Our Approach to the Treatment of Pancreatic and Liver Disease

"Pancreatic and hepatobiliary surgery" is surgery of the pancreas, liver, and bile ducts, including the gallbladder. 

We at Maryland Surgeons believe that the relationship between patient and surgeon is crucially important to providing top-notch and personalized care.

Our surgeons work closely with our patients to ensure that the best possible treatment is provided in a caring and compassionate setting.  We aim to ensure our patients understand clearly their disease and how each treatment option will benefit them.

Maryland Surgeons are highly skilled in pancreatic and hepatobiliary surgery and use state of the art equipment and advanced techniques when they perform surgery.  Depending upon the patient, our surgeons can perform minimally invasive (laparoscopic or robotic) surgery.  These surgical techniques offer easier recovery, increased precision, and improved cosmetic outcomes.

Saint Agnes is a high-volume pancreatic and hepatobiliary surgery center and both Dr. Patel and Dr. Cunningham are board-certified, fellowship-trained experts.   

We specialize many pancreatic and hepatobiliary procedures, including the following:

Pancreatic procedures

• Whipple operation (pancreaticoduodenectomy)
  • The Whipple is an operation in which the head (the right side) of the pancreas, the duodenum (sometimes with part of the stomach), and the lower bile duct are all removed.  And the remainder of the pancreas, the bile duct, and the stomach are all reconnected to the small intestine. It is generally done for cancers or precancers occurring in this area.  Because it is a complex operation, it should be done by a specialist in a high-volume institution, such as Saint Agnes Hospital Center.  
    
    Click here to see Dr. Cunningham discussing the Whipple operation.  Dr. Patel and Dr. Cunningham will spend time explaining this a clear and straightforward way in the office using a color-illustrated diagram.
• Distal (or left) pancreatectomy
  • A distal pancreatectomy is done for lesions of the body and tail (the left side) of the pancreas.  As in the Whipple operation, these lesions may be cancers, precancers, or other lesions.  Unlike the Whipple, no reconstruction is necessary, because the connections of the pancreas to the GI tract and the bile ducts is not removed (as it is in the Whipple operation). 
• Pancreatic debridement and drainage
  • Sometimes pancreatitis can be so severe as to require surgery.  This is referred to as pancreatic debridement and sometimes includes drainage of the pancreas through a “back-door” to the intestine if the usual “front door” drainage is not available due to having been too damaged by the pancreatitis. 

Liver procedures

• Major and minor partial hepatectomy
  
  • "Hepatectomy" means removal of liver.  Partial hepatectomies are typically done for a variety of liver lesions, such as cancers, precancers, and cysts, and may be done with minimally invasive surgery or traditional open surgery.
• Liver biopsy
  • Liver biopsy is often done to help diagnose a liver mass, such as a tumor, or to test the liver for scarring, or cirrhosis.
• Drainage of liver cysts
  • Liver cysts, even when benign, can sometimes be so large as to require surgery to unroof (permanently drain) them.  This can almost always be done with minimally invasive surgery (laparoscopic or robotic surgery).

Biliary procedures

• Bile-duct resection
  
  • Bile-duct resection is removal of the bile ducts, typically for cancer or precancer of the bile ducts.  Because the bile ducts are the way that bile gets from the liver to the intestine, the flow of bile is re-routed to the intestines after bile-duct removal.
• Simple cholecystectomy [ko-lee-sis-TECT-o-mee]
  • Simple cholecystectomy is removal of the gallbladder, as is done commonly (nearly one million times per year in the USA) for gallstones, etc.  It is almost always done with minimally invasive surgery (laparoscopic or robotic surgery), but sometimes requires open surgery.
• Extended cholecystectomy
  • An extended cholecystectomy is typically done for gallbladder cancer.  Because the gallbladder is attached to the liver, gallbladder cancer cells sometimes invade the liver such that simple cholecystectomy may leave behind cancer cells.  An extended cholecystectomy, by contrast, removes a small portion of the liver attached to the gallbladder so that all the cancer cells are removed.

Please contact us at (443) 574-8500 to set up an appointment or to get more information about how our surgeons can help you.

Frequently Asked Questions – Pancreatic and Hepatobiliary Surgery

Overview

Q. What is a "lesion"?
A. A "lesion" of the pancreas is just a fancy word for a spot, or any abnormal area of the pancreas or liver (or any organ).  Lesions are often found in the pancreas and liver and may be benign (not cancer) or malignant (cancer).

Q. What are the pancreas, liver, and bile ducts, and what do they do?
A. Pancreas:  Even though to the naked eye it looks like just one organ, the pancreas is really two organs in one, and the difference is obvious under a microscope. One “organ” or part of the pancreas serves an exocrine function and the other part an endocrine function.  The exocrine cells of the pancreas secrete digestive enzymes into the intestine that help to break down your food into useful parts that can be absorbed by your intestines into your bloodstream.  The endocrine cells of the pancreas secrete hormones like insulin directly into your bloodstream to help your body handle sugar.

A. Liver:  The liver the largest solid organ in the abdomen.  The main functions of the liver are to produce the many proteins that perform important bodily functions, to make the bile that helps to digest food, to store energy, and to metabolize chemicals, medicines, and other molecules.  It is the only organ that has such a tremendous ability to regenerate itself. Sometimes, because of tumors, infections, or injuries, a surgeon may have to remove, or resect, part of the liver. Eighty percent of an otherwise healthy liver may by safely removed without major change in liver function.  From the remaining 20%, all or most of the missing 80% will grow back again, much like the remaining branches of a pruned tree or bush will get bigger after pruning. The liver will not need to regenerate if only a small portion is removed.

A. Bile ducts:  The gallbladder functions to store and concentrate bile, which is a solution mostly of salts and fats.  When you eat a meal, the gallbladder squirts the stored bile out through the gallbladder’s bile duct (aka the cystic duct) to the main bile duct, then into the intestines to help digest your food.

Q. What are pancreatic and hepatobiliary cancers?
A. Pancreatic cancers may arise from one of two parts of the pancreas, the part that makes digestive enzymes (adenocarcinomas) and the part that makes insulin (neuroendocrine tumors).  Hepatobiliary cancers are those of the liver and bile ducts.  Liver cancers include both primary cancers of the liver (that start in the liver) and metastatic cancers of the liver (that spread to the liver from some other place, usually in the GI tract).  Bile-duct cancers include those that arise from the gallbladder as well as the bile ducts themselves.  All of these types of cancers are treated surgically.

Pancreas

Q. What is pancreatitis?
A. Pancreatitis is inflammation of the pancreas gland.  It is usually treated without surgery, but in some cases of very severe pancreatitis, surgical help is essential.  Our expert pancreatic surgery team has experience with the full range of state-of-the-art surgical treatments for pancreatitis, as well as pancreatic and hepatobiliary cancer.

Q. What are some common risk factors for pancreatic cancer?
A. Pancreatic cancer is one of deadliest cancers due to the symptoms not arising until the later stages of the disease.  Patients often present with yellowing of the skin and eyes, commonly referred to as jaundice.  The most common risk factors include current smokers and those with a history of smoking, a family history or pancreas cancer, a personal history of chronic pancreatitis, and increased age. You can lower your risk by quitting smoking.

Q. What are the different kinds of pancreatic lesions?
A. There are many different types of pancreatic lesions:

• Pancreatic tumors can originate from either the endocrine cells or the exocrine cells of the pancreas.
• Either type may be benign or malignant.
• In addition to solid lesions, cystic lesions can also occur commonly.
• Pancreatic cysts are increasingly common and some have a high chance of harboring a cancer or a precancerous area, while others do not.

Q. What are pancreatic cysts and should I be worried about mine?
A. Pancreatic cysts are common and may be found incidentally on tests done for other reasons or may cause symptoms leading to imaging that may reveal their presence in your pancreas.  There are many different kinds of pancreatic cysts:

• Some of these cysts have a high incidence of cancer and should be removed, whereas others are safe to observe without an operation.  
• Figuring out which is which is complex and requires a careful evaluation.  During his training at Johns Hopkins, Dr. Steven Cunningham designed a Pancreatic Cyst Worksheet for Johns Hopkins to help other medical professionals accurately diagnose pancreatic cysts.  You can also see a video of Dr. Cunningham discussing pancreatic cysts here.

Q. How is the pancreatic cancer treated?
A. Pancreatic cancer is typically treated through surgery, radiation, chemotherapy or a combination of these treatments. All pancreatic cancers are treated with a multidisciplinary approach.  The experts that are typically involved in a multidisciplinary team include:

• Liver surgeons
• Medical oncologists
• Radiation oncologists
• Hepatologists
• Gastroenterologists
• Diagnostic and interventional radiologists
• Pathologists
• Genetic counselors

Surgery is the most common method of treatment. Your surgeon may recommend removal of the part of the pancreas that has the cancer or precancerous area. Some pancreatic operations can be done in a minimally invasive fashion, including laparoscopy and robotic surgery.

The most common surgical treatment is called the Whipple procedure, which is done for cancers or precancerous areas in the head of the pancreas. In this operation, part of the pancreas, part of the stomach, the gallbladder, the first 10% or so of the small intestine and the lower bile duct are removed.

For cancers or precancerous areas in the body or tail of the pancreas, a distal pancreatectomy is often performed.  Both are complex procedures that require an experienced surgeon.

Chemotherapy is often used for pancreatic cancer, sometimes before surgery, sometimes after, and sometimes both.  Our multidisciplinary team will help you figure out which is right for you.

Radiation treatment is sometimes used to shrink the tumor before it can be removed with surgery.  Similar to chemotherapy, radiation is sometimes used before and sometimes after surgery.

Liver

Q. What are the warning signs of liver cancer?
A. Some common indicators include weight loss, nausea and pain, swelling or tenderness in the liver, and yellowing of the skin or the whites of the eyes (jaundice).  Consult your doctor immediately if any of these symptoms occur.

Q. How is liver cancer detected?
A. Liver cancer is detected using blood tests or imaging exams like a CT scan, MRI scan or ultrasound.

Q. What causes liver cancer?
A. There are several risk factors for liver cancer:

• Men are more likely than women to develop liver cancer
• Those with a family history of liver cancer may have an increased risk
• Heavy alcohol use
• Liver diseases such as cirrhosis or Hepatitis B and C

Q. What are the different kinds of liver lesions?
A. Just as for the pancreas (see above) there are many different kinds of liver lesions:

• Liver cancer
• Colorectal cancer that has spread to the liver
• Neuroendocrine (aka carcinoid) tumors that have spread to the liver
• Gallbladder cancer
• Bile-duct cancer
• Benign lesions such as liver cysts, blood-vessel deformities such as hemangiomas (which are like birthmarks of the liver) and adenomas (benign growths - similar to polyp of the colon - that can rupture, bleed, or become cancer)

Q. How is liver cancer treated?
A. At Maryland Surgeons, we take a multidisciplinary team approach to find the right diagnosis, and to design the best individual plan for you personally.  We will help you understand your diagnosis and treatment options. The experts that are typically involved in a multidisciplinary team include:

• Liver surgeons
• Medical oncologists
• Radiation oncologists
• Hepatologists
• Gastroenterologists
• Diagnostic and interventional radiologists
• Pathologists
• Genetic counselors

Our patients are offered a full range of multidisciplinary state-of-the-art diagnostic and treatment modalities:

• Surgery is the most common method of treatment.  Many liver operations can be done in a minimally invasive fashion, including laparoscopy and robotic surgery.
• Chemotherapy is often used for most types of liver cancer, sometimes before surgery, and sometimes after.
• Radiation treatment is sometimes used to shrink the tumor before it can be removed with surgery.
• Ablation is used to destroy (usually with very high temperature) liver tumors instead of removing them. The two main types of ablation are radiofrequency ablation and microwave ablation.  Both types can be done either with a percutaneous approach (by interventional radiologists, without surgery, using a needle through the skin) or with an operative approach.
• Transarterial therapies are those treatments that are given through a catheter placed into an artery, like the way heart stents are placed.  These therapies may be used alone or with surgery or ablation.
• Portal-vein embolization is sometimes used as a bridge to surgery.

Bile ducts

Q. What is a bile-duct cyst?
A. A bile-duct cyst is a choledochocele [ko-lee-DOUGH-ko-seal], a precancerous cystic enlargement of the bile duct.  They are uncommon but the most common type is called type 1.  These cysts have an unknowable exact risk of developing cancer within the cyst, although it is probably between 5% and 30%.

Q. What causes gallbladder problems?
A. Just like a supersaturated solution of salt water will tend to form crystals of salt, stones can form from the concentrated bile in the gallbladder and then can block the gallbladder duct, which causes pain, and can cause inflammation and even infection.  Some risk factors include being female, pregnant, and overweight, but gallbladder disease is very common in all kinds of people.