History is Created with Successful Surgery of Rare Pancreatic Condition

A 67 year old lady presented before Dr Suddhasattwa Sen, with almost 4 months of delay accompanied with severe abdominal pain, which was unbearable. It has been already diagnosed as a very rare cystic tumor of Pancreas in body tail region called Serous Cystadenoma but probably had cancer changes to serous Cystadenocarcinoma which is extremely rare. 

After tests and observations finally the condition in the patient is detected as Serous Cystadenocarcinoma of Pancreas body, a very rare condition, only 15 to 18 cases reported so far in International Health Journals. The patient was refused surgery at most centers due to multiple blood vessels involvement. But operation was her only chance that could do total removal along with blood vessels and Liver blood vessel again re constructed. 

Dr Suddhasattwa Sen, who led team for the successful operation says, “Biggest happiness comes when you do something which you thought would be near impossible for you…BUT you do it, you feel happy.”

It was regionally advanced to involve splenic artery at its origin and also caused splenic vein thrombosis along with severe varices/collaterals at peri pancreatic area and splenic hilum. Also lymph nodes encased the main artery called Coeliac trunk from Aorta from where 3 main vessels arise namely Common Hepatic artery, Left Gastric artery and splenic artery. To add to difficulty tumor was apparently stuck to stomach and Superior mesenteric artery partially (SMA 2nd main abdominal branch from Aorta).

Speaking to News Sense, Dr Suddhasattwa Sen says, “Multiple biopsies done outside couldn’t prove malignancy so no Neo adjuvant chemotherapy could be given to try shrinking tumor so that operation becomes less difficult. 

It was deemed inoperable by many centers. And most didn’t want to do the operation but her pain was too severe and this was difficult case but not impossible. A famous cancer centre in Mumbai suggested that trial operation was only method to go ahead and before that we had seen and same was our opinion. We fail if we don’t give exams. We pass or fail if we do.

The patient has other co morbidities for which blood thinners were stopped and sugar of diabetes was controlled and with high risk we planned for OT. 

Dr Sen further adds, “We went in and it was horrendously difficult but with extreme caution and endurance we could dissect adhesions off from stomach and colon, we could dissect tumor out off SMA and we could also dissect extensive lymph nodes and tumors from Coeliac axis to spleen including Gerota s fascia which covers left kidney , it’s vein and left adrenal gland . (This is called Posterior RAMP aka Radical Antegrade modular Pancreatosplenectomy plane). Flow to hepatic arteries through GDA i.e gastroduodenal arteries was fine on clamp CHA test.”

But we could resect entire body tail Pancreas with spleen with Gerotas fascia with Coeliac axis partially at roots of Left gastric and splenic artery and re implanting CHA whose base was minimally cut to take specimen out on clean Coeliac axis, freely seen after lymph nodes removal. No inter aortocaval lymph nodes seen, no ascites, no Mets.  

So resection was justified. This is called Modified Appleby procedure with re implantation of CHA at Coeliac axis stump. The team has done quite few of these and RAMPS over last 4 to 6 years but this was by far the most difficult. Total OT time 3 hrs 15 minutes. Blood loss – 80 to 100 ml. She got discharged in just 6 days. Patient is doing fine and stable so far. 

Dr Sen rejoices the moment with his team and says, “Frankly WE DIDNT expect to succeed but only hoped that we could be better than our own fears and past break points. Especially because she was suffering and this was the only way to light at the end of the tunnel. A patient is a human with so many emotional ties. We have to keep fighting for all those emotions. We win most. Some we can’t.  Still try and hope and repeat. 

We did at Ashok NH which has seen Many of these surgeries over years by us but isn’t easy to do such cases in such places or for that matter anywhere. We do many similar GI HPB basic to high end to laparoscopy cases at AMRI too. Place is important, team and instruments more important, courage and endurance and diligence most important.  When there is will, there is a way. Not our 1st but definitely most difficult so far. Maybe next times even more steep climbs but then Exams are always failed if not appeared for.”

The condition was one of the rarest, 15 approx cases in History of World (till 2016) of SCNCA body tail Pancreas. Major Blood vessels encased but not involved. The surgery was successful and history is once again made inside the OT. 

Our fears limit our eternity within. Stress and heart thumps. But when the dusts settles, a smiling face and faces are worth everything.