Surgery for the treatment of pancreatic cancer involves not only the operation itself, but also preoperative and postoperative considerations.     

Preoperative Biliary Drainage

Bile ducts are tubular structures that carry bile from the liver to the small intestine. Like the tributaries of a river, the small bile ducts in the liver converge into two large bile ducts. These join to form a large bile duct outside the liver. The gallbladder, which concentrates the bile, also empties into this large bile duct. Finally, this duct (common bile duct) traverses a portion of the pancreas and drains into the small intestine. Because of the intimate proximity of the common bile duct and the pancreas, tumors of the pancreas can obstruct the flow of bile. This causes jaundice, a yellowish discoloration of the skin or eyes.

Formerly it was common practice to perform a drainage procedure (biliary drainage) to relieve the obstruction before the main surgery. But studies have shown that biliary drainage is not without its own risks. Thus, biliary drainage today should be limited to those patients who have specific problems associated with biliary obstruction, such as infection of the bile ducts, severe malnutrition, or bleeding tendency. In addition, it may be appropriate to perform biliary drainage if the main surgery cannot be arranged within 2 weeks.

Surgical Resection of Pancreatic Cancer

After the incision is made, but before the resection commences, the surgeon first inspects the abdominal organs for signs that the cancer has spread to the liver, peritoneum, or certain lymph nodes. Despite careful preoperative evaluation with imaging tests and other procedures, sometimes these fail to detect the spread of pancreatic cancer. If there is evidence of widespread cancer noted during surgery, complete removal of the cancer is not possible.

If resection of the pancreatic tumor is actually possible, it requires removal of the tumor itself as well as various adjacent tissues and organs. The specific operation depends on the location of the tumor within the pancreas.

If the tumor is in the head of the pancreas (near the portion where the pancreatic duct empties into the small intestine), the operation is called a pylorus-preserving pancreaticoduodenectomy. The head of the pancreas, containing the tumor, is removed along with a portion of small intestine (duodenum), the entire gallbladder, and the common bile duct. Reconstruction involves attaching the pancreas, bile duct system, and remaining duodenum to the next segment of small intestine. For tumors located in the other portions of the pancreas, the operation is simpler. The involved portion of the pancreas and the neighboring spleen are removed. During both types of operation, lymph nodes adjacent to the tumor are also removed as these often contain pancreatic cancer cells. Tubes are placed in the abdomen and brought out through the skin to drain any fluid that might collect in the abdomen. These drains are typically removed within one week.

Techniques for surgical resection of pancreatic tumors are continually being honed and studied. Issues currently under investigation include the extent of lymph node removal, the removal of tumors invading blood vessels, and various methods of reconstruction after the resection.

Post-operative Issues

Approximately one-third of the patients experience complications after the surgery. These include infection, bleeding, delayed stomach emptying, leaking of pancreatic fluids into the abdomen, and dysfunction of the remaining pancreas.

Possible infections include superficial infection of the incision site as well as deep collections of pus within the abdomen. Adequate pre-operative cleansing of the bowels, sterile surgical technique, and administration of antibiotics are measures designed to reduce the chance of infection.

Bleeding within the abdomen after surgery is a serious complication that may require subsequent surgery to correct. Careful monitoring of vital signs and blood counts are necessary to detect post-operative bleeding.

Delayed stomach emptying may occur, manifesting as vomiting and the inability to pass food beyond the stomach. Patients may need a tube placed into their stomach from the nose in order to decompress the distended stomach. Certain medications may stimulate stomach emptying enough to prevent this complication.

Sometimes the remaining pancreas can leak a significant amount of fluid into the abdomen after surgery. This often delays the removal of the previously placed drainage tubes. If the leak continues, new tubes can be placed. Occasionally another operation is required to stop the leak.

It is hoped that enough pancreatic tissue remains and functions normally after the surgery to compensate for the portion that was removed. However, sometimes it fails to produce enough hormones or enzymes needed for normal digestion of food and management of sugar, resulting in fatty stools or diabetes. Patients may need medications to supply that which is not provided by their own pancreas.

Surgical Palliation

Surgical palliation refers to a surgical operation performed to relieve symptoms when complete cure is not possible. It is estimated that as many as 40% of patients undergoing surgery are found to have extensive spread of the pancreatic cancer at the time of surgery. These patients are candidates for surgical palliation. Jaundice and obstruction of the small intestine can be relieved or prevented, at least temporarily, by these palliative procedures. Pain control can also be improved by injecting certain nerve bundles with ethanol.

           Page 1 | Page 2 | Page 3 ____________________________________________________________
AUTHOR: Kevin Hwang, MD
Reviewed by Jiade J. Lu, MD
The Cancer Information Network
Date Modified: 010/05/02