Existem 2 tipos de cirurgia utilizados para o câncer de pâncreas:
- Cirurgia Potencialmente Curativa. É realizada quando os resultados dos exames sugerem que é possível remover todo o tumor.
- Cirurgia Paliativa. Realizada se os exames de imagem mostram que a doença está disseminada. Esta cirurgia é realizada para aliviar os sintomas da doença ou prevenir determinadas complicações, como um ducto biliar bloqueado ou obstrução intestinal. Mas, não tem objetivo curativo.
Cirurgia Potencialmente Curativa
Alguns estudos mostraram que a remoção de apenas uma parte do tumor não aumenta a sobrevida, de modo que a cirurgia potencialmente curativa é realizada apenas se for possível remover todo o tumor.
Mesmo assim, esta é uma das cirurgias mais difíceis de ser realizada, devido as possíveis complicações e à recuperação pós-cirúrgica lenta. A equipe médica junto com o paciente devem avaliar os potenciais benefícios e riscos antes de optarem pela cirurgia.
Cerca de 20% dos cânceres de pâncreas parecem estar confinados ao pâncreas, no momento do diagnóstico. Mesmo assim, nem todos estes são realmente operáveis. Muitas vezes, apenas após o início da cirurgia é que o cirurgião constata que o tumor cresceu demais para ser completamente removido. Quando isso acontece, a cirurgia é interrompida ou o cirurgião decide continuar o procedimento com o objetivo de aliviar ou prevenir sintomas. Isso porque a cirurgia planejada dificilmente curaria a doença, além de poder levar a importantes efeitos colaterais e, ainda prolongar o tempo de recuperação no pós-cirúrgico, o que poderia atrasar o início de outros tratamentos.
A cirurgia é a única chance real para curar o câncer de pâncreas exócrino, mas nem sempre leva à cura. Mesmo que todo o tumor visível seja removido, algumas células cancerígenas remanescentes já se disseminaram para outras partes do corpo. Estas células podem, eventualmente, se transformarem em novos tumores, que podem ser mais difíceis de serem tratados.
As taxas de sucesso a longo prazo para a cirurgia em tumores neuroendócrinos do pâncreas são melhores. Estes tumores são mais susceptíveis de serem curados cirurgicamente.
A maioria das cirurgias curativas estão indicadas para tratar os tumores localizados na cabeça do pâncreas. Como esses tumores se encontram perto do conduto biliar, alguns provocam icterícia e podem ser diagnosticados mais precocemente para serem removidos.
Existem três tipos de procedimentos usados para remover os tumores do pâncreas:
Duodenopancreatectomia (Cirurgia de Whipple). Esta é a cirurgia mais comum para remover o câncer de pâncreas exócrino. Algumas vezes, também é utilizada para tratar os tumores de pâncreas neuroendócrino. Neste procedimento é retirada a cabeça do pâncreas e, às vezes o corpo. Também é removido parte do estômago, intestino delgado, gânglios linfáticos perto do pâncreas, vesícula biliar, parte do canal biliar. O restante do canal biliar é ligado ao intestino delgado, para que a bile possa continuar chegando ao órgão. As possíveis complicações cirúrgicas decorrentes deste procedimento incluem vazamento entre as conexões dos órgãos envolvidos na cirurgia, infecções, hemorragia e alterações gástricas. Outras complicações, a longo prazo podem incluir perda de peso, problemas de deglutição, problemas intestinais e diabetes, em alguns pacientes.
Pancreatectomia Distal. Esta cirurgia remove apenas a cauda do pâncreas ou a cauda e uma porção do corpo do pâncreas. O baço também é normalmente removido. Esta técnica é utilizada frequentemente no tratamento dos tumores neuroendócrinos encontrados na cauda e corpo do pâncreas. Raramente é utilizada para tratar o câncer de pâncreas exócrino, porque geralmente estes tumores já estão disseminados quando diagnosticados.
Pancreatectomia Total. Este procedimento já foi usado para tumores no corpo ou na cabeça do pâncreas, e remove todo o pâncreas e o baço. Raramente é utilizada para tratar tumores exócrinos. Hoje não parece mais ser uma vantagem a remoção de todo o pâncreas. Quando o pâncreas inteiro é removido, os pacientes ficam sem quaisquer células que produzem a insulina. Esses pacientes desenvolvem diabetes, que pode ser difícil de controlar, por se tornarem totalmente dependentes de insulina.
Cirurgia Paliativa
Se o câncer se disseminou qualquer tipo de cirurgia a ser considerada é destinada a aliviar ou prevenir os sintomas. Como o câncer de pâncreas pode progredir rapidamente, a maioria dos médicos não aconselha uma grande cirurgia para tratamento paliativo, especialmente para os pacientes com a saúde debilitada.
Os tumores que crescem na cabeça do pâncreas podem bloquear o ducto biliar, podendo provocar problemas digestivos e dores, uma vez que a bile não consegue chegar ao intestino.
Existem duas opções para aliviar a obstrução do ducto biliar:
Colocação de Stent. A abordagem mais comum para permeabilizar o ducto biliar bloqueado não envolve uma cirurgia real. Em vez disso, um stent é colocado no conduto para mantê-lo aberto. Isso geralmente é feito através de um endoscópio, com o paciente sedado. Muitas vezes, esse procedimento é parte de uma colangiopancreatografia endoscópica retrógrada. O stent, que é geralmente metálico, ajuda a manter o canal biliar aberto e resiste à compressão dos tumores circundantes. Os stents também podem ser colocados antes da cirurgia para diminuir os níveis de bilirrubina e consequentemente a icterícia antes do pâncreas ser removido.
Cirurgia de Ponte ou Bypass. Outra opção para o ducto biliar obstruído, em pacientes com bom estado de saúde geral, é a cirurgia para redirecionar o fluxo da bílis a partir do ducto biliar comum diretamente para o intestino delgado. A colocação de um stent é muitas vezes mais fácil e a recuperação mais rápida. Por essa razão é realizada com mais frequência do que a cirurgia de bypass. Mas, a cirurgia pode ter algumas vantagens, como:
- Pode proporcionar um alívio mais duradouro do que o stent, que precisa ser higienizado ou substituído.
- Pode ser uma opção se, por alguma razão, o stent não pode ser colocado.
- Durante a cirurgia, o cirurgião pode seccionar os nervos que inervam o pâncreas ou injetar álcool, o que pode reduzir ou eliminar qualquer dor provocada pela doença.
Cirurgia para o Tratamento de Tumores Neuroendócrinos do Pâncreas
Alguns procedimentos menos extensos podem ser usados para remover os tumores pancreáticos neuroendócrinos.:
Enucleação. Quando o tumor é pequeno, apenas o próprio tumor é removido, isto é chamado de enucleação. Esta cirurgia pode ser realizada utilizando um laparoscópio. O procedimento pode ser usado para tratar um insulinoma, um tumor frequentemente benigno. Os gastrinomas pequenos podem ser tratados com enucleação, mas às vezes o duodeno também é removido.
Procedimento Whipple ou Pancreatectomia Distal. Os gastrinomas maiores podem exigir uma duodenopancreatectomia ou uma pancreatectomia distal, dependendo da localização do tumor.
Cirurgia para Doença Disseminada. A cirurgia pode ser usada para remover metástases se a doença se disseminou para o fígado ou pulmões. A remoção das metástases pode melhorar os sintomas e aumentar a sobrevida dos pacientes. Em casos raros, pode ser realizado um transplante de fígado.
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