Tuesday, October 9, 2007

Tough case

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.

9 comments:

Bongi said...

well left. call me skeptical (comes from watching my aunt die of pancreas ca) but consider omitting the chemo.

rlbates said...

Tough case indeed. So sorry for all involved.

rlbates said...

Please submit this post to SurgExperience 106 (http://intraoporate.blogspot.com/2007/10/casting-call-surgexperiences-106.html).

Hildy said...

not that it would help people with unresectable disease, but did you see the UIC announcement about robotic whipple's? I know that it's already becoming a specialised procedure, but if the robots (ie laparoscopic) make it a safer/better recovery procedure, patient factors may become less of an issue.

tom said...

Nice post; good call on retreating-I suppose there are some out there that would have pushed on with the procedure, perhaps hastening the inevitable.
You gave this man the only good thing associated with his cancer; time to get his life in order and address any unfinished business with family and friends.

Well done

Anonymous said...

The patient might want to ask Dr. Alexander Rosemurgy at University of South Florida in Tampa if he qualifies for the GV1001 peptide vaccine clinical trial just recruiting for metastatic pancreatic cancer. The vaccine works on the telomerase principles and has essentially no side effects. Although the jury is still out this is a Phase III trial i believe and in Europe where GV1001 was created they had one patient with over 2 years without progression. the chemo regimens available don't work except to extend life a few months. If I had pancreatic cancer I would definitely take a shot at GV1001 if I could get it. The Tampa Clinical trial Coordinator is Jennifer Cooper and her telephone # is: (813) 844-4218. You can give her my name. If the wife wants to talk i'd be happy to talk to her. My wife was diagnosed with unresectable hilar intrahepatic cholangiocarcinoma last October and we have found great treatments that have held off the disease so far. The "unrestectable" tumor (according to Dr. DeMatteo at Memorial Sloane Kettering - Dr. Blumgart's heir apparant) was destroyed by Y-90 microsphere radioembolization performed at Wake Oncology by Dr. Andrew Kennedy in a two hour out[patient procedure that had no side effects. Very impressive although it sounds like it won't be applicable to your patient. They should also check out the University of Pittsburg where so cutting edge therapies for pancreatic cancer are being studied.

Wayne Parsons
wparsons@hawaii.rr.com
808-753-0290

make mine trauma said...

That is too bad. It is unfortunate at times that one cannot forsee the extent or nature of a disease without the exploratory laparotomy. He showed a lot of trust in you and you served him well. For what it's worth, I agree with bongi re chemo although I suppose that is ultimately the patients choice.

Unless you object, I agree with rlbates, I would like to include this post in SurgeXperiences 106

Buckeye Surgeon said...

Thanks for the info anon.

Buckeye Surgeon said...

Final path came back today: All specimens with poorly diffrentiated pancreatic CA. The choledochal node was almost completely replaced.