Pancreatic Cancer Surgery and Whipple Procedure
Surgery for adenocarcinoma of the pancreas is only offered to patients whose tumor is localized and meets other criteria. Only about 15-20% of those individuals with pancreatic cancer will be found to be eligible for surgery. In these cases, surgical resection (removal) of the tumor from the pancreas (and resection of the pancreas and select surrounding tissues) gives the best chance for a cure and generally confers a better overall prognosis in contrast to medical therapy for pancreatic cancer. This is one reason why so much effort is given in pre-operative testing for pancreatic cancer to try to identify those patients who may be good candidates for surgery. Another reason for such care is to avoid offering unnecessary surgery to patients who are already ill.
At surgery, the first job of the surgeon is to assess the nature and extent of the pancreatic cancer – to verify if the patient is a true candidate for surgical resection. If the pancreatic cancer has advanced further than the pre-operative testing has indicated (which is not uncommon), then certain palliative surgical measures as noted below (aimed at symptomatic relief) may be offered, but the resection would typically NOT proceed.
The resection, known as the Whipple operation / procedure (or pancreaticoduodenectomy) is typically done for patients who have tumors which are located in the head of the pancreas or which are located in regions adjacent to the head of the pancreas. There are a number of variations of the Whipple procedure. The classic procedure, a modification of the surgery described by A.O. Whipple and his colleagues in 1935, is a fairly extensive and somewhat complicated two-step process whereby certain key structures in the surrounding vicinity are removed (including that portion of the involved pancreas), followed by a kind of surgical bypass-reconstruction, in effect re-routing the digestive tube around the affected area.
One of the fundamental questions among researchers and surgeons relates to the necessary scope and extent of the pancreaticoduodenectomy surgery. Which tissues should be resected (and what are the optimal amounts to be taken) in order to get the best chance of survival, as balanced against quality-of-life issues. This topic is controversial and there has been a see-sawing back and forth over time between advocates of more radical procedures and those who advocate less extensive surgery.
If the pancreatic tumor is located in the tail of the pancreas, often that portion of the pancreas will be removed along with the nearby spleen.
The Whipple surgery itself can take several hours and is often grueling for the surgical team. The region of the body where the pancreas lies is very busy and complicated anatomically. Not only is the normal anatomy complex, but individual anomalies are frequent among the various blood vessels and ducts in the area. However, one of the great successes in the treatment of pancreatic cancer has been the improvement in mortality related to the Whipple surgery. The mortality was extremely high even a couple of decades back, but this has dramatically improved. Now, operative mortality related to the Whipple procedure is variously reported as 2-3%, but in some major U.S. institutions the more recent operative mortality has been reported at less than 1%.
Nevertheless, recovery can be an ordeal for the patient. Serious complications following surgery are still effect up to one-third of patients. These include the development of fistulas (false channels), and leakage from the site of the bowel reconnection. The judicious placement of surgical drains may tend to reduce the incidence of these kinds of complications. The survival of patients who received the Whipple procedure in one study (from a very experienced Johns Hopkins team) were reported out in 1995 as a 21% five-year survival rate, with a median survival of 15.5 months.
If it is determined that the pancreatic cancer is too advanced to make surgical resection a viable option, then certain palliative procedures or surgery may be offered. These are typically targeted at the primary symptoms or causes of symptoms in pancreatic cancer: pain, small bowel obstruction and jaundice due to physical compression of the bile duct. Thus a nerve block of the celiac nerve plexus may be done (for pain), and/or a gastrojejunostomy (stomach bypass) surgery, and/or bile duct bypass surgery. Stents (inner wall supports) may be placed for certain of these procedures.
There are two principles that need to be introduced at this time. Adjuvant therapy is a concept that connotes the practice of giving medical and/or radiotherapy after surgery for pancreatic cancer to help augment the effects of surgery. And neoadjuvant therapy is the term that describes the practice of giving such treatment prior to surgery for potentially resectable (surgical removal) pancreatic cancer disease. For long while it has been fairly common practice in the U.S. to give chemoradiation (chemotherapy plus radiation) as adjuvant treatment after the Whipple procedure surgery for pancreatic cancer. This practice is based on the results of a 1985 landmark study which demonstrated an almost double survival advantage for those who received such therapy. The radiation aspect of this practice has challenged in recent times as offering no statistical survival advantage in pancreatic cancer. But this issue remains a controversy as some experts doubt the challenge.
The use of neoadjuvant therapy is an intriguing area of research in pancreatic cancer. According to some studies, chemoradiation may push back the pancreatic cancer enough to allow some patients (a minority) with apparent unresectable cancer of the pancreas who otherwise might not be candidates – to be eligible for surgery, and thus may offer some survival advantage to select patients.
The following are descriptions of titles of abstracts of medical journal articles that may be interesting or useful to those who are interested in further information about this topic.These abstracts can be searched Here.
- 1-Oct-16 – Duration period from surgery until adjuvant therapy may not be critical
- 1-Oct-16 – FOLFIRINOX for induction therapy
- 1-Oct-16 – Surgery for hepatic mets in successful chemo rx of cancer of the pancreas ?
- 1-Oct-16 – Induction therapy improves outcomes
- 29-Sep-16 – 2nd surgery for return of cancer of the pancreas in the remaining pancreas
- 7-Sep-16 – Primary cancer surgery AFTER positive chemo response in advanced pancreatic cancer
- 6-Sep-16 – Percutaneous electroporation in locally advanced Cancer of the pancreas
- 1-Sep-16 – Induction therapy with FOLFIRINOX
- 1-Sep-16 – Induction therapy with Gemzar plus Abraxane
- 1-Sep-16 – Adjuvant Gemzar cisplatin post-Whipple
- 1-Aug-16 – Does chemoradiation induction therapy confer advantage vs. initial surgery ?
- 1-Mar-16 -Induction therapy may increase survival in adenocarcinoma of the pancreas
- 1-Feb-16 – Post-surgical advantage of chemoradiation plus interferon in cancer of the pancreas
- 1-Jan-16 – Metformin plus statins may increase survival after surgery for cancer of the pancreas
- 1-Sep-15 – Electroporation plus chemo as induction therapy for locally advanced cancer of the pancreas
- 1-Mar-15 – Do Extensive Whipple Procedures Confer Longevity?
- 18-Feb-15 – Minimal surgery for Non-malignant Pancreatic Cancer and NETS
- 1-Feb-15 – Cure of Advanced Cancer of the Pancreas with Novel Neoadjuvant Regimen and Surgery
- 31-Jan-15 – Tissue Adhesive Repair of Post-operative Pancreas Fistulae
- 1-Feb-14 – How Significant is the Time Duration Between Induction Therapy and Surgery in Cancer of the Pancreas
- 1-Feb-14 – RFA for Locally Advanced Cancer of the Pancreas
- 22-Jan-14 – HIFU for Advanced Pancreatic Cancer
- 3-Jan-14- Clinical Effect of Adjuvant Chemoradiation and Node Dissection in Cancer of the Pancreas
- 3-Jan-14- Pre versus Post-op Radiation for Pancreatic Cancer
- 1-Jan-14- IRE for Local Cancer of the Pancreas
- 1-Jan-14- Portal Vein Surgery for Pancreatic Cancer
- 17-Dec-14- Increased Duration of Adjuvant Chemotherapy in Cancer of the Pancreas
- 5-Dec-14 – Induction Therapy and Vascular Surgery for Locally Advanced Cancer of the Pancreas
- 1-Dec-13 – Adjuvant Chemoradiation and Intraoperative Electron Irradiation for Pancreatic cancer
- 21-Nov-13 – Post -surgical Chemotherapy in Older Persons with Adenocarcinoma of the Pancreas
- 21-Nov-13 – Neoadjuvant Combination Chemoradiation
- 20-Oct-13 -Post-surgical Radiation for Cancer of the Pancreas
- 16-Oct-13 -Tomographic Classification Tool as a Surgical Decision Aid
- 9-Oct-13 -Post-surgical Gemzar as Adjuvant Therapy
- 1-Oct-13 – Induction Chemo with Gemzar and S-1
- 1-Oct-13 -National Cancer Data Base: Adjuvant Chemoradiation
- 1-Oct-13 -“Surgery” with Microwave Technology in the Pancreas
- 1-Oct-13 -Biotherapy Plus Cold Therapy in the Treatment of Cancer of the Pancreas
- 1-Sept-13 – Outcomes of PVR Decision During the Whipple Procedure
- 1-Aug-13 – Chemoradiation with Gem plus Avastin Regimen
- 15-Jul-13 – Tarceva plus chemoradiotherapy as Adjuvant Treatment in Adenocarcinoma of the Pancreas
- 5-Jun-13 – Minor Surgical Procedures in Advanced Cancer of the Pancreas: Are They Worth It?
- 1-Dec-12 – Simultaneous Surgery on Tumor and Liver Mets in Islet Cell Tumors
- 1-Sep-12 – Re-treatment with Surgery for Return of Solitary Pancreatic Cancer Tumor
- 1-Jul-12 – Neoadjuvant Therapy May Improve Results In Patients with Pancreatic Cancer Surgery
- 1-Jun-12 – Sub-groups After Induction Therapy Predict Surgical Candidates
- 1-Jan-12 – Surgical Dissection of the Superior Mesenteric Artery Plus Pre-op Chemotherapy and Radiation
- 15-May-11 – Induction Therapy Enhances Post-surgical Survival in Pancreatic Cancer
- 28-Feb-10 – Pancreatic Surgery in Stage II Disease
- 1-Jan-10 – Post-surgical Chemotherapy with Radiation for Pancreatic Cancer
- 1-Dec-09 – Surgery for Metastasis in Advanced Pancreatic Cancer
- 1-Oct-09 – Problems with Stapling to Close Surgery for Pancreatic Cancer
- 1-Oct-09 – Bioabsorbably Staples for use in Pancreatic Cancer
- 28-Feb-09 – Palliative Surgery for Older Patients with Pancreatic Cancer
- 1-May-05 – Pylorus Preserving Whipple Surgery vs. The Classical