Pancreatic Cancer Surgery: Types, Procedures, and Survival Rates

Pancreatic Cancer Surgery

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Pancreatic Cancer Surgery

INTRODUCTION

SURGERY

Surgery is a common treatment option for pancreatic cancer, and the type of surgery depends on the location and stage of the cancer.¹ Complete tumor resection is probably the most relevant prognostic factor for patients with resectable pancreatic cancer. While the 5-year overall survival of patients with pancreatic cancer is approximately 5%, surgery is the only potential cure with 5-year survival increasing to more than 20% in patients who have had surgery in combination with other treatment approaches.^2,3

Not all patients with pancreatic cancer are candidates for surgery, especially if the cancer has spread extensively or if the patient’s overall health is not suitable for surgery. The surgery is often combined with other treatment modalities, such as chemotherapy or radiation therapy, depending on the stage of the cancer. The goal of surgery is to remove as much of the tumor as possible and, in some cases, to address nearby lymph nodes or other affected tissues. The optimal surgical procedure for resection of the primary tumor depends on tumor location and its relationship to the bile duct and vasculature.⁴ If there is vessel invasion, vascular resection and reconstruction may be required. Tumors located in the head of the pancreas or uncinate process usually require a pancreaticoduodenectomy, or “Whipple procedure.” Tumors located in the neck of the pancreas neck without bile duct involvement), the pancreas body or the tail usually required a distal pancreatectomy. These procedures are described in more detail below.

Whipple Procedure (Pancreaticoduodenectomy)

This is the most common surgery for tumors in the head of the pancreas. Its Involves removal of the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder, part of the bile duct, and sometimes a portion of the stomach. The remaining pancreas, bile duct, and stomach are then connected to allow for digestive function. Pancreaticoduodenectomies have the highest rates of adverse events with a 10% rate of delayed gastric emptying occurring and a 13% rate of pancreatic leaks.⁵Surgical outcomes are better if the operating surgeon performed more than 30 procedures per year at a high-volume center.⁵

Total Pancreatectomy

The procedure results in the removal of the entire pancreas. It is rarely performed because it results in the loss of all pancreatic function, leading to diabetes and other complications. Pancreatectomy should be performed when a margin-negative resection is feasible. If the tumor has invaded the portal vein, it should undergo resection and reconstruction to ensure margin-negative resection is obtained.⁴ Pancreatectomies which are performed via a minimally invasive approach are associated with a shorter hospital length of stay with no difference in complication rates when compared to those performed via an open surgical approach.^6,7

Cure rate associated with pancreatic cancer surgery

The cure rate for pancreatic cancer after surgery depends on various factors, including the stage of the cancer, the success of the surgical procedure, and whether the cancer has spread beyond the pancreas. Resection margin, either successful complete removal of tumor or tumor cells remaining following the procedure, is an important prognostic factor following surgery for pancreatic cancers. A meta-analysis⁸ reported that complete tumor removal with negative resection margins is obtained in 72% of patients following surgery when 0mm margin (R0) is used and 41% when a 1mm margin (R1) is used. Across all studies assessed, patients with a R0 resection had a 23% to 46% reduction in the risk of death compared to patients with an R1 resection. The same analysis reported that local recurrence developed in 27% to 38% of patients with R0 resections and from 39% to 44% in patients with R1 resections. Distant recurrence 28% and 40% of R0 and R1 resections, respectively. A multicenter trial comparing surgical resection to radiochemotherapy in patients with pancreatic cancer invading the pancreatic capsule without involvement of the superior mesenteric artery or the common hepatic artery, or without distant metastasis reported better 1-year survival (62% vs 32 %, p=0.05) and mean survival time (>17 vs 11 months, p < 0.03) in the surgery group.⁹

Since pancreatic cancer is often diagnosed at an advanced stage, the ability to achieve a cure through surgery alone is more likely in cases where the cancer is localized and has not spread extensively. Some general considerations:

Early Stage (Stage I and some Stage II) – surgery may offer a chance for a cure when the cancer is confined to the pancreas, with the Whipple procedure or distal pancreatectomy typically being performed.
Locally Advanced (Some Stage II and Stage III) – in cases where the cancer has spread to nearby structures but is still potentially resectable, surgery combined with chemotherapy and/or radiation therapy may be considered. Achieving a cure becomes more challenging.
Metastatic (Stage IV) – pancreatic cancer that has spread to distant organs is typically not curable with surgery alone. In some cases, surgery may be performed to relieve symptoms and improve the quality of life, but it is not intended to cure the cancer.

References

National Comprehensive Cancer Network®. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Pancreatic Adenocarcinoma. Version 1.2024 — December 13, 2023
Neoptolemos JP, Stocken DD, Bassi C, et al. Adjuvant chemotherapy with fluorouracil plus folinic acid vs gemcitabine following pancreatic cancer resection: a randomized controlled trial. JAMA 2010; 304:1073–81.
Oettle H, Post S, Neuhaus P, et al. Adjuvant chemotherapy with gemcitabine vs observation in patients undergoing curative-intent resection of pancreatic cancer: a randomized controlled trial. JAMA 2007; 297: 267–77. Park W, Chawla A, O’Reilly EM. Pancreatic Cancer: A Review. JAMA. 2021 Sep 7;326(9):851-862. doi: 10.1001/jama.2021.13027. Erratum in: JAMA. 2021;326:2081.
Park W, Chawla A, O’Reilly EM. Pancreatic cancer: A review. JAMA. 2021;326(9):851-862.
Schmidt CM, Turrini O, Parikh P, et al. Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience. Arch Surg. 2010;145:634-640.
Correa-Gallego C, Dinkelspiel HE, Sulimanoff I, et al. Minimally-invasive vs open pancreaticoduodenectomy: systematic review and meta-analysis. J AmColl Surg. 2014;218:129-139.
de Rooij T, Lu MZ, SteenMW, et al; Dutch Pancreatic Cancer Group. Minimally invasive versus open pancreatoduodenectomy: systematic review and meta-analysis of comparative cohort and registry studies. Ann Surg. 2016;264:257-267. doi:10.1097/SLA.0000000000001660
Chandrasegaram MD, Goldstein D, Simes J, et al. Meta-analysis of radical resection rates and margin assessment in pancreatic cancer. Br J Surg. 2015;102:1459-72.
Imamura M, Doi R, Imaizumi T, et al. A randomized multicenter trial comparing resection and radiochemotherapy for resectable locally invasive pancreatic cancer. Surgery 2004; 136: 1003–11.