Cutting through the serosa of the pancreas.

Two videos I’ve made of surgery for pancreatic cancer was published on www.oncolex.no last week. The first one is a laparoscopic resection of the tail of pancreas. As always, the voice overs are in Norwegian, so I publish a short summary in English here.The patient in question has a tumor in the distal part of the tail of pancreas, together with several splenic infarctions. In this operation the tail of pancreas and the spleen is going to be removed en bloc.

The left colic flexure is taken down and the omental bursa is opened. Several varicose short gastric veins are visible between the liver and pancreas.

The splenic artery is identified and dissected above the pancreas, and the splenic vein below it. An endoscopic ultrasound probe is used to confirm that the area of the pancreas they want to cut through is tumor free. Both splenic vessels are then cut using an EndoGIA stapler. The pancreas is cut with a larger versio of the EndoGIA.

The varicose short gastric veins are then cut with several stapler magazines and the spleen is dissected from the diaphragm. There is a lot of inflammatory adhesions between the stomach and the spleen. These are carefully dissected and the stomach and spleen is separated. The specimen, consisting of the spleen and tail of pancreas is put in an endobag and removed via an umbilical incision. The remaining pancreas is covered with a surgical patch.

The final picture shows the specimen cut open with a yellowish tumor inside.

A gastroenterologist watching the monitors during an ERCP.

A video I’ve made of endoscopic retrograde cholangiopancreatography (ERCP) was published on www.oncolex.no yesterday. This is an endoscopic procedure used both for diagnosis and treatment of pancreatic-, gallbladder- and bile duct cancer. I provide a brief summary of the video here, as the voice overs are in Norwegian.

The patient is placed in the prone position. A duodenoscope, which has a sideways-facing camera and working channel, is used to locate the ampulla of Vater – where the joint common bile duct and pancreatic duct enters the duodenum.

A catheter is inserted into the ampulla, via the working channel of the scope, and is moved up into the bile duct. Radiocontrast is injected and the biliary ductal system is visualized using a fluoroscope. This patient has multiple blockages of the ducts, caused by infections.

A guide-wire is inserted into the catheter and the catheter is removed. A special brush is inserted and used to clear the blockages and to get material for cytopathologic analysis.

The last part of the video is from another patient and shows the placement of a self-expanding metallic stent in the ampulla of Vater.

Organs removed in the Whipple procedure.

A post over at IntraopOrate reminded me of a belief I held before knowing much about surgery. Reading it also coincided with an operation I was filming this week, in which the patient’s pancreatic tumor turned out to be inoperable.

Surgery is the last resort, right? You break your ankle and the fracture is so complicated you have to have an operation. Not good. I used to think this applied to all surgery, and I guess a lot of people do. But most of the time it’s exactly the opposite that is true, especially with cancer surgery. If you can have surgery, the disease is most likely not too advanced, and you have a chance of curation. If the tumor has infiltrated too many organs and vital blood vessels, surgery can do no good. The tumor is inoperable.

The Whipple procedure (image credit) is standard surgery for tumors on the head (caput) of the pancreas. Being suited for surgery is indeed a good sign for patients with pancreatic cancer. It is one of the most aggressive forms of cancer, and is often not discovered until it has reached an advanced stage, because it often does not cause any symptoms. How advanced the disease is can however be difficult to tell before the patient’s abdomen is opened.

The patient I was filming was thought to be operable. For three hours the surgeons dissected around the tumor and discussed if they would go ahead with the resection. They finally decided the tumor was technically resectable and started to remove the gall bladder. When moving on to the small intestine however, a number of small metastases were discovered. As they examined the entire length of intestine, more and more metastases were found. It was suddenly no point in completing the operation. His pancreatic cancer was too advanced. No bridges were burnt anatomically, so there was just a matter of closing the wound. The patient will be offered a palliative chemotherapy treatment, but the median survival from diagnosis is 3 to 6 months. For inoperable patients even less.