At the Edge of Innovative Care

EHM talks to Andrew Warshaw of Massachusetts General Hospital about the importance of minimally invasive techniques in diagnosing pancreatic cancer.

“MGH is not a factory or a clinic model. It’s a personal physician model, and we as surgeons get personal with our patients”
-Andrew Warshaw, Massachusetts General Hospital

A man of multiple layers, Andrew Warshaw is not just a surgeon. He spent nearly four decades in the area of academic surgery, focusing specifically on pancreatic diseases and using his findings in his academic writing and mentoring faculty. As a faculty member at MGH since 1972, his focus has been pancreatic cancer, and he has watched as the field has dramatically changed since the time, owing to new tools to investigate the disease.

“When I started we didn’t have CT, ultrasound, ERCP or any kind of invasive measures of evaluating the pancreas. All of that has come in and allowed us to increase our knowledge of pancreatic diseases exponentially. That has then led to the development of new techniques, new understanding about disease processes and increased safety,” Warshaw explains.

He points to the example of a Whipple operation for pancreatic cancer producing statistics of a 25 percent mortality rate in the 1970s and the contrast of that to 2009, where it now has a two percent mortality rate with a higher number of patients treated each year. 

One operation that Warshaw developed himself is the middle segment pancreatectomy; there is now much more laparoscopic work done around the pancreas and Warshaw and his team have developed a whole new field of understanding of the pancreatic cystic neoplasms and the development of these into cancer. In the 1970s, pancreatic tumors were still not understood as a separate group of pancreatic tumors.

Research
“My laboratory concentrated for the first 20 years on understanding the pathogenesis and mechanisms, and so the treatment of pancreatitis has now switched entirely to pancreatic neoplasms, and the research world has become a world of molecular biology and cellular biology. We’re trying to understand the cellular machinery that makes the cancer in the pancreas. We’ve got wonderful young scientists who understand much more than I do now about the basic genetics, genomic, and proteomics of pancreatic cancer and we’re trying to figure out how to deal with it at that level, not just at the surgical level.

The development of the middle segment pancreatectomy was first done in the MGH in 1998, the previous method before that time being either a distal pancreatectomy or a Whipple operation, depending on which side the tumor was located. “Very often the tumor sits in the middle or close to the middle and it’s very wasteful to throw away a lot of good, normal pancreas to get a small benign tumor out. We asked the question, ‘Why do we have to do that?’ and decided that rather than using the previous method, we would take out a slice, a segment in the middle instead that gets rid of the tumor, and then it becomes a matter of how do you put things back together?

“You can’t reattach the two remaining pieces of the pancreas, so we sewed up the one on the head of the pancreas side, the right, and brought a loop of intestine up to give drainage to the remaining body and tail, and that works. Now we’re doing an increasing number of those, especially as we’re finding more appropriate tumors to do it for, such as cystic tumors and neuroendocrine tumors. We probably do 30 or 40 a year now of those, which didn’t exist 10 years ago,” explains Warshaw.

Invasive techniques
MGH’s minimally invasive techniques have produced huge benefits to patients over the past 40 years; by saving more pancreatic tissue, there is a far lower risk of patients developing diabetes. Warshaw also used invasive techniques when he developed laparoscopy for staging pancreatic cancer in the early 1980s, allowing physicians to look for potential metastatic lesions that didn’t show up on CAT scans.

Since then, the department has streamlined this technique further to define which patients it is appropriate for, and in the next phase of development, the team developed approaches to treatment, not just diagnosis or staging. “We’ve developed treatments in a number of directions. In the pancreas, the distal left-sided pancreatectomy is commonly done with a laparoscopic technique. There are people in the world who’ve done Whipples laparoscopically. From my point of view that’s overkill and foolish and perhaps even dangerous and serves no real advantage.

“In other areas, laparoscopic colosesectomy took the world by storm in 1990 and now the laparoscopic techniques are pretty routine for colectomy. They’re being advanced for esophagectomy and a number of other inter-abdominal types of resections and repairs.

“The next generation of minimally invasive approaches is endoluminal. Whether it’s fixing the gastroesophageal reflux by going down the esophagus and using one of a variety of techniques that are being developed or actually going through the wall of either the stomach or the esophagus, or coming up from the other end, the colon, the rectum or even the vagina, people are using natural orifice transluminal endoscopic surgery. So nothing through the skin but only through these natural orifices.”

This approach is very much a throwback to early experimental approaches to surgery. MGH is highly involved in this technique, and it is currently in its developmental phase. However, the extent of this development is dependent not only on new techniques and instruments, but also on the knowledge and definition of what are the appropriate operations to be carried out. “We don’t yet know the advantage of doing something such as this and what the added risk of infection will be. That’s a very early potentially exciting area that we’ve been working on here. One of my division chiefs is highly involved in that with a group of colleagues in the lab.

 “There’s a potential danger that one hopes that people don’t do something in a minimally invasive way because they can, rather than because it’s the best way, but there are sometimes even economic drivers. Back in 1990 what drove laparoscopic colosesectory was a marketing explosion. Why would you want to have an open operation when you could do it laparoscopically?

Advantage
“It turns out that that was perfectly correct but sometimes you have to be able to show an advantage. If there’s an advantage in terms of safety or an advantage in terms of length of hospitalization, or an advantage in terms of injury to the body or scars, then you can justify it. Sometimes people do because they can. The mountain is there so you climb it. We’re obligated on all of these to test the cost benefit ratio of any of these putative advances,” he says.

More and more invasive techniques being used, and used correctly. Warshaw notes that as new technologies are developed, more can be achieved than was ever envisioned. His division is particularly keen on using a multi-disciplinary approach to various treatments, and the benefits have been far reaching.

“Increasingly in a number of disease processes, there may be benefits to more than one modality of treatment; for example, surgery plus radiation or surgery plus chemotherapy or surgery plus chemotherapy and radiation, or alternatively chemotherapy or radiation and not surgery. So the multi-disciplinary approach often benefits cancer in particular – although it’s also true for inflammatory bowel disease, ulcerative colitis and Crohn’s disease.

 “As soon as you have competing approaches or competing technologies or complementary approaches, it’s good to have the proponents and experts from each of those have a consensus about treatment. If it isn’t strictly cookie cutter, it’s good to be able to come to a consensus about treatment for individual patients, and not have patients have to run from my office today to somebody else’s office across town tomorrow or the next day.

“If you get everybody together and you make a consensus decision after hearing the same discussion, there are great benefits to that. A real paradigm to that has been when the multi-disciplinary breast clinics have become the state of the art in managing breast disease, at least in an institution like this.

“However, there is a big drawback. For the individual physician participant, it can be horribly inefficient. The difference between my seeing however many patients an hour I can see in my office versus sitting in the multi-disciplinary clinic doing one patient an hour and hearing a lot of things that I perhaps didn’t need to hear or didn’t contribute, it’s a time sink from that point of view. The balance is what’s better for the patient versus what’s better for the physician and I think that the multi-disciplinary clinics for the right sorts of disease processes are, at least in an institution like this, valued,” explains Warshaw.

Patient care
Ascertaining the correct balance between the needs of the patient and the efficiency needed by the physician is something that MGH certainly pride itself on. According to its own survey, 99 percent of patients say they would recommend MGH general surgery to a friend or family member, and the hosptial seems to be striking the balance. Warshaw attributes these glowing results to the ‘MGH culture’ of placing great value upon the personal relationship between the patient and physician.

“MGH is not a factory or, in a pejorative sense, a clinic model. It’s a personal physician model and we as surgeons get personal with our patients. We make a relationship, maintain a relationship, and people look at us as their doctors. It’s quite usual for patients to come from long distances, not just the local region, and we treat a lot of people from out of region or even out of state or out of country,” he says.

The clinic’s treatment of the patient does not simply end with the closing stitches of the operation. Its doctors pride themselves on maintaining a long-established relationship with each individual patient, and it is this quality that differentiates it as a healthcare institution.

Andrew Warshaw is a graduate of Harvard College and of Harvard Medical School. His residency training was at Massachusetts General Hospital. He also spent two years as a Clinical Associate in the Section on Gastroenterology of the National Institutes of Health. Since 1972, he has been on the staff at the Massachusetts General Hospital and the faculty of Harvard Medical School. In 1987, he became Professor of Surgery at Harvard and in 1997, the W. Gerald Austen Professor of Surgery, Surgeon-in-Chief and Chairman of the Department of Surgery at the Massachusetts General Hospital.