Pancreatic Cancer: Surgery
Surgery can sometimes be used to treat pancreatic cancer. Different kinds of surgery may be done. The type you have depends on where the cancer is, how much it has spread, the goal of surgery, and other factors.
When might surgery be used for pancreatic cancer?
Surgery is sometimes an option to try to remove all of the cancer if it’s still at an early stage. Unfortunately, pancreatic cancer has often spread too far by the time it’s found to remove it all. For more advanced cancers, surgery can also sometimes be used to help prevent or relieve symptoms.
If your healthcare provider recommends surgery, be sure you understand the goal of the operation. Is it to try to cure your cancer or is there a different goal? Surgery for pancreatic cancer is complex. It can cause major side effects, so it’s important that you understand it and are healthy enough for it. You should also have it done at a center that has experience treating this cancer.
Types of surgery for pancreatic cancer
Surgery to determine the extent of the cancer
Surgery to remove pancreatic cancer is a major operation. It’s very important to know just how far the cancer has spread before attempting this type of surgery. Sometimes it can be hard to tell how far the cancer has spread based on imaging tests alone. So, your healthcare provider may recommend laparoscopic surgery first. This can give your healthcare team a better idea of exactly how far the cancer has spread. This can help them determine if surgery to remove the cancer might be an option.
For this surgery, your surgeon makes several small incisions in your abdomen. Then he or she inserts long, thin tools, one of which has a small video camera on the end, into the incision. This lets the surgeon look at your pancreas and nearby organs. He or she can also take biopsy samples to check how far the cancer has spread.
Surgery to try to remove all of the cancer
Whipple procedure (pancreaticoduodenectomy)
This is the most common surgery for removing tumors from the pancreas. It’s used for cancers in the head of the pancreas. In this complex operation, your surgeon removes:
Head of your pancreas, and sometimes the body of the pancreas as well
Duodenum (first part of the small intestine)
Part of your stomach, in some cases
Gallbladder and part of the common bile duct
Nearby lymph nodes
After this surgery, bile from your liver, food from your stomach, and digestive juices from the remaining part of your pancreas all enter your small intestine. You can still digest foods, but some people might need to take pancreatic enzymes to help with this.
You may have this surgery if the cancer has spread through your pancreas, but not beyond it. This is done less often than the Whipple procedure. In this operation, your surgeon removes the following:
Part of your stomach
Gallbladder and part of the common bile duct
Once your surgeon removes your pancreas, you won’t be able to make pancreatic juices or insulin. You’ll have diabetes, so you’ll need to test your blood sugar levels, give yourself insulin shots, and take other steps to keep your blood sugar in check. You’ll also need to take pancreatic enzyme pills with food to aid in digestion.
This surgery might be an option if your cancer is confined to the tail of your pancreas. For this operation, your surgeon removes only the tail of your pancreas. He or she may also take out part of its body, the middle section. The surgeon also usually removes your spleen. This operation is not done much because tumors in the tail of the pancreas have usually spread by the time they’re found.
For more advanced cancers, sometimes other procedures can help with certain symptoms. But these surgeries cannot cure the cancer. These procedures may help restore your bile flow, allow food to leave your stomach into your small intestine, or ease pain.
For instance, surgery may relieve a blocked bile duct by bypassing it. Surgery may also relieve a blockage at the outlet of your stomach to the first part of the small intestine by bypassing it. This is called gastric bypass surgery. These are some of the types of palliative surgery:
Surgery to redirect the flow of bile directly into your small intestine
Surgery to allow your stomach to empty into another part of your small intestine
Injections to block or numb nerves near your pancreas to prevent or relieve pain
Placing a small tube (stent) inside the bile duct or duodenum to help keep it open
Possible risks, complications, and side effects of surgery
All surgery has risks. Some of the risks of any major surgery include:
Reactions to anesthesia
Blood clots in your legs or lungs
Damage to nearby organs
Risks from surgery for pancreatic cancer
Along with the risks above, pancreatic cancer surgery can sometimes cause other problems.
Pancreatic cancer surgery increases your risk for infection. Healthcare providers can treat some skin infections by allowing them to drain and by using clean dressings. More serious infections can occur inside your abdomen. These may require additional surgery. Antibiotics are often very helpful in treating infections.
After your surgeon removes parts of your stomach, intestines, and/or bile ducts, he or she attaches them back together. Leaks can sometimes occur at these spots. If the leak is small, treatment may involve observation and diet. This lets it heal itself over time. If the leak is large, it can be life-threatening. You may need surgery to fix it.
Changes in bowel function and what you can eat
Some people might need to take enzyme supplements or change their diets. They might also have different bowel patterns after surgery.
If a large part or your entire pancreas is removed, you might have trouble controlling your blood sugar levels. You might need to take insulin.
Getting ready for your surgery
Before you go for surgery, you’ll meet with your surgeon to talk about it. At this time, ask any questions and share concerns you may have. This is also a good time to review the side effects of the surgery and to talk about its risks. You might ask if the surgery will leave scars and what those scars will look like. You might also want to ask when you can expect to return to your normal activities. After you have discussed all the details with your surgeon, you’ll sign a consent form that says that he or she can do the surgery.
A few days before your surgery, your healthcare provider might give you laxatives and enemas to help clean out your colon. He or she will tell you when and how to use these. You may also be told to follow a special diet.
On the day of your surgery, you should arrive at the hospital admission area a couple of hours before the time your surgery is set to start. There, you'll complete the needed paperwork and go to a preoperative area. In this area, you’ll undress and put on a hospital gown. During this time, your healthcare team will ask you about your health history. They’ll also ask about medicine allergies and talk about the procedure. Try not to get frustrated by the repetition. These questions are repeated to help prevent mistakes.
While you’re in the preoperative area, an anesthesiologist or a nurse anesthetist will do an evaluation. He or she will also explain the anesthesia you’ll have during your surgery. The purpose of the anesthesia is to put you to sleep so that you won't feel any pain. Be sure to answer all the questions thoroughly and honestly. This will help prevent complications. Also, ask any questions you have about your anesthesia. You will sign a form that states that you understand the risks involved.
Your surgeon will also see you in the preoperative area. You can ask any last-minute questions you have. This will help put your mind at ease.
What to expect during surgery
When it’s time for your surgery, you’ll be taken into the operating room. There will be many people there. These include the anesthesiologist, surgeon, and nurses. Everyone will be wearing a surgical gown and a face mask. Once in the room, someone will move you onto the operating table. There your anesthesiologist or nurse will place an intravenous line (IV) into your arm. This requires just a small skin prick. Someone will place special stockings on your legs to help prevent blood clots. EKG wires with small, sticky pads on the end will be attached to your chest. This is done to monitor your heart. You’ll also have a blood pressure cuff wrapped around your arm. When all the preparation is complete, you’ll receive the anesthetic through the IV and will fall asleep.
During surgery, a Foley catheter may be placed through your urethra and into your bladder. This is a hollow tube used to drain urine. You’ll also have a breathing tube placed in your windpipe. A breathing machine (ventilator) will control your breathing. Also, a nasogastric tube may be placed in your nose. This is a suction tube that extends into the esophagus and stomach to drain stomach contents.
What is removed during surgery and where your incisions are depend on the type of surgery you have. This is based on where the tumor is.
After your surgery is done, medical staff will move you to the recovery room. There, they will watch you for another hour or two. When you wake up, don't be alarmed by the number of tubes and wires attached to you. These are normal monitors for after surgery. When you’re fully awake in the recovery room, your family will be able to see you for a short time. Once you’re awake and stabilized, the staff will transfer you to the regular hospital floor.
What to expect after surgery
Your hospital stay will depend on the type of surgery you had. Recovery after you leave the hospital may last for one month or more.
For the first few days, you’re likely to have pain from the incisions. You can control your pain with medicine. Your doctor will prescribe this to you. You may have an epidural catheter put into your lower back so that it’s easier to give you pain medicine. You may have a patient-controlled analgesia pump (PCA). This is an IV form of pain medicine that you control by pressing a button. Before you leave the hospital, your healthcare provider will give you an oral pain medicine instead. Talk with your healthcare team about your options for pain relief. Some people are hesitant to take pain medicine, but doing so can actually help your healing. If your pain is not controlled well, for instance, you may not want to cough or walk. You need to do this while you recover from surgery.
Your healthcare provider may have placed a small drain or drains in your lower stomach during surgery. You may go home with one or more drains still in place.
You may feel tired or weak for a while. The amount of time it takes to heal from an operation is different for each person.
You may have constipation from using pain medicine, not moving around, or not eating or drinking very much. Talk with your healthcare provider about how to keep your bowels moving.
If your surgeon removed your entire pancreas, you no longer make enough insulin. This leads to diabetes. You’ll need to learn how to test your blood sugar and to give yourself insulin shots. The diabetes educator at the hospital will help you to manage your diabetes. He or she will teach you how to keep your blood sugar levels within a normal range.
If your surgeon removed your pancreas, or it can no longer make enzymes, you may need to take digestive enzyme tablets to help you digest food.
You’ll also need follow-up care after surgery. Make an appointment with your surgeon and get any other information for home care and follow-up when you leave the hospital.
Talk to your healthcare team
If you have any questions about your surgery, talk to your healthcare team. They can help you know what to expect before, during, and after your surgery.
March 21, 2017
Alteri, Rick, MD,Gersten, Todd, MD