Pancreatic Cancer

About

Dr. Deepak Chhabra

Surgical Oncologist

MS. (Bom), DNB, M.R.C.S. (Edin. UK)

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FAQ

  1. What is cancer
  2. Cancer Risk factors
  3. Stages of Cancer
  4. Early signs of Cancer
  5. Early detection of Cancer

The world knows this man as a consultant oncosurgeon with vast experience in Gastrointestinal and Hepatobiliary-Pancreatic cancers,who specializes in stapled anastomosis for bowel cancers and sphincter saving resections for rectal cancers. In short, he is the person to be contacted for all kinds of cancer related cases.

Richa AgrawalPancreatic Cancer

Thank you Dr Deepak for all you have done for mum, for putting the smile back of her face. I wish you success in all your future endeavors and know that you will continue to touch peoples lives and help them be healthy - the way you have done for my mum….. and me.

Nicola MathiasStomach Cancer

For 67years I've led a very healthy life and thank the "Almighty" for it. However as I said all good things come to an end some time and so be it. Out of the blues was detected the dreadful illness "C" which had shown no signs or symptoms whatsoever..... Time had now come for me to choose a very efficient Oncologist for my treatment.

Patient

My mother was diagnosed of colon cancer, and I was recommended to see Dr Deepak Chhabra for consultation.
The first impression of Dr Chhabra was… he is so young! But after consulting him we realized his level of experience and there was a sense of confidence he spilt over us.We knew we could trust him.....

Neelu GroverColon Cancer
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What is Pancreas?

The pancreas is a thin, lumpy gland that lies between your stomach and your spine. It is normally about six inches long and is shaped something like a thin pear, the organ is wide at one end and narrow at the other end and has three sections. The wider right end is called the head, the midsection is the body, and the narrow left end is the tail. It is joined by a duct (the ‘pancreatic duct’) to the first part of the small bowel (the duodenum) into a common opening with the bile duct called the ampulla.

The pancreas plays two major roles in your body’s digestive system.

  • It produces insulin, which controls the amount of sugar in your blood. If the pancreas does not produce enough insulin, you will develop diabetes.
  • Other parts of the pancreas produce substances called enzymes, which help you to digest food. These enzymes pass from the pancreas into your duodenum through the pancreatic duct. If the release of these enzymes is blocked for any reason, the body cannot absorb food completely and may result in diarrhoea and weight loss.

About

What is cancer of pancreas?

Cancer of the pancreas develops when healthy cells in the pancreas become abnormal and grow too quickly. The abnormal cells form a mass in the pancreas called a tumor. When a tumor has the ability to spread to other parts of the body, it is called malignant (cancer).
The most common malignant tumors of the pancreas, known as adenocarcinoma, come from cells involved in the production of enzymes for digestion and accounts for 95 percent of all pancreatic cancers. Sometimes mass develops in the specialised cells of pancreas called islet cells.

Islet cell carcinoma involves cells that can secrete a variety of hormones. These tumors can be functional and make abnormally high amounts of hormones or can be non-functional and not produce any hormones. Most islet cell tumors are malignant, but some are benign such as insulin-producing islet cell tumors.

Which part of the pancreas is affected with cancer?

Cancer can affect any part of the pancreas, the head, body or the tail but is more common in the wide right end or commonly called as the head of pancreas. Sometimes a common label of “periampullary cancer” is used indicating that the location of cancer can be either in the head of pancreas, at the common opening called ampulla, at the lower end of the bile duct or at the intestine where the pancreatic duct opens.

Causes

What are the causes of pancreatic cancer?

The exact causes of pancreatic cancer are still undetermined, but there are some known risk factors that can make a person more likely to get this disease.

Having a risk factor, or even several risk factors, does not mean that you will get the disease. And many people who get the disease may not have had any known risk factors.

Research has shown that some of these risk factors affect the DNA of cells in the pancreas, which can result in abnormal cell growth and may cause tumors to form.

  • Age: Pancreatic cancer can strike at any age, but it occurs most often in men and women over 50 years old.
  • Smoking: Smokers (and smokeless tobacco users) have a 2 to 10 times greater risk of developing pancreatic cancer than non-smokers.
  • Obesity: Very overweight people are more likely to develop exocrine pancreatic cancer, as are people who don’t get much physical activity. Exercise lowers the risk of this cancer.
  • Diet: A diet low in fruits, vegetables and fibre and high in fat may increase your risk.
  • Type 2 Diabetes: Pancreatic cancer is more common in people with this disease. The reason for this link is not known. This type of diabetes most often starts in adulthood. It is often related to being overweight or obese.
  • Chronic Pancreatitis: This means a long-term inflammation of the pancreas. This condition is linked with an increased risk of pancreatic cancer, but most patients with pancreatitis never develop pancreatic cancer. The link between chronic pancreatitis and pancreatic cancer is strongest in smokers.

Symptoms

What are the common symptoms of pancreatic cancer?

Symptoms of early pancreatic cancer include a painful or burning sensation in the abdomen, heartburn or indigestion (dyspepsia).

  • Jaundice: Jaundice occurs when bilirubin, a substance produced in the liver, builds up in the blood. Bilirubin travels down the bile duct and passes through the pancreas just before emptying into the duodenum, a section of the small intestine. If the bile duct becomes blocked (by a tumor, for example), bilirubin builds up in the blood causing noticeably yellow skin and eyes.
  • Change in colour of the Stool or Urine: Urine may turn orange or the colour of iced tea. Stool may turn grey or chalky-white. These are also symptoms of a blocked bile duct.
  • Pain: Pain in the back and upper abdomen occurs when a pancreatic tumor presses against the nerves in those areas. Typical pancreatic pain is dull, fairly constant and mostly localized to the mid and upper back and upper abdomen. Sometimes the pain starts in the abdomen and radiates to the back or shoulder.
  • Indigestion: (especially with fatty foods), Lack of Appetite, Nausea, Diarrhoea and/or Weight Loss. These may occur when a pancreatic tumor presses against the stomach and small intestine. Digestion problems may also occur for complex reasons not specifically related to the location of the tumor.
  • Sudden Onset of Diabetes, or for Diabetics, a Sudden Change in Blood Sugar Control: Diabetes may be an early symptom and a risk factor.
  • If you have not been diagnosed with pancreas cancer and are just looking through this booklet, please be aware that most symptoms of pancreatic cancer are nonspecific and can be caused by several different problems.
  • It is important to see your doctor if any of these symptoms occur and do not resolve with simple management.

Tests

What tests are carried out to diagnose pancreatic cancer?

This section lists common tests that may be performed and it is not necessary for all the tests to be performed for a patient. Your doctor will select the tests that will assist him /her to have the maximum information about the tumor/ disease.

Computerised tomography (CT) scan

A CT scan is a type of x-ray that gives a picture of organs and other structures (including any tumours) in your body. It is used to see more details of a cancer and its relation to the surrounding organs in your body. It also gives information related to cancer spread into the lymph nodes, liver or lungs.

Endoscopy (ERCP)

In this test, a thin, flexible ‘telescope’ called an endoscope is put into your mouth then passed down your throat into your digestive system so that the doctor can examine you inside.

The procedure is called ERCP, or endoscopic retrograde cholangio-pancreatography. Through the endoscope, the doctor can inject a liquid directly into the pancreatic duct and bile duct, allowing images of these organs to appear on x-ray pictures.

The test can show blockages and inflammation in these ducts, and allow the doctor to judge whether these are due to cancer or other problems.

The doctor is also able to take a tissue or fluid sample through the endoscope, to help with the diagnosis.

Positron emission tomography (PET) scan

This test may be used to build up more information after an MRI or CT scan. PET-CT scan is not necessary for all patients. Your doctor will decide if you need to undergo this scan.

This test is combined with a CT scan by injecting a radioactive material in the body to highlight all areas where the tumor has or can spread.

Blood Tests

Blood tests check how well the liver and kidneys are working and provide a full blood count. Pancreatic cancer often sends a protein (Ca 19.9) into the blood. This can be measured. It is not used to diagnose pancreatic cancer, but it can give your doctor important information about the cancer and its response to treatment.

Treatment

What is the treatment of pancreatic cancer?

Many years of treating cancer patients and testing treatments in clinical trials has helped doctors know what is likely to work for a particular type and stage of cancer. You will be advised on the best treatment for your cancer. This will depend on the type of cancer you have, where it is and how far it has spread and your general health.

Surgery

Surgery For Pancreatic Cancer

The main treatment for pancreatic cancer is surgery. Though cancer surgeries are extensive and take longer hours; with advanced medical care, surgeries have become safer and better equipments are now available to perform surgeries. Improved techniques of anaesthesia and post-operative monitoring have significantly contributed to overall safety of surgical procedures for cancers.

If you are found suitable for the surgery, you will be usually admitted one or two days prior to the proposed date of surgery. There may be dietary restrictions and you may be given laxatives to evacuate your bowels prior to surgery. Your blood group will be checked and blood is usually reserved for all major abdominal surgeries.

It is always a good idea to start with deep breathing exercises once you are admitted to the hospital. Your doctor may summon a physiotherapist to assist you with the same. You will have most of your body parts shaved for the surgery. You will be given a consent form for your signature.

The form would have details of the procedure to be performed on you by your treating surgeon. In case you have any doubts you should feel free to ask them to the surgical team.

Paliation

The surgeries for pancreatic cancers depend on the location of the tumor in the pancreas.

Majority of the pancreas cancer however are in the head region of the pancreas and the operation performed is “Whipple’s surgery”.

“Distal Pancreatectomy” is performed for tumors located in the tail or body portion of the pancreas and the surgery involves removal of the body and tail portion of the pancreas along with the spleen.

Whipple’s Surgery:

This major operation involves removal of:

  • part of the pancreas
  • part of the first part of the small bowel (duodenum)
  • part of the stomach
  • part of the gall bladder and part of the bile duct.

The diagram below shows what your surgeon removes

pancreas
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The surgeon reconnects the remainder of the pancreas, bile duct and stomach to different sections of the small bowel so the digestive tract keeps working.

pancreas cancer

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A feeding tube may be placed during the surgery to replenish nutrition to the patient after surgery.

Distal Pancreatectomy:

This operation is performed for certain types of pancreatic tumors located in the tail or body portion of the pancreas. This surgery involves removal of only the tail of the pancreas or the tail and a portion of the body of the pancreas. The spleen is usually removed as well.

distal pancreatectomy

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Bypass Surgery:

Sometimes surgery may begin with the hope it will cure the patient, but the surgeon discovers this is not possible. In this case, the surgeon may continue the operation as a palliative / bypass procedure to relieve or prevent symptoms.

Cancers growing in the head of the pancreas can block the common bile duct as it passes through this part of the pancreas. This may cause pain and digestive problems because the bile can’t get into the intestine and patient develops jaundice and vomiting. The bile chemicals will build up in the body

There are 2 options for relieving bile duct blockage.

Surgery can be done to reroute the flow of bile from the common bile duct directly into the small intestine, bypassing the pancreas. Sometimes, the stomach connection to the duodenum (the first part of the small intestine) is rerouted at this time as well. Often, late in the course of pancreatic cancer, the duodenum becomes blocked by cancer, which can cause pain and vomiting that requires surgery. Bypassing the duodenum before this happens can help avoid a second operation.

stent

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A second approach to relieving a blocked bile duct does not involve surgery. Instead, a stent (small tube) is placed in the duct to keep it open. This is usually done through an endoscope (a long, flexible tube) while the patient is sedated. The doctor passes the endoscope down the patient’s throat and all the way into the small intestine. The doctor can then insert the stent into the bile duct through the endoscope. The stent helps keep the bile duct open and resists compression from the surrounding cancer.

Drinking and eating after surgery.

After an anaesthetic, the movement of the bowel slows down and usually takes about 72 hours to get back to normal. After about 48-72 hours you will probably be ready to start taking small sips of water, however your doctors will tell you when it is appropriate for you to start drinking some fluids. This will be gradually increased after a couple of days until you are able to eat a light diet.

Going home.

You will probably be ready to go home in about 10-14 days after your operation and once your stitches have been removed. If deemed appropriate your doctor may send you home with stitches and call you later to remove the stitches. By and large you should be able to climb several flights of stairs after your discharge from the hospital and you will be given diet instructions.

Before you leave hospital you will be given an appointment for a post-operative check-up at the outpatient clinic.

Diet after pancreas surgery.

You will be transferred to the Intensive care unit after the surgery. Your recovery will depend on the magnitude of surgery performed. After the operation, the patient is usually monitored in the ICU for 48 to 72 hrs and the overall hospital stay (if no complications) is usually between 10–14 days.

Your pain and discomfort will be taken care of by the anaesthetic team. You will be given pain-killers and an intravenous infusion (drip) to replace your body’s fluids until you are able to drink and eat again after a few days. You will also have a naso-gastric (NG) tube in place.

This is a thin tube that passes down your nose into your stomach or small intestine and allows any fluids to be removed so that you don’t feel sick. It is usually taken out within 48 hours. Sometimes a small tube (catheter) is put into the bladder to drain your urine into a collecting bag.

After your operation you will be encouraged to start moving about as soon as possible. This is an essential part of your recovery. If you have to stay in bed the nurses will encourage you to do regular leg movements and deep breathing exercises. You will be seen by a physiotherapist who can help you to do the exercises.

At first, even tiny meals may make you feel uncomfortably full. You will need to eat very small amounts very often at first. Then, gradually increase the amounts and then the time between meals. At first, you may find you need to eat every hour or so in order to get enough nutrition.

There is no restriction on the type of food you eat after a pancreas surgery and you should be able to eat all that you did before surgery. Fizzy drinks can make you feel full – it is probably best not to drink with meals at all, as any liquid will fill you up.

Try keeping a food diary if you are having problems you think are related to your diet. Take a small notebook and draw a line down the centre of each page. Write down what you eat and when on the left of the page. Write down any symptoms you get and when on the other side of the page. After a few days, you may be able to spot which foods cause which symptoms.

Some people need to take tablets to help digest fat and proteins, and some people develop diabetes, which may require treatment.