 days. The minimally invasive robotic Whipple method requires a few small cuts. This results in a shorter hospital stay, faster recovery, and less pain and scarring.
• Advanced Whipple — this surgery has all aspects of the standard Whipple along with the removal of the portal or superior mesenteric veins.
• Appleby operation — this is the removal of locally advanced cancers of the pancreas body that have invaded the celiac or hepatic artery. Robotic methods are not available for this operation.
• Small bowel (small intestine) resection — this is the resection of the pancreatic tumor along with the part of the bowel that it has invaded.
• Total gastrectomy — extensive tumor involvement may require a total gastrectomy. This is when the surgeon removes some or all of the diseased pancreas along with the entire stomach and nearby lymph nodes. Often, this also involves removing the spleen and parts of the intestine. This radical surgery leads to connecting the esophagus directly to the bowel.

Your pancreatic cancer surgery will depend on the type of procedure. Surgeons also consider other factors like your response to the procedure and your overall health.

Studies show when experienced surgeons perform the procedure, patients usually have fewer complications and better outcomes.

Recovery times vary. The open Whipple requires a longer hospital stay of 7-10 days after surgery, while the robotic Whipple has a faster recovery time.

You will likely experience side effects from your surgery. You may see changes in your digestive system that cause side effects like diarrhea, gas, or stomach pain.

Pancreatic cancer surgery carries potential short-term and long-term side effects, including:

• Diarrhea
• Gas
• Stomach pain
• Weight loss
• Diabetes
• Bleeding
• Infections

Because of the difficulties of pancreatic cancer, it is possible that a surgeon can’t fully remove the cancer. The surgeon then will shift to a palliative procedure. The cancer also may not go away completely, or it may spread to another part of the body. This makes follow-up appointments important.