Pancreatic cancer surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Sudarshana Datta, MD [2]

Overview[edit | edit source]

The mainstay of therapy for pancreatic cancer is surgery. The different surgical techniques that may be used for resectable pancreatic cancer include pancreaticoduodenectomy (Whipple Procedure), pylorus sparing Whipple procedure, distal pancreatectomy and total pancreatectomy. The method of surgical resection depends on the locally invasive characteristics and size of the neoplasm. The National Comprehensive Cancer Network (NCCN) has recommended certain guidelines on resectability of pancreatic neoplasms based on resection margins, probability of cure, age, and comorbidities. Extrapancreatic disease requires palliative therapy and curative resection is not performed in such patients. CA19-9 levels help predict the likelihood of complete resection, the prognosis of patients with resectable disease and the presence of occult metastasis.

Surgery[edit | edit source]

• In patients with pancreatic cancer, surgery is the primary modality of treatment.
• Various methods of surgical resection may be employed and each of these has its own sets of risks and perioperative complications.
• The benefits, risks and complications are discussed by the patient and surgical team before arriving at a well-informed decision. The method of surgical resection depends on the following features:^[1][2][3]
  • Locally invasive characteristics of the neoplasm
  • Size

Criteria for Unresectability[edit | edit source]

• Tumor larger than 5 cm
• Tumor invading adjacent tissue of organs (excluding duodenum)
• Encasement, stenosis, or occlusion of the celiac artery, celiac artery branches, and/or SMA
• Portal vein(PV) and/or Superior Mesenteric Vein (SMV) encasement (some centers will operate with venous invasion)
• Hepatic metastasis
• Distant metastasis (i.e. non regional lymph nodes)
• Peritoneal carcinomatosis

Surgical methods of curative resection include:

• Distal pancreatectomy
• Total pancreatectomy
• Pancreaticoduodenectomy, where pylorus may or may not be spared on an individual basis

The National Comprehensive Cancer Network (NCCN) has recommended certain guidelines on resectability of pancreatic neoplasms based on a statement passed by the American pancreatic association:^{[4][5][6][7][8]}

• Patient selection is based on:
  • Resection margins
  • High probability of cure
  • Age of the patient
  • Comorbidities
• Curative resection is not contraindicated in all patients with vascular invasion:^{[9][10][11][12][13]}
  • Involvement of the portal or superior mesenteric vein can be resected and reconstructed with the help of splenic, saphenous or internal jugular veins.^{[14][15][16][17]}
  • The involvement of arteries such as the hepatic, celiac or superior mesenteric are contraindications to resection.^[18]
• Extrapancreatic disease requires palliative therapy and curative resection is not performed in such patients.
• The European Society for Medical Oncology (ESMO) has certain guidelines on the treatment of pancreatic cancer:^[19][20][21]
  • The only curative therapy for pancreatic cancer is surgical resection.
  • The five year survival of patients with pancreatic cancer is 10 percent.
  • Patients with node-positive tumors have very poor long term survival.
  • Chemotherapy is not preferred metastatic cancer.
  • Gemcitabine is preferred over 5 FU in case of metastasis.
  • Treatment in case of metastatic cancer is symptomatic with bypass surgery or stent placement for gastric outlet obstruction or obstructive jaundice.
• In case of locally advanced disease which is unresectable, the following methods of treatment are preferred:^[22]
  • Microwave ablation
  • Photodynamic therapy
  • Irreversible electroporation
  • Photodynamic therapy
  • High-intensity focused ultrasound (HIFU)
  • Iodine-125–cryosurgery
  • Iodine-125
  • Stereotactic body radiation therapy (SBRT)
  • Radiofrequency ablation (RFA)

• Treatment of pancreatic cancer depends on the stage of the cancer.^[23]
• There are different surgical techniques that may be used for resectable pancreatic cancer and their prognosis has been extensively studied: ^{[1][6][7][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38]}

Pancreaticoduodenectomy (Whipple Procedure)[edit | edit source]

Various features of Whipple procedure are as follows:^{[19][6][39][40][41][42][43][44]}

• Whipple procedure is mainly performed for tumors located in:^[45][40][46]
  • Periampullary region
  • Duodenum
  • Bile duct (cholangiocarcinoma)
  • Pancreatic duct
  • Head of pancreas
• Whipple procedure involves removal of the following components due to common blood supply:
  • Stomach antrum
  • Gallbladder
  • Duodenum
  • Head of pancreas
• After removal of the above structures, the biliary and distal pancreatic ducts are anastomosed to the jejunum to facilitate surgical drainage.
• Biliary drainage may also be performed preoperatively to decrease chances of infection.^[47]

• Whipple procedure is associated with several morbidities that may increase patient mortality:^{[48][49][50][51][52][53][54][55][56][57][58][59][60]}
  • Postoperative abscess
  • Wound infection^[61]
  • Anastomotic leak
  • Delay in gastric emptying^[62]

Pylorus sparing Whipple procedure[edit | edit source]

• The pylorus may be spared as a modification of Whipple procedure to decrease gastric emptying due to antrectomy.^[63][64]
• Pylorus sparing surgery significantly reduces the incidence of nutritional deficiencies arising from this surgery.

Distal Pancreatectomy[edit | edit source]

• This procedure has a limited use in curative resection of pancreatic cancer. ^[48][65][66]
• It is mainly performed for tumors located in:^[67][68]
  • Body of pancreas
  • Tail of pancreas
• Distal Pancreatectomy involves the following components:
  • Separation of the distal pancreas bearing the tumor from the normal tissue.
  • Resection of the affected portion.
  • Oversewing of the distal pancreatic duct.
• This form of surgery has fewer morbidities than the Whipple procedure.
• This procedure is associated with the following morbidities:^{[69][70][71][72]}
  • Pancreatic endocrine insufficiency
  • Bleeding
  • Leakage of pancreatic stump

Total Pancreatectomy[edit | edit source]

Various features of total pancreatectomy are as follows:^{[48][73][74][75][76][77][78][79]}

• Total pancreatectomy is the least preferred surgery due to high mortality rate.
• Total pancreatectomy is mainly performed for tumors located in:
  • Neck of the pancreas
• Involvement of the neck of pancreas may lead to the development of insulin dependent DM.

Lymphadnectomy[edit | edit source]

• Removal of positive nodes is preferrable, but some surgeons prefer extended as opposed to standard lymphadenectomy.^{[33][34][80][81][82][83][84][85][86]}

CA 19-9 level[edit | edit source]

• Elevated levels of CA19-9 can help in the following ways:^[87]
  • Predict the likelihood of complete resection
  • Predict prognosis of patients with resectable pancreatic cancer
  • Predict the presence of occult metastasis
• CA19-9 levels are not used to dictate the initial strategy for treatment of pancreatic cancer.

 Palliative Therapy[edit | edit source]

Palliative therapy in patients with pancreatic cancer mainly involves the management of symptoms arising as a result of complications of surgery:^{[88][89][90][91][92][93][94][95]}

Pain:[edit | edit source]

• There are various techniques for pain management as palliative therapy in patients.

• Surgical techniques used to treat pain in advanced pancreatic cancer include:
  • Endoscopic decompression with stent placement in patients with biliary or pancreatic duct obstruction
  • Neurolysis of the celiac ganglia by approaches, such as:
    • Intraoperative
    • Transgastric
    • Transthoracic
    • Transabdominal

Jaundice:[edit | edit source]

• Obstructive jaundice can present with features of cholangitis:
  • Fever and chills
  • Nausea, vomiting
  • Clay-colored stools
  • Dark urine
  • Yellowish discoloration of skin
  • Pruritus
  • Right upper quadrant pain
  • Anorexia
• Preferred treatment in patients with obstructive jaundice:
  • Endoscopic decompression with stent placement in patients with biliary obstruction.
• Techniques of biliary decompression:
  • Cholecystojejunostomy
  • Choledochojejunostomy

• Types of stents:
  • Metal- costly, longer lifespan
  • Plastic- cheaper, need replacement every three months

Duodenal obstruction[edit | edit source]

• Preferred treatment:
  • Endoscopic stenting of duodenal obstruction
  • Gastrojejunostomy

References[edit | edit source]

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