New Stanford Program Puts Pancreas at Center of Comprehensive Care Team
07.01.2012
Like tens of millions of Americans, Mitzi Moynihan had occasional, sometimes even frequent, digestive problems. She suspected the cause was acid reflux, and like many who experience similar discomfort, she reached for over-the-counter medication to quell the pain. Most of the time, those medications worked.
Then came the afternoon when the pain was overwhelming, and Moynihan went to the emergency room for help. The sensation was so intense that she needed a heavy dose of multiple prescription painkillers to relieve it. But it was not her stomach that was the problem. It was her pancreas, inflamed into a condition called acute pancreatitis. Follow up with your doctor, she was told.
More than 200,000 patients each year learn what Moynihan did—that the pain they think comes from the stomach actually stems from the pancreas, a somewhat wrinkled, hot dog-sized gland tucked behind the stomach between the kidneys. The pancreas is perhaps best known for the lethal cancer that can grow there, but it is workhorse of the digestive system. "After food leaves the stomach and reaches the first portion of the intestine, the pancreas releases enzymes that break down food so we can absorb its nutrients," said Brendan Visser, MD, surgical director of the recently established Stanford Benign Pancreas Program.
These benign diseases are certainly benign technically, meaning they're not cancerous, but that doesn't mean they don't cause a lot of pain and suffering.
The pancreas’'other job is to make insulin, the hormone that controls the body's use of its basic fuel, glucose. Those two functions put the pancreas at the heart of the body's nutritional chemistry; when things go wrong, however, the pain can be intense and the damage long-lasting.
The Stanford Benign Pancreas Program aims to shine a light on treatment for a long-neglected set of illnesses that arise in this often-overlooked but quite important organ. "We want to give more attention to these under-recognized pancreatic diseases," Visser said. "Pancreatic cancers, relatively rare in incidence, have had the bulk of the medical community's focus. The benign, far more common pancreatic disorders have had far less. Doctors learn less about them in medical school, so patients don't always get the care they deserve. These benign diseases are certainly benign technically, meaning they're not cancerous, but that doesn't mean they don't cause a lot of pain and suffering."
Gathering new knowledge
Even with a bit of extra knowledge, that pain and suffering are easy to understand. The pancreas is just, by nature, "a finicky little organ," Visser said. "It tends to bite back when you poke at it. When you're operating, as fast as you're trying to cobble it together, pancreatic juice is working to get out through the seams." The gland also can clog, and then the pancreas begins to digest itself, eventually leading to scarring, more pain and debilitated function. In short, pancreatic surgery is technically demanding and not to be attempted without great caution and respect for the risks involved.
After a thorough round of image-based evaluations at Stanford, Moynihan's gallbladder was found to have accumulated gallstones, which had likely caused the acute attack of pancreatitis. The images also showed something abnormal within her pancreas, possibly a small cyst, which would be checked out again after the surgery to remove her gallbladder.
She recovered quickly from that procedure. To get a better look at her pancreas, Moynihan's physicians ordered a test that extracted fluid from the lesion they had spotted. The cells, lab analysis showed, confirmed that Moynihan's pancreas had been harboring a cystic tumor. The tumor was producing a thick fluid, called mucin, which was blocking the pancreatic ducts, sending the gland's protein-dissolving enzymes to work on the pancreas itself.
That's when Moynihan sat down for a serious talk about her options with Visser, one of three pancreatic surgeons on the program's multidisciplinary team. She had heard great things about him from a friend who had been his patient, but she had also heard that he often recommended against surgery. That track record reflects the program's special approach.
It's been quite exciting to be able to bring togehter, to interact and partner with, some very bright individuals in their respective specialties who each bring a unique perspective to the disease.
"Pancreatic disorders have traditionally been treated by the surgical specialties because we haven’t really had any medications to offer," said gastroenterologist Walter Park, MD, medical director of the Stanford Benign Pancreas Program. "A lot has changed since then in imaging, in biopsy, in our knowledge of the underlying biology, and that has led to the diseases best being managed by a group of specialists who attack problems from a variety of angles."
This new knowledge has changed the surgery-first protocol to a comprehensive examination of all aspects of a patient's condition in a way that incorporates the latest research and emphasizes cooperative, coordinated care directed by experts in the field. The Benign Pancreas Program, Visser said, "is an attempt to bring in patients with these less understood diseases for care in one setting from a variety of specialists."
Acute pancreatitis is one form of pancreatic disease, with severe attacks often caused by gallstones, as was the case with Moynihan. Hospitalization is usually required. Most episodes are short, Park said. Chronic pancreatitis, in which pain can be a constant and eating becomes frightening, can be long term, with repeated bouts, Visser said.
I've done really well and I'm enjoying my life!
"We are still in the search for therapies that can effectively treat the pain without common side effects," Park said, "as well as trying to stop the process that initiates pancreatitis." Last year, Stanford launched the related, multidisciplinary Gastrointestinal Pain Program, which created a coordinated pathway for patients to see physician specialists in both pain and gastrointestinal disorders.
Focused collaboration
The Benign Pancreas Program is a large-scale, comprehensive group effort by experts to coordinate care of patients with pancreatic disorders. "It's a dream come true," Park said. "It's been quite exciting to be able to bring together, to interact and partner with, some very bright individuals in their respective specialties who each bring a unique perspective to the disease." Stanford has also built a large body of experience: It is consistently among the top five medical centers in California as measured by annual volume of pancreas operations. Each year, its physicians care for more than 600 cases of acute pancreatitis and 250 cases of chronic pancreatitis.
The program's team represents almost 20 clinicians in gastroenterology, radiology, pain management, nutrition, pathology, therapeutic endoscopy and endocrinology. Each plays an important role in care decisions, Park said. Pain, for example, can be a cardinal symptom of pancreatic conditions; the endocrine system is also affected, sometimes altered enough to trigger diabetes. Because the pancreas is so central to how the body processes food, its disorders often produce nutritional deficiencies. "It's hard to eat when you feel bad afterwards," said Neha Shah, MPH, the program's clinical nutritionist. "We help our patients translate the science of nutrition into practical food choices."
Diagnosis, and sometimes treatment, is enhanced with newer technology carried by endoscopes; the program has three experts in therapeutic endoscopy.
Another area of interest is developing new tests that could predict if a particular benign cyst might turn malignant, and which patient with chronic pancreatitis will develop more severe complications.
Visser also is one of a small handful of surgeons in the United States skilled in pancreatic laparoscopy, a minimally invasive surgical approach that avoids large, slow-to-heal incisions. He chose the specialty in part because of the challenge. "When I was a trainee," he said, "the pancreas was the jewel in the crown of surgery cases." Now, after more than 200 pancreatic laparoscopies, Visser is still on high alert. "Every case is its own challenge and every case has to be as perfect as a human can make it," he said.
Visser told Moynihan that her cyst was in the tail of the pancreas, on the left side, near the spleen. Deeper analysis of cells in the cyst revealed that they were certainly pre-cancerous. She could have chosen to wait, in that state called watchful observation, but did not want to live with the anxiety that comes from wondering when and if something has changed. She wasn't eager for any uncertainty, or being tested once or twice a year for years. Even if diagnosed at its earliest stages, pancreatic cancer is among the most lethal forms of cancer. Moynihan did not want to worry about what might be going on between tests. And she had complete confidence in Visser. "I was very comfortable with him, very impressed," she said.
Quick return to health
Visser’s laparoscopic approach meant Moynihan was home in a couple of days, going up and down her stairs on her first day home. The lesion was gone, and she had had less internal alteration to a neighboring organ than had been expected: Traditionally, because the blood vessels of the spleen are immediately adjacent to the pancreas, physicians have removed the spleen in such surgeries. But when allowed by the specific location of the cyst and the patient’s anatomy, Visser leaves the spleen to reduce trauma to the body. He was able to do that with Moynihan.
"I never felt bad and had any pain after the surgery," she said, and she has taken back the regular rhythm of her life. She’s a docent at the National Trust for Historic Preservation’s Filoli Gardens in Woodside, leading tours through its expansive acreage. She meets friends for outings and bridge games. She also delights in being an active grandmother of two little boys.
"She's had no troubles at all with the function of her pancreas," Park said. "She hasn't missed a beat."
As do many when they hear that a friend is having pancreatic problems, some of Moynihan's friends had been fearful for her. She's been happy to prove their fears unfounded. "I've done really well," she said, "and I'm enjoying my life!"