The extent of pancreatic cancer surgery depends on where the tumor is located. In the case of pancreatic head cancer, for example, the pancreatic head is removed together with the gallbladder and the main bile duct, the duodenum and the surrounding lymph nodes.
Pancreatic cancer surgery can only achieve a cure if the entire tumor tissue can be removed.
Thepancreas is located in the upper abdomen behind the stomach and is divided anatomically from right to left into
from right to left.
The pancreatic head lies in the arch of the duodenum, into which the bile duct and the pancreatic duct lead. Both ducts pass through the head of the gland, where they join and flow into the duodenum via the papilla.
The body of the gland lies in front of the large abdominal artery(aorta) in the immediate vicinity of the vessels supplying the upper abdominal organs and the intestine.
The tail of the gland extends to the spleen and shares the vessels with it.
A dense network of lymphatic ducts runs through the posterior abdominal cavity, in which tumor cells can spread widely. The gland is very well supplied with blood from several directions. The insulin-producing cells are particularly dense in the tail.
Fig.1: Schematic anatomy of the pancreas. The stomach in front of the gland is silhouetted. L=liver, G=gall bladder and ducts, M=stomach, B=pancreas, Mi=spleen, Z=duodenum, Ba=abdominal artery, P=portal vein.
However, as nature plans generously in the development of organs and creates sufficient reserves, a loss of more than 50% of glands due to illness or surgery can have no negative effect on the patient. This does not apply to diabetics whose insulin production is already insufficient. The lack of pancreas can be compensated for relatively easily by the family doctor by taking appropriate digestive enzymes and administering insulin.
The pancreas has a dual function:
Pancreatic cancer is a malignant proliferation that can originate from all cell populations in the gland, from the actual gland cells, from the insulin-producing cells, from the connective tissue cells, etc. However, the most common variant originates from the pancreas itself. However, the most common variant arises from the ductal system(ductal carcinoma, 95%), which is why this is discussed in this article.
Pancreatic cancer is aggressive and is characterized by uncontrolled growth and early metastasis (spread). It reaches the organ capsule at a size of just a few centimetres, which, as a delicate membrane, does not really represent a barrier. Behind it lie vital structures that are infiltrated once the cancerous node has broken through.
At an early stage, tumor cells wash into the dense network of lymph nodes via the lymphatic system. However, it is not a multi-stage filter station, as we know it from colorectal cancer, so that lymph node involvement is usually an indicator of generalized cancer spread.
This metastasis occurs primarily via the dense bloodstream system to distant organs, first and foremost to the liver, where liver metastases then develop accordingly.
Finally, the cancer can also spread directly into the abdominal cavity by exfoliation of superficial tumor cells, where the metastases can lead to intestinal obstruction.
With 15,000 new cases, pancreatic cancer is the eighth most common cancer in Germany.
Little is known about its causes. Nicotine, alcohol and diabetes mellitus are weak risk factors. A few patients have a family history of the disease. However, it has not yet been possible to define a clearly definable risk group for which screening could be carried out.
Some carcinomas - similar to bowel cancer - probably develop from polyp-like precursors of the duct (e.g. intraductal papillary mucinous neoplasia (IPMNs), pancreatic intraepithelial neoplasia (PanIN)), but there is no endoscopy of the ductal system as a screening test.
Early detection by ultrasound of the organ located far in the posterior abdominal cavity is also impossible. For this reason, most pancreatic tumors are only detected radiologically using computer tomography(CT) or magnetic resonanceimaging (MRI). The new PET-CT does not yet play a role in clinical routine.
For this reason, cancer is usually only diagnosed after symptoms have appeared.
However, the tumor symptoms are non-specific and are usually signs of advanced growth:
It is not surprising that valuable months can pass between the first symptoms and diagnosis. When the tumors move towards the papilla (the exit of the bile and pancreatic ducts), they obstruct the outflow of bile into the intestine and cause increasing jaundice. This painless jaundice is the leading symptom of pancreatic head tumors.
The rule of thumb is: the closer to the papilla, the earlier the typical jaundice and tumor diagnosis; the further away the cancer is from the papilla, the later the symptoms and discovery.
If tumors are confined to the pancreas, they can be removed by radical surgery. Oncological pre-treatment with chemotherapy or radiotherapy is not established for pancreatic cancer.
Clarification of operability includes radiological spread diagnostics (in particular CT), which can be used to precisely localize the tumour and detect its infiltration of neighbouring structures and spread to lymph nodes and other organs such as the liver.
In general, only localized cancer is operated on. To date, there is no effective oncological therapy for advanced carcinoma, only symptom-oriented chemotherapeutic treatment.
The extent of pancreatic cancer surgery depends on the location of the tumor. Pancreatic head cancer requires the removal of the pancreatic head together with the gallbladder and the main bile duct, the duodenum and the surrounding lymph nodes.
This pancreatic cancer surgery is called pylorus-preserving duodenopancreatectomy according to Traverso-Longmire (Fig. 2) and has replaced the classic resection with partial gastrectomy according to Kausch-Whipple as the gold standard over the last twenty years.
Fig. 2: Extent of resection in pancreatic head carcinoma
In the second part of this complex pancreatic cancer operation, which lasts several hours, continuity must be reconstructed: The pancreas, like the bile duct and the stomach, must be connected to the small intestine using sutures (Fig.3). Occasionally, the glandular remnant is also drained into the stomach.
This complex pancreatic cancer surgery is reserved for a few specialists and is almost exclusively performed using the traditional open technique.
Fig.3: Reconstruction with the small intestine pulled upwards, to which the rest of the pancreas, the bile ducts and the stomach are connected.
Tumors in the glandular body rarely require surgery, as they break out into the neighboring vessels at an early stage and are therefore no longer operable.
In the rare cases of operable corpus carcinoma, the corpus is removed together with the surrounding lymphatic vessels in an open operation. The gland can be sutured shut towards the head, but the tail of the pancreas must be connected to a loop of intestine that has been removed if it is not sacrificed.
Cancer in the tail of the pancreas is only exceptionally discovered in time and is therefore rarely operable.
Radical pancreatic tail resection is comparatively simple (Fig. 4). The tail is separated from the glandular body and removed together with the spleen due to the common vascular supply. A complex reconstruction is not necessary.
These pancreatic resections, also known as left resections, are often performed minimally invasively (keyhole technique or laparoscopically).
Fig. 4: Extent of pancreatic tail resection. The end of the glandular remnant is closed.
Only very rarely are more extensive pancreatic cancer operations performed, e.g. partial removal of affected neighboring organs such as the colon, stomach or liver.
Total removal of the pancreas (pancreatectomy) is also not a standard oncological therapy, but rather part of complication management in cases of severe inflammation. However, taking the portal vein is different if the cancer in the head area infiltrates this vessel, which is essential for the blood supply to the liver. The experienced pancreatic surgeon can reconstruct the vessel in this particular challenge.
A cure is only achieved if the pancreatic cancer surgery can remove all tumor tissue. After the organism has recovered and adapted to the newly reconstructed upper abdominal anatomy, which can take several months, a completely normal life without restrictions is possible.
If the tumor has spread (metastases), there is no cure. However, this can often only be recognized after the pancreatic cancer operation when the pathologist examines the lymph nodes in detail under the microscope using special stains.
If he finds microscopic small tumor cell nests here, the prognosis is poor, as the cancer usually returns within two years, either as a local recurrence at the same location in the posterior abdomen or as distant metastases in the liver, lungs or bones.
In this situation, there is no specific treatment; instead, it is based on the individual symptoms such as pain, food intake and jaundice. For this reason, there is no meaningful standardized oncological aftercare following pancreatic cancer surgery; instead, medical and nursing care is palliative in nature.
Pancreatic cancer operations are demanding, challenging special procedures. The results of surgery have steadily improved over the last few decades, but pancreatic cancer surgery remains stressful for patients.
After extensive pancreatic resections, the function of the remaining gland should be checked. If necessary, pancreatic enzymes are added to the diet and insulin is administered according to a schedule.
To date, there is no effective non-surgical therapy. Chemotherapy and radiotherapy cannot bring about a cure or even a relevant prolongation of life.
Tumor therapy therefore focuses on the symptoms and accompanies the patient in the few remaining months of life.
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