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PANCREATIC CANCER

Pancreatic Cancer Surgery - Whipple Procedure Singapore

WHAT IS PANCREATIC CANCER?

By Dr. Lee Ser Yee
The pancreas is a gland located behind the stomach and next to the intestines. It is made of exocrine cells which produce enzymes that digest food, and endocrine cells which make hormones such as insulin that control blood sugar levels.

Cancer of the pancreas is when pancreatic cells grow out of control (pancreatic adenocarcinoma). It is one of the deadliest forms of cancer. Pancreatic cancer is mainly a genetic disease, a cancer caused by damage to the DNA. These mutations can be inherited or acquired as we age. Symptoms may not appear in the early stages, making it difficult to detect. As the disease progresses, common symptoms include abdominal pain, weight loss, jaundice, loss of appetite, and digestive problems.

Risk factors of pancreatic cancer include -

  • 1. Smoking
    • Smoking increases the risk of pancreatic cancer and is associated with cancer at an early age. It is the leading preventable cause of pancreatic cancer.
  • 2. Age
    • Risk of developing pancreatic cancer increases with age. Over 80% of pancreatic cancers develop between the ages of 60 and 80 years.
  • 3. Gender
    • Cancer of the pancreas is more common in men.
  • 4. Chronic pancreatitis
    • Long-term inflammation of the pancreas (pancreatitis) has been linked to pancreatic cancer.
  • 5. Alcohol
    • Excessive alcohol intake can cause inflammation of the pancreas (pancreatitis) and is also linked to an increase in the risk of pancreatic cancer.
  • 6. Diabetes
    • Diabetes mellitus can be a symptom of pancreatic cancer, and long-standing adult-onset diabetes also increases the risk of pancreatic cancer.
  • 7. Obesity
    • Obesity increases the risk of pancreatic cancer. Studies suggest that a body mass index ≥ 30 has a higher risk.
  • 8. Diet
    • Diets rich in red meats, cholesterol, fried foods and nitrosamines may increase risk, while diets high in fruits and vegetables reduce risk.
  • 9. Genes
    • One is at a higher risk if you have a family history of pancreatic cancer (≥ 2 first-degree relatives with pancreatic cancer.
    • Inherited cancer syndromes increase the risk of pancreatic cancer e.g. breast cancer syndrome (BRCA2), Lynch syndrome, and Peutz-Jeghers syndrome.
  • 10. Environment
    • Exposure to cancer-causing substances (called carcinogens) such as asbestos, pesticides, dyes, and petrochemicals may be linked to pancreatic cancer.

WHAT ARE THE SIGNS AND SYMPTOMS OF PANCREATIC CANCER?

Many signs and symptoms are not specific and may occur late or not at all.

Some of the common signs and symptoms -
  • Jaundice
    • Jaundice is the yellowing of the eyes and skin; this is often one of the first signs, it is caused by the build-up of bilirubin which the liver excretes as bile.
    • When the bile duct becomes blocked by cancer, bile can’t reach the intestines and the level of bilirubin in the body builds up.
  • Tea-coloured urine
    • Dark urine may be noticed as the first sign. As bilirubin levels in the blood increase, the urine becomes brown in colour.
  • Pale or greasy stools
    • Bile gives stools their brown colour. If the bile duct is blocked, stools might be pale or grey.
    • When bile and pancreatic enzymes can’t get to the intestines to digest fats, the stools can become greasy and might float in the toilet.
  • Itchy skin
    • When bilirubin builds up in the skin, it can start to itch and turn yellow as well.
  • Abdominal or Back pain
    • Pain in the abdomen or back is common in pancreatic cancer. It can grow and press on other nearby organs or affect nerves, causing pain.
  • Loss of Weight and appetite
    • Unintended weight loss and poor appetite are very common in people with pancreatic cancer.
  • Nausea and vomiting
    • If the cancer presses on the stomach it can block the outlet and this can cause nausea, vomiting, and pain that tend to be worse after eating.
  • Gallbladder or Liver swelling
    • If the cancer blocks the bile duct, the gallbladder can be enlarged and felt as a lump under the right ribcage.
    • The liver also can be enlarged if the cancer has spread to the liver.
  • Diabetes
    • Sudden Adult-onset Diabetes can be a sign- pancreatic cancers cause diabetes (high blood sugar) because they destroy the insulin-making cells.

Stages of Pancreatic Cancer

Pancreatic cancer is classified into different stages based on the extent of the disease. This staging system helps doctors plan the most appropriate treatment and determine the patient's prognosis. (AJCC TMN 8th edition)

  • Stage 0 – In this early stage, also known as carcinoma in situ, abnormal cells are found only in the lining of the pancreatic ducts and have not spread to nearby tissues or organs.
  • Stage I – At this stage, the cancer is localised to the pancreas and may be further divided into two sub-stages:

    • Stage IA – The tumour is confined to the pancreas and measures less than 2cm in size.
    • Stage IB – The tumour is still limited to the pancreas but has grown larger, measuring more than 2cm, but no more than 4cm.
  • Stage II – The cancer is larger than 4cm, but has not reached the major blood vessels. Stage II can also be divided into two sub-stages:

    • Stage IIA – The tumour is larger than 4cm and has not spread to nearby lymph nodes.
    • Stage IIB – The tumour has invaded regional lymph nodes(N1) but has not reached major blood vessels and other parts of the body.
  • Stage III – At this advanced stage, the cancer has spread extensively to nearby blood vessels and/or more (N2)lymph nodes but has not spread to distant sites.
  • Stage IV – This is the most advanced stage of pancreatic cancer, where the cancer has spread (metastasized) to distant organs, such as the liver, lungs, or abdominal cavity.

Diagnosing Pancreatic Cancer

  • Medical History and Clinical Evaluation – During the initial consultation, the specialist may conduct a comprehensive review of the patient’s medical history, including symptoms, risk factors, and family history.
  • Blood Tests – Blood samples may be taken to assess bilirubin levels, which can rise due to pancreatic cancer, and liver function tests may be performed. The doctor may also examine the carbohydrate antigen 19-9 (CA19-9) and/or other tumour marker indicative of potential cancer.
  • Imaging Studies – Imaging tests, including CT scans for detailed cross-sectional images, MRI for additional information on tumour extent, and PET scans for detecting increased metabolic activity, are used to assess pancreatic cancer and determine its stage.
  • Endoscopy (+/- Ultrasound) – Endoscopic procedures, such as endoscopic ultrasound (EUS), are performed for further evaluation and biopsy tissue sampling. During an endoscopy, a flexible tube with a light and camera is used to visualise the pancreas and surrounding structures. An ultrasound (EUS) may be used for more detailed imaging and to guide the biopsy if deemed necessary.
  • Biliary drainage – In patients who are jaundiced due to the blockage of the bile duct, pre-operative decompression of the bile ducts with stents may be required to reduce the jaundice and to prevent serious infection (cholangitis)

Treatment for Pancreatic Cancer

If discovered early, the best treatment option is surgery. This provides the best chance of a potential cure if it has not spread to surrounding or distant organs.

Pancreatic Cancer Surgery

Depending on the location and extent of the cancer, the following surgeries may be recommended

  • Whipple surgery

  • Distal pancreatectomy

  • Subtotal pancreatectomy

  • Total pancreatectomy

  • Specialized procedures e.g. RAMPS

Minimally invasive surgery with laparoscopic or robotic approaches is possible for selected cases and can improve recovery for these patients.

Beyond surgery – the other mainstays of pancreatic cancer treatment are chemotherapy, radiation.

Whipple Operation

The Whipple surgery, also known as a pancreaticoduodenectomy, is a complex surgical procedure performed to treat certain conditions affecting the pancreas, bile ducts, and the small intestine. In particular, this procedure may be necessary to remove tumours or lesions in the pancreas and treat pancreatic cancer.

The Whipple operation can be performed using two approaches:

  • Open Whipple’s Procedure

    The open Whipple procedure involves making a large abdominal incision to access the affected area and check for metastasis. If other organs are unaffected, the surgeon removes the pancreas head, first portion of the small intestine (duodenum/jejunum), a small part of the stomach, gallbladder, a part of the bile duct, and regional lymph nodes. Vascular reconstruction may be necessary if the tumour is near or has invaded major blood vessels.
  • Laparoscopic / Robotic Whipple’s Procedure

    Laparoscopic Whipple operation uses a minimally invasive approach which involves making small abdominal incisions using specialised surgical instruments and a laparoscope. The surgery is the same as the Open Whipple’s procedure, though it requires specialized training. This approach offers benefits such as reduced pain, faster recovery, and shorter hospital stays compared to traditional open surgery without compromising the principles of cancer surgery(Surgical oncology).

    Robotic surgery is another minimally-invasive approach, its assistance may be beneficial in selected cases.

Who Is a Good Candidate for a Whipple Procedure?

Generally, the Whipple operation is suitable for patients whose tumour has only affected the head of the pancreas. Hence, it will not be suitable if the cancer has already spread to the liver, lungs, major blood vessels, the abdominal cavity, and the body or tail of the pancreas.

What Are the Risks of a Whipple Procedure?

The Whipple procedure is a complex surgery that comes with its attendant risks. These include infection, bleeding, pancreatic fistula formation, delayed gastric emptying and initial weight loss. However, when performed successfully on eligible patients, it can potentially cure and/or provide the best survival benefits and quality of life. When recommended, the overall benefits will outweigh the risks.

Recovering From a Whipple Surgery

Enhanced Recovery program will be instituted prior surgery to optimize recovery and minimize post- surgery complications Recovery from a Whipple procedure involves initial hospitalisation and close monitoring for possible complications until one is cleared for discharge. Patients also have to initially adapt to a modified diet to optimize digestion and nutrition. Minimally invasive approaches (laparoscopic, robotic) can minimize pain, enhance recovery and shortened hospital stay.

Physical activity will be slowly reintroduced, and a multidisciplinary approach involving pain management, physiotherapy and nutrition support. Follow-up check-ups is key to a successful recovery. Complete recovery can take around 3 to 4 weeks on average. Most patients have a normal digestion and have good quality of life after.

FAQs ABOUT PANCREATIC CANCER

While jaundice is one of the signs of pancreatic cancer when the cancer is located at the head of the pancreas, it must be highlighted that pancreatic cancer is not the most common cause of jaundice. Other benign causes, such as gallstones, hepatitis, and other liver and bile duct diseases, are much more common. Nonetheless, it is important to seek an HPB surgeon early.

There is no sure way to prevent pancreatic cancer. Some risk factors such as age, gender, race, and family history are not modifiable. But there are things one can do that might lower the risk.

Don’t smoke or quit smoking. Limit alcohol use. Eat a healthy diet, with an emphasis on vegetables and fruits every day. Choose whole-grain breads, pastas, and cereals instead of refined grains, and eat fish, poultry, or beans instead of processed meat and red meat. Stay at a healthy weight. Getting regular physical activity and exercise can help you stay at a healthy weight.

In certain at risk or high groups, such as a strong family history, or close relatives with pancreatic cancer especially at an early age (familial pancreatic cancer), there are screening options. It will be recommended to consult a specialist pancreatic surgeon early.

If discovered early, the best treatment option is surgery. This provides the best chance of a potential cure if it has not spread to surrounding organs, lymph nodes or distant organs e.g. lungs or brain. It will be best to consult a specialist pancreatic surgeon early.

This cancer is usually detected when the patient presents with the above-mentioned signs and symptoms. The tests include blood tests such as liver panel, tumour markers and imaging such as CT or MRI. Endoscopy with or without ultrasound is often useful for further evaluations and biopsies.

Pancreatic cancer is often associated with substantial pain especially as the disease progresses. It is often described as a dull, gnawing pain that starts in the upper abdomen and moves to the sides or the mid back. The pain is usually caused by the tumour pressing on nerves or surrounding organs, or by the tumour obstructing the bile duct.

Pancreatic cancer, unfortunately, is considered an aggressive cancer that often grows and spreads quite rapidly. Furthermore, as early-stage pancreatic cancer rarely causes symptoms; by the time symptoms are present, the cancer is often already in the advanced stages.

Pancreatic cancer is more commonly diagnosed in older adults. The average age at the time of diagnosis is around 60-70 years old, with the vast majority of patients aged between 50 and 80.

Foods that are harder to digest can exacerbate symptoms for patients with pancreatic cancer. It is advisable to avoid high-fat foods, such as greasy and fried foods. Additionally, foods high in sugar and refined carbohydrates should also be avoided.

Pancreatic cancer is not directly caused by a poor diet. However, certain dietary habits may increase the risk of developing pancreatic cancer. This includes having a diet high in red and processed meats, low intake of fruits and vegetables, as well as heavy alcohol consumption.

Although it is possible to live without a pancreas, its removal results in a complete loss of natural insulin production, which leads to diabetes. Individuals who have their pancreas removed require insulin replacement therapy to manage their blood sugar levels well. Additionally, they are given digestive enzyme supplements to aid in food digestion.

Itching can be associated with pancreatic cancer when the tumour blocks the bile duct, leading to a buildup of bile salts in the blood. This can cause itching, also known as pruritus, throughout the body.

Several conditions can be mistaken for pancreatic cancer, including acute and chronic pancreatitis, fatty change of the pancreas, duodenitis, autoimmune pancreatitis, and other cancers such as bile duct cancer. These conditions can have overlapping symptoms and imaging features similar to pancreatic cancer. This is why consulting a HPB specialist is crucial for an accurate diagnosis.

“Pancreatic cancer treatment has advanced in recent years, bringing new hope to patients. Better surgery and newer treatments have shown promising success. Today, we have many more options than we did decades ago.”

Dr Lee Ser Yee
Dr Lee Ser Yee
Senior Consultant Hepatopancreatobiliary Surgeon

MBBS, MMed (Surgery), MSc, FAMS, FRCSEd

Dr Lee Ser Yee is an experienced hepatopancreatobiliary (HPB) surgeon who is skilled in the diagnosis and treatment of pancreatic cancer. He was a founding member and Senior Consultant at the Department of HPB and Transplant Surgery at the Singapore General Hospital; and completed dual USA fellowships in Advanced Laparoscopic HPB Surgery, Surgical Oncology and Liver Transplantation. Dr Lee strives for optimal clinical outcomes for his patients with compassion, supported by a Multidisciplinary team.

Doctor Lee Ser Yee

Mount Elizabeth Medical Centre
#08-07, 3 Mount Elizabeth, Singapore 228510
Tel: 6454 0054 | Fax: 6764 0054 | Email: ask@surgicalassociates.sg

Gleneagles Medical Centre
#05-01, 6 Napier Road, Singapore 258499
Tel: 6471 0054 | Fax: 6271 0054

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