Changing paradigms in Surgery of the Pancreas: What it means for the patients

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'noli me tangere' -  Latin phrase for 'Touch Me Not'

According to the Wikipedia, the organ that typically fits the description of this phrase is the pancreas. This is due to some of the perceived attributes of pancreas and its surgery - the location of pancreas with resultant difficulty in accessing it during 'routine' abdominal operations, its close relation to major blood vessels and significant morbidity of pancreatic operations.

No wonder the maxim "eat when you can, sleep when you can, don't mess with the pancreas" was a common surgical anecdote. In the current times, such wisecracks are merely of historical interest and no longer hold any validity.

Emergence of specialized pancreatic surgeons with better understanding of pancreatic diseases & refined surgical techniques coupled with an effective management of procedure related complications has resulted in the current era of pancreatic surgery with low mortality and acceptable morbidity.

Modern pancreatic surgery can aptly be described as being safe, elegant, patient friendly surgery that is based on highest quality medical research ('medical evidence') and increasing utilizes minimally invasive surgery techniques such as robotic surgery.

Over last 2 decades, notable advancements have been made in all domains of pancreatic surgery for:

1.      Pancreratic necrosis following severe acute pancreatitis

2.      Chronic pancreatitis

3.      Pancreatic cancer

These are briefly discussed in following sections.

1.      Surgery for infected pancreratic necrosis following severe acute pancreatitis (SAP)

SAP with bacterial infection of pancreatic necrosis is one of most serious pancreatic diseases that necessitates intervention for salvage. About a decade ago, this disease entity was treated by open surgical removal of dead peripancreratic tissue ('necrosectomy') – a procedure associated with high mortality and complication rates.

Over the last decade, 'Step Up Approach' has emerged as the preferred alternative treatment strategy for SAP patients with infected necrosis. As an initial management, surgical drains are placed in such infected collections under CT scan guidance. This minimally invasive approach may help avoid further surgical intervention in up to 2/3 of SAP patients with infected necrosis. The patients who do not adequately respond to such drain placement are advised to undergo a laparoscopic necrosectomy.Modern management of infected pancreatic necrosis has thus evolved towards more patient friendly minimally invasive interventions with better outcomes.

2.      Surgery for chronic pancreatitis (CP)

The aim of treatment for patients with CP is lasting relief of pain and available options include endoscopic therapy and surgery. It is pertinent to add that pancreatic ductal stones in the absence of pain do not require any further treatment. High impact studies over last 10 years show that following endotherapy, pain is likely to recur in up to 2/3 of patients within 2 years. In contrast, surgery for CP has several advantages. It can be performed safely with minimal blood loss and postoperative complications and offers a lasting pain relief in up to 80% patients. Also there is emerging evidence that an early surgery may lead to preservation of pancreatic function.

Minimally invasive surgical techniques are being increasing utilized which make surgery for CP more acceptable option than ever before.

3.      Whipple's procedure for resectable cancer of head of the pancreas

 Whipple's procedure is the only currently available treatment that can potentially provide long term survival for pancreatic head cancer. Emergence of specialized pancreatic surgeons, refinements in surgical techniques and image guided, effective management of complications have resulted in mortality of Whipple's procedure ranging between 1-5% at centers of excellence

With safety of the Whipple's procedure no longer a matter of debate, novel strategies are now being adapted to expand the indications of surgery. These include the concept of 'Borderline Resectable Pancreas Cancer' and initiation of neoadjuvant therapy to downstage the disease in order to make it amenable for margin negative resection.

Also in line with other domains of pancreatic surgery, minimally invasive surgery techniques such as robotic assisted surgery are being increasing utilized for Whipple's procedure without any compromise on quality or safety of surgery.

Dr Nitin Vashistha

Dr Dinesh Singhal

Department of Surgical Gastroenterology, Max Super Speciality Hospital, Saket, New Delhi, India
E mail: gi.cancer.india@gmail.com

Understanding Pancreatic Tumors: What Manohar Parrikar & Steve Jobs fought with dignity

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Several prominent members of the civil society - much loved and respected political leaders, film stars and IT industry pioneers in India and abroad have lately been diagnosed with pancreatic tumors leading to much public interest and headlines on the social media. The dignity and determination with which each one of them faced the disease shall be an inspiration for one and all.

The generic term ‘pancreatic tumors’ includes pancreatic cancers (medically known as pancreatic ductal adenocarcinoma or PDAC), neuroendocrine tumors (NET) and cystic tumors. These tumors differ in terms of investigations and treatment strategies (no surgical intervention i.e. observation for some cystic tumors to major pancreatic resections for cancers and NET). They also differ in biological behaviour and outcomes (NET and cystic tumors often are slow growing and have an indolent behaviour as compared to pancreatic cancer).

For all pancreatic tumors, pancreatic protocol abdominal CT scan with is an essential part of diagnostic work up and may reveal one of the clinical scenarios:

1.      Localized disease (confined to the pancreas and surrounding (regional) lymph nodes):

For patients who are medically fit to undertake major surgery, upfront pancreatic resection (i.e. surgical removal) is the best treatment option that provides chances of long-term survival or cure.

Surgery involves removal of a part of pancreas (depending of tumor location) along with lymph nodes that drain this section of pancreas. Thus, tumors located in the body and tail of pancreas are removed by distal pancreatectomy whereas tumors in the head, neck or uncinate process require a more complex operation - Whipple’s procedure or pancreatoduodenectomy.

There have been several advancements in imaging, surgical techniques and critical care that have made pancreatic surgery more patient friendly and safer (reported mortality of 1-5% for Whipple’s procedure from centres of excellence). Some of the notable recent advances include:

- Increased utilization of laparoscopic / robotic techniques so as to avoid large incisions

- Interventional radiology techniques for management of complications

2.      Locally advanced pancreatic cancer (limited involvement of adjacent major vessels, borderline resectable):

Novel chemo & radiotherapy protocols have been introduced in clinical practice with an intent to downstage such tumors and make them resectable. According to current medical literature, up to 20% of such tumors can now be successfully down staged to undergo curative surgery

3.      Advanced tumors (spread to other organs such as liver, lungs or peritoneum i.e. metastatic) or where curative surgery is not feasible due to serious medical conditions:

In such patients, the aim is to provide good quality of life with multidisciplinary management involving endoscopy, chemotherapy and pain management services. In many patients extended survival is possible.

In summary, for medically fit patients with pancreatic cancer confined to the pancreas, surgery is the best treatment option where long-term survival or cure is feasible. For borderline resectable tumors, successful management protocols for down staging such tumors are available. For patients with metastatic disease, emphasis is on providing good quality of life that may also help extend survival.

Dr Nitin Vashistha
Dr Dinesh Singhal
Department of Surgical Gastroenterology, Max Super Speciality Hospital, Saket, New Delhi, India
E mail: gi.cancer.india@gmail.com