Stan: An Adverse Intra-operative Discovery turns into an Unexpectedly Good Outcome
Stan was in his early 70s and had a history of heavy drinking and smoking. After multiple episodes of acute pancreatitis, he was eventually diagnosed with chronic pancreatitis. At the urging, or threats, from his wife and daughters, he quit drinking and smoking and became compliant with the recommendations of his doctors. Despite pancreatic enzyme supplements and pain medicine, he lost weight and was hospitalized with more abdominal pain. His doctor performed an ERCP to see if there was a mechanical reason for his increased pain. A tight narrowing or stricture of the main pancreatic duct was found in the head of the pancreas, without any signs of a tumor. The stricture looked like it was due to scar formation so he underwent a trial of pancreatic duct stenting, where a hollow plastic tube was wedged through the strictured area of the duct, to see if relieving the blockage would help but after the removal of the stent three months later, his pain returned and he was unable to eat, so he was referred to me for possible surgery to relieve his pain.
Stan was friendly and self-effacing during our first meeting. He was reluctant to undergo an operation but was resigned to the fact that he needed to have something done to relieve his symptoms. His wife was also very pleasant but was very concerned about the details of the surgery and the likelihood that it would offer a lasting benefit. She had kept detailed records of all of Stan’s hospitalizations and doctors’ visits, and it seemed apparent that she was the decision-maker of the family who had suffered from Stan’s behavior over many years. She was still clearly devoted to Stan.
Stan’s chronic pancreatitis seemed fairly classic in its presentation. He had a strictured duct with evidence of obstruction, which appeared as a widened dilatation or swelling of the duct upstream from the area of the stricture. (Figure 1) There were scattered calcifications in the pancreas, typical of an advanced degree of inflammation, and although he was taking pancreatic enzyme supplements to compensate for his loss of pancreatic enzyme production, he was not diabetic which indicated that he still had some preserved function of the gland.
Figure 1. Typical ERCP appearance of dilated pancreatic duct caused by stricture of the duct in the head of the pancreas (from Kalloo AN, Norwitz L, Yeo CJ Chronic Pancreatitis Johns Hopkins)
The surgical options for this form of chronic pancreatitis included a Whipple procedure or removal of the head of the pancreas, or a version of what had become known as a “hybrid procedure,” or removal of the central part of the head of the pancreas together with decompression or drainage of the distal pancreatic duct. In 1980, Hans Beger, then the chief of surgery at the University of Ulm in Germany, had published his results of a “duodenum-preserving pancreatic head resection” or DPPHR which quickly became known as the Beger procedure. The operation required dividing the pancreas in half at the neck of the gland, as for the Whipple procedure, and then removing most of the head of the pancreas while preserving the duodenum, a thin rim of the pancreas, and the distal common bile duct. Randomized trials in Germany which compared the Beger procedure with the Whipple procedure suggested that the results for the Beger procedure were better, but it was an operation that was used mainly in Europe.
In 1987, Charles Frey, a professor of surgery at the University of California Davis campus in Sacramento, published a new operation which he called a “Local Resection of the Pancreatic Head with Longitudinal Pancreatico-jejunostomy” or LR-LPJ, which quickly became known as the Frey procedure. The Frey procedure avoided the division of the pancreatic neck that was common to the Whipple and Beger operations, and instead took the opening of the pancreatic duct all the way down to the very beginning of the pancreatic duct at the duodenum. (Figure 2)
Figure 2. The Frey procedure. The pancreatic duct is opened in its entirety from the head of the pancreas to the tail. The center of the head of the gland containing the strictured duct is excavated or removed and the entire opened duct is then drained into a limb of the small intestine.
The main pancreatic duct travels from the tail of the pancreas through the mid-portion or body of the gland, in a fairly superficial depth that is easy to locate and open. Frey’s operation continued the opening of the duct into the head of the gland where the duct suddenly dives posteriorly so that opening the duct requires a more extensive removal of the front or anterior part of the head of the gland. This excavation of the pancreatic head, in order to gain access to the duct, was the innovative part of the procedure, and essentially allowed for the removal of the central portion of the head of the gland. (Figure 3)
Figure 3. Operative view of the excavated head of the pancreas in the Frey procedure. The center of the head of the gland is “cored out” leaving the inflamed (red) back wall of the duct visible. The core is then submitted for microscopic analysis.
Frey’s operation was tested against the Whipple and Beger procedures for the treatment of chronic pancreatitis in randomized trials and was found superior with a lower risk of complications and in-hospital stay. The degree of pain relief was equal or superior to that of the other operations, and the technique was simpler than that of either the Whipple or Beger procedure. It became a popular operation among American surgeons and was our preferred operation for patients with chronic pancreatitis.
Stan was not an ideal candidate for any pancreatic surgery. His smoking addiction had resulted in a mild degree of emphysema, or chronic lung disease, and his pulmonary function was further impaired by his moderate kyphosis, or curvature of the spine, due to progressive osteoarthritis. His muscle mass was clearly reduced from his former years, and he was able to walk without assistance but at a slow pace. He led a pretty sedentary life at home, but his weight was stable and he had a positive attitude about the rigors of going through surgery.
I explained the options to Stan and his wife and told him that I thought the best operation for him was the Frey procedure. I also explained that we would immediately look at the removed tissue from the head of the pancreas under the microscope and that if there was any sign of cancer, that we would have to consider converting the operation to the Whipple procedure. Stan and his wife agreed to the plan, and he was prepared for the surgery.
On the day of the operation, Stan, his wife, and his daughters all appeared with positive attitudes and assurances that he would do well. I just hoped that their optimism would be rewarded. When we opened the abdomen and exposed the pancreas, it was very firm as expected, and his swollen pancreatic duct was easy to feel running along the length of the gland. I carefully pushed a small needle into the duct and withdrew some clear pancreatic juice, which was saved for later tests. Then I used a cautery needle to burn down through the top of the pancreatic duct to open the duct widely along its path over the neck of the pancreas. The duct appeared scarred along its interior, and flecks of calcified debris coated the edges of the divided pancreas. We worked our way toward the head of the pancreas and followed the duct down into the deep part of the pancreatic head into the area of the narrowing or stricture, which had a hard consistency. Then we cored out the area of the scarring with the cautery, so as to create a bowl or cup-shaped excavation of the central part of the pancreatic head and removed the walnut-sized mass of tissue. We sent it off to the pathologist to freeze the tissue and look at it under the microscope, while we began to prepare the opened pancreas for the connection, or anastomosis, with the limb of the intestine.
The phone rang in the operating room and the circulating nurse answered it and said the pathologist was on the line. I went to the phone which the nurse held to my ear and listened as the pathologist said that the center of the specimen clearly had a focus of pancreatic cancer. “Are you sure?” I asked. “Absolutely,” came the reply. “Don’t do anything,” I told the team, “I’ve got to speak to the family.”
I broke scrub and went out to the waiting room to sit down with Stan’s wife and his daughters. I told them the results of the frozen section and said that we had two options. One was to merely close the opening in the pancreas by attaching it to the intestine, as we had planned, with the knowledge that we had not done a correct cancer operation. This meant that almost certainly the cancer would reappear, but that Stan would probably recover from the surgery and be able to spend with his family whatever time he had before the cancer progressed. The other option was to proceed with the Whipple procedure. Nothing we had done at surgery so far prevented us from converting the surgery to a Whipple procedure, although the fact that we had cut into the cancer increased the chances of recurrence of the cancer. On the other hand, if the Whipple was successful, he might have a longer time, two three or more years, before the cancer reappeared. No cure could be predicted or expected, and his recovery from the Whipple would be extremely challenging. His wife and daughters held each other with tears in their eyes, but quickly and quietly just said “Go ahead, and do your best.”
I returned to the OR, told the team what the decision was, and embarked on the Whipple procedure. When we liberated the duodenum and the head of the pancreas from the retroperitoneum, we were relieved that there were no enlarged lymph nodes in the area. The liver had no evidence of metastatic deposits, and every other area in the abdomen looked “clean,” with no evidence of distant disease. We completed the Whipple in about 7 hours.
Stan’s postoperative course was “rocky,” as predicted. His lungs required extra support, and he was on the ventilator with a breathing tube in place for several days. Slowly, his strength of breathing increased, and with all of his hard work and that of the intensive care specialists helping him, he avoided developing pneumonia and came off of the ventilator without a problem. After another day or so, he was able to dangle his legs over the side of the bed, and on about the fifth or sixth day, was able to sit in his bedside chair for about an hour, with a big smile on his face, and on the faces of his wife and daughters. Slowly, he began to eat a little, and we reduced his intravenous nutrition as his own intake gradually increased. He began to take a few steps with a walker, and finally, about two weeks after his surgery, Stan graduated to the regular surgical floor, a quiet room, and something that resembled a more normal pattern of recovery. He had clearly shown us all that he was a “tough old bird.”
His final pathology report came back showing no other cancer than the small focus which had been found at the center of the stricture in the pancreatic duct, and none of his removed lymph nodes showed any sign of spread. So his diagnosis was Stage I or the earliest stage of pancreatic cancer, and the only worry was that I had cut into the tumor in the process of removing it. This was a violation of the basic rule that you give the cancer, any cancer, a wide berth while removing it to avoid disrupting it and sending miniscule bits into the operative field.
After discharge home, Stan’s mobility slowly increased, although he had clearly lost strength and energy as a result of his ordeal. Visiting nurses came and helped with exercises and check-ups at home, and the intervals of his follow-up visits with me in the clinic began to stretch into weeks and then months. He had become diabetic as a result of the surgery and his underlying pancreatic disease, so monitoring his blood sugar levels was a new routine at home. Despite pancreatic enzyme supplements, he still had troubles with occasional loose stools, and both he and his wife complained that he had become a “gas factory,” which made any gathering a musical event. His wife held her nose and said that she couldn’t believe how much gas Stan seemed capable of generating. Stan just smiled.
Six months went by, then a year, and all of Stan’s blood tests and CT scans looked stable with no sign of recurrent cancer. Another 6 months, and then another year went by, and Stan seemed to have regained more of his strength although he was still pretty sedentary in his routine. Other than the gas problem, he seemed to be doing pretty well, and his wife’s meticulous records of his weight, his blood sugars, and his activity helped to monitor his progress. After five years had passed, I received a photo of Stan, which was signed on the back, “Thanks for five more years with my family.”
In the course of operating on many patients with chronic pancreatitis, I had discovered undiagnosed pancreatic cancer in about 10 percent of patients with severe pancreatitis. Despite careful testing including biopsies and brushings of the pancreatic duct to rule out cancer, patients with strictures or narrowing of the duct were known to be at risk of harboring a cancer that had developed against a background of chronic inflammation and scarring. As imaging techniques improved, and better methods to biopsy the pancreas became more available, the incidence of a missed diagnosis of cancer seems to have fallen. But bad surprises still happen.
Stan’s good luck was that his doctors encouraged him to undergo surgery after a short course of attempted endoscopic therapy of his narrowed duct. All too often, patients with chronic pancreatitis are subjected to many trials of stenting despite the clear evidence that the disease is persistent. So although we all agree that endoscopic therapy, or endotherapy as it is called, should be used first, we also strongly believe that if it fails after one or two or three attempts, a surgical consultation is the needed next step. What specific operation is best depends on several factors. In Stan’s case, his disease was due to the combined toxic effects of alcohol and tobacco, and the Frey procedure was the right choice if only pancreatic inflammation was present. The discovery of the small Stage I cancer was unforeseen, but Stan and we were lucky that everything went well.