‘Neurosurgery’ on the Pancreas
|Unconvinced that the swelling in his patient’s foot had a vascular origin, Michael Fox’s physician ordered a CT scan to see if a lymph node abnormality might be the culprit. The lymph nodes appeared to be fine. But to the consternation of both doctors—Fox is a Colorado Springs radiologist—the imaging showed a 4-centimeter mass on the head of his pancreas.|
Fox spent the next 18 days researching his options. He underwent an endoscopic ultrasound with biopsy; he had an MR scan. Everyone agreed the tumor looked benign. And with a single exception, his colleagues said his sole treatment possibility was the Whipple procedure, which would remove not only the head of his pancreas but his gallbladder, common bile duct and part of his duodenum as well. Only the surgeon in his group practice, citing “a lot of morbidity and mortality,” advised against the operation.
“Finally,” says Fox, “someone said I should go to a major center: Sloan-Kettering, M. D. Anderson, Hopkins. For some reason, that last name stuck. I went to the Web and searched surgeons, organ, pancreas. Up came Dana Andersen’s picture and information on his duodenum-sparing procedure. I wondered if that might be my surgeon.”
Andersen, chief of surgery at Johns Hopkins Bayview Medical Center, understands why most physicians hear pancreatic lesion and immediately think Whipple. Although less drastic operations were introduced in the 1980s for benign and premalignant tumors or chronic inflammation on the head of the pancreas, they’re rarely performed in the United States. Andersen believes that should change. He’s developed a technique for excavating the central core of the pancreatic head and removing the proximal main pancreatic duct while preserving the posterior capsule and neck of the pancreas. His “less-than-a-Whipple” means that because he’s resecting a smaller portion of the pancreas and none of the small intestine, morbidity is lower and patients are unlikely to have subsequent digestive problems or diabetes.
Still, Andersen says, “the pancreas is very vascular, so coring out the head is technically challenging.” To do that safely, he uses an ultrasonic aspirator and dissector, an instrument more commonly found in the hands of neurosurgeons. “It has a high-frequency pulse at the tip that shakes apart the tissue ahead of it, but in a minute area,” he says. “The tissue separates before you, like the biblical parting of the waters. You can see the blood vessels before you get to them. That’s why brain surgeons love it, but most pancreatic surgeons are unaware of its utility for ‘our organ.’”
Andersen first used his excavation procedure to relieve chronic pancreatitis. He’s since shown that it’s also a godsend for patients like Fox. “By our standard,” Andersen says, “the Whipple is very safe and reasonable for bad disease of the pancreas but it may be overkill for patients without invasive cancers.”
Eager to learn if Andersen’s approach could apply to him, Fox e-mailed the Hopkins surgeon, then sent him his imaging studies. Andersen concurred that Fox’s tumor had all the radiologic characteristics of a benign lesion and thought he’d be a good candidate for excavation. One reason was size.
“We discover a lot of these lesions because more patients are having CT scans,” Andersen says. “Some lesions are very tiny, and we’re in no rush to remove them; benign little cysts can stay benign little cysts. So, we follow them with endoscopic ultrasound or CT if they’re less than 2.5 centimeters. But once they get bigger, the risk for malignancy begins to rise.”
Fox, who finally felt he had enough information to make a decision, flew to Baltimore in October. He was discharged five days after the operation and stayed another week in a local hotel in case of complications (there were none). The 49-year-old still doesn’t know what’s wrong with his foot, but he has developed a mission.
“I teach residents at Colorado University,” he says. “I’m putting up my case for discussion, and I’m telling them that there are two treatment paths, not one. I’m also telling them that, unfortunately, they may be the only ones who know about this.”