 A diagnosis of pancreatic cancer has long been the epitome of bad news for patients and a tremendous challenge for physicians. Now, the team of highly specialized surgeons at The Hodes Comprehensive Liver and Pancreas Center at St. Joseph Medical Center is meeting that challenge head-on with a multidisciplinary approach that includes the latest in minimally invasive surgical techniques.
Mark Fraiman, M.D., FACS, the Center’s surgical director, is focused on creating a specialty center where patients receive compassionate care and cutting-edge treatment. Dr. Fraiman trained at the University of California, Los Angeles (UCLA), one of the country’s highest-volume centers for complex hepatobiliary procedures. He later developed a reputation for successfully per- forming these procedures at various hospitals in the Baltimore area in a private practice model before partnering with St. Joseph to create the Hodes Center two years ago. “While the more complex liver and pancreas surgeries have traditionally been performed at major academic centers, my vision was to bring this type of surgery out to the community,” he says.
Last summer, hepatobiliary and pancreatic surgeon Richard Mackey, M.D., joined the center after completing his surgical train- ing and his hepatobiliary fellowship at the Cleveland Clinic. “Dr. Mackey brings the laparoscopic approach to surgery of the liver and pancreas,” says Dr. Fraiman. “It’s cutting edge because barely anyone in town is doing it.”
The center’s multidisciplinary approach means taking a fast track to diagnosis and treatment. With all of the cancer specialists under one roof, patients can attend multiple appointments in a very short period of time. The team, including gastroenterologists, hepatologists and interventional radiologists, meets weekly to discuss every case in detail.
The Whipple procedure (pancreaticoduodenectomy) is a complex operation to treat malignancies involving the pancreas, duo- denum or common bile duct. The Whipple procedure requires a large measure of skill and experience and is best performed in a specialized center. Dr. Fraiman is one of few surgeons in the area with extensive experience in performing this procedure as part of an aggressive approach to pancreatic cancer. “Surgery is the only chance for long-term survival of pancreatic cancer,” he says. “In keeping with my vision to bring this complex surgery to the community, we are doing it now in high volume and our outcomes are superior.”
That experience is essential for this type of surgery. According to the American Cancer Society, about 2% to 5% of patients die as a direct result of complications from surgery when this operation is performed in cancer centers by surgeons experienced in the procedure. When performed in small hospitals by doctors with less experience, up to 15% of patients may die as a result of surgical complications.
The Whipple procedure involves removing the head of the
pancreas, the duodenum, the distal bile duct and sometimes a portion of the stomach. A reconstruction is then performed by sewing the pancreas, bile duct and stomach to the small intestine. The operation takes three to five hours to perform. In addition to pancreatic cancer, the Whipple procedure is indicated for ampullary tumors, duodenal tumors, chronic pancreatitis, cystic neoplasm of the pancreas and rare pancreatic tumors.
A surgical evaluation should be part of every treatment evaluation when liver or pancreatic lesions are present. — Richard Mackey, M.D.
The demand for minimally invasive procedures is rapidly increasing across all surgical specialties. In the case of hepatobiliary and pancreatic surgery, the methods are extremely complex, according to hepatobiliary and pancreatic surgeon Richard Mackey, M.D., who came to St. Joseph Medical Center from the Cleveland Clinic. “This specialty requires fellowship training and a real specific interest in the benign and malignant processes that occur in the liver and pancreas,” he says. “In addition, you need to develop a different skill set to do laparoscopic approaches to those disease processes. Usually, that involves some level of advanced training and not many institutions are doing a lot of minimally invasive hepatobiliary work. The fact is that doing it at all is cutting edge.”
Dr. Mackey performs a variety of laparoscopic procedures at The Hodes Comprehensive Liver and Pancreas Center at St. Joseph Medical Center. They include:
• Hepatic liver resection. While certain anatomic locations lend themselves to a laparoscopic approach, not every liver lesion is amenable to laparoscopic resection. This approach is often indicated for segmental resections or partial hepatectomies. Patients that have malignant tumors resected laparoscopically have the same oncologic outcome as patients who have open surgery. The blood loss is comparable, if not better; incisions are smaller; and recovery times and lengths of stay are shorter. “It’s the same procedure with a different technique, a different approach and different tools,” Dr. Mackey says, “and with comparable if not better results.” Candidacy for the laparoscopic procedure is contingent mainly on location, type and size of the lesion and the extent of the disease. It’s important to have that decision made by a specially trained and experienced surgeon.
• Laparoscopic radiofrequency ablation. This non-resectional treatment for malignant diseases of the liver, both primary and metastatic, is a palliative procedure that is also used to control and potentially cure malignant tumors in a minimally invasive approach. Patients usually go home within 24 hours. Lap RFA is often used in combination with other procedures, such as hepatic resection. It’s important that patients be referred to a high-volume center in order for this procedure to be successful.
• Distal pancreatectomy. Removal of the left half of the pancreas can be done with and without spleenectomy, depending on the indication. Indications for laparoscopic distal pancreatectomy include benign lesions of the pancreas, specifically cystic neoplasms and some select solid lesions. In the case of known adenocarcinoma, it is often advised to proceed with a standard open resection of the tumor following diagnostic laparoscopy.
 In another highly specialized surgical procedure — hepatic resection — primary and secondary neoplasms of the liver are removed. The amount of liver to be excised is determined by the number and location of the tumors. Because of the liver’s ability to regenerate, up to 75% of the organ can be safely removed. The most common referrals for hepatic resection are patients with colon cancer that has spread to the liver, and patients with primary hepatocellular carcinoma (HCC).
Because of the liver’s dual blood supply and intricate anatomy, only surgeons with highly specialized training should perform this procedure,” Dr. Fraiman says. “Survival rates for patients with liver resections performed by a skilled surgeon can reach as high as 50% at five years.”
Larger tumors that cannot be treated by surgical resection are often treated with radiofrequency ablation (RFA). Electrical energy is delivered via a probe and is used to “burn” liver tumors without harming surrounding tissue. RFA can be performed as open or laparoscopic surgery by a skilled surgeon or as a CT-guided procedure by a skilled radiologist. RFA is also used as an adjunct to resection when multiple tumors are present.
Overall survival of patients treated with a combination of RFA and chemotherapy were proven to be significantly higher than those treated with chemotherapy alone. A three-year study at the Cleveland Clinic showed that patients with primary liver cancer had a three-year survival rate of 38% when treated with both modalities, compared to 10% for patients who had chemotherapy only. Patients with liver cancer that has metastasized from colorectal cancer showed a three-year survival rate of 60% when treated with both RFA and chemo, compared to 10% for patients who had chemotherapy only.
The ability to screen and find smaller tumors at an earlier stage, thus leading to more cures, is the goal for the next decade. Pancreatic cancer can be difficult to diagnose in the absence of symptoms; yet, in the case of cystic neoplasms, more benign pancreatic lesions are already being detected earlier and, therefore,patients are undergoing resection prior to developing a potential malignancy.
“It’s a common misconception that all pancreatic cancer patients do very poorly,” explains Dr. Mackey. “You have to get them referred
to a high-volume center. A surgical evaluation should be part of every treatment evaluation when liver or pancreatic lesions are present.”
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