Treatment to remove the cancer

Your surgeon may recommend other treatments before surgery to shrink the tumour, or after surgery to destroy any remaining cancer cells.

Treatments given before surgery are known as neoadjuvant therapies, while treatments given after surgery are called adjuvant therapies. They both may include:

• chemotherapy – the use of drugs to kill or slow the growth of cancer cells
• chemoradiation – chemotherapy combined with radiation therapy

Surgical removal (resection) of the tumour is the most common treatment for people with early-stage cancer who are in good health. It may also be considered for some stage 3 cancers, usually with chemotherapy (and sometimes radiation therapy) to shrink the tumour first. These stage 3 cancers are known as borderline resectable cancers, which means that surgery might be able to remove them.

The aim of resection is to remove all the tumour from the pancreas, as well as a margin of healthy tissue. The type of surgery you have will depend on the size and location of the tumour, your general health and your preferences. Your surgeon will talk to you about the most appropriate surgery for you, as well as the risks and any possible complications. Types of surgery include:

Whipple procedure – This treats tumours in the head of the pancreas. Also known as pancreaticoduodenectomy, it is the most common surgery for pancreatic tumours.

Distal pancreatectomy – The surgeon removes only the tail of the pancreas, or the tail and a portion of the body of the pancreas. The spleen is usually removed as well. The spleen helps the body fight infections, so if it is removed you are at higher risk of some types of bacterial infection. Your doctor may recommend vaccinations before and after a distal pancreatectomy.

Total pancreatectomy – When cancer is large or there are many tumours, the entire pancreas and spleen may be removed, along with the gall bladder, common bile duct, part of the stomach and small bowel, and nearby lymph nodes.

If the cancer has spread

During surgery to remove the cancer, the surgeon may find that the cancer has spread around one or more of the major blood vessels in the area or into the lining of the abdomen (peritoneum). This may occur even if you had several scans and tests beforehand.

If this happens, the surgeon will not be able to remove the cancer. However, they may be able to perform procedures (such as a bypass) that will relieve some of the symptoms caused by the cancer.

How the surgery is done

Surgery for pancreatic cancer is carried out in hospital under a general anaesthetic. There are three main approaches:

• Open surgery involves one larger cut in the abdomen so the surgeon can remove the cancer.
• Laparoscopic surgery involves a number of small cuts in the abdomen. It is sometimes known as keyhole or minimally invasive surgery. The surgeon inserts a long, thin instrument with a light and camera (laparoscope) into one of the cuts and uses images from the camera for guidance. The surgeon inserts tools into the other cuts to remove the cancer.
• Robotic-assisted surgery is a type of minimally invasive surgery. The surgeon sits at a control panel to see a three-dimensional image and moves robotic arms that hold the instruments.

Open surgery is usually the best approach for pancreatic cancer, but laparoscopic or robotic-assisted surgery may be offered as an option in some circumstances.

Talk to your surgeon about what options are available to you, ask about the risks and benefits of each approach, and check if there are any extra costs.

Having a Whipple procedure

The Whipple procedure (pancreaticoduodenectomy) is a major, complex operation. It has to be done by a specialised pancreatic or hepato-pancreato-biliary (HPB) surgeon.

The surgeon removes the part of the pancreas with the cancer (usually the head); the first part of the small bowel (duodenum); part of the stomach; the gall bladder; and part of the common bile duct. Then the surgeon reconnects the remaining part of the pancreas, common bile duct and stomach (or duodenum) to different sections of the small bowel to keep the digestive tract working. This rearrangement allows food, pancreatic juices and bile to continue to flow into the small bowel for the next stage of digestion. Many people need to change their diet after a Whipple procedure.

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While you are recovering after surgery, your health care team will check your progress and help you with the following:

Pain control – You will have some pain and discomfort for several days after surgery. You will be given pain medicines to manage this. If you are in pain when you return home, talk to your doctors about a prescription for pain medicine.

Surgical drain – You may have a thin tube placed in the abdomen to drain fluid into a small bag or bottle. The fluid can then be checked for potential problems. The tube is usually removed after a few days but may be left in for longer. Surgical drains are never permanent.

Drips and tubes – While in hospital, you will have a drip to replace your body’s fluids. At first, you may not be able to eat or drink (nil by mouth). You’ll then be on a liquid diet before slowly returning to normal food. A temporary feeding tube may be put into the small bowel during the operation. This tube provides extra nutrition until you can eat and drink normally again. The hospital dietitian can help you manage changes to eating.

Enzyme supplements – Some people will need to take tablets known as pancreatic enzymes after surgery. These are taken with each meal to help digest fat and protein.

Insulin therapy – Because the pancreas produces insulin, people who have had all or some of their pancreas removed may develop diabetes after surgery and need regular insulin injections (up to four times per day). A specialist doctor called an endocrinologist will help you develop a plan for managing diabetes.

Moving around – Your health care team will probably encourage you to walk the day after surgery. They will also provide advice about when you can get back to your usual activity levels.

Length of hospital stay – Most people go home within two weeks, but if there are problems, you may need to stay in hospital longer. You may need rehabilitation to help you regain physical strength. This may be as an inpatient in a rehabilitation centre or through a home-based rehabilitation program.

If the surgery successfully removes all of the cancer, you will have regular appointments to monitor your health, manage any long-term side effects and check that the cancer hasn’t come back or spread. Check-ups will become less frequent if you have no further problems. Between appointments, let your doctor know immediately of any symptoms or health problems.

Unfortunately, pancreatic cancer is difficult to treat and it often does come back after treatment. This is known as a recurrence.

Most of the time, surgery is not an option if you have a recurrence. Your doctors may recommend other types of treatment with the aim of reducing symptoms and improving quality of life. You may also be able to get new treatments by joining a clinical trial.