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Whipple procedure is the most common surgery done to remove the cancer of the head of the pancreas. Besides removing cancer of the pancreas, this surgery is also performed in case of chronic pancreatitis and the trauma of the duodenum or pancreas.
Whipple procedure, named after a famous American surgeon, who first performed this surgery, is also known as Pancreaticoduodenectomy.
Cancer of the pancreas carries a poor prognosis because it is rarely detected or diagnosed in its early stages. There are no signs or symptoms in its initial stages. By the time, it is detected, it has already grown and spread extensively.
Treatment may be surgery, radiation therapy, chemotherapy either alone or combined.
Whipple surgery, a complex surgery, can be a viable treatment option for some patients with pancreatic cancer and even offer potential cure besides increasing life expectancy of the patient. This surgery involves the removal of the head of the pancreas along with some part of the duodenum, a part of common bile duct, gall bladder and sometimes part of the stomach. It is eventually followed by reattaching the remaining part of the intestine, bile duct and pancreas.
It is a highly complex surgery that calls for a superspecialty hospital with all the infrastructure in place and highly skilled and experienced surgeons to carry out Whipple surgery. Surgeons who have successfully performed the Whipple procedure on high volume of patients are ideal.
A1 An organ or a mixed gland (with exocrine and endocrine parts) that lies behind the stomach. It is 6 inches long pear shaped organ. It has three parts head, body and tail.
It secretes digestive juice that aids in digestion and also, hormones like Insulin and Glucagon that control blood sugar.
Pancreatic tissue has two components, Endocrine pancreas and Exocrine pancreas
Endocine Pancreas consists of cells called Islets of langerhans. They secrete hormones like Insulin and Glucagon. They form only 1% to 2% of the pancreatic tissue. Beta cells of the Islets of Langerhans secrete Insulin whereas Alpha cells of the Islets of langerhans secrete Glucagon.
Insulin is a hormone that plays a crucial role in the regulation of glucose metabolism. It facilitate conversion of glucose to Glycogen in liver and muscles where it is stored for future utilization. Insulin is secreted when blood glucose level increase especially after food digestion and absorption.
In absence of Insulin, blood glucose levels increase in the blood and cause a condition called DIABETES MELLITUS.
On the other hand, Glucagon is another hormone secreted from alpha cells of Islet of langerhans cells of the endocrine pancreas. It acts on the liver cells and break down Glycogen to Glucose (Glycogenolysis) causing increase in the blood glucose levels, referred to as Hyperglycemia.
It also promotes Gluconeogenesis, which literally means formation of new glucose molecules, as opposed to the breakdown of glycogen to glucose.
Furthermore, it also decreases the glucose uptake and utilization by cells, another factor causing increase blood sugar levels.
A2 Cancer that affects the tissues of the pancreas are referred to as Pancreatic Cancer.
Cancer is an uncontrolled growth of abnormal cells.
These abnormal cancer cells keep accumulating to form a tumor and has the ability to spread and invade other adjacent or distant body tissues.
Pancreatic cancer usually affects the cells lining the ducts of the pancreas.
This type of cancer is known as pancreatic Adenocarcinoma or Pancreatic Exocrine cancer.
However, when cancer affects the hormone producing cells of the pancreas, though rare, this type of cancer is better known as Pancreatic Endocrine Cancer and Pancreatic Neuroendocrine tumor.
A3 Signs and symtoms are not apparent in the initial stages of pancreatic cancer and therefore it is hard to detect and diagnose cancer of the pancreas in early stages.
The signs and symptoms when appear, they may be
New Onset Diabetes
Unexplained Weight loss
Anorexia or loss of appetite
Pain in the upper abdomen that radiates to the back
A4 If your doctor suspects presence of pancreatic cancer, he may suggest the following tests to confirm the diagnosis.
Imaging tests: USG (Ultrasound), CT scan, MRI scan, PET scan
Biopsy which means taking a tissue sample and studying it under the microscope
A5 Factors that are considered as potential risk factors for cancer of the pancreas are:
Chronic Pancreatitis- Long standing inflammation of the pancreas, progressive ( worsens with time) eventually leading to the permanent damage to the organ and causing impaired digestion and regulation of the blood glucose.
Presence of family history of Genetic Syndromes
Old age, usually more than 65 yrs
These risk factors when combined, increase the risk manifold for occurrence of pancreatic cancer.
A6 The potential complications of pancreatic cancer may be:
A7 Not exactly. However, the risk of getting cancer of the pancreas may be minimized by following:
Healthy Diet full of vegetables, fruits and whole grains.
Keeping Healthy Weight
A8 The following factors determine the type of treatment option for pancreatic cancer:
Stage of cancer
Location of cancer
Overall health of the patient
Personal preference of the patient
Foremost goal of the treating specialist is to eliminate the cancer, if possible. In case, elimination of pancreatic cancer is not feasible, the next step forward is to treat it in the best possible way so as to prevent its further growth or spread, improve the quality of life of the patient.
Treatment modalities may be broadly classified into the folowing categories:
These treatment options can be either used alone or combined for maximum benefit.
Palliative care is provided to patients with advanced pancreatic cancer when all the treatment modalities fail to offer any benefits.
Palliative care refers to an approach with an aim to provide relief from annoying symptoms, reducing mental and physical stress and improving quality of life for the patient and his/her family.
A9 If the cancer/tumor is in head of pancreas: Whipple procedure or pancreaticoduodenectomy is the surgery of choice.
If the cancer/tumor is in the body or tail of the pancreas: Distal pancreatectomy may be recommended which involves the removal of body and tail of the pancreas. Sometimes spleen is also removed.
Total Pancreatectomy surgery involves removal of the whole pancreas. After removal of pancreas, you may require lifelong insulin and enzymes to make up for absence of pancreas.
In case tumor or cancer has spread to nearby blood vessels: Surgery is usually not recommended under such condition. However, in small fraction of patients, surgery may be done alongwith the removal of the part of the affected blood vessel followed subsequently by its reconstruction.
A10 Whipple surgery is a viable option for selected patients with pancreatic cancer, who have the cancer restricted to only head of the pancreas.
At times, it may be a viable option for those patients with pancreatic cancer who have locally advanced cancer, cancer that has spread to the other parts of the pancreas such as its body and tail or may spread to the superior mesenteric vein or artery.
A11 When cancer of the pancreas spreads or metastasize, whipple surgery does not serve the purpose and so it is not recommended.
Whipple surgery may be performed by a minimally invasive technique(Laparoscopic Whipple procedure). It involves several small incisions instead of a single long incision. It has the following benefits:
Minimal blood loss, therefore hardly any need for blood transfusion
Short hospital stay
A13 Like any other major surgery, the potential complications of Whipple surgery may be:
Difficulty in emptying of stomach post meals
The most frequent complication that may occur are fistula formation (an abnormal channel between two structures) or leakage at a place where the intestine was reconnected.
A14 Chemotherapy is administration of cancer killing drugs either orally or through vein. One or more drugs can be used together to kill cancer cells. Chemotherapy coupled with radiation therapy, is referred to as chemoradiation.
This therapy is used in case of cancer that has advanced or spread to the surrounding organs. Chemotherapy or chemoradiation can be given prior to surgery or post surgery.
The goal is different in each way. When given prior to surgery, the goal is to shrink the tumor. However, when given after surgery, it reduced the chances of recurrence of tumor.
A15 Radiation therapy comprises of delivery of high energy beams of x-rays or protons in order to kill the cancer cells. The way it is administered varies. It can be given either before or after the pancreatic surgery and usually coupled with chemotherapy.
In case surgery is not advised, due to advanced pancreatic cancer or otherwise, only chemotherapy combined with radiation therapy may be recommended.
A16 Pancreatic cancer prognosis is determined by the following factors:
Whether it is operable or not
Whether it is advanced or confined to the pancreas.
Patient's general health
Is it a recurrent pancreatic cancer or happened for the first time.
Tumor which is confined to the organ itself has better chances of recovery and may be successfully removed by the pancreatic surgery. However, if it is advanced, then palliative treatment is given in order to subside the symptoms and control the impending complications and improve the patient's quality of life.
A17 When tests and procedures are carried out to confirm the diagnosis, staging is done at the same time. Stages of cancer of the pancreas range from Stage 0 to Stage 4. The cancer of the pancreas worsens from stage 0 to stage 4. Stage 4 is the most advanced stage with poor prognosis.
Staging is crucial in order to plan the treatment and find out the chances of the recovery for the patient.
In layman's terms staging is basically defining the extent of the cancer(where and how much cancer present in the body at the time of diagnosis).
At the time of diagnosis, the extent of cancer is defined and cancer is subsequently classified after taking into account the following factors such as
Which part of the organ has the cancer
Size of the tumor
Has the cancer spread and if yes, then where
Stage 0 It is also referred to as carcinoma in situ, a latin word meaning "at its place". Abnormal pancreatic cells are found in the lining of the pancreas, may form into cancer and spread in adjoining normal healthy tissue. CIS, carcinoma in situ is a group of abnormal cells, a form of neoplasm (abnormal mass of tissue formed as a result of uncontrolled growth of abnormal cells or cells that do not die as they are supposed to do after a definite time period, may be non cancerous or cancerous). It is not classified into cancer, may be termed as precancer.
Stage I Cancer confined to pancreas. This stage is further sub divided into
Stage I A Tumor of size less than or equal to 2 cms
Stage I B Tumor of size more than 2 cms and upto 4 cms.
Stage II This stage is further classified into the following stages depending upon the size of the tumor and its spread.
Stage II A Size of tumor more than 4 cms.
Stage II B Tumor of any size alongwith its spread to 1 to 3 lymph nodes
Stage III Tumor may be of any size and has spread to
i) 4 or more nearby lymph nodes or
ii) Major blood vessels near pancreas such as portal vein, superior mesenteric artery or common hepatic artery, celiac trunk.
Stage IV Any size cancer and spread to distant organs such as lungs, liver or peritoneal cavity. A cavity that holds all the abdominal organs in place.
A18 Cancer spreads from its place of origin to other parts of body in three ways:
Tissue:Simple progession into adjoining tissues.
Lymph System: Cancer spreads through lymph vessels.
Blood: Cancer spreads through blood vessels.
This spread of cancer is termed as metastasis, in medical terminology. The cancer at its place of origin is termed as Primary tumor and where it spreads, it is better referred to as metastatic cancer or tumor.
The metastatic cancer is the same type of cancer as the primary tumor. If cancer A spreads to an organ B, then the cancer is known as metastatic cancer A, not cancer B.
Dr Adarsh Chaudhary
MBBS, MS (General Surgery), FRCS
Chairman, GI Surgery, GI Oncology and Bariatric Surgery
Institute of Digestive and Hepatobiliary Sciences
Medanta Medicity Hospital, Gurgaon, Delhi-NCR
Dr Amanjeet Singh
MBBS, MS (General Surgery), DNB
Associate Director, GI Surgery, GI Oncology and Bariatric Surgery
Institute of Digestive and Hepatobiliary Sciences
Medanta Medicity Hospital, Gurgaon, Delhi-NCR
Dr Rajesh Kapoor
MBBS, MS (General Surgery), MCh( Surgical Gastroenterology)
Director, Department of Hepatopancreatobiliary Surgery
Jaypee Hospital, Noida, Delhi-NCR
Dr Dinesh Singhal
MBBS,MS, FACS, DNB (Surgical Gastroenterology)
Senior Director and HOD, Surgical Gastroenterology
Max Super Specialty Hospital, Saket, Delhi
Dr V.P Bhalla
MBBS, MS, FICS
Director, Institute of Digestive and Liver Diseases
BLK Super Specialty Hospital, Delhi
Saket, New Delhi
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