Diagnosis and Surgery FAQ

• Stage 0: The cancer hasn’t spread. It’s limited to one layer of cells in your pancreas. It’s not visible to the naked eye or on imaging tests.

• Stage I: The cancer shows local growth. It’s limited to your pancreas but has grown to less or greater than two centimeters (stage IA and stage IB).
• Stage II: The cancer shows local spreading. It has spread to neighboring lymph nodes or has grown outside your pancreas.
• Stage III: The cancer shows wider spread. Your tumor expands into neighboring nerves or major blood vessels but hasn’t metastasized.
• Stage IV: The cancer shows confirmed spread. It has spread to distant organs.

When you’re in the early stages of dealing with a cancer diagnosis, getting a second opinion from a specialist will also allow you to receive confirmation about a diagnosis, review other treatment options, and select a course of action. You can contact Dr. Fraiman to learn more about this process here: https://liverandpancreassurgeon.com/getting-a-second-opinion/

Dr. Mark Fraiman is a board-certified liver and pancreatic surgeon in Baltimore, MD who has been practicing for over 20 years. He is recognized as an expert in pancreatic and liver conditions and is one of the few doctors in the Baltimore area performing liver and pancreatic surgeries. Call to set up an appointment or get a second opinion with Dr. Fraiman.

A typical procedure will take three to eight hours, depending on the complexity of the operation and the complications that may arise during surgery.

Standard abdominal surgeries will require a drain. This is done for the following reasons:

• Tubes for providing you with medications and fluids
• A feeding tube
• A drain under your skin for draining fluid from the wound site
• A catheter in your bladder to collect your urine
• An epidural catheter system to deliver pain relief after your surgery

Our surgeries usually involve the removal of tumors in the pancreas, liver and gallbladder. Because these are major open surgery operations, you will be admitted to a high-dependency unit (HDU) for one to two days. Then, you will transition from the HDU to a lower-acuity unit within the hospital for approximately seven days to continue the recovery process.

You may continue to have regular appointments with Dr. Mark Fraiman in our center after your hospital discharge to monitor your health and check that the cancer has not returned.

Your recovery timeline after surgery will depend on your post-surgery condition and the possibility of any long-term side effects. Dr. Fraiman will discuss your recovery options with you, but it is important to allow yourself adequate time to recover as needed.

Every patient and condition is different and can require a tailored post-surgical plan. Dr. Fraiman and his team will create a patient-centered plan compiling all important patient information and instructions for further treatment. Members of our care team will collaborate with your new care team to share the plan and ensure a smooth handoff.

Surgical treatment can affect certain activities until you are cleared with a full recovery. For example, with liver surgery, we recommend not lifting anything over five pounds for at least eight weeks post-surgery. During this time, ensure supporting friends or family members are around to assist you as needed.

While surgeons do their best to eradicate a tumor, cancer recurrence can happen if some cancer cells remain in your body following surgery. Contact our care team to address your concerns if this happens. We will be there to develop a plan for your next steps.

Health insurance doesn’t always provide complete cancer treatment coverage. However, insurance can provide options through primary benefits in preventive care, hospitalization, medical prescriptions and follow-up appointments. If you are over 65, look into your Medicare benefits for coverage options.

Common side effects of surgery can include:

• Leakage of Pancreatic Fluids
• Stomach Paralysis
• Pancreatic Insufficiency
• Fever

Rarer side effects can include:

• Hiccups
• Diabetes
• Low Blood Sugar
• Weight Loss
• Acid Reflux
• Infection
• Fluid in the Abdomen

Liver cancer can vary from primary to secondary tumors. Here is a list of the most common liver cancers:

• Malignant tumors: Malignant tumors are cancerous and can grow into nearby tissue.
• Primary cancers: Primary liver cancer is a disease in which abnormal cells begin to form in the tissues of the liver. If your physician determines that these cells are malignant, this is diagnosed as primary liver cancer. Primary cancers can include hepatocellular carcinoma and cholangiocarcinoma.
• Secondary cancers: Secondary liver cancer is a cancer that starts somewhere else in your body and spreads — or metastasizes — to your liver. This category includes colorectal liver metastasis.

Depending on the severity of your condition, your liver can become scarred and not function correctly. This condition is known as cirrhosis and can restrict your liver’s access to regular blood flow and essential nutrients. If you are feeling fatigue, nausea and abdominal pain, these symptoms could be initial signs of cirrhosis.

Liver cancer can be diagnosed through several ways, including CT scans, MRIs, PET scans and blood tests. If an abnormality is detected, your doctor may recommend an abdominal ultrasound for a more detailed look at your liver. An ultrasound-guided liver biopsy may be recommended if the abdominal ultrasound shows a suspicious lesion or mass.

Liver cancer can be challenging to detect initially since its symptoms aren’t always present until its later stages. The most common symptoms include:

• Loss of appetite
• Unexplained weight loss
• Upper abdominal pain
• Weakness and fatigue
• Nausea and vomiting
• Yellow discoloration of the skin (jaundice)
• White, chalky stools

Liver cancer can progress quickly and most often metastasizes to the lungs and bones. Pain with breathing and movement can come and go or worsen.

Liver cancer is often treatable — the earlier you start treatment, the better. Cancer treatment success can vary depending on the stage at which you receive your diagnosis. Early detection and treatment can often lead to better outcomes. Treatment may become more challenging as it advances, but options are still available to manage the disease and improve quality of life.

When getting ready for liver treatment and surgery, continue eating well, getting sufficient sleep and being as active as possible. This focus on your overall well-being can keep your body preemptively strong and healthy to endure whatever treatment is needed.

Depending on the location of your liver cancer, several options are available. The most common liver surgeries include liver resections, radiofrequency ablation (RFA), irreversible electroporation, microwave ablation and liver transplants.

Your liver surgery can vary depending on the number of tumors on your liver. Most surgeries can take two to four hours, while others can take longer. Dr. Fraiman and his team will walk you through the timeline before surgery so you know what to expect.

Following most surgeries, you will be admitted into a high-dependency unit for one to two days to ensure you are recovering well. From there, you will move to a lower-acuity unit in the hospital, where you can continue the recovery process for five to seven days before being sent home.

Your care team will monitor your recovery at the hospital for around a week, where you will receive pain medication treatments and be educated on how to recover at home. Feeling fatigued following liver surgery is normal and should improve over time.

The most common types of pancreatic cancer include:

• Adenocarcinoma: This cancer forms in the cells lining the pancreatic duct.
• Neuroendocrine neoplasms: This tumor forms in your neuroendocrine system.
• Psuedopapillary neoplasms: This malignant tumor is prone to occur in younger women.
• Intrapapillary mucinous neoplasms: These tumors can form in the ducts of the pancreas and become malignant.
• Endocrine pancreatic cancer: This tumor growth affects the endocrine cells in the pancreas, specifically where insulin and other important hormones release into the bloodstream.
• Exocrine pancreatic cancer: This form of pancreatic cancer develops in the exocrine cells of the pancreas.

Your doctor may use certain tools to detect pancreatic cancer, such as:

• • Medical history - to learn your story of the disease, its nature, time of onset, and location of the pain.
  • Physical examination - Your doctor will feel the abdominal mass and check for jaundiced skin, swollen lymph nodes in your neck, or weight loss.
  • Lab tests - Tests should show if you have blocked bile flow or other abnormalities.
  • Imaging tests -
    • Magnetic resonance imaging (MRI)
    • Computed tomography (CT scan)
    • Ultrasound
    • Positron emission tomography (PET scan)

• Potentially Curative Surgery: Used when exam and test results suggest the surgeon may be able to resect (remove) all your cancer. Potentially curative surgeries include the Whipple procedure (pancreaticoduodenectomy), Distal pancreatectomy and total pancreatectomy.
• Palliative Surgery: Used when your imaging tests show the surgeon won’t be able to remove all your cancer because it’s too widespread.
• Whipple procedure: This operation involves the removal of the head of the pancreas, the gallbladder, part of the duodenum, small intestine and stomach, to get rid of any cancerous tumors.
• Open and laparoscopic distal pancreatectomy: This cancer removal procedure usually involves removing the tail of the pancreas rather than the head, as well as the spleen.

Pancreatic cancer can be diagnosed with ultrasounds, CT scans, MRIs and PET scans. If an abnormality is found, Dr. Fraiman will extract a tissue sample to be tested for cancerous cells — a procedure called a biopsy.

Pancreatic cancer can be challenging to identify as cancer in some cases. More severe pancreatic cancer symptoms will only show if the condition is advanced. Some of the early signs to look for include:

• Abdominal pain
• Fatigue
• Jaundice
• Depression
• Blood clots
• Unexplained weight loss
• Loss of appetite
• Nausea and vomiting
• Diabetes

You may experience certain signs and symptoms if your cancer has spread beyond your pancreas. You may feel more fatigued, experience abdominal pain or bloating and have increased pain in areas where cancer may have spread.

Once you get diagnosed and receive a second opinion, you should consider treatment. Surgery paired with chemotherapy or radiation therapy can be most effective for the early stages of pancreatic cancer.

To best prepare your body for treatment or surgery, maintain a healthy diet of fruits, vegetables, whole grains, lean meat and fish. Keeping up with this diet while staying as active as possible can strengthen your body to endure what treatment. Try to avoid alcohol, smoking and large portion sizes.

Dr. Fraiman is one of the best pancreatic cancer doctors in Maryland and can provide open and minimally invasive surgical options, depending on the severity of your condition. Some of these include:

• Whipple procedure: This surgery is done when the cancer is confined to the pancreas head and the patient can withstand the operation. The Whipple procedure removes the pancreas head, a duodenum portion, the gallbladder, part of the small intestine and part of the stomach before connecting the remaining organs for digestion.
• Distal pancreatectomy: This procedure removes the affected pancreas area while leaving the head intact. While not as complicated as the Whipple procedure, a distal pancreatectomy is still significant.
• Chronic pancreatitis surgery: This surgery provides Puestow and Frey’s procedures to treat chronic pancreatitis.
• Debridement of pancreatic necrosis: A debridement includes removing areas of the pancreas with dead tissue for proper functioning.

A pancreatic operation can vary from two to seven hours, depending on the procedure. For example, the Whipple operation is the most intensive, lasting five to seven hours.

Following pancreatic surgery, you will be admitted into an intensive care unit (ICU) to monitor your recovery progress around the clock. After one or two days in the ICU, you will spend around a week in a lower-acuity unit before being cleared to go home.

You should expect to stay in the hospital for a few days following your surgery so our team can monitor your progress and ensure you are healing. Once you return home, a full recovery can take two to six months.