Pancreatic Cancer Surgery

When surgery is possible

A tumor is considered resectable if it does not involve the major arteries, contact with the veins is minimal and there are no distant metastases. These patients have surgery first, followed by adjuvant chemotherapy for about 6 months. With a high CA 19-9 or other signs of a biologically aggressive tumor, the tumor board may recommend starting with chemotherapy.

Before treatment the doctor decides which tests are needed. Depending on the situation, they include:

• pancreas-protocol CT — a multiphase contrast study that shows the tumor and its relationship to the portal and superior mesenteric veins, the superior mesenteric artery, the celiac trunk and the hepatic artery;
• liver MRI — to look for small metastases not visible on CT;
• endoscopic ultrasound with biopsy — confirms the diagnosis; a biopsy is mandatory if treatment starts with chemotherapy;
• the CA 19-9 tumor marker — assessed after jaundice has been relieved;
• diagnostic laparoscopy — when small metastases on the peritoneum or in the liver are suspected;
• genetic testing for inherited mutations, which is recommended for all patients, and molecular testing of the tumor.

The disease itself, its symptoms and tests are described on the page “Pancreatic Cancer”.

If the tumor involves blood vessels

A borderline resectable tumor surrounds more than half of a vein or narrows it, but the vein can be removed and reconstructed, or it contacts the arteries over no more than half of their circumference. A locally advanced tumor surrounds more than half of the superior mesenteric artery or the celiac trunk, or involves a vein so that it cannot be reconstructed.

These patients first receive chemotherapy — usually 4–6 months of a combination regimen, sometimes followed by radiation therapy. It acts on micrometastases and selects patients with favorable tumor biology: if metastases appear during this time, surgery would not have helped. After chemotherapy, CT often shows the tumor almost unchanged: CT cannot tell the scar tissue that forms in place of the tumor from viable tumor. That is why the decision is not based on CT alone: what matters is the absence of new lesions, a decrease in CA 19-9 and good general condition. If these conditions are met, the tumor board reassesses whether curative-intent surgery is possible.

During such an operation the tumor is removed together with the affected segment of the portal or superior mesenteric vein, and the vein is reconstructed with direct sutures or a graft from the patient’s own vein or a prosthesis. We resect the vein together with the team. We do not perform arterial resections. More details are on the page “Borderline Resectable and Locally Advanced Pancreatic Cancer”.

If you were refused surgery because of the blood vessels, show the CT discs to a surgeon who works with such tumors — a second opinion from an oncologist is suitable for this.

If surgery is not possible right now

With distant metastases, the basis of treatment is combination chemotherapy; the choice depends on general condition. Patients with an inherited BRCA mutation and no progression after at least 16 weeks of platinum-based chemotherapy may receive maintenance therapy with a PARP inhibitor, and those with rare molecular alterations, targeted drugs. For a stable locally advanced tumor, radiation therapy, including stereotactic radiation, and further observation are possible; the response to treatment is reassessed every few months.

Jaundice is treated with a stent in the bile duct, narrowing of the duodenum with a stent or a bypass anastomosis, and pain, among other methods, with a celiac plexus block.

How the operation is performed

For a tumor of the pancreatic head, a pancreaticoduodenectomy — the Whipple procedure — is performed: the head of the pancreas, the duodenum, the gallbladder and the lower part of the bile duct are removed with the lymph nodes, and then the pancreatic remnant, the bile duct and the stomach are joined to a loop of small bowel. For tumors of the body and tail, a distal pancreatectomy is performed — removal of the body and tail of the pancreas together with the spleen and lymph nodes. Sometimes the whole pancreas has to be removed.

When the tumor location and extent of resection allow it, a distal pancreatectomy is performed laparoscopically — through a few small incisions.

If the tumor has caused jaundice, a stent is not always placed before surgery. When the operation can be done soon and the jaundice is not complicated by cholangitis, surgery without prior drainage is recommended. A stent is needed with cholangitis, very high bilirubin, before chemotherapy or when surgery is postponed; ideally it is placed after CT. More details are on the page “Malignant Obstructive Jaundice”.

Hospital stay, recovery and further treatment

Recovery follows the enhanced recovery (ERAS) protocol: early mobilization, early eating, controlled pain relief. After operations with vascular reconstruction the hospital stay is longer, and the first days are usually spent in the intensive care unit; the reconstructed vessels are checked with ultrasound or CT.

After surgery, enzyme supplements with meals are often needed, and some patients need treatment for diabetes. After removal of the whole pancreas, enzymes and insulin are needed permanently. Adjuvant chemotherapy is started once the patient has recovered — ideally within the first 12 weeks; if chemotherapy was given before surgery, the tumor board decides on further chemotherapy based on the pathology report.

In the first 2 years CT and CA 19-9 are done every 3–6 months, and later less often; the schedule is set by the doctor. Weight, digestion, blood glucose and vitamin deficiencies are also monitored. Pain, jaundice or weight loss should be reported right away.

Risks and complications

Risks are what patients ask about least often, although they are the most important thing to discuss before surgery. The main ones are:

• pancreatic fistula — leakage of pancreatic juice from the join between the pancreas and the bowel or, after distal pancreatectomy, from the cut surface of the pancreas;
• delayed gastric emptying after the Whipple procedure;
• bleeding during or after surgery;
• infection and general surgical complications, including blood clots.

Fistula and delayed gastric emptying are the most common complications of the Whipple procedure; they are usually treated without reoperation, but the hospital stay is longer. I will explain the risks in your particular case at the consultation.

What the cost depends on

The cost depends on the extent of surgery, whether vein resection is needed, the approach, the number of days in the hospital and the tests. The exact amount is named once the treatment plan has been defined. The payment can be split into parts — installments are available. The in-person consultation is free. More details are on the page “Cost of Surgery: What It Depends On”.

What documents are needed and how to book

• pancreas-protocol CT and MRI discs with reports — the actual discs, not just the reports; if chemotherapy was given, CT before treatment and after each stage;
• CA 19-9 results (over time, if repeated), bilirubin, blood chemistry;
• the histology or cytology report from the biopsy, if one was done;
• the procedure report and discharge summary if a stent or drain has been placed;
• records of chemotherapy or radiation therapy, genetic test results and the written report in which you were refused surgery, if available.

Book a consultation by phone or through the form. If you are from another city, send the documents in advance — how to do this is described on the page “Online Oncologist Consultation”.