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Minimally Invasive Technique Leads to a Dramatic Result for Pancreatic Patient

Pancreatic Patient Joseph Mangano with wife, Ellen Joseph Mangano (right) smiles with his wife, Ellen Mangano, RN.

Born a year apart, Joseph and Ellen Mangano grew up one block from each other on Chicago's West Side. As teenagers, they danced the night away at his senior prom in 1952 and at hers the following year.

After 55 years of marriage and five children, they still act like newlyweds, exchanging smiles and genuinely enjoying each other's company. They spend their free time traveling the world together or cultivating new hobbies, like watching opera. "We do a lot of laughing, I have to say," said Ellen, RN, 74. Yet six years ago, they found themselves facing a potentially tragic ordeal.

It started one Sunday morning in September, when Joe awoke with "a little queasiness" in his stomach. "Something's a little off today," he told Ellen.

He tried to shake it off by cooking breakfast, but suddenly ran from the stove, overcome with nausea. Less than an hour later, Joe was in the emergency room battling excruciating abdominal pains.

Ellen, a retired nurse, saw his lab results and knew the culprit immediately: pancreatitis. An inflammation of the pancreas that can range from mild to life-threatening, the condition is often associated with family history, alcoholism or obesity, none of which fit Joe.

Subsequent tests revealed a "pseudocyst," a pooling of fluid in his pancreas, but physicians reassured the couple it was nothing to worry about. Over the next two years, Joe suffered more pancreatitis attacks. "The longer it went on, the antsier Ellen got," Joe said. "I was the dummy, just bouncing along."

"It was really frightening for me," said Ellen, who lost her mother to pancreatic cancer at age 87 and knew chronic pancreatitis could be a warning sign for the disease. Notorious for low survival rates, pancreatic cancer is seldom caught early, making it the fourth leading cause of U.S. cancer deaths.

In August 2007, the Manganos consulted a specialist at the University of Chicago who diagnosed the lingering cyst as a mucinous cystic neoplasm, a malignant tumor, and recommended immediate surgery. A month later, at a hospital closer to their Cary, Illinois, home, Joe underwent a 10-hour Whipple procedure to remove the head of his pancreas, which had a carcinoma in situ.

"That's the scariest part," Joe said, now 76. "You think you're on the right track and later on you find out you've been on the wrong path. It could be a whole different outcome right now."

The operation removed the carcinoma, but a year later, Joe's pancreatic duct became blocked, producing dangerous weight loss -- and more pancreatitis. Several physicians tried unsuccessfully to drain the obstruction.

Irving Waxman Left to right: Irving Waxman, MD, director of the Center for Endoscopic Research and Therapeutics, and Lynne Stearns, RN, the Center's nurse coordinator.

This past winter, the Manganos turned to Irving Waxman, MD, director of the Center for Endoscopic Research and Therapeutics (CERT) and professor of medicine and surgery at the University of Chicago.

"Nobody had been able to help him," said Barbara Cislo, MMS, PA-C, a physician assistant for CERT. To fix the blockage, Joe needed a stent between his stomach and pancreas, but prior surgery made the area difficult to access.

Fortunately, he was an ideal candidate for a groundbreaking, non-surgical treatment known as endoscopic ultrasound (EUS) guided transluminal therapy. Since the early 2000s, Waxman had used EUS to peer inside the gastrointestinal tract. Now he also was using the technology to do therapeutics -- all without a single incision.

Lynne Stearns, RN, nurse coordinator for CERT, walked the couple through the details. Ellen, she recalled, "was really anxious and wanted to get moving on things."

Using light anesthesia, Waxman inserted a specially designed endoscope through Joe's mouth into the stomach. He used an ultrasound device on the scope to locate the blocked duct, puncture it with a needle and place the stent.

The University of Chicago Medicine, a leading developer of state-of-the-art EUS applications, performs roughly 850 such endoscopic ultrasonographic interventions annually. "There haven't been a lot of innovations" in endoscopy, Waxman said. Transluminal therapy "is really disruptive thinking. It's the future of the field."

Nearly six months after Waxman reopened Joe's pancreatic duct, his quality of life has improved dramatically.

"Once in a while, I'll have symptoms, but they're much better," Joe said. A low-fat diet often fixes things. "I eat instant oatmeal three meals a day for a day or two, then it just resolves itself and I'm full speed ahead." This past May, he and Ellen took a riverboat cruise through Belgium and the Netherlands and will spend the summer camping.

When it comes to pancreatic cancer, often discovered too late, Joe is one of a handful of survivors. "I was lucky because I had a real pancreatic attack at the very beginning," he said. "I feel lucky all the time."

June 2010