Pancreatic Cancer Surgery Improvements

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals, exploring the latest innovative research in clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig phase one and sarcoma programs. Today I'm happy to be joined by Dr. Matthew Walsh, Department Chair of General Surgery at Cleveland Clinic. He is here today to talk to us about surgery for pancreatic cancer. So welcome, Matt.

Matthew Walsh, MD: Thanks, Dale. It's a pleasure to be a guest.

Dale Shepard, MD, PhD: Yeah. Maybe start off, give us a little idea what your role is here at Cleveland Clinic.

Matthew Walsh, MD: So I'm Chair of the Department of General Surgery, which includes the surgical training programs and there are quite a few sections within the department spanning the 10 hospitals in northeast Ohio. There's over 110 staff in the department and its multidisciplinary focused, so it includes the majority, obviously surgeons, but also internists, psychologists to support our programs.

Dale Shepard, MD, PhD: Very good. We're going to talk about surgery for pancreatic cancer. So let's just start really general.

Matthew Walsh, MD: Sure.

Dale Shepard, MD, PhD: Patients show up with pancreatic cancer to either see you or see us in medical oncology. How many of those patients can have surgery?

Matthew Walsh, MD: Well, there are two basic forms of surgery, one is curative and one is palliative. Fortunately, what has changed with advanced imaging is that we don't do unnecessary or non-therapeutic surgery anymore. So it's rare that we don't proceed if we think we're going to be doing a curative resection in patients with pancreatic cancer. So the staging both in the abdomen of the pancreas itself and for metastatic diseases has a high fidelity to it. So what we're looking for in terms of surgery is to be able to achieve a 100% resection in terms of a negative margin and get adequate lymph node sampling. So that may be aided in some patients with new regimen therapy now as we have more powerful multi-drug regimens as you know. But the goal is to include surgery as part of the definitive treatment for pancreatic cancer, even though as you I think alluded to, the majority of patients unfortunately still today, when they're found, do not have curative disease.

Dale Shepard, MD, PhD: From a surgical standpoint, we think about big surgeries, Whipple procedures as kind of... always comes to mind when we think about doing surgery for pancreatic cancer. How has surgery sort of progressed through the years?

Matthew Walsh, MD: Well, we still have big surgery. One of the challenges, most people who go into this field of pancreatic surgery, which is what I do primarily, and I take care of both benign and malignant pancreatic disease, which there's quite a bit on both sides of that coin, but what has changed interestingly is the overall approach. It is interesting, the son of one of the founders, so George Crile was one of the principal founders of the clinic, Barney Crile, his son, wrote a fairly provocative paper in the 1970s saying no one should get a Whipple because the survival was so poor and the surgical outcomes were so bad. That has all changed fortunately and we're much better at doing the operation and having low morbidity and mortality and many things have contributed to that. Success in anesthesia, for ICU care, originally critical care, even though most patients, the vast majority, don't go to the intensive care unit after a Whipple now, and we have concentrated efforts on teams because things need to happen sometimes, whether it's an interventional procedure before or after the operation.

And we're very good now at looking at outcomes. And we're part of a NSQIP consortium of over 100 hospitals that compares our outcomes and it drives quality improvement. And I'm actually very proud of where we fall on that spectrum as a department in terms of pancreatic surgery. So what happens now is roughly our length of stay is five days actually in the hospital after a Whipple procedure, even open. So we pretty much try and span the perioperative care around advancing patients, getting them up, doing blocks on their abdominal wall for open surgery. And one of the things I'm interested in is pre-habilitation to get the patients in the best shape possible and we actually have a randomized trial for that now. So we're trying to really approach the surgical experience in a way that patients are going to do well, get out of the hospital and recover.

One of the things that does mean to improve is the role of adjuvant therapy. As you know, adjuvant chemotherapy, depending on what you think of its effectiveness, it's not going to work at all if patients don't get it. So a large proportionate over many decades never made it to chemotherapy afterwards. So that's one of the big goals, and it's one of the goals of doing minimally invasive surgery, which can be laparoscopy or robotic surgery.

Dale Shepard, MD, PhD: And I guess as the morbidity and mortality from the procedure has improved, has that increased the number of patients who can actually go to surgery and have a procedure even if...

Matthew Walsh, MD: Yes. Well, it has expanded the patients. I recall early in my career when I was a fellow in this field, I can tell you people didn't get a Whipple if they were over 70 and I've done people over 90. So the fact that it has become safer and most hospitals, including our own, have a less than 1 percent mortality rate, even though what's troubling still to most of us is the morbidity rate hasn't changed a whole lot over time, but we're just better at what we call surgical rescue, which is identifying a problem early and taking care of it so that patients don't succumb to a complication. But esophagectomy and Whipple procedure are probably the two highest morbid operations done and often those, as you know, are done for cancer.

Dale Shepard, MD, PhD: In many cases, there's a thought of decreasing what's taken out, for lack of a better way to put it, and minimizing the surgery itself. Has that been a consideration? Seems like the procedure's been kind of stable for a long period of time.

Matthew Walsh, MD: If we're talking about a Whipple procedure, then yes, that is the same operation whether we do it laparoscopically, open or robotically. The goal of minimally invasive surgery in that case is really to minimize the wound complications, allow patients to be up and mobile and hopefully back to return of normal function. In particular for patients with pancreatic cancer, get them to adjuvant therapy sooner. So those are the goals of it in terms of the Whipple procedure. In a distal pancreatectomy for the body and tail, we are seeing more precancerous or early cancerous lesions and the robotic procedures do allow us to preserve the spleen where that was never done before. So on occasion, we will add that component and the fidelity of the robot helps us preserve the spleen in a way that we save both the splenic artery and splenic veins. So that is one of the things that has changed with the minimally invasive procedure.

Dale Shepard, MD, PhD: And I guess just kind of help walk us through when we talk about minimally invasive, what that means compared to robotic surgeries.

Matthew Walsh, MD: So robotic surgery is the same as minimally invasive surgery, it still uses minimal access ports, so small incisions ports to access the abdomen. It's typically five or six ports depending on what you're doing. Patients really tolerate that a lot better. There is one bigger port where we have to extract the specimen, but pretty small. So laparoscopy and robotics fit into the same minimally invasive approach. And we do all of those approaches for pancreatic cancer, whether it's a Whipple procedure or a distal pancreatectomy. And the Whipple procedure robotically, we like it because of, again, the fidelity that the robot brings. So you can do things technically the same with a robot as you do open because the degree of flexion at the wrist is 270 degrees. So it can do more than I can do open actually. So using what we call straight sticks with laparoscopy is really aided by the robot.

And the optics are really excellent too, they're 3D optics with magnifications, so in auto focused, it's really fantastic. It does take longer and what we've noticed... So first off, you're taking a very complex operation, right? High morbidity, high stakes and the pancreas as you know lies on a lot of major blood vessels, bleeding is a potential serious complication, so it sort of proliferated widely, but not in any great volume. So honestly, even though quite a few hospitals tried it, it hasn't stuck at many places because actually some of the complications were higher and the outcomes weren't great if you weren't well trained. So what initially happened was looking at the feasibility, the technical feasibility of doing the operation. And that has been shown through many studies, including our own that shows that it is feasible to do safely.

But then the question is what is the added benefit? And some of that isn't so clear. It didn't revolutionize surgery the way going from open cholecystectomy to minimally invasive where laparoscopic cholecystectomy has done. It's still critically important to do the best cancer operation. What that means, certainly is to get negative margins and the technique shouldn't be the driving force for that because the differences aren't that remarkable, to be honest, to justify it just because and occasionally, including last week, I saw a patient who had a robotic Whipple done elsewhere where they cut straight across the tumor. Well that didn't help the patient at all. So you shouldn't ever compromise the operation just to achieve a certain technique. It is very much a team based approach I'll say. You have to have people that are interested in helping each other in the operating room, having a very experienced nursing team who's used to doing these advanced procedures as well as the surgical team. And we do it as a team, the HPB team, we operate together and so we can help each other, whether it's a robot case or an open case.

Dale Shepard, MD, PhD: I guess from a surgical cancer outcome standpoint, from the ability to reach things, better optics and things, has that changed the resectability? And when you think about vessel involvement and things like that, can you do things with a robotic approach that you couldn't do otherwise and make something resectable that might not have been before?

Matthew Walsh, MD: No, I wouldn't say that's true. You can do virtually everything you do robotically that you can do open with enough experience. We, like most places, do vein resections as needed and we tend to do them open just because we feel that we get a better operation that way, but they certainly can be done robotically. I wouldn't say it extends the capability of the surgery, but it at least is comparable and maybe better in terms of lymph node clearance just because of the optics that are involved with the robot, but not in terms of doing the operation differently. The operation is essentially... I tell patients the operation is the same and hopefully the morbidity is a little bit better and in our experience, in the typical experience, you might be home a day earlier.

Dale Shepard, MD, PhD: You've mentioned experience and that sort of thing a couple of times. What kind of volume center, if someone's listening in and they want to think about something from a robotic standpoint, how many of these should someone have done to be considered competent?

Matthew Walsh, MD: Yeah, great question. Competency certainly is different for individuals. I think the most important thing in terms of robotics is you have to be competent as an open surgeon to start. I guess one of the challenges in our field is that many of the HPB surgeons that do high quality open surgery haven't actually trained as minimally invasive surgeons and aren't as comfortable, especially with these very advanced procedures. So you need people who are comfortable with both and you can't do it alone, although the robot does allow you to do certain parts of the operation totally alone. But it's best to have colleagues who are experienced and can assist you in these advanced procedures.

There are some data that it may take over 200 cases to be really proficient at a robotic Whipple. I wouldn't say necessarily that's true, but at least 30 and many hospitals tried them and only did less than 10. And that's part of the problem. So a solo surgeon who's an HPB surgeon out there, remember the access... patients don't necessarily want to travel and so they'll often go to a local hospital. So although there are associations of volume related to outcome, it's not always surgeon, its hospital related because it is a team approach on many levels.

Dale Shepard, MD, PhD: How have we utilized the simulation center and things like that to help train the surgeons?

Matthew Walsh, MD: So Intuitive... Currently there's one major robotic company, and that's from Intuitive Surgical, and they are actually proactive and want to see their product used well. So they participate in a lot of the training. And we do have training simulation with robotics at the Cleveland Clinic in our simulation center. And we're geared now mostly towards resident training and fellow training.

Dale Shepard, MD, PhD: And I guess just sort of back to the patients may show up and they're interested in a particular type of surgery, I know in prostate that happened a lot, people, they really wanted robotic surgeries. Does this happen in pancreas and who's appropriate?

Matthew Walsh, MD: Yeah. That's an interesting question. It hasn't happened as much as I thought, to be honest. Patients are first interested if you're able to do surgery. Everyone... every patient is well aware that pancreatic surgery is not a favorable diagnosis to have and they know that if you're able to have a successful surgery, that's the key. And most patients want to hear that. And then they want to know how you think the best way to achieve that is. Some people will come specifically for that procedure and if they're a good candidate, meaning depends on the size of the lesion, where it's located, what's its association with the vessels, if they've had radiation therapy before, things like that. So those are very technical considerations and we consider all those. The majority of patients, we don't do robotically for that reason, but I think it's a great operation that we do include and it's nice that we have the capability and I feel that we do it well.

Dale Shepard, MD, PhD: If we think about pancreatic surgery, what are the gaps? Where do we need to get better?

Matthew Walsh, MD: Well, it would be great if we could really diagnose the disease earlier. That's probably the single biggest thing. I think the morbidity profile in terms of being able to reduce the fistula rate from the pancreas that is the Achilles heel of the operation. Actually, we're going to be participating in a trial looking at a way to reduce that complication, although we're very favorable compared to other hospitals in that regard. But that is the single greatest thing that leads to complications in morbidity is that leak. Unfortunately, that's often temporary and rarely requires operation. The other thing that we probably could do better as society is people who are resectable don't necessarily need a lot of preoperative testing in terms of some people who present with jaundice, but it's at a low level can go right to surgery, not everyone needs a stent. And if we facilitated some of the care paths that we promote and have developed here at the clinic, I think that helps patients tremendously reduce costs and get them to the appropriate therapy earlier.

Dale Shepard, MD, PhD: Excellent. I guess in the last couple minutes, in your role overseeing general surgery, thinking about minimally invasive or robotic surgery, where's the next frontier? Where's the next big area for progress?

Matthew Walsh, MD: So I think we're well positioned. We like to feel that if there's something happening in surgery, it's happening here as well. One of those is in the minimally invasive realm in terms of living liver transplant donation. And we do that minimally invasively with laparoscopy and we're starting a robotics program in that. And actually, we are the biggest program in the country and that really has expanded the donor pool for living related liver transplant. And the outcomes have been fantastic. So that's a real revolutionary approach that is new. And we do very innovative gut rehab surgery and intestinal transplant as well as robotic, speaking of robotics, around the whole area of hernia care that were on the cutting edge of. So there's a lot of things in surgery that are both novel techniques open as well as minimally invasively.

Dale Shepard, MD, PhD: Very good. Well, you've given us some great insight today. Thanks for being with us.

Matthew Walsh, MD: It's been a pleasure, Dale. Thanks.

Dale Shepard, MD, PhD: To make a direct online referral to our Taussig Cancer Institute, complete our online cancer patient referral form by visiting clevelandclinic.org/cancerpatientreferrals. You will receive confirmation once the appointment is scheduled.

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