Surgical intervention plays a critical role in the care of patients with pancreatic tumors. There are a wide variety of therapeutic and diagnostic procedures that may be offered to patients based on their individual needs. With minor exceptions, surgical removal of a pancreatic tumor provides the only chance for cure. In some instances surgery may be used to relieve symptoms of an incurable cancer that can not be effectively palliated by other, non-operative means. The increasing use of laparoscopic, minimally invasive techniques further advances a patient’s comfort and quality of life. It is thus important that the surgeon counseling a patient with a pancreatic tumor be well versed in all the surgical and non-surgical options available to meet a patient’s needs.
- Diagnostic Laparoscopy. Modern diagnostic imaging techniques, including dynamic CT and PET scans, provide accurate and reliable preoperative staging information for the majority of patients. In this manner most patients who would not benefit from an operation to remove the tumor can be screened out. In some instances, however, ambiguous or equivocal findings on diagnostic imaging can be clarified with a diagnostic laparoscopy, a minimally invasive, often outpatient, procedure that allows the surgeon to visually inspect (and biopsy, if necessary) the contents of the abdominal cavity. The additional information provided by this procedure may increase the likelihood of successful outcomes for patients with these tumors.
- Surgical Resection. Once a patient has been deemed an appropriate candidate for resection (surgical removal) of the tumor, the surgeon’s goal is to provide the safest, most successful and least invasive procedure to achieve the patient’s goals. In individualizing the surgical approach to a patient’s tumor, the surgeon must consider a number of factors related primarily to the size and location of the tumor, as well as other factors such as prior surgery and co-morbid conditions. The goal of the surgery is to completely remove the tumor (achieving negative margins) and surrounding lymph nodes that may harbor metastatic cancer. In some instances this requires cutting or removing other organs that are intimately involved with the cancer or that portion of the pancreas. These organs must then be reconstructed to return normal gastrointestinal function.
- Whipple Procedure (also known as pancreaticoduodenectomy). This procedure is designed to remove tumors in the head (picture) of the pancreas. Technical considerations involving shared blood vessels and lymph node distribution mandate that the duodenum as well as portions of the stomach and bile duct may also need to be removed (picture). In some instances the surgeon may deem it appropriate to preserve all the stomach (“pylorus preserving pancreaticoduodenectomy”). Once the tumor has been removed, GI functional anatomy is restored by reconnecting the intestine to the pancreas, bile duct and stomach.
- Distal pancreatectomy. This operation is used to remove tumors in the tail and body of the pancreas (picture). In most instances there is no need to cut across the stomach and bile duct and so the reconstructions necessary with the Whipple operation are not performed. At time it may be necessary to remove the spleen, a hematologic organ intimately involved with the end of the pancreas.
- Total pancreatectomy. This operation is used to treat multiple (“synchronous”) cancers in the pancreatic head, body and tail. Its complexity is similar, in some respects, to the Whipple operation, with the exception that there is no pancreas left to reconstruct. As a result patients become insulin-dependent diabetic and need supplemental pancreatic enzymes to assist with digestion.
- Enucleation. This rare procedure (picture) is only used to remove small benign neuroendocrine tumors and is not appropriate for tumors that may be cancerous.
- Palliative Surgery. Some patients may be diagnosed with cancers that cannot be cured with surgery. While those patients may benefit from successful anti-cancer treatments such as chemotherapy and radiation, in most instances it is preferable to minimize the invasive procedures they are offered. Patients with pancreatic cancer may experience blockages in the bile duct and, more rarely, the stomach. Relieving the symptoms caused by these mechanical obstructions often requires an invasive procedure. For many patients the best approach to relieve a blocked bile duct is with through the endoscopic placement of a stent (a plastic or metal tube inside the bile duct) by a gastroenterologist. In the event this is not successful, bile duct blockages can be also be relieved by an interventional radiologist or, ultimately the surgeon. This surgery can involve connecting the intestine to the bile duct (choledochojejeunostomy) or gallbladder (cholecystojejeunostomy) Blockages in the stomach, although rare, usually require surgical intervention in the form of a gastrojeunostomy in which the blockage is bypassed by connecting the stomach to the intestine (picture). When surgery is required for patients with incurable pancreatic cancer, the procedures may be less invasive being performed through smaller incisions or even laparoscopically. Finally, patients with significant pain caused by pancreatic cancer may benefit from a celiac plexus block, an injection of alcohol into the nerves behind the pancreas.