What is the Role of Pancreas Units Today

Department of Surgery, University ‘Vita Salute’, San Raffaele Hospital. Milan Italy
Summary
The study of pancreatic diseases requires
specific knowledge and experience. There are
many reasons for the need of a specific
approach: pancreatic diseases are rare, their
clinical presentation is often misleading,
diagnostic investigations pose many
challenges and pancreatic surgery is very
complex. Due to these characteristics, it is
difficult for a physician who only
occasionally deals with a pancreatic disease to
correctly manage it. For example, it is not
sufficient to make a diagnosis of “pancreatic
tumor”, because we have to precisely define
its extension and its relationship with the
surrounding vessels, to recognize rare
histological
types
different
from
adenocarcinoma, to have a “pancreatic”
surgical experience to lessen the risk of
serious surgical complications. On the other
hand, several reports have shown that
pancreatic resections have lower mortality
rates and better long-term outcomes if carried
out in Centers with a high caseload of
patients. These considerations support the
creation of Pancreas Units, not mere high-
volume Departments specialized in pancreatic
diseases, but multidisciplinary teams
(composed of surgeons, oncologists,
gastroenterologists, pathologists, radiologists,
radiotherapists and different types of
researchers) devoted to all aspects (etiology,
pathogenesis, diagnosis, treatment) of
pancreatic diseases. We think that the
adoption of a Pancreas Unit model could
represent the right answer to the recent
changes observed in Medicine and could offer
a better approach to patients with pancreatic
diseases.
In recent years, we have observed profound
changes in Medicine which is now
significantly different from the Medicine we
knew in the last century. This development
has involved different fields; technology has
improved with amazing speed involving
advances in imaging techniques, minimal
access operations, endoscopy, catheter-based
therapies, laser, information technology and
computer-based surgery. The basic sciences
have also achieved spectacular innovations in
molecular biology, molecular genetics and
pharmacogenetics. The changes in Medicine
have not only involved the expansion of
knowledge; however, the rapid advances in
medical technology have increased the
complexity of surgical, interventional and
intensive care, and have led to an intense
development of specializations and sub-
specializations. Moreover, patients have also
changed; the advent of the Internet,
teleconferencing and e-mail has dramatically
improved the speed and the quality of
worldwide
communications;
as
a
consequence, the increasingly well-informed
patients now play a more dominant role in
their own care.
Due to this technology and the expansion of
knowledge, strong specializations and sub-
specializations and a different patient attitude,

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JOP. J Pancreas (Online) 2006; 7(1):101-103.
© 2006 JOP and author(s). Free circulation of this article is permitted only for research and study purposes. Any commercial and for-profit usage is
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JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 7, No. 1 Supplement - January 2006. [ISSN 1590-8577]
102
health care has shifted from being specialty-
based to being disease/diagnosis-based;
patients will expect to be cared for in an
environment based on a multidisciplinary
approach rather than on the method of
treatment.
The traditional clinical organization, based on
Departments, does not seem to be fully
adequate for meeting the new needs of this
world of quickly changing Medicine. In fact,
the traditional organization represents a
vertical, structural and rigid model. We need a
different model; we need a multidisciplinary
approach in order to optimize diagnosis and
treatment decision-making. We think that the
choice of functional Departments, constructed
on Disease Units, could represent the right
answer to the changes we have described. In
fact, functional Departments represent a
model for organization which is horizontal
and not vertical, functional and not structural,
flexible and not rigid: the characteristics are
closer to the recent advances in health care
delivery.
Disease Units are monothematic units devoted
to all aspects (etiology, pathogenesis,
diagnosis, treatment) of a disease. Disease
Units bring all the laboratory and clinical
researchers focused on a single disease
together in periodic meetings. Scientific and
clinical exchange of information occurs
between basic investigators and clinicians in
order to create a flow of information “from
the laboratory to the bedside” and vice versa.
Possible fields of application of Disease Units
are represented by complex diseases like
hematological malignancies, breast diseases,
pulmonary neoplasms and pancreatic
diseases. In particular, pancreatic diseases
represent an interesting model for Disease
Units. They are quite rare often complex and
pose a challenge for diagnostic investigations
and therapeutic choices; every aspect of
pancreatology needs a specific approach. But
what are the advantages of choosing a model
based on Disease Units? First of all, there are
advantages for the patients. We can
reasonably obtain earlier diagnoses; patients
are more conscious of being involved in
clinical research programs and are able to
receive
correct
information.
A
multidisciplinary approach is expected to
offer a better quality of life as far as nutrition,
pain control, etc. is concerned and most
importantly, patients are always taken care of
by the same team, with a clear improvement
in the relationship between physicians and
patients. Then there are the advantages for
research. It is easier to recruit large numbers
of patients for clinical studies and there are
better relationships between basic research
and clinical work in order to create true
“translational medicine”. Finally, there are
also advantages for the Institute. There is
better cooperation between physicians
belonging to different areas of specialization;
the definition of diagnostic and therapeutic
protocols for specific diseases, to be applied
in all Institutes; the improvement of scientific
activity and the production of papers and
advantages in the recruitment of financial
funds and attracting patients.
Organization by Disease Units is not to be
confused with a simple high-volume
Department. The advantages of high-volume
hospitals are well-known; there is
considerable evidence that patients
undergoing high-risk surgical procedures or
complex treatments have lower mortality rates
and otherwise better outcomes if care is
provided in Centers with a high caseload of
patients having the same condition than if
care is provided by hospitals with a low
caseload of such patients. Hospital organized
by Disease Units have the same advantages as
high-volume hospitals but they also have the
advantage of a multidisciplinary approach.
Organization by Disease Units could find a
useful application in pancreatic diseases. In
this case, we would have a Pancreas Unit, a
multidisciplinary team with surgeons,
oncologists, gastroenterologists, pathologists,
radiologists, radiotherapists, nuclear medicine
physicians and different types of researchers.
Whereas many reports deal with high-volume
Pancreatic Centers all over the world, very
few experiences with Pancreas Units are
reported and they are all in the United States,

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JOP. J Pancreas (Online) 2006; 7(1):101-103.
© 2006 JOP and author(s). Free circulation of this article is permitted only for research and study purposes. Any commercial and for-profit usage is
subject to authorization by the Publisher: see the JOP Special Copyright Statement at http://www.joplink.net/jop/special.html for license details.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 7, No. 1 Supplement - January 2006. [ISSN 1590-8577]
103
such as the MD Anderson Cancer Center and
the UC Pancreatic Disease Center of
Cincinnati.
A Pancreas Unit was established at the San
Raffaele Hospital in Milan in 2002, thanks to
the activity of a young researcher, Dr Paolo
Dellabona, who chaired the Pancreas Unit
until one year ago when it was turned over to
a clinician, Professor Valerio Di Carlo. The
activity of this Pancreas Unit includes
scheduled meetings for an exchange of
information, the definition of diagnostic-
therapeutic protocols and the coordination of
basic and clinical research programs.
Several research projects are currently
ongoing thanks to the Pancreas Unit activity.
As far as diagnosis is concerned, the
following studies are under investigation:
pancreatic cancer diagnosis by Mn-based
magnetic resonance, comparison between
multislice CT and echoendoscopy, the role of
optical coherence tomography (OCT) and the
role of PET combined with growth tumor
markers. Among the therapeutic protocols, we
are dealing with studies on new
chemotherapeutic regimens in the treatment
of pancreatic cancer, the application of
tomotherapy, the development of active
immunotherapy based on dendritic autologous
cells and natural peptides derived from
allogenic tumor cells. Several projects involve
the basic sciences: the characterization of
genetic lesions in familial pancreatic cancer,
the investigation of relationships between
ductal pancreatic cells and malignant
transformation and the role of interaction
between stroma and tumor cells in pancreatic
cancer growth.
We think that all the clinical and scientific
activities of our Pancreas Unit will help us to
improve our knowledge of pancreatic
diseases, to devise new therapeutic strategies,
to improve our clinical results and to offer a
better approach to patients with pancreatic
diseases. It is important that scientific
organizations (both national and international)
recognize the existence and the role of
Pancreas Units; we hope that, in the near
future, many other Pancreas Units will be
established in different Centers, and that we
will be able to create a strong network
between them.
Keywords
Hospital Units; Pancreatic
Diseases; Pancreatic Neoplasms; Pancreatitis,
Acute Necrotizing; Therapeutic Human
Experimentation
Abbreviations OCT: optical coherence
tomography
Correspondence
Valerio Di Carlo
Dipartimento di Chirurgia
Università Vita Salute
Ospedale San Raffaele
Via Olgettina, 60
20132 Milano
Italy
Phone: +39-02.2643.2667
Fax: +39-02.2643.2871
E-mail: valerio.dicarlo@hsr.i

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