Drs. Wolfgang, Edil and Lennon meet with
a patient.
About 20 percent of patients with pancreas cancer will be cured with surgery. While most surgical patients will have a Whipple procedure, (also called a pancreaticoduodenectomy) a complex operation perfected at Johns Hopkins, about one out of three patients will be a candidate for a less invasive surgery known as distal pancreatectomy.
Surgery can be performed as a curative or palliative measure if the cancer is contained within the pancreas and has not spread to blood vessels, lymph nodes or other organs. This treatment option should be discussed with your physician to see if it is a viable option.
Johns Hopkins performs more pancreas cancer surgeries than any other institution in the world. Each year, our surgeons perform an average of 250 Whipple procedures and 100 distal pancreatectomies. Our team of experienced surgeons also includes the most experienced nurses and experts in gastroenterology, cancer genetics, and social work to provide the best and most complete care to our patients.
The Whipple Procedure
Until recently, pancreatic surgery was associated with a very high risk of surgically related mortality. Johns Hopkins Medicine surgeon John Cameron honed the Whipple procedure to the point where the mortality rate now stands at two percent, when performed by experienced surgeons. Dr. Cameron has performed more than 1,400 of these surgeries -- more than anyone else in the world. He has trained a team of pancreatic surgeons at Johns Hopkins Medicine to carry on his legacy.
During the Whipple procedure, surgeons remove the head of the pancreas, most of the duodenum (a part of the small intestine), a portion of the bile duct, the gallbladder, and associated lymph nodes. In some cases, the entire duodenum and a portion of the stomach must be removed. In these instances, surgeons reconstruct the digestive tract. The surgery takes about six hours to complete. Most patients stay in the hospital for two to three weeks following the Whipple procedure.
Minimally Invasive Pancreas Surgery
Minimally invasive or laparoscopic surgical techniques can sometimes be used in pancreatic surgery, depending upon factors such as location of the tumor. Our surgical oncologists can help determine whether you are a candidate for a minimally invasive procedure – we are committed to offering patients the best surgery for their individual needs.
Distal Pancreatectomy
Source: National Cancer Institute
In a distal pancreatectomy, surgeons remove tumors of the body and the tail of pancreas and leave the head of the pancreas intact. This surgery takes less time and has a shorter recovery period than surgeries like the Whipple procedure that remove the head of the pancreas. The distal pancreatectomy can also be done laparoscopically. Laparoscopic procedures are performed with three small incisions in the abdomen through which telescope-guided instruments are placed. Conventional surgeries require a longer incision and wider opening of the abdomen. With laparoscopic procedures, surgeons are generally able to reduce blood loss and risk of infection for the patient. They also tend to recover quicker: two weeks versus four for conventional operations.
Checking Your Margins
At Johns Hopkins, our surgeons and pathologists work together to make sure that each patient's tumor margins around the surgical excision are evaluated during surgery. Margins are the edge or border of the pancreas cancer tissue that is removed during surgery. When a pathologist describes a margin as negative or clean, it means the pathologist finds no cancer cells at the edge of the tissue, suggesting that all of the cancer has been removed. When the margin is described as positive or involved, it suggests that all of the cancer has not been removed. Checking tumor margins is a process done under the microscope by our pathologists in real time, during surgery. This enables our pathologists to guide the surgical team on whether cancer cells remain in the borderline areas of the tumor and whether or not more tissue needs to be removed, if possible. In some cases, not all cancerous cells can be completely removed.
Total Pancreatectomy
This procedure is the least common of all of the surgeries performed for pancreas cancer and is used when tumors extend throughout the pancreas. In a total pancreatectomy, surgeons remove the entire pancreas and the spleen, gallbladder, common bile duct, and portions of the small intestine and stomach. Most patients will be in the hospital for two to three weeks. Removing the entire pancreas leaves patients unable to produce enzymes for digestion and insulin for controlling blood glucose (sugar) level. As a result, following surgery, patients take supplemental enzymes and insulin for the rest of their lives.
Improving Standards of Surgical Care Through Research
With the availability of laparoscopic pancreas cancer removal, Johns Hopkins surgical oncologists are studying whether systemic chemotherapy that is given earlier to patients because of shortened recovery periods with laparoscopy is safe and feasible. Because pancreas cancer is an aggressive disease, the goal is to deliver systemic therapies as quickly as possible, and this study will determine whether laparoscopic procedures may help reach that goal.
Surgical and medical oncologists at Johns Hopkins also are studying the use of experimental vaccines given before surgery to remove the pancreas in an effort to boost the immune system and help it identify and kill cancer cells.
Another study will involve using radiotherapy during surgery for pancreas cancer tumors that are anatomically difficult to remove. With these tumors, there is a good chance that pancreas cancer cells may remain in the margins surrounding tissue that is removed. Radiation delivered externally through the stomach can be given only in low doses, so Johns Hopkins scientists are planning to study whether high doses of radiation in seed implants positioned next to the tumor site during surgery could be more effective than external radiation.
Palliative Surgical Procedures
These operations, such as a double bypass or a celiac nerve block, are performed to improve a patient's quality of life.
- A double bypass creates a bypass to the bile duct and a bypass to the stomach, which can relieve jaundice, nausea, and vomiting for patients with advanced tumors in the head of the pancreas.
- A celiac nerve block lessens tumor-associated pain and reduces the need for pain medications.
Most patients stay in the hospital for two to three weeks following the Whipple procedure and should expect to take a two month leave from their job to recuperate from the operation.
The Pancreas Surgery Team
Primary pancreas surgical team
Christopher L. Wolfgang, M.D., Ph.D., FACS
Assistant Professor of Surgery and Oncology
Director, Pancreas Surgery Program
Barish Edil, M.D., FACS
Assistant Professor of Surgery and Oncology
Director, Laparoscopic Pancreas Surgery Program
John L. Cameron, M.D., FACS
Professor of Surgery
The Alfred Blalock Distinguished Service Professor of Surgery
Martin A. Makary M.D., M.P.H., FACS
Associate Professor of Surgery
Richard D. Schulick, M.D., FACS
Professor of Surgery and Oncology
Chief, Division of Surgical Oncology
Other Surgeons with Expertise in Pancreas Surgery
Nita Ahuja, M.D., FACS, Assistant Professor of Surgery and Oncology
Michael A. Choti, M.D., M.B.A., FACS, Professor of Surgery and Oncology,
The Jacob C. Handelsman Endowed Chair of Abdominal Surgery
Mark K. Duncan, M.D., FACS, Associate Professor of Surgery and Oncology, Johns Hopkins Bayview Medical Center
Frederic Eckhauser, M.D., FACS, Professor of Surgery
Timothy Pawlik, M.D., Associate Professor of Surgery and Oncology
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