Week 1 - Shadowing the Liver Transplantation, Hepatobiliary & Pancreatic Surgery Team

The first week of the program was mostly onboarding, familiarizing myself with the hospital environment, and settling down in Dr. Rohit Chandwani's lab.

I have discussed plans for my summer project with one of the postdocs working on the mouse and organoid models for pancreatic cancer. I have decided what pilot experiments to run for future collaboration to investigate the role of Rac1 in PDAC invasion and metastasis into the blood and lymphatic vessels. I will attend Dr. Chandwani's group meeting next week to better understand their studies and research projects on the epigenetic dysregulation of pancreatic cancer initiation.

Besides the lab work, I have also shadowed Dr. Chandwani on a pancreatectomy surgery on a pancreatic cancer patient. This was a challenging case due to the size of the tumor and the weight of the patient. It took a longer time to expose all the relevant organs (i.e. liver, pancreas, gall bladder, stomach, duodenum, and ileum) due to the thick subcutaneous layer. Since the tumor had not been metastasized to the liver, only the pancreas and the gall bladder (including the bile duct) were removed. Tumor mass blocking the hepatic duct was also cleared using the harmonic scalpel and electric scalpel. The small intestine was then stitched back to the stomach and liver using three anchor points. The whole surgery took about 7 hours. In the OR, I witnessed how biomedical devices (all kinds of scalpels) have advanced the surgical process for cancer patients. I also witnessed how the surgeon, residents, nurses, and the anesthesiologist worked together as a team to ensure the safety and wellness of the patient.

I also participated in the patient rounding in the hospital inpatient care unit. This was an absolutely astonishing experience when one witnessed how doctors work as a team to discuss each patient's case. The rounding team normally consists of an internist (a hepatologist or gastroenterologist in this case), a surgeon, two physician assistants, as well as a few medical fellows and residents. It was inspiring to see how a large number of test results were delineated, interpreted, and made sense through discussion, finally leading to meaningful clinical decisions (either increase or decrease the administration of a medication, or need further tests or biopsy).

I also had the chance to see a few outpatients, a wide range of cases ranging from 43-76 years old with surgical procedures performed three years ago to preoperation diagnosis. When a surgical oncologist is seeing a new case, they will normally have the following considerations:

1. Is it removable? If the tumor mass is too close to the arteries, conservative treatment with chemo or radiation is more suggested;
2. Has it spread? CT scan will tell if the tumor has spread to other places such as the liver (more common for pancreatic cancer) or lung (rare). The metastasized tumor is more challenging to be fully removed and would more likely to come back after the surgery. Other treatments such as immunotherapy will be recommended with the consultation with a medical oncologist;
3. Is the patient healthy enough for the procedure? Multiple physiological indices and the lifestyle of the patient will be taken into account.

Normally pancreatic cancer is very hard to be diagnosed until the late stage, unless the tumor mass blocks the pancreatic and bile duct, causing jaundice (clinical symptoms are yellow skin and eyes); in this case, the patient is "lucky" to have the tumor mass discovered early from CT scans. A tumor biopsy is normally performed before the procedure to see whether the tumor is benign or malignant. The false-negative result for a malignant tumor is surprisingly high: more than 30%, so regardless of the lab results a surgical procedure to remove the tumor is recommended. However, considering the age of the patient or other serious clinical conditions, a conservative treatment plan may be carried out after comparing the benefits and risks of the procedure. Genetic testing is also performed on the tumor sample after the procedure for any possibility of relapse or chemotherapy resistance. According to the most recent clinical studies, the sequence of chemotherapy and surgical removal of the tumor does not affect the clinical outcome, meaning that the patient can either receive chemotherapy before or after the procedure.

All the patients seen and treated by Dr. Chandwani had no sign of metastasis to the liver or the regional lymph nodes, nor any recurrence, which is quite surprising due to the high relapse rate of pancreatic cancer in other cases. This data is meaningful for my research on pancreatic cancer metastasis and immunity.

Meanwhile, I have identified a few challenges in the clinical diagnosis and treatment steps:

1. Gap in communication. Some patients do not speak English and require an interpreter to translate what the doctor is saying, which might cause misunderstanding easily. One patient was surprised when the interpreter said "you have a tumor but the tumor is small", but indeed what the doctor said was "you had a tumor and the tumor was small." The gap in communication would make doctors more difficult during diagnosis and care, and patients more challenging to follow doctors' orders.
2. Coordination with other departments in the hospital before the surgery. Many other steps are required before a procedure such as CT scans, cardiac echo ultrasounds, and COVID tests. Although the patient and surgeon would like to have the surgery as soon as possible to limit the progression of the tumor and alleviate pain, they have to coordinate with other hospital teams to make it happen.
3. Insurance coverage. Most of the time the insurance companies have certain preferred network hospitals. Even if you would like the most experienced surgeon to operate on you, you will have to be referred to another doctor in another hospital if your insurance and the hospital do not like each other.

Moreover, the COVID-19 pandemic also made it harder for patients who previously had surgery to schedule follow-up CT scans to check for tumor recurrence or other complications. Some patients are worried about the COVID virus and had not come back to see the doctor for over two years, while a complex surgery like this requires reexamination at least every six months for the first five years.