Dr. Aditya Kulkarni is a Consultant Laparoscopic and Robotic Gastrointestinal, Hepato-biliary-pancreatic and Cancer Surgeon at the renowned Ruby Hall Clinic,
What is Pancreas Cancer?
The pancreas is a flat long organ lying in upper abdomen behind the stomach. It has parts such as head, body, and tail. Many vital structures such as hepatic artery (providing blood supply to liver), superior mesenteric artery (providing blood supply to small intestine), portal vein (drains blood from small intestine and provides blood supply to liver), splenic artery (provides blood supply to spleen) and splenic vein (drains blood from spleen) passes through it or close to it. It is closely attached to duodenum, which is a part of intestine. The bile duct also courses through head of pancreas before draining into duodenum. The pancreatic juice also drains into duodenum through a thin, slender tube carrying it, which is called pancreatic duct. Pancreas has many important functions. It produces enzymes for digestion (exocrine function) and various hormones (endocrine function)
Pancreas cancer is an abnormal growth of cells that begins in the stomach. Pancreas cancer can affect any part of the pancreas- head, neck, body, or tail. Pancreatic cancer occurs when cells in your pancreas develop changes (mutations) in their DNA. These cancers tend to develop slowly over many years. Before a true cancer develops, pre-cancerous changes often occur, which rarely cause symptoms and therefore often go undetected.
Most pancreatic cancer begins in the cells that line the ducts of the pancreas. This type of cancer is called pancreatic adenocarcinoma or pancreatic exocrine cancer. Less frequently, cancer can form in the hormone-producing cells or the neuroendocrine cells of the pancreas. These types of cancer are called pancreatic neuroendocrine tumors, islet cell tumors, acinar tumors or pancreatic endocrine cancer.
Pancreas cancer is a lethal disease, made more so by the fact that it doesn’t usually cause any symptom till it is advanced. There aren’t any noticeable signs or symptoms in the early stages of pancreatic cancer. The signs and symptoms of pancreatic cancer, when present, are like the signs and symptoms of many other illnesses. Cancer in the head of pancreas will usually compress the bile duct and cause yellowing of eyes and urine called as jaundice, this is usually accompanied by pale stools and itching. Some concerning symptoms are:
- Jaundice (yellowing of the skin and whites of the eyes)
- Light-colored stools
- Dark urine
- Pain in the upper or middle abdomen and back
- Weight loss
- Loss of appetite
- Feeling very tired
Factors that may increase your risk of pancreatic cancer include:
- Chronic inflammation of the pancreas (pancreatitis)
- Family history of genetic syndromes that can increase cancer risk, including a BRCA2 gene mutation, Lynch syndrome and familial atypical mole-malignant melanoma (FAMMM) syndrome
- Family history of pancreatic cancer
- Older age, as most people are diagnosed after age 65
The combination of smoking, long-standing diabetes and a poor diet increases the risk of pancreatic cancer beyond the risk of any one of these factors alone.
In addition to a physical examination, the following tests may be used to diagnose pancreas cancer. Not all tests listed below will be used for every person.
- Blood tests: Blood tests check for the liver and kidney functions. The hemoglobin and blood clotting parameters are checked.
- Tumor marker test: A procedure in which a sample of blood, urine, or tissue is checked to measure the amounts of certain substances, such as CA 19-9, and carcinoembryonic antigen (CEA), made by organs, tissues, or tumor cells in the body. Higher levels may indicate that the tumour might be advanced.
- Ultrasound: An ultrasound uses sound waves to create a picture of the internal organs to find out if cancer has spread. The ultrasound transducer is pressed against the skin of the abdomen and directs high-energy sound waves (ultrasound) into the abdomen. The sound waves bounce off the internal tissues and organs and make echoes. The transducer receives the echoes and sends them to a computer, which uses the echoes to make pictures called sonograms.
- Chest x-ray: X-ray of the chest can help doctors find out if the cancer has spread to the lungs.
- Computed tomography (CT or CAT) scan: A CT scan takes pictures of the inside of the body. It can be used to measure the tumor’s size. Special dye called a contrast medium is given before the scan to provide better images. This dye is injected into a patient’s vein. In a person with pancreas cancer, a CT scan can check for the spread of cancer to the lungs, liver, and other organs.
- MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
- Positron emission tomography (PET) or PET-CT scan: It is a procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and takes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do. A PET scan and CT scan may be done at the same time. This is called a PET-CT.
- Endoscopic ultrasound: A procedure in which an endoscope is inserted into the body through the mouth. An endoscope is a thin, tube-like instrument with a light and a lens for viewing. A probe at the end of the endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. An ultrasound image of the pancreas helps to determine the size of tumour, and how far the cancer has spread in the pancreas and nearby lymph nodes, tissue, and organs. This procedure is also called endosonography.
- Endoscopic retrograde cholangiopancreatography (ERCP): A procedure used to x-ray the ducts (tubes) that carry bile from the liver to the gallbladder and from the gallbladder to the small intestine. Sometimes pancreatic cancer causes these ducts to narrow and block or slow the flow of bile, causing jaundice. An endoscope (a thin, lighted tube) is passed through the mouth, esophagus, and stomach into the first part of the small intestine. A catheter (a smaller tube) is then inserted through the endoscope into the pancreatic ducts. A dye is injected through the catheter into the ducts and an x-ray is taken. If the ducts are blocked by a tumor, a fine tube may be inserted into the duct to unblock it. This tube (or stent) may be left in place to keep the duct open. Tissue samples may also be taken.
- Percutaneous transhepatic cholangiography (PTC): A procedure used to x-ray the liver and bile ducts. A thin needle is inserted through the skin below the ribs and into the liver. Dye is injected into the liver or bile ducts and an x-ray is taken. If a blockage is found, a thin, flexible tube called a stent is sometimes left in the liver to drain bile into the small intestine or a collection bag outside the body. This test is done only if ERCP cannot be done.
- Laparoscopy: A surgical procedure to look at the organs inside the abdomen to check for signs of disease. Small incisions (cuts) are made in the wall of the abdomen and a laparoscope (a thin, lighted tube) is inserted into one of the incisions. Other instruments may be inserted through the same or other incisions to perform procedures such as taking tissue samples from the pancreas or a sample of fluid from the abdomen to check for cancer.
- Biopsy: Biopsy is the removal of a small amount of tissue for examination under a microscope. Biopsy can make a definite diagnosis of pancreas cancer. A biopsy may be performed in many ways. A fine needle or a core needle may be inserted into the pancreas during an x-ray or ultrasound to remove cells. It may be done during endoscopic ultrasound, or it may be done on any tissue that is removed during surgery. Tissue may also be removed during a laparoscopy or surgery to remove the tumor.
Stage-wise classification: The following stages are used for pancreatic cancer:
- Stage 0: No spread. Pancreatic cancer is limited to the top layers of cells in the ducts of the pancreas. The pancreatic cancer is not visible on imaging tests or even to the naked eye.
- Stage I: Local growth. Pancreatic cancer is limited to the pancreas but has grown to less than 2 centimetres across (stage IA) or greater than 2 but no more than 4 centimetres (stage IB).
- Stage II: Local spread. Pancreatic cancer is over 4 centimetres and is either limited to the pancreas or there is local spread where the cancer has grown outside of the pancreas or has spread to nearby lymph nodes. It has not spread to distant sites.
- Stage III: Wider spread. The tumour may have expanded into nearby major blood vessels or nerves but has not metastasized to distant sites.
- Stage IV: Confirmed spread. Pancreatic cancer has spread to distant organs.
Clinical Classification: Based on the result of these tests your disease will be classified into resectable, borderline resectable, unresectable or metastatic.
Resectable: when the disease is picked up at as stage where it can be clearly removed by surgery.
Borderline resectable: when the disease has grown to a stage where the cancer is infiltrating some vital vessel coursing through or adjacent to pancreas. But it can be removed by surgery, by either cutting or re-joining the involved vessel and/or, decreasing the size of tumor by giving chemotherapy or chemoradiotherapy prior to surgery called as neoadjuvant treatment.
Unresectable: when the staging scan shows that disease has reached such a stage where it cannot usually be removed surgically.
Metastatic: when the pancreatic cancer had spread to organs beyond the pancreas. This is advanced stage and curative treatment is not possible.
SURGERY: The only treatment that can cure pancreas cancer is surgery. All other forms of treatment like chemotherapy and radiotherapy can only reduce risk of recurrence of cancer after surgery but cannot cure the cancer. Several different surgical procedures are available to treat tumours of the pancreas. The choice of surgery depends upon the location, size, and type of the tumor. (Figure8)
The cancers in the pancreatic head are treated by Whipple procedure or pancreaticoduodenectomy and cancers in the body and tail is removed by distal pancreatectomy or distal pancreaticosplenectomy. Some tumours in the body of the pancreas can be removed by central pancreatectomy.
Whipple Procedure or Pancreaticoduodenectomy(Figure9)
Whipple procedure or pancreaticoduodenectomy is a complex surgical procedure, which is done to remove pancreatic cancer or tumours and cysts of the head of the pancreas and periampullary cancers. This operation is named after Allen Whipple, who was the first surgeon to perform this operation.
In this operation, head of the pancreas, bile duct, gall bladder, first part of the small intestine and a portion of the stomach is removed. Intestinal continuity is then restored by joining the cut end of the pancreas to small intestine or stomach, cut end of the bile duct is joined to small intestine and stomach is joined with the small intestine. It is a complex operation which takes several hours to complete and demands great skill and expertise. Moreover, sometimes these cancers are stuck to these vital blood vessels, which need to be cut and joined to achieve complete removal of the tumour.
Not all patients with pancreatic or periampullary cancer will undergo this operation. Only about 20 per cent of patients suffering from these cancers are eligible for surgical removal. In these patients, cancer has not spread to nearby blood vessels, liver, lungs and abdominal cavity.
The patient would stay in the hospital until he recovers. Initially, the patient is monitored in the ICU and is then shifted to the ward once the condition is more stable. once the movement of intestine returns oral feeding will be started. During this surgery, tubes are placed in the abdomen to monitor for bleeding or leakage and they will be removed once the secretions dry up. The recovery generally takes 8-10 days but can be prolonged if there are complications. There can be many complications following this surgery, but the most common ones are pancreatic fistula, delayed gastric emptying, bleeding and infection. At the time of discharge, most patients are eating a normal diet and can carry out activities of daily living. Depending on the stage of the tumour, you might be advised further chemotherapy or radiotherapy called adjuvant treatment.
This surgery is performed for cancer arising in body and tail of the pancreas. It removes the body and tail of pancreas including the tumour. In this surgery, the pancreas and pancreatic duct are divided at neck or body depending upon the location of the tumour. The cut end of the pancreas is either sutured closed or stapled close. The spleen is removed if the tumour involves splenic vessels or if lymph nodes need to be cleared in advanced tumours, termed pancreatosplenectomy. In distal pancreatosplenectomy, the blood supply of the spleen, which is through splenic artery and vein is cut. The spleen is then mobilised and removed along with the pancreas.
In spleen preserving pancreatectomy the splenic artery and vein are preserved. The blood supply of the liver and intestine must be meticulously preserved in either case. Before proceeding with surgery we ensure that cancer has not spread. If the tumour involves adjacent organs, such as stomach and colon, the part of the involved organ is also resected. A drainage tube is generally inserted to drain fluids from the operated area.
Recovery after distal pancreatectomy
Recovery after the surgery takes around three to five days. In extensive surgery for advanced or complicated tumours, the recovery might take longer. The drainage tube is watched for the content plus amount and removed when appropriate.
Complications of the procedure include bleeding, infection and intra-abdominal collection. The cut end of the pancreatic duct can leak, a condition identified as pancreatic fistula. Most of these complications are manageable but may result in prolongation of hospital stay. At the time of discharge, most patients are eating a normal diet and can carry out activities of daily living. Depending on the type and stage of the tumour, you might be advised further chemotherapy or radiotherapy called adjuvant treatment. In the long term, some of the patients may develop indigestion due to pancreatic enzyme insufficiency or diabetes due to deficiency of hormones.
Laparoscopic distal pancreatectomy (Figure11
In less advanced cases this operation is now done laparoscopically. In laparoscopic surgery, instead of long incision, the procedure is done through small holes made over the abdomen. Your abdomen is filled with gas to expand and fill it like a soft balloon. A long and slender camera is then inserted through one of these holes, which projects high-resolution images of the inside of the abdomen on a high-definition monitor. Specially designed long thin instruments are placed inside the abdomen through rest of the ports to carry out the surgery.
Laparoscopic distal pancreatectomy has many advantages. A long incision on your belly is avoided. Postoperative stress and pain are markedly decreased. The recovery from the operation is faster and consequently, the hospital stay is shorter. The overall complication rate is decreased. All this results in earlier return to home and work.
Placement of a feeding tube
Some patients have trouble taking in enough nutrition after surgery for pancreas cancer. To help with this, a tube can be placed into the intestine at the time of gastrectomy. The end of this tube, called a jejunostomy tube or J tube, remains outside of the skin on the abdomen. Through this, liquid nutrition can be put directly into the intestine to help prevent and treat malnutrition.
Palliative surgery for unresectable cancer
For people with unresectable pancreas cancer, surgery can often still be used to help control the cancer or to help prevent or relieve symptoms or complications.
Gastric bypass (gastrojejunostomy): Tumours in the head of the pancreas may eventually grow large enough to block food from leaving the stomach. For people healthy enough for surgery, one option to help prevent or treat this is to bypass the lower part of the stomach. This is done by attaching part of the small intestine (the jejunum) to the upper part of the stomach, which allows food to leave the stomach through the new connection.
Stent placement: Another option to keep a tumour from blocking the stomach is to use an endoscope to place a stent (a hollow metal tube) in the opening. This helps keep it open and allows food to pass through it. The stent is placed at the junction of the stomach and the small intestine.
Feeding tube placement: Some people with pancreas cancer are not able to eat or drink enough to get adequate nutrition. A minor operation can be done to place a feeding tube through the skin of the abdomen and into the distal part of the stomach (known as a gastrostomy tube or G tube) or into the small intestine (jejunostomy tube orJ tube). Liquid nutrition can then be put directly into the tube.
Open surgery: It involves large cuts or incisions on the patient’s body to make a big opening through which the surgery is done. It is highly painful; there is chance of increased blood loss, infection, and prolonged recovery. (Fig 12)
Minimal invasive surgery: In these surgeries, the entire procedure is performed using small keyhole incisions, which leads to less pain, less blood loss, faster recovery of the patient. These can be done with laparoscopic or robotic techniques. (Fig 13)
Using minimal invasive technique, pancreas cancer surgery can be performed with improved comfort. Whipples procedure or distal pancreatectomy when performed by laparoscopy or robotic surgery avoids most of the complications which are mainly related to wound. Patients will have faster recovery, with less blood loss, less chances of infection and less chances of hernia later.
Robotic surgery for pancreas cancer: The surgeon operates several precision-guided robotic arms that hold and manipulate miniaturized instruments that are inserted through keyhole-sized incisions. A small video camera provides surgeons with magnified 3D images of the operating site. The robotic arms, which can rotate 360 degrees, enable surgical instruments to be moved with greater precision, flexibility, and range of motion than in standard minimally invasive laparoscopy.
Chemotherapy: Chemotherapy uses drugs to destroy cancer cells. For pancreas cancer, chemotherapy might be recommended after surgery to kill any cancer cells that might remain. Chemotherapy combined with radiation therapy might also be used before an operation to shrink a large cancer so that it is easier to remove with surgery. Chemotherapy can also be used to relieve symptoms of pancreas cancer that cannot be removed with surgery or that has spread to other areas of the body.
Radiation therapy: Radiation therapy uses powerful energy sources, such as X-rays and protons, to kill cancer cells. In people with pancreas cancer, radiation therapy is often combined with chemotherapy that makes the cancer cells more likely to be damaged by the radiation. It can be used after surgery to kill any cancer cells that might remain or it can be used before surgery to shrink a cancer and make it easier to remove.
Combined chemotherapy and radiation therapy: Combining chemotherapy and radiation therapy (chemoradiotherapy) makes cancer cells more vulnerable to radiation. The combination is often used for larger pancreas cancers and those that have a higher risk of returning after surgery.
Chemoradiotherapy may be recommended:
- Before surgery: Chemoradiotherapy may help shrink the cancer enough to make a less invasive surgery possible.
- After surgery: If surgery was the first treatment, doctor may recommend chemoradiotherapy afterward if there is an increased risk that the cancer may return.
- As the primary treatment: Doctor may recommend chemoradiotherapy to control the growth of cancer if cancer is advanced or if surgery is not an option.
Surgery for pancreas cancer is difficult and can have complications. These can include bleeding from the surgery, blood clots, and damage to nearby organs during the operation. The new connections made between the ends of the pancreas and intestine are prone to leakage in some cases. There may be delayed gastric emptying in some patients, leading to nausea and vomiting.
Surgery for pancreas cancer takes a skilled surgeon who is experienced in pancreatic surgery to remove the tumour successfully. Studies have shown that the results are better when the surgeon has extensive experience in treating patients with pancreas cancer. The outcome of this surgery is more likely to be successful if performed by a qualified and experienced GI cancer surgeon
Dr. Aditya Kulkarni is the best pancreas cancer surgeon, advanced laparoscopic cancer surgeon and robotic surgeon in Pune, Maharashtra, who is qualified and experienced in pancreas cancer surgery.
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