Surgical Procedures: Surgery for Pancreatic Cancer

When there are cancer cells in the pancreas, it is called pancreatic cancer. The pancreas is a pear-shaped gland that sits between the stomach and spine. There are three parts to the pancreas: the head, the body, and the tail. The pancreas makes digestive enzymes and hormones that help control blood sugar.

The most common type of pancreatic cancer is adenocarcinoma of the pancreas, which targets the exocrine cells. Pancreatic neuroendocrine tumors (NETs) are a less common type of pancreatic cancer. About 2 out of 100 cases of pancreatic cancer are NETs. Staging and treatment may be similar for both adenocarcinoma and pancreatic NETs but talk with your care team about your type of cancer and treatment options.

What is staging and how is it done?

Staging is a way to find out if and how far the cancer may have spread in your body (metastasized). Your provider will have you get a few tests to figure out the stage of your cancer. For pancreatic cancer, these tests may be:

Physical Exam: This is a general exam to look at your body and to talk about past health issues.

Imaging: Radiology tests can look inside your body at the cancer and see if it has spread. These tests are:

• CAT scan (CT scan).
• Positron emission tomography scan (PET scan).
• Magnetic resonance imaging (MRI).
• Abdominal ultrasound.
• Endoscopic ultrasound.
• Endoscopic retrograde cholangiopancreatography (ERCP).
• Percutaneous transhepatic cholangiography (PTC).

Blood Tests: Labs may be drawn to look for any changes in your blood. You may also be checked for tumor markers, such as CA 19-9 and carcinoembryonic antigen (CEA).

Pancreatic cancer can metastasize (spread) to other parts of the body through the tissue, lymphatic, and blood systems. Your healthcare team will use the American Joint Committee on Cancer TNM staging system to figure out:

• The tumor size (T).
• Spread to the lymph nodes (N).
• Distant metastasis (spread) (M).

The TNM is then used to assign a stage from 0 to IV (4).

What is pancreatic cancer surgery and how is it done?

Many types of procedures can be used to help diagnose and treat pancreatic cancer. These are:

• Whipple Procedure:
  • Standard Whipple (pancreaticoduodenectomy): The pancreatic head (and at times the body), gallbladder, bile duct, part of both the stomach (pylorus) and small intestine (duodenum), and surrounding lymph nodes are removed (taken out). The part of the pancreas left will keep making digestive juices and insulin in your body.
  • Pylorus Preserving Whipple: The same as the standard Whipple, but the pylorus is not removed.
• Pancreatectomy:
  • Distal Pancreatectomy: The body and tail of the pancreas are removed. The spleen is often removed also. There are two ways a distal pancreatectomy can be done:
    • Open Distal Pancreatectomy and Splenectomy: The removal of the pancreatic body and tail, and the spleen through an open incision (surgical cut).
    • Laparoscopic Distal Pancreatectomy: Removal of the body or tail of the pancreas by laparoscopy. Laparoscopy is the use of small incisions and the use of surgical tools through these incisions.
    • Total Pancreatectomy: The whole pancreas, part of the stomach and small intestine, common bile duct, gallbladder, spleen, and lymph nodes are removed.
• Palliative Surgery: This type of surgery is done to ease or prevent symptoms caused by the cancer. These include:
  • Endoscopic Stent Placement: This unblocks the bile duct by placing a thin tube, (called a stent) into the bile duct through an endoscope or during a percutaneous transhepatic cholangiography (PTC). This lets the bile flow either into the small intestine or through a catheter to a bile collection bag outside of the body.
  • Bypass Surgery: The bile from the common bile duct is moved directly to the small intestine.
  • Gastric Bypass: The stomach is joined to the small intestine.
  • Biliary Bypass: When the small intestine is blocked by a tumor, bile may collect within the gallbladder and a bypass is needed. The gallbladder or bile duct will be cut and connected directly to the small intestine.

The method used for these surgeries (open vs laparoscopic) is based on many factors. Your provider will talk to you about what surgery is best for you.

• Surgery for Neuroendocrine Tumors of the Pancreas:
  • See above.
  • Laparoscopy: This can be done to tell how far the cancer has spread. This is done through small incisions and by using a thin laparoscope with a camera to see your organs and take biopsies.
  • Enucleation: Removal of the tumor. This is often used only for small tumors.

Sometimes, more surgery is needed later for neuroendocrine tumors to remove liver and/or lung metastasis. Your healthcare provider will talk with you about these procedures.

What are the risks of pancreatic cancer surgery?

As with any surgery, there are risks and likely side effects. These can be:

• Pancreatic fistula (leaking of pancreatic fluid where the pancreas attaches to the intestine).
• Gastroparesis (stomach muscles stop working).
• Delayed gastric emptying.
• Long-term digestive issues, such as bowel habit changes, not absorbing (taking in) food well, changes in diet, diabetes, and weight loss.
• Bleeding.
• Infection.

What is recovery like?

A stay in the hospital may be needed for one to three weeks, based on the type of surgery done. While in the hospital you may have:

• Abdominal (belly) drains to drain fluid that collects after surgery.
• Nasogastric (NG) tube (tube placed into your nose and down into your stomach) to keep your stomach empty.
• Bladder catheter to empty urine from your bladder.

Depending on your situation, you may also have:

• Epidural tube that gives you pain medications.
• Feeding tube placed into your stomach or an intravenous line (IV) to give you nutrition.

You may leave the hospital with some of these drains, tubes, or intravenous lines. You will be taught how to care for these.

Before leaving the hospital, your medical team will talk with you about the medications you will be taking for blood clot/infection prevention and pain management.

Your healthcare team will give you information on your diet after surgery. Digestive enzyme supplements may be needed to prevent diarrhea, aid in food digestion, and help control blood sugar levels. This may be brief or lifelong, based on your situation.

Your team will also talk with you about any activity changes you need to make while you are at home. These changes may be to:

• Eat small, frequent meals. Take insulin, supplements, and enzymes as told.
• Walk as much as you can.
• Do not lift anything heavy.
• Do not drive while taking narcotic pain medications.
• Prevent constipation by drinking fluids and/or taking stool softeners.

What will I need at home?

• A thermometer to check for fever, which can be a sign of infection.
• Loose clothing.
• Clean towels for drying incision.
• Incisional care supplies will likely be given to you at the hospital.

Which symptoms should I report to my healthcare team?

• Fever. Your team will tell you at what temperature they should be called.
• Chills, incisional/drain site swelling, separation, drainage, redness, or a change in the drainage (foul-smelling and/or creamy).
• Any new or worsening pain.
• Nausea, vomiting, diarrhea and/or constipation.
• Being unable to eat.

How do I care for my incision?

You will be told how to care for your incision before leaving the hospital.

To care for your incision you should:

• Wear loose clothing.
• Wash the incision very gently with soap and water, patting dry with a clean towel when done.
• Not tub bathe and do not put your incision under water.
• Not use any lotions, powders, or ointments.

How can I care for myself?

You may need a family member or friend to help you with your daily tasks until you are feeling better. It may take some time before your team tells you that it is ok to go back to your normal activity.

Be sure to take your prescribed medications as directed to prevent pain, infection and/or constipation. Call your team with any new or worsening symptoms.

There are ways to manage constipation after your surgery. You can change your diet, drink more fluids, and take over-the-counter medications. Talk with your care team before taking any medications for constipation. 

Taking deep breaths and resting can help manage pain, keep your lungs healthy after anesthesia, and promote good drainage of lymphatic fluid. Try to do deep breathing and relaxation exercises a few times a day in the first week, or when you notice you are extra tense.

• Example of a relaxation exercise: While sitting, close your eyes and take 5-10 slow deep breaths. Relax your muscles. Slowly roll your head and shoulders.

This article contains general information. Please be sure to talk to your care team about your specific plan and recovery.