Rebekka Haefeli: Toni K. says he is a lucky man. It was five minutes to midnight when he needed emergency surgery.
Toni K.: I had 1,000 guardian angels, 2,000, 3,000, I say. The team – one hour after the alarm went off – were back at Inselspital and were able to open my abdomen and clear everything out.
Rebekka Haefeli: What they cleared out was Toni K.’s pancreas. After an initial cancer operation, he developed a severe complication. This episode of Wissen gegen Krebs is about surgery for pancreatic cancer, the podcast of the Swiss Cancer Research foundation. I am Rebekka Haefeli and I am meeting Toni K. at Inselspital Bern together with pancreatic specialist Anna Wenning. Anna Wenning is a senior physician at the University Clinic for Visceral Surgery. At our meeting she has Toni K.’s CT scans displayed on the screen in front of her.
Anna Wenning: The pancreas would have been located here. Where we left one of the tubes in place. You can see a tube coming out through the abdominal wall.
Rebekka Haefeli: A few years have passed since the diagnosis in 2021. Toni K., who is 73 years old, still remembers well how it all began.
Toni K.: It was a colleague who noticed that something was wrong. He said you don’t look well. I felt a bit tired. I went home but realized it was not getting better. I called my doctor. I described how I was feeling. He told me to come immediately. As soon as I arrived, even from a distance he said I was yellow, that I was turning yellow. That’s when the alarm went off. Straight to the emergency department. There I was connected to medical equipment to find out what was going on. They saw that the liver was blocked.
Rebekka Haefeli: The pancreatic cancer was not discovered right away. But when it did not improve after a short time, they carried out more detailed examinations.
Toni K.: I was able to go straight to Inselspital. On Saturday evening a professor was still there. He saw that I had a tumor on the pancreas.
Rebekka Haefeli: But Toni K. was fortunate in his misfortune. No metastases were found. The tumor was located in the head of the pancreas. The pancreas is an organ about 15 to 20 cm long, divided into head, body and tail. It is important for digestion and blood sugar regulation. Pancreatic cancer is often detected late. That is because symptoms are absent for a long time, says physician Anna Wenning.
Anna Wenning: It is still the case that in the majority of people pancreatic cancer is diagnosed too late. Around 75 to 80 percent of patients either have a tumor stage where the tumor in the pancreas is already relatively advanced, or metastases are already present,
for example in the liver.
Rebekka Haefeli: As a rule, patients receive chemotherapy in addition to surgery. When a tumor, like in Toni K.’s case, is located in the head of the pancreas, either part of the organ is removed or the entire pancreas. In any case it is a major operation lasting several hours.
Anna Wenning: This is an operation we can do in four hours, but sometimes it can take eight. Typically we say around six or seven hours.
Rebekka Haefeli: Because such an operation always involves risks, methods and techniques are constantly being optimized. That is exactly what Anna Wenning’s research project is about, which is supported by the Swiss Cancer Research foundation. The focus is the question whether in the case of a tumor in the head of the pancreas only part of the organ should be removed or the entire pancreas.
Anna Wenning: There are many situations in which part of the pancreas can be left in place and safely sutured. But there are also situations in which suturing the pancreas is difficult. This can lead after surgery to a leak in the pancreatic suture and pancreatic fluid can escape.
Rebekka Haefeli: The digestive fluid is aggressive and such a leak, referred to as a fistula, can lead to infections and bleeding. In Toni K.’s case, initially only the tumor and part of the pancreas were removed. But he developed exactly such a fistula. The suture was not tight.
Toni K.: Five or six days later, while I was still at Inselspital, on the right side where a tube was coming out of my abdomen, on the left side there was also a tube, on the left the fluid was fine, and on the right you could see from the fluid that was coming out that it was slimy. Then suddenly I felt a sharp pain in my abdomen. That was one of the times I pressed the call button.
Rebekka Haefeli: He pressed the bell and the nursing and medical team reacted immediately. In an emergency operation the rest of Toni K.’s pancreas was also removed.
Anna Wenning: Yes, it was exactly such a leak from the pancreatic suture. We then saw that the remaining pancreas had developed such severe inflammation that it could not heal. So we removed it.
Rebekka Haefeli: As part of this current study, specialist Anna Wenning and her research team want to find out which surgical strategy is best for which patient. The worldwide standard in a case like Toni K.’s, with a tumor in the head of the pancreas, is still partial removal.
Anna Wenning: That is what the oncology guidelines state, that the tumor should be removed together with the affected part of the pancreas and the remaining part left in place. We are essentially questioning the current standard. From our clinical experience, we know
that there are pancreatic sutures where we can say with very high probability that they will leak. These are patients where we can no longer fully support performing such a suture. Surgeons in Europe and in America have begun to adapt this approach, but without solid studies.
Rebekka Haefeli: All of this must be seen in the context of medical progress. Anna Wenning says that today life without a pancreas is possible. However, its main functions must be replaced. The production of enzymes that help with digestion and insulin that regulates blood sugar metabolism.
Anna Wenning: Enzyme production can be replaced with tablets taken with meals. Insulin production can be replaced with a continuous glucose monitoring device, a sensor, and with an insulin pump that automatically delivers insulin. These are innovations of the last six to eight years. I believe the generation before me, the surgeons, would never have considered removing the pancreas because they had seen patients with poor quality of life. The resulting diabetes was extremely difficult to manage. Patients could no longer move around normally outside, eat normally and had to monitor everything constantly. Today, with the measures we have, our threshold for removing the pancreas has become lower because we know that patients can achieve a good quality of life.
Rebekka Haefeli: What is still missing are data showing in which case which operation is best.
Anna Wenning: After surgery we measure and document whether there were complications. Did the patient need antibiotics again because of a wound infection? Was another operation necessary? How long was the hospital stay? How long did it take until chemotherapy started? What percentage of patients completed chemotherapy fully? The main goal of our study is to measure which operation, with its possible consequences, leads to longer life expectancy. That means which operation may generate additional months or years of survival without tumor recurrence when the entire pancreas is removed.
Rebekka Haefeli: It is also important that this study is not only about length of life but also about quality of life. This is assessed using questionnaires completed by study participants.
Anna Wenning: Even if we perform a perfect operation, and patients tolerate chemotherapy perfectly afterwards, not every patient ends up sitting here like Mr K. In some cases, the tumor can return. That is why we have always said quality of life must also improve in parallel.
Rebekka Haefeli: Toni K. recovered well in rehabilitation after the emergency operation. Afterwards he underwent chemotherapy, which he tolerated quite well. And today, a few years after the diagnosis, he can again do what he enjoys.
Toni K.: I can go for walks, I can ski. Nothing too extreme, but I’m still here!