Pancreatic cancer surgery

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

Overview

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

  • 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

Surgical methods of curative resection include:

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]

Pancreaticoduodenectomy (Whipple Procedure)

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

Pylorus sparing Whipple procedure

Distal Pancreatectomy

Total Pancreatectomy

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

Lymphadnectomy

CA 19-9 level

  • 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

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:

Jaundice:

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

Duodenal obstruction

References

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  2. ↑ Allen PJ, Kuk D, Castillo CF, Basturk O, Wolfgang CL, Cameron JL, Lillemoe KD, Ferrone CR, Morales-Oyarvide V, He J, Weiss MJ, Hruban RH, Gönen M, Klimstra DS, Mino-Kenudson M (2017). "Multi-institutional Validation Study of the American Joint Commission on Cancer (8th Edition) Changes for T and N Staging in Patients With Pancreatic Adenocarcinoma". Ann. Surg. 265 (1): 185–191. doi:10.1097/SLA.0000000000001763. PMID 27163957.
  3. ↑ Bilimoria KY, Bentrem DJ, Ko CY, Ritchey J, Stewart AK, Winchester DP, Talamonti MS (2007). "Validation of the 6th edition AJCC Pancreatic Cancer Staging System: report from the National Cancer Database". Cancer. 110 (4): 738–44. doi:10.1002/cncr.22852. PMID 17580363.
  4. ↑ Fonseca AL, Fleming JB (2017). "Surgery for pancreatic cancer: critical radiologic findings for clinical decision making". Abdom Radiol (NY). doi:10.1007/s00261-017-1332-z. PMID 28948329.
  5. ↑ Al-Hawary MM, Francis IR, Chari ST, Fishman EK, Hough DM, Lu DS, Macari M, Megibow AJ, Miller FH, Mortele KJ, Merchant NB, Minter RM, Tamm EP, Sahani DV, Simeone DM (2014). "Pancreatic ductal adenocarcinoma radiology reporting template: consensus statement of the Society of Abdominal Radiology and the American Pancreatic Association". Radiology. 270 (1): 248–60. doi:10.1148/radiol.13131184. PMID 24354378.
  6. ↑ 6.0 6.1 6.2 Khorana AA, Mangu PB, Berlin J, Engebretson A, Hong TS, Maitra A, Mohile SG, Mumber M, Schulick R, Shapiro M, Urba S, Zeh HJ, Katz MH (2016). "Potentially Curable Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline". J. Clin. Oncol. 34 (21): 2541–56. doi:10.1200/JCO.2016.67.5553. PMID 27247221.
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  15. ↑ Fuhrman GM, Leach SD, Staley CA, Cusack JC, Charnsangavej C, Cleary KR, El-Naggar AK, Fenoglio CJ, Lee JE, Evans DB (1996). "Rationale for en bloc vein resection in the treatment of pancreatic adenocarcinoma adherent to the superior mesenteric-portal vein confluence. Pancreatic Tumor Study Group". Ann. Surg. 223 (2): 154–62. PMC 1235091. PMID 8597509.
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