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The PancChat Podcast is a collaborative effort from Let’s Win Pancreatic Cancer and the Pancreatic Cancer Action Network (PanCAN), inspired by the long-running #PancChat Twitter/X chat.
Hosted by award-winning journalist Alisyn Camerota, each episode features conversations with leading researchers, clinicians, patients, and advocates who are shaping the future of pancreatic cancer care and research. Together, we deliver expert insights, personal journeys, and the latest breakthroughs—bridging the gap between science and lived experience.
Whether you’re a patient, caregiver, healthcare professional, or simply want to learn more, join us to connect, be inspired, and learn how you can help to accelerate progress in the fight against pancreatic cancer.
Cindy Gavin: Hi everybody and welcome back. I'm Cindy Gavin, CEO and co-founder of Let's Win Pancreatic Cancer. On today's episode, we will talk about the different techniques for pancreatic cancer surgery. Now over to you, Alisyn.
Alisyn Camerota: Hi, everyone. I'm Alisyn Camerota. Welcome to PancChat. This is our eighth episode. In the last episode, we learned about the Whipple procedure, which is a surgery for pancreatic cancer.
Today, we'll take a closer look at the different techniques that can be used during pancreatic cancer surgery. First, we want to thank our sponsor, Revolution Medicines. Let me tell you a bit about our next guest. Dr. Nipun Merchant is Chief of the Division of Surgical Oncology and Vice Chair of Surgical Oncologic Services and Chief Surgical Officer for University of Miami Hospitals and Clinics.
In addition, he is also Professor of Surgery and Director of Surgical Oncology Research Programs at the Sylvester Comprehensive Cancer Center. He is a PanCAN Research grantee. Welcome, Dr. Merchant.
Dr. Nipun Merchant: Thank you. It's a pleasure being here, Alisyn.
Alisyn Camerota: Great to have you. Okay. So surgery, as we've learned to remove tumors in the pancreas, has evolved, thankfully, over the years. It's made big improvements. It now includes several techniques.
So let me spell those out as I understand them. Number one, open surgery. Number two, minimally invasive laparoscopic surgery. Number three, robotic procedures. So just take us through those and tell us the difference and what they're used for.
Dr. Nipun Merchant: Sure. Absolutely. So pancreatic surgery is really among the most challenging operations in medicine. And, over the last couple of decades, our surgical techniques have really expanded quite significantly. Traditionally, everything was done using an open surgical approach.
This involves making a long incision on the abdomen so the surgeon can see and feel everything directly. The advantage of this approach is the excellent exposure that you get and the ability to feel structures and manage unexpected findings. In some situations with this approach, recovery can be a little bit slower with more pain and longer hospital stays. And then with the advent of minimally invasive surgical approaches came first laparoscopic surgery. This approach uses several small incisions measuring about a centimeter or so.
A camera is introduced into the abdomen and long instruments are used to do the surgery. With this approach, patients generally have less pain, shorter hospital stays, and many times faster recovery. The limitation of this approach, however, is that the instruments are rigid and the surgeon works from a two-dimensional view, which can make very fine work on the pancreas and around some major blood vessels very challenging. Robotic surgery really builds on laparoscopy.
The surgeon sits at a console away from the Operating Room table. He controls the robotic arms with wristed instruments that mimic the motion of the human hand. And we see the anatomy in a very magnified three-dimensional view.
That gives us much more precision and dexterity, which is particularly helpful for delicate suturing and dissection around some of the major blood vessels that the pancreas wraps around.
Now it's important to note that the key points or benefits of minimally invasive surgery versus open surgery can differ depending on which pancreatic operation we're talking about.
For tumors in the head of the pancreas, we perform a Whipple procedure that I know you discussed on your previous podcast.This is a very complex operation. We remove the head of the pancreas, part of the small intestine, the bile duct, the gallbladder, and sometimes part of the stomach. And then we have to reconnect all those structures to the intestine. Whether this is done open or robotically, the operation remains just as complex. And the risks and recovery are fairly similar.
Robotic Whipple can make some of the technical steps easier for the surgeon and may reduce pain a bit in the early period. But in terms of long-term outcomes, complications, hospital stay, survival, the differences between open and robotic Whipples are still relatively limited. What's also important to note is that there is a steep learning curve for surgeons with robotic Whipples. It takes a large number of cases to master the technique so that most meaningful benefits are really seen when it's performed in experienced centers or high-volume centers.
This is in contrast to tumors of the body or tail of the pancreas where we do a distal pancreatectomy. The operation doesn't require reconstruction of any of the digestive tract, we just remove the diseased portion of the pancreas often with a spleen. Here the difference between open and minimally invasive approaches is much more significant. Robotic or laparoscopic distal pancreatectomy almost always results in smaller incisions, less pain, shorter hospital stays, and quicker return to normal activities.
And since the operation is itself less complex, the learning curve for robotic distal pancreatectomies is much shorter than for a Whipple and many centers can adopt it much more successfully. So basically the approach we use, whether it's open, laparoscopic, or robotic, describes how we get to the pancreas.
The procedure whether it's a Whipple or distal pancreatectomy describes what we remove based on the location of the tumor. And the value of the minimally invasive techniques is much more pronounced in distal pancreatectomy than in the Whipple procedure.
Alisyn Camerota: I see. That's fascinating, Doctor. I didn't know that there were all of those options. I thought it was just open surgery. Obviously there have been advancements.
How do you determine which patient needs which approach?
Dr. Nipun Merchant: That's a really important question because the decision is never one size fits all. We look at several key factors. And the choice often depends on whether we're talking about a Whipple procedure or a distal pancreatectomy.
First, it depends on the location of the tumor and potential involvement of nearby structures. You know, the head of the pancreas wraps around some major blood vessels that if they're involved by the tumor can make the surgery much more complicated.
So when a Whipple procedure is required, we often favor an open approach if the tumor is close to blood vessels because it gives us the safest way to control and reconstruct these blood vessels. Robotic Whipple is possible in select patients, but because of the steep learning curve, it really should be offered only in centers that do high surgical volumes and have established expertise.
On the other hand, if the tumor is in the body or tail of the pancreas requiring a distal pancreatectomy, minimally invasive surgery robotic, or laparoscopic, is often the best choice. The benefits are clear in this setting because it's associated with less pain, shorter hospital stays, faster recovery, and the learning curve, as I said, for robotic distal pancreatectomy is much shorter so more surgeons and centers can perform it safely.
The next thing we look at is a patient's overall health and anatomy. A younger, healthier patient without a lot of prior surgeries may be an excellent candidate for minimally invasive surgery. For someone needing a Whipple, however, the choice of approach may be more dictated by tumor complexity and surgeon experience rather than the patient's health alone.
And third, perhaps most importantly, what we look at is the surgeon's and the institution's experience. High-volume centers consistently have better outcomes for all types of pancreatic surgery. But this is especially true for robotic Whipples.
At experienced centers, they can be done safely. At others, an open approach may still be the safer operation. So the decision is really about balancing safety, oncologic principles, recovery. Minimally invasive surgery is clearly advantageous for distal pancreatectomy while for the Whipple differences are smaller. And the learning curve really plays a major role in determining whether robotic Whipple can be done safely.
Alisyn Camerota: So Dr. Merchant, let's talk about it from the patient's point of view. How can the patient decide or know, I guess, if they're going to a high-volume center, if they're going to a doctor who has done this routinely, or if they're going to somebody who doesn't have a lot of experience with surgery?
Dr. Nipun Merchant: That's a very good question because most patients usually they get referred to a hospital or a physician or a surgeon for their treatment. But it's really important to ask the surgeon that they're seeing, what their experience in doing this is, what the volume that the institution sees as a whole.
Management of pancreatic cancer is a multidisciplinary approach. And you have to make sure that there's a team of physicians that are managing the patient comprehensively. It involves a combination of medical oncologists, expert radiologists, surgeons.
You know, we at experienced centers have multidisciplinary tumor boards on a weekly basis where we discuss every case, we review the imaging, and we discuss what the best approach for each individual patient may be in terms of the overall comprehensive treatment. So it's important to ask the physicians that you see, the surgeons that you see, what the experience they have in doing this is.
Alisyn Camerota: And what's the right answer for how many of these have you done or how many does your institute have? What is the right answer for what high volume means?
Dr. Nipun Merchant: That's a great question. I don't know. I mean, we can you know, there are several studies in the literature that show what defines high-volume centers. And believe it or not, high-volume centers that do more than 20 to 25 cases per year, actually do have better outcomes than centers that do less than that per year. But, most very experienced pancreatic centers around the country will have done well over a 100 to over 200 pancreas procedures per year.
Alisyn Camerota: Wow. That is high volume. It's hard for patients because, geographically, they're limited. You know, not everyone is in I mean, are the high-volume centers generally in major metropolitan areas?
Dr. Nipun Merchant: Yes. Usually, high-volume centers are academic medical centers that are in major metropolitan areas. So it's important to at least, if you're in a rural area, and you get an opinion from a surgeon or a team of physicians that are going to be managing your pancreas cancer, sometimes it's good to get a second opinion, and it may be worth traveling a further distance to get that opinion. Many times, the treatment plan can be long. We give chemotherapy before we do the surgery in most circumstances nowadays, and that could last months.
However, if you get that opinion from an expert team, many patients go back home, their local oncologist can deliver the chemotherapy and treatments that are necessary and then you can make one trip down for a surgery that is more complicated, instead of having to spend multiple days for the entire treatment at a major metropolitan center that may be far away from where you live.
Alisyn Camerota: That's good advice. I mean, I think that that's really practical, would be more practical for people who are not in a major city. So I know that there are also other surgeries and procedures that are part of pancreatic cancer treatment. What are those kinds of surgeries for?
Dr. Nipun Merchant: Yes. And this is an important point. Surgery for pancreatic cancer isn't always just about removing the tumor. There are other procedures we use sometimes as a part of the initial treatment, sometimes to help manage symptoms, and sometimes to make a major surgery safer.
Sometimes a tumor can't be removed because it's completely encasing some of the nearby blood vessels, but the tumor could be blocking the bile duct or the outlet of the stomach, which would result in patients developing jaundice or have trouble eating.
There are more minimally invasive approaches endoscopic approaches nowadays that we can use to stent the bile duct or even stent the stomach and the first part of the intestine. But if these other less invasive approaches don't work, then we can surgically create a bypass connecting the bile duct or the stomach directly to the small intestines to relieve that blockage.
This doesn't necessarily cure the cancer, but it can significantly improve quality of life.
Many times for patients with advanced disease when the tumor can't be removed, but the patient is in a lot of pain, sometimes we do procedures through interventional radiologists or surgical approaches where we can control the symptoms better. For example, something called a celiac plexus block, which involves injecting alcohol around some of the nerves around the pancreas, can reduce severe abdominal pain by disrupting some of these nerve signals.
Other procedures in some patients, particularly those undergoing a Whipple procedure, the tumor may involve nearby veins like the portal vein or the superior mesenteric vein. And in those cases, we can remove and reconstruct part of the vein allowing us to achieve a complete resection.
This is one reason why an open Whipple procedure may be preferred, because it gives us more control if we need to reconstruct any of the blood vessels.
Distal pancreatectomies can also involve some vascular reconstruction, but it's less common.
And the other approach, many times before committing a patient to a major Whipple or a distal pancreatectomy, we sometimes do a minimally invasive look inside.
We do a diagnostic laparoscopy to check to see if there are small areas where the tumor could have spread, that the scans may not necessarily pick up sometimes. So by just putting a couple of small incisions and putting a camera inside looking inside, if we find that the tumor has spread to other areas, we can actually avoid putting the patient through a large operation that wouldn't really help them if they already have metastatic disease.
So surgery for pancreatic cancer can be either curative, it can be preventive, it can be palliative. The exact role really depends on the patient's situation and the type of surgery that's being considered.
And again, the balance is really different depending on whether we're planning a Whipple or a distal pancreatectomy. The complexity, the risks, and the recovery time aren't the same for the two procedures.
Alisyn Camerota: Yes. And do you want to touch on that in terms of the recovery time for some of these?
Dr. Nipun Merchant: Yeah. So as I said, the biggest difference is the reconstruction part. For Whipple, it's much more complicated because when we remove part of the bile duct, part of the stomach and part of the pancreas, we have to reconstruct all those. So we take the intestines and we have to hook it back up to the pancreas, to the bile duct, the stomach. Just that rerouting alone adds complexity to the procedure and because of that it just takes time, more time for the stomach to start emptying normally, for the patient to start eating normally, and you know, post-operatively the biggest wait is really return of bowel function, right, until they can eat.
So the recovery time in the hospital is longer, and even recovery completely till they're back to normal eating can take several weeks to months sometimes.
When we do a distal pancreatectomy, there's no reconstruction, we just remove that part of the pancreas so we don't have to reconstruct anything. So the recovery, the return of bowel function and the recovery is much quicker with fewer days in the hospital and getting back to normal eating and things happens on a quicker basis.
Alisyn Camerota: What else, Dr. Merchant? What have I missed?
Dr. Nipun Merchant: You know, I think the most important thing for patients and families to know is that pancreatic surgery is no longer kind of a one-size-fits-all operation. We have multiple approaches now, multiple techniques that can be tailored to each person's tumor and overall health. It's not just about one operation or one surgeon. It's about a whole team, as I mentioned, a strategy that can really develop a personalized plan for each individual patient, depending on the extent of their tumor, the location of their tumor, their overall health. And when surgery is combined with modern chemotherapy, advanced imaging, minimally invasive techniques, we can really safely take on very complex cases nowadays that even a few years ago we wouldn't have dreamed of doing.
So the message I want to leave people with is that there are options, there's progress, and there is real hope for pancreatic cancer nowadays.
Alisyn Camerota: That's a wonderful message, Dr. Merchant. It's incredible the advancements that you all have made over the years with this incredibly complicated and deadly disease. So I really appreciate you trying to spread the word about how many options there are now.
Dr. Nipun Merchant: And you know, we do a lot of research on this also. And we're learning more and more about the tumor microenvironment in pancreas cancer, which is very complicated. And there's a lot of research going on – on how to kind of reprogram the entire tumor microenvironment to make chemotherapies more effective. You know, immunotherapy right now is not very effective in pancreas cancer, but a lot of research ongoing in terms of how if we can reprogram the tumor microenvironment, we can make more targeted therapies and immunotherapy also more effective.
Alisyn Camerota: Excellent. Anything else you want to get out there, Dr. Merchant?
Dr. Nipun Merchant: No, I think as I said, a lot of times patients come and see me for a second opinion and their doctors have told them, there's no hope, you have pancreatic cancer, get your affairs in order. And they take this very nihilistic approach. But that's really not the case anymore. And I think there are many, many options, as I said, progress is being made on a daily basis. There is real hope.
You know, if you don't like the answer you get from the first physicians you see, it's always better to get a second opinion at an experienced high-volume center.
Alisyn Camerota: Absolutely. And a third and a fourth if necessary. Yes. That is great advice. Well, Dr. Merchant, thank you so much for your time today and getting the word out.
Dr. Nipun Merchant: Really a pleasure. Thank you so much.
Alisyn Camerota: You too. Thanks for listening, everybody. I'm Alisyn Camerota. I'll see you next time.
Julie Fleshman: Hi, I'm Julie Fleshman, President and CEO of PanCAN. If you or a loved one has been diagnosed with pancreatic cancer, navigating this journey can feel overwhelming, but you don't have to do it alone. Visit PanCAN at pancan.org and Let's Win at letswinpc.org for more resources and support on this topic. Together, PanCAN and Let's Win are committed to guiding you through every step of the pancreatic cancer journey, offering support, information, and hope. Tune in next month when the PancChat podcast will take a closer look at hereditary risk and genetic mutations for pancreatic cancer.
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