Whipple Procedure | Pancreatic Surgery Singapore

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 makes 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.

Some of the risk factors 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 also linked to increase 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 suggests that a body mass index ≥ 30 have 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, 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 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 the 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 color.
Pale or greasy stools
- Bile gives stools their brown color. If the bile duct is blocked, stools might be pale or gray.
- 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 as well as turning yellow.
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 is 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.

Evaluation

A full medical history and clinical evaluation
Blood Tests - Liver function tests and tumour markers e.g. Ca 19-9
Imaging – CT, MRI or PET scans may be used for assessment and staging
Endoscopy (+/- ultrasound) - may be useful for further evaluations and biopsy

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.

FREQUENTLY ASKED QUESTIONS

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.

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, brain. It will be the best to consult a specialist pancreatic surgeon early.

This cancer is usually detected when patient presents with the above-mentioned sign 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 are further evaluations and biopsy.

“Pancreatic cancer treatment has advanced in the 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.”