Pancreatic Disorders

There have been major advancements in treatments for diseases and disorders of the pancreas in recent decades. In this episode of Advance with MUSC Health, Katherine Morgan, M.D., professor of surgery and chief of the Division of  Gastrointestinal Surgery and Laparoscopic Surgery at MUSC Health, talks about the function of the pancreas, causes of pancreatic disorders, and the different treatment options available at MUSC Health.

“Many of the procedures that we previously performed, open or laparoscopically, we're now able to perform robotically, which has been really exciting. But it seems to allow patients to recover more quickly from some pretty big surgeries and hopefully get them on to the next stages of life or treatment so that they can go back to living their lives.”
— Katherine Morgan, M.D.

Topics Covered In This Show

• The pancreas has two functions: the endocrine function that makes insulin and the other hormones that help to regulate your blood sugar and the exocrine function, which makes the digestive enzymes that help you digest and absorb food.
• There is a spectrum of pancreatitis and treatments for the condition. Some cases can be self-resolving with supportive care, but more severe cases can require surgery.
• Alcohol is the most common cause of pancreatitis. Smoking is also a contributing risk factor. Avoiding both is the best way to preserve the health of your pancreas.
• Morgan founded the Islet Cell Transplant program, which offers a unique treatment option for patients with chronic pancreatitis or with recurrent acute pancreatitis. The treatment includes autotransplantation, the infusion of a patient's own pancreatic islet cells into the portal vein of the liver. Because the body recognizes these islet cells as its own, there is absolutely no rejection of these cells by the patient's body.
• Morgan and her team at MUSC Health have only recently started routinely testing patients to see if they have a related gene mutation that's causing or lending a predisposition to pancreatitis. They are unsure of how common or rare this is.
• She discusses the use of robotic surgery and its advantages. She says the robotic instrumentation is flexible, so it can act like a wrist and perform complex movements needed for some of the surgeries around the pancreas.
• In terms of pancreatic cancer, Morgan says improvements in chemotherapy and surgical instrumentation such as the nano knife make it possible in some cases to extend the lives of people with the disease. Long-term survival rates of those with pancreatic cancer have doubled in the last ten years, from 5% to 10%.

Read the show transcript below:

Erin Spain, M.S. [00:00:04] Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Disorders and diseases of the pancreas are often difficult to treat, but advances in surgical therapies are bringing relief to thousands of people every year.

Here at MUSC Health, Dr. Katherine Morgan leads a top team of gastrointestinal surgeons, and she specializes in surgery for pancreatic cancer and pancreatitis. She joins me today to talk about these conditions and the incredible results her team is able to provide many patients here at MUSC Health. Welcome to the show, Dr. Morgan.

Katherine Morgan, M.D. [00:00:47] Thank you so much for having me here.

Erin Spain, M.S. [00:00:49] You're a gastrointestinal surgeon and chief of the division of GI and laparoscopic surgery. Tell me about the wide range of people that you treat and the conditions that they have.

Katherine Morgan, M.D. [00:00:59] So in a benign spectrum, we see a lot of patients with gut problems, such as gastroesophageal reflux disease or a paraesophageal hernias with pancreatitis as a very common one and other benign liver disorders that are more surgical, such as liver lesions and things like that that are benign. And then on the cancer spectrum, we see cancers in those same organs, so pancreatic cancer, gastric cancer, liver cancer and bile duct cancer.

Erin Spain, M.S. [00:01:25] Explain the pancreas. What does this organ do?

Katherine Morgan, M.D. [00:01:29] So the pancreas is an endocrine and an exocrine organ. So it's located in the way back of your upper abdomen, behind the stomach, and it has two main broad functions. The first is the endocrine function, and so it makes insulin and the other hormones that help to regulate your blood sugar. And then the other function is its exocrine function, which is its digestive function. So it makes the digestive enzymes that help you digest and absorb your food, particularly fat and protein.

Erin Spain, M.S. [00:01:57] You mention pancreatitis, so you have a particular interest in this disease. Explain it to me. How is it diagnosed and how does it impact patients?

Katherine Morgan, M.D. [00:02:05] Pancreatitis is really a spectrum of disease. Acute pancreatitis is a sort of sudden event that happens in patients that can be very severe and life threatening. Often it's self resolving with supportive care, but sometimes in the more severe conditions, it requires surgery and surgical management to get better and so we see patients from around the region with that problem.

Chronic pancreatitis is a related disorder that can go hand in hand with acute pancreatitis or can be individual and come along in patients without preceding acute pancreatitis. And that's a longer term disorder that's really marked by pain, severe pain, and so patients sometimes need a surgical management of that to relieve their pain.

Erin Spain, M.S. [00:02:46] What causes this condition?

Katherine Morgan, M.D. [00:02:48] So most commonly is alcohol, so drinking alcohol. There's a lot of genetic related disorders that we're very interested in and have become commonly recognized in the more modern era. And smoking has also been indicated as a common risk factor for chronic pancreatitis as well as acute pancreatitis. And then gallstones also can cause acute pancreatitis.

Erin Spain, M.S. [00:03:08] Have there been more cases of pancreatitis in recent years? What are you seeing?

Katherine Morgan, M.D. [00:03:13] Yeah, there's an increasing incidence of pancreatitis for sure. And I think there's also an increasing recognition of pancreatitis as a disease, probably 20, almost 30 years ago now, typically we saw pancreatitis or thought of it as patients just with alcoholism who would come into the emergency room with pain and have these severe bouts. And more and more often we're finding it's in patients who've suffered with chronic abdominal pain for some time and then undergo a full evaluation and are found that that pancreatitis is the culprit.

Erin Spain, M.S. [00:03:43] You mentioned a genetic form of the disease. How rare is that?

Katherine Morgan, M.D. [00:03:47] We don't really know. But it seems that more and more often we're finding that patients have underlying genetic conditions that predispose to pancreatitis. We only recently, probably in the last five years or so, have started routinely testing patients to see if they have a related gene mutation that's causing or lending a predisposition to pancreatitis. So we don't know the actual incidence, but I think it's more common than we realize. Even alcoholic pancreatitis, which is routinely just felt to be a disorder related more to alcoholism or to alcohol excess, has been found to have an underlying genetic predisposition for that.

Erin Spain, M.S. [00:04:23] What are the other genetic conditions that seem to be related to this genetic form of pancreatitis?

Katherine Morgan, M.D. [00:04:28] There's some overlap with some other disorders, such as cystic fibrosis, but more commonly it's a genetic problem that's in and of itself. So the most distinct form is called hereditary pancreatitis, and it was the first abnormal gene to be recognized. And it's a very strongly inherited familial trait. It's a specific gene that's mutated that causes the inappropriate activation of trypsin, which is one of the pancreas enzymes. And so you end up with an almost autodigesting of your own pancreas in these patients and they can present in childhood. So it's a pretty dramatic form of disease.

Erin Spain, M.S. [00:05:01] Here at MUSC Health, in 2009, you founded a program, the Islet Cell Transplant Program, for pancreatitis treatments. Tell me about that program.

Katherine Morgan, M.D. [00:05:11] So in patients with chronic pancreatitis or with recurrent acute pancreatitis that have failed lesser management, so usually the frontline management isn't surgery. The frontline management is typically supportive medications or even endoscopic therapies. But patients that still have pain despite these treatments may come to a larger resection.

A pancreatic resection for this benign disease. And so what we hate to do is to give them pancreatic insufficiency when we remove their pancreas to help with the pain and so while these patients may do well with removing the whole pancreas in the past, we haven't wanted to do that because we don't want to give them severe diabetes. And so what this technology allows us to do is to take the pancreas that we remove and then preserve it and do a process where we isolate out the islet cells. Those are the cluster of cells that have the endocrine function. So they have the insulin producing cells and the other cells that regulate blood sugar. And we take these clusters of cells and separate them from the rest of the pancreatic tissue and we give them back to the patient. It's called an auto transplantation. All happens on the same day. And so we take the cells and put them back into the liver of the patient where they're able to then function again in a pretty normal fashion.

Erin Spain, M.S. [00:06:21] That's pretty incredible. You've been doing this for more than a decade now. Are other institutions following suit?

Katherine Morgan, M.D. [00:06:27] Yes. It's actually become much more common over the last decade or so. The first auto transplantation for chronic pancreatitis was actually done back in the late 1970s. The problem was that pancreatic surgery at that time wasn't quite as advanced and safe, and the technique of isolating the islets and then the infusion process hadn't really been hashed out until more recently, so that it was a reasonable, safe and appropriate indication or procedure for people.

Erin Spain, M.S. [00:06:54] How often are you doing that procedure now?

Katherine Morgan, M.D. [00:06:56] About 20 patients a year or so. It varies between 15 and 35 patients a year that we've done here.

Erin Spain, M.S. [00:07:03] Tell me about the robotic surgery offerings in your division.

Katherine Morgan, M.D. [00:07:07] Over the past several years, there's been the development of a much better and more usable robot for surgery. And so in our division, we've been able to adopt that into our practice. Many of the procedures that we previously performed, open or laparoscopically, we're now able to perform robotically, which has been really exciting. But it seems to allow patients to recover more quickly from some pretty big surgeries and hopefully get them on to the next stages of life or treatment so that they can go back to living their lives.

Erin Spain, M.S. [00:07:37] When you say robotic surgery, tell me what that means and what you're doing in the O.R. and the instrumentation you're using.

Katherine Morgan, M.D. [00:07:45] So robotic surgery is a form of minimally invasive surgery where we use small incisions rather than a big incision to access the abdomen and do the procedure. It's very much like laparoscopic surgery and we use similar type instruments. But what we do is we access these instruments into the abdomen through small incisions and then hook the robot up to them. And then we are able to use the robot and to control the robot to do the surgery. And the advantage is that the robotic instrumentation is much more flexible than the laparoscopic instruments, so it can act like a wrist and be more adept at some of the more complex movements we need to do some of the surgeries around the pancreas.

Erin Spain, M.S. [00:08:27] It's like an extension of your hand.

Katherine Morgan, M.D. [00:08:29] Yes, it is. It's actually, it allows us to do some procedures easier than we can open with the robotic platform. It enlarges the image for us. The camera can give us a 3D visualization actually inside the abdomen. So it does help us.

Erin Spain, M.S. [00:08:43] How common is it to have access to this type of robotic surgery?

Katherine Morgan, M.D. [00:08:47] Right. So the robot has gained popularity across the country and across the world really over the past several years. We've been lucky to have several robots at our facility that have allowed us to develop these procedures. The majority of surgeons, pancreatic surgeons, perform these surgeries in an open fashion. And so we've been lucky to be able to develop this platform here and have really enjoyed being able to offer that for our patients.

Erin Spain, M.S. [00:09:10] You mentioned alcoholism or drinking. Alcohol and excess can cause pancreatitis. What are ways, besides reducing alcohol that people can protect the health of their pancreas?

Katherine Morgan, M.D. [00:09:20] Yeah, you know, I get that question a lot. And there's been a lot of research into how to keep your pancreas healthy, particularly in patients who have had pancreas disease or pancreas surgery and want to obviously protect their pancreas.

I think the clearest evidence is for avoidance of alcohol and smoking. Beyond that, there's been some low level evidence of some of the anti-inflammatory supplements, antioxidants and anti-inflammatory things such as turmeric or green tea and things like that.

Erin Spain, M.S. [00:09:49] And I'm also curious, are diabetics more likely to have pancreatitis?

Katherine Morgan, M.D. [00:09:54] It's not that they're more likely to have pancreatitis, but chronic pancreatitis is a process where the pancreas actually gets replaced by scar. And so the end result of chronic pancreatitis is that patients develop pancreatic insufficiency or pancreas failure and develop diabetes.

Erin Spain, M.S. [00:10:11] Pancreatic cancer has been historically very difficult to treat, but there have been some recent advances and treatments for these patients. Tell me about these advances and which ones excite you the most?

Katherine Morgan, M.D. [00:10:24] Probably realistically, the biggest advancement in pancreatic cancer over the past couple of decades has been chemotherapy. So we've had very successful chemotherapy results that have really improved survival with pancreatic cancer. And so realistically, that's set the stage for us to be able to treat patients that we previously weren't able to treat.

And so in surgery, to go hand in hand with the successful chemotherapy, we've had some advancement, particularly in being able to operate on more locally advanced tumors. And so the problem with pancreatic cancer is that the area that it affects is a pretty tight area with some of the important vital blood vessels. And so more recently, we've found safer ways and more effective surgical techniques to remove a tumor, for example, that involves the blood vessels around it.

And so that's a huge advancement. Initially, when I was a medical student resident, we were trained that those cases were just too dangerous and that those patients didn't do well. But it turns out that with the proper chemotherapy treatment and a good surgery, these patients can have similar survival to people who do not have vascular involvement. So that's exciting.

More recently, we've also, to dovetail off that, have developed technology with the nano knife, which is an irreversible electroporation, which is a local way to oblate pancreas cancer that isn't entirely removable. So a cancer that may be wrapped around blood vessels that we can't remove.

Erin Spain, M.S. [00:11:47] Tell me about the life expectancy for these patients. You know what it used to be maybe 20, 30 years ago and where we're at now with these new advancements.

Katherine Morgan, M.D. [00:11:56] So pancreatic cancer is one of the more aggressive cancers with, you know, really historically we've had a terrible long term prognosis and still do. But over the last ten years, we've gone from a long term survival of 5% in all comers, not surgery patients, but in all comers to 10%. So that's kind of double in a decade where we hadn't had any progress for many decades before that. So that's exciting.

And again, there's been so much more technology or science, I guess, that's just emerging that's really helping us to improve that survival rate. Patients that I see that have localized disease, so disease that hasn't spread outside the pancreas, we're seeing long term survival rates approaching 40%. And patients who do well with chemotherapy and are able to get all of their chemotherapy and a nice surgery to respect the tumor. So that's exciting.

Erin Spain, M.S. [00:12:44] So if someone is listening, they or a loved one has recently had a pancreatic cancer diagnosis, how important is it for somebody to seek out care, like at MUSC Health, an academic medical center that has these programs in place? How far should people travel for this type of care?

Katherine Morgan, M.D. [00:13:01] Yeah, pancreatic cancer does well, I think in a tertiary referral setting, just because we do have some resources and some options that for obvious reasons are not able to be provided at every institution in the region. And so we're able to sort of localize our resources here and offer some options that maybe aren't available elsewhere.

We have a nice multidisciplinary group, so our team is not just the surgeons, we're a small part of it. We've got fantastic medical oncologists and radiation oncologists and we have fantastic gastroenterologist, radiologists. You know, all these different pathologists are amazing. We work together as a team. We actually once a week meet and talk about pancreatic cancer and other cancer patients to come to a consensus for what the best treatment options are.

We also have some clinical trials that we participate in. Currently, we have a clinical trial for every stage of presentation of pancreatic cancer, and so the options for treatment are really pretty wonderful here.

Erin Spain, M.S. [00:14:00] What do you do to optimize your health and live well?

Katherine Morgan, M.D. [00:14:03] Caffeine is the big vice of mine, so I'll lay that out there. I'm definitely not someone to role model your healthiest behavior after, but I do make sure to get some exercise every day. That's probably my biggest thing. And you know, sometimes that exercise isn't exactly intense, but at least it helps with my emotional and mental health to exercise. And so that's probably the thing that I do the best in terms of taking care of myself.

Erin Spain, M.S. [00:14:27] Well, Dr. Katherine Morgan, thank you so much for joining me today.

Katherine Morgan, M.D. [00:14:30] Thank you so much for having me. It's been my pleasure.

Erin Spain, M.S. [00:14:36] For more information on this podcast, check out Advance.MUSCHealth.org.