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Jessica: Hi guys. Welcome back to The Absite Smackdown podcast. This is your host, Jessica. And with me today is Dr. David Kashmer. Hey Dr. David!
Dr. Kashmer: Hey Jessica. Good to be back again and look forward to talking with you today.
Jessica: Well, we actually have kind of an interesting topic for our podcast today. It is called don't F*ck with the pancreas.
Jessica: Well, I laughed when I heard this, I think I was asking you about a splenectomy and I was trying to find the right kind of picture for our Instagram post and I was talking to you about it. And that's when you told me that saying, and I didn't really understand why. And I was like, explain that. Why is that so well known? So why don't you tell us why that's a saying!
Dr. Kashmer: Well, probably by now, a lot of the listeners know already that the pancreas is kind of a, I don't know, sensitive organ. When it does get disrupted, especially when there's ductal disruption, it leaks. And the way this comes up with splenectomy is in about 10% of patients, the tail of the pancreas, the very tail sits almost in the splenic parenchyma, and you take out the spleen and you send it to pathology and they say something like “trace pancreatic tissue” and you go, Oh my gosh, that went with the spleen. And I was amazed when I used to do organ transplant when I'd be prepping the pancreas on the back table. That statistic is really true. I didn't appreciate it as a general surgical resident. I didn't appreciate it when I did trauma as a general surgery resident, but yeah, that tail of the pancreas, no joke, the very tip of it lives in the spleen.
Dr. Kashmer: So when you put this large clamp across the hilum of the spleen, it sure is important to try to put it as much to the spleen side, even into the splenic parenchyma and just make sure that the big tie you put around it (zero silk or whatever you choose to use) is nice and firm and occlusive.
And so people will do all these things. Jessica, like clip the area, tie it twice, etc. etc. all to try to protect against the pancreatic leak. And just to make sure the pancreas doesn't sort of start to digest itself away. And a lot of people leave drains. even though there's some evidence that increases sub phrenic abscess, but they'll leave drains.
If they're concerned about the tail of the pancreas being involved or the tail of the pancreas being injured as part of the trauma in those situations, they'll leave drains to monitor, but usually not routinely. Long story short: the pancreas seems like it's pretty sensitive and when it gets hurt, it almost hurts itself more. And the surrounding organs more. If it leaks it digests itself. It sort of digests itself away. There's of all these zymogens and things like that. And it starts to auto-digest.
Jessica: I don't know if sensitive is actually the right word for that.
Dr. Kashmer: Yeah. I don't know. And it's interesting because it turns into this soapy appearance and when you have a drain in the area, you can shake the fluid in the drain and it kind of bubbles, and that's a hint that it's undergoing, what's called saponification of the fat and the surrounding tissues. And it looks like soap in the drain. Anyhow “sensitive” is sort of an understatement.
Jessica: So what you're telling me right now is that the pancreas can, if disrupted, make soap Fight Club style is what you're saying. Hahaha.
Dr. Kashmer: Well, yeah. Sort of Fight Club style…that was a great movie. And yeah, I remember the Brad Pitt character, you know, they go to get this a human fat to make soap. That's what you're talking about.
Fight Club is a great movie. Anyhow this is one tough organ.
Anyhow it's really interesting that you mention Fight Club that because one of the people who taught me pancreas transplant, when I was a transplant fellow, used to say that pancreas transplant is like street fighting. So it's kind of interesting. You bring up Fight Club and he would say that because it's really hard to monitor for rejection. If you have a pancreas after kidney (PAK) or a pancreas alone transplant, you don't have the kidney to biopsy (as you do in a simultaneous pancreas and kidney transplant) to help see pancreas is rejecting because in a PAK the organs are from different people. They may not match up.
And so he used to say, yeah, you just kind of have to use your best guess as to whether it's rejection. And he used to say, pancreas transplant is like street fighting. It's tough. It's not really glorious when you do whole organ transplants. So it's actually really funny that you mentioned Fight Club in the context of saponification.
Jessica: Oh, it was just the visual I got, I don't, I can't control where my mind goes. It is odd to me though that people do pancreas transplant even though the old saying is “Don’t F*ck With The Pancreas”.
Dr. Kashmer: Well. Yeah. That's part of why I was interested in learning more about transplant. My residency was not as strong in foregut procedures. And that actually is very common in modern residencies, the foregut procedures, like ulcer disease, et cetera, has really been affected by proton pump inhibitors and all these meds you can take for ulcers now. And so we don't get around that area that much and the exposures are not as common. Meaning we don't set the area up to be operated on much because we're not there that much. So I was really interested in transplant. And then I learned that, wow, we actually, we transplant the pancreas. I mean, of course I'd heard of it as a medical student and a general surgery resident. I mean, I knew it happened, but I was thinking to myself, boy, after being taught as a general surgery resident “don't F with the pancreas” that's like the ultimate f-ing with the pancreas. To put it in another person is no joke. And so I really wanted to understand how that happened and how it works. And so that was one of the attractions for me to learn about it.
Jessica: I just find that completely fascinating. It's almost counterintuitive to what you first learned and then going into transplant and then getting to “f with the pancreas”.
Dr. Kashmer: In major ways. That's totally true. And, there's a lot of those things in general surgery residency, where we learn the basics and they're really important. And then after you were through that, you may go into your subspecialty and you learn, you know, kind of the next level about it. There are a lot of things like that. And pancreas surgery is definitely one.
Jessica: So really the Absite is just basically the building blocks for everything else for you as a surgical resident, it's like the start.
Dr. Kashmer: My feeling is that you can't progress to the higher level things until you've learned the ABCs really well. And a lot of what's on the Absite, the content that's covered, I would send the review book. It is almost the least you need, at least you need to know, and they're kind of like surgical truisms and the aphorisms and all these things that are really just the basics. And then after you've done that, you say, okay, you know that, but that's not really the way anymore. Now we're better at treating rejection. Or now we have a lot more success with a liver transplant and pancreas transplant than we did with the classic review book level stats, which aren't exactly the way it is anymore. So yeah, Jessica, there are actually a lot of things like that in general surgery.
Jessica: Well, yeah, I think it's teaching the common, not the exception. So when you know the common, then you can learn the exception later.
Dr. Kashmer: That's a really good point. Yeah.
Jessica: So do you have any other points or any interesting stories that you would like to share about a time that maybe you or someone you worked with f-ed with the pancreas?
Dr. Kashmer: Well, yeah, there are a lot of these, you know, I've got a bunch, I want to say a couple things since I have the time and your ear, and there's some people listening.
Everybody jokes around about pancreatitis from a scorpion bite. And it's when you ask medical students, you know, what causes pancreatitis. They say all these medical things, including thiazide diuretics and certain meds and they say “scorpion bite” because it sticks out in everybody's head. Well, that's only one scorpion on one Island. I think it's Trinidad and Tobago. It always cracks us up. It's like a classic. That thing always comes up!
Another is how amylase is not in Ranson's criteria. Ranson's criteria are a set of criteria to tell you how bad pancreatitis is when patients come in. There are lots of scoring systems, but this one gets mentioned all the time.
Dr. Kashmer: And there's an acronym “GA LAW” for the key prognostic factors. It's classic review level stuff, but what's not in Ranson's criteria is amylase level. People really want to use this blood test, amylase level, to correlate with severity of pancreatitis. And it doesn't no matter how bad we want to make that the case. So somehow that comes up on a lot of tests directly or indirectly: amylase doesn't correlate with pancreatitis. It's not in Ranson's criteria. Don't be confused. That's not what either of the A's stand for in Ranson's criteria.
Another item: fluid sequestration greater than six liters, meaning you give them a bunch of fluid and they keep in them six liters more than what they put out. and you give them a bunch of fluid. That's a really important prognostic factor for how severe pancreatitis is. It’s like burn on your inside.
Dr. Kashmer: So while we're talking about the pancreas, those things come up, a lot of them are medical and yeah, I definitely have surgical things to talk about with it.
First off, you know, the interesting stuff is how common it is to see people who have pancreaticum divisum. So we deal with a lot of gallstone pancreatitis and this stuff, but sometimes we get consulted for pancreatitis on patients who have gallstones, but it may or may not be the gallstones because lots of Americans have those. There are lots of other cases and other reasons.
One of the obscure (but interesting) ones is a failure of the ducts in the pancreas to fuse. And it turns out that the buds that go to form the pancreas ultimately, and there’s a dorsal and ventral, those come from the duodenum. If memory is right about fourth week, they kind of revolve around the duodenum.
Dr. Kashmer: They kind of twist around the duodenum and they come together and unify to form what looks like one gland, but really the pancreas is almost two glands stuck together. And there's a dorsal and ventral duct. And the smaller one is the duct of Santorini. The other duct is Wirsung’s duct and then sometimes they don't fuse. They don't fuse together. The rest of the pancreas, it actually looks like one organ. It's like one fused thing, but those don't fuse.
And that's when you have pancreaticum divisum or divided pancreas. Again it may look like one pancreas often, but the ducts are not fused. And you can tell that with certain tests. Now it's a cause of pancreatitis and the number of people who have this, and this is the cool part: it's surprisingly high. It's like 10% of the population.
Dr. Kashmer: That's a review book level statistic. So it's something we don't really talk about all that much. We don't really think about it all the time with surgeons, but it's so cool to me because 10% of people or so walk around with this, but only rarely does it cause pancreatitis. So I know I'm yapping at you for a while, but those are some interesting facts about the pancreas that are in our surgical review books. It is a cause of pancreatitis. That's seen only about 1% of the time, but again, about 10% of people have the abnormality. It just doesn't cause a problem that often. Now I've got all sorts of war stories about ulcers from the duodenum that eroded into the pancreas and weird cancers and all these things. But I think for this Absite podcast, it's really useful to remind people of those interesting pancreatic facts.
Dr. Kashmer: if you look in the pediatric sections, for example, if you have someone who's buds from their duodenum did not spiral around the duodenum and they stayed where they were, you'll have a pancreas the grows around the duodenum like a ring. It's called annular pancreas. So if you open these people up, if they may have an obstruction, a blockage from this annular pancreas. You do not divide that part of the pancreas to free it up. You leave that annular pancreas as it is, and you bring up a piece of bowel and you attach it to the stomach typically. You bypass the area.
And really the take home message for that is don't F with the pancreas—there’s no need to divide it and you do what you can to leave it in place and you bypass it. So if you have a gastric outlet obstruction or something similar from an annular pancreas, hopefully the staff that listen to this will remember you don't divide that. You just bring up a piece of bowel and you bypass that area. So that’s a lot of talking, but you asked me for some stories or interesting stuff, and I've seen really all those situations now in my career. And it's been really interesting and it just drills home the take home message: don't F with the pancreas!
Jessica: So the takeaway from today is basically television, you know? In a Fight Club style, the body can make soap and scorpion bites can lead to pancreatitis…which is more likely to be on an episode of House or Grey's Anatomy than seeing it in an actual hospital! It was a great subject. And thanks so much for talking to us about it today. And for all you out there, remember: #AbsiteSmackdown!