We'd been consulted on this cool guy a week ago regarding obstructive jaundice. Initially, this was thought to be a garden variety case of gallstones/choledocholithiasis but a couple of details didn't make sense. For one thing, he didn't have much pain. (Painless jaundice is a huge red flag.) Another, his total bilirubin was 12. You don't see that degree of hyperbilirubinemia, generally, in gallstone disease. I sent off a Ca 19-9 (tumor marker seen elevated in foregut cancers) and they scheduled him for ERCP. The ERCP was aborted because the endoscopist couldn't access the common duct secondary to either "stricture" or "extrinsic mass". The CT showed grossly dilated biliary ducts and pancreatic duct, suggesting chronic, high grade obstruction, but no obvious pancreatic head mass or evidence of metastases. Percutaneous transhepatic cholangiography was then done, demonstrating a high grade distal CBD cut-off suggestive of malignancy. Ca19-9 came back over 6,000 (off the charts). This was either a cholangiocarcinoma or pancreatic CA. He wanted his surgery done locally at our hospital, and he wanted me to do it. It was obvious that a Whipple was necessary. This is the Big Daddy of general surgery cases. There is some evidence to suggest that morbidity/mortality rates are lower when Whipples are performed at tertiary referral centers. But I know how to do the case. I've done two since leaving residency, with good outcomes. I did a lot when I was a chief resident, I was trained by excellent surgeons in Chicago, I didn't have any problem accepting the case myself. But I did offer to transfer him downtown to a hepatobiliary specialist, if he preferred. He declined. You take it all out, he said to me.
Initially, the case went well. No evidence of carcinomatosis. The liver looked cholestatic, but without gross metastases. I did the usual maneuvers. The gallbladder removed, duodenum kocherized, gastrocolic ligament divided. I identified the SMV below the pancreas. Right gastric artery tied off. And then some troubling things started to become apparent. The pancreas was diffusely rock hard. Tumor infiltration? Chronic changes from obstruction? And then my heart dropped as I went to identify the gastroduodenal artery. The Common hepatic artery seemed unusually close to the superior aspect of the pancreas. The tissues seemed harder, more fibrotic. Usually, dissection proceeds beautifully through thin, diaphanous planes that just fall away with the gentlest of prodding. This artery was stuck to the pancreas. No doubt about it. I futzed around for a while. A branch that appeared to be the GDA disappeared into the woody, matted mess near the head of the pancreas. The SMV was clear, however. Now what? Well, I paused. I had my partner scrub in and take a look. I sent off multiple core biopsies of the pancreatic head. I sent a choledochal lymph node that seemed abnormal, and some of the lymphatic tissue around the pancreas. It all came back on the frozen sections as cancer. Game over. Hepatic artery invasion with positive nodes in the porta hepatis. Unresectable disease. I did a roux choledochojejunostomy, placed a J-tube for feeding purposes, and left a few JP drains. His wife was devastated. Hopefully chemo can extend his life.