The Department of Surgery at Cedars-Sinai provides consultation and treatment for pancreatic and biliary conditions that cannot be treated endoscopically or through other minimally invasive techniques.
Special Pancreatic and Biliary Surgery
Patients with chronic pancreatitis, a painful, incurable disease, often need surgery to relieve pain. Various procedures are available to do that. Surgically draining the pancreatic ducts can relieve pain in about one-third of patients. There are procedures that combine duct drainage with resection (cutting away of the pancreas head). The long-term success rate for those procedures is in the 80% range. Some patients may need to have the pancreas completely removed. Two recent advances in surgical procedures preserve the stomach, duodenum and bile duct. Cedars-Sinai also offers pancreatic and kidney transplantation.
Surgery (resection) is the only way to cure pancreatic cancer. Even with surgery, however, the survival rate is quite low. In over 90% of cases, helical CT and CT angiography can detrmine whether a cancer can be operated on. In some instances where it is unclear if the cancer can be operated on, further testing, such as an endoscopic ultrasound, MRCP, and/or laparoscopy, can further determine if the cancer is operable.
The extreme shortage of livers for transplantation has led to interest in live donors who are related to potential recipients. These would-be donors have to have a thorough evaluation before surgery. Part of that evaluation involves non-invasive imaging techniques called hepatic imaging. This can include endoscopic retrograde cholangiography (ERCP), magnetic resonance imaging and digital subtraction angiography (computerized images of blood circulation).
Extracorporeal Shock Wave Lithotripsy (ESWL)
Endoscopy is usually the first choice for removing pancreatic and bile duct stones in patients with chronic pancreatitis. But when the stones can't be removed endoscopically, extracorporeal shock wave lithotripsy (ESWL) is often used as a minimally invasive alternative.
ESWL crushes the remaining stones using sound waves generated by a lithotriptor placed outside the body. (It is commonly used to treat kidney stones.) First an ERCP finds the number and location of stones. Then saline is injected to enhance the sound wave penetration. The ultrasound locates the stones, and ESWL crushes them. Along with endoscopy, ESWL can significantly improve the success rates of patients undergoing nonsurgical treatment of chronic pancreatitis.
Laparoscopic Pancreaticobiliary Surgery
Laparoscopes are like endoscopes. Both have an optical system for seeing inside the body. However, endoscopes are more often inserted through the mouth or other natural opening. Laparoscopes tend to be rigid and are inserted into the body through small incisions.
Laparoscopic pancreaticobiliary surgery is delicate. It requires a great deal of skill, largely because of the complex anatomy of the pancreas and surrounding organs. A few medical centers, Cedars-Sinai among them, are experimenting with laparoscopic procedures for pancreas and liver resection (partial removal of diseased tissue), as well as draining pancreatic pseudocysts.
So far the medical community has had more experience with laparoscopic cholecystectomy (gallbladder removal). That involves making a small cut in the abdomen and inserting the laparoscope to capture an image of what's inside. Then, using surgical instruments inserted through other abdominal incisions, the surgeon takes out fluid and stones, and deflates the gallbladder so it can be removed through one of the small incisions. Recovery times are much shorter than with traditional gallbladder removal. Laparoscopic cholecystectomy is safe and effective for most patients, except those who are poor surgical risks. As a result, it's become standard in treating most gallstone cases.
Laparoscopy is also being used to remove stones in pancreatic ducts and treating patients with gastroesophageal reflux diseases. In cancer patients, laparoscopy is excellent for diagnosing and staging tumors in the abdominal region. Although it can add to the diagnostic expense, laparoscopy picks up finer details better than MRCP or CT scans.
More recently, laparoscopy has been paired with ultrasound in surgery (intraoperative ultrasound) to better guide the surgeon. This is especially so in cases involving liver, bile duct and pancreatic cancers. It overcomes the limitations of endoscopic ultrasound, which can miss some malignancies. Some believe that laparoscopic intraoperative ultrasound will become an indispensable tool in difficult pancreaticobiliary cases.
Pancreaticobiliary diseases are complex conditions that often require a multidisciplinary approach to the problems. Many diagnoses or treatments may involve injection of an X-ray contrast directly into the bile duct or placement of external drainage tubes to relieve blockages of the biliary tract. Our interventional radiologists are highly experienced and skilled in dealing with the most difficult situations in this area. They are also a key member of the expert team in managing biliary conditions in patients who have undergone liver transplantation.