Changing patterns in surgery of the pancreas

Complications of adjacent organs in chronic pancreatitis managed by duodenum-preserving resection of the head of the pancreas

Chronic pancreatitis frequently generates complications through involvement of adjacent organs. Distal common bile duct stenosis and segmental duodenal stenosis, the most frequent complications, are usually treated by resection or bypass procedures. This study presents experience with duodenum-preserving resection of the head of the pancreas in the treatment of patients with chronic pancreatitis with predominant involvement of the pancreatic head and coexisting complications involving adjacent organs. This procedure preserves the structure and function of the bile duct and duodenum. Sixty-six patients with severe chronic pancreatitis underwent duodenum-preserving resection of the head of the pancreas. Thirty-eight had associated complications of neighbouring organs: 37 had distal common bile duct stenosis, seven had duodenal stenosis, ten had evidence of segmental portal hypertension and one suffered from a pancreatopleural fistula. Details of all patients were documented prospectively; mean follow-up was 4.2 years. The complications of adjacent organs were permanently eradicated in 36 of 38 patients. Two patients required endoscopic stenting for persisting bile duct obstruction. There was substantial or complete relief of all symptoms in 35 patients. Duodenum-preserving resection of the head of the pancreas is effective in the treatment of severe chronic pancreatitis with predominant involvement of the pancreatic head and provides definitive management of associated complications of adjacent organs.

Percutaneous drainage of pancreatic pseudocysts: a prospective study

We classify pancreatic pseudocysts in 3 types: post-necrotic type I, related to acute pancreatitis; post-necrotic type II, related to an acute attack superimposed on chronic pancreatitis; and retention type III, due to chronic pancreatitis with ductal stricture. A prospective study on percutaneous catheter drainage of post-necrotic pseudocysts (type I and II) was undertaken from 1987 to 1990. Twenty-three pseudocysts in 21 patients were drained. Overall recurrence rate was 4%; 2 patients had fistulization of the catheter into bowel; no deaths occurred. The procedure was successful in all type I cysts; in type II cysts it was associated with prolonged drainage and increased risk of complications when cyst-duct communication was present. Percutaneous drainage has no role to play in type III retention cysts. Guidelines regarding indications for treatment and the techniques employed are described.

Pancreatic pseudocysts: a proposed classification and its management implications

Pancreatic pseudocysts in 83 patients were classified according to clinical and radiographic criteria. Group I (45 patients) had acute, 'post-necrotic' pseudocysts with normal pancreatic duct anatomy and rarely duct-pseudocyst communication. Percutaneous drainage was curative in all patients in whom it was used. Group II (26 patients) included 'post-necrotic' pseudocysts developing in patients already suffering from chronic pancreatitis. The pancreatic duct was diseased but not strictured, and duct-pseudocyst communication was often present. Percutaneous drainage is possible for such patients but it may have to be prolonged; surgical internal drainage was usually successful. Group III (12 patients) had chronic 'retention' pseudocysts. The pancreatic duct was grossly diseased and strictured and duct-pseudocyst communication was present in all cases. Percutaneous drainage is contraindicated and surgical internal drainage has a high recurrence rate. Operative procedures in this group should address the specific ductal pathology. An improved classification of pseudocysts could help the surgeon to choose the most appropriate form of treatment.

Duodenum-preserving resection of the head of the pancreas in chronic pancreatitis with inflammatory mass in the head

In 141 patients with chronic pancreatitis and an inflammatory enlargement of the head of the pancreas, a duodenum-preserving resection of the head of the pancreas was performed within a 16-year period. The hospital mortality was 0.7%; the late mortality was 5%. Seventy-seven percent of the patients were completely free of abdominal pain; 67% returned to their former occupation. After a follow-up period of 3.6 years, glucose metabolism was unchanged in 81.7% of the patients, in 10.1% it deteriorated, and in 8.3% it improved permanently. In patients with severe chronic pancreatitis and an inflammatory mass in the head of the pancreas, a duodenum-preserving resection of the head of the pancreas is an alternative procedure to the Whipple operation. The surgical technique of the duodenum-preserving resection includes 2 major steps: first, subtotal resection of the head of the pancreas conserving the duodenum; second, restitution of the exocrine pancreatic secretory flow from the body and tail of the pancreas by using the first jejunal loop as an interposition. In comparison to the Whipple procedure, the duodenum-preserving resection of the head of the pancreas in chronic pancreatitis spares the patient a gastric resection, a duodenectomy, and a common bile duct resection. With respect to long-lasting pain relief and preservation of the endocrine function of the pancreas, duodenum-preserving resection of the head is a highly effective surgical procedure with a low early and late morbidity and mortality due to the limited surgical resection.

Duodenum-preserving resection of the head of the pancreas in severe chronic pancreatitis. Early and late results

In 128 patients with severe chronic pancreatitis and inflammatory enlargement of the head of the pancreas, a duodenum-preserving resection of the pancreatic head was performed. Median post-operative hospitalization was 15.5 days, and the frequency of reoperation was 5.5%. One patient died during the early post-operative phase, and hospital mortality amounted to 0.8%. After a median follow-up period of 3.6 years (range of 7 months to 16 years), six of 127 patients died (late mortality of 4.7%). Seventy-seven per cent of the patients were completely free of abdominal pain, 67% returned to their former occupations. During the late follow-up period, the glucose metabolism was unchanged in 80.7% of the patients, in 13.7% it deteriorated, and in 5.5% it improved permanently; 80% of the patients experienced a marked increase in weight averaging 8.7 kg. Compared with the Whipple procedure, the duodenum-preserving resection of the head of the pancreas spares the patient with chronic pancreatitis a gastrectomy, duodenectomy, and resection of the extrahepatic biliary ducts. In terms of a subtotal resection, the limited operative intervention at the head of the pancreas and the preservation of the duodenum explain the low early and late postoperative morbidity and mortality.

[Chronic pancreatitis. Surgical therapy by resection procedures]

In 606 resections operative mortality fell from 10 to 1.2%. In distal resections in 66% good results were observed with a late mortality of 11%. A total mortality of 40% was found in total pancreatectomy, therefore this procedure was cancelled in 1980. In 289 partial duodeno-pancreatectomies combined with duct occlusion by Ethibloc our operative mortality was 1%. Late follow-up: Free of pain 88%, recurrence in only 2.1%. Preservation of endocrine function proven by a prospective study.

Surgical treatment of pancreatic pseudocysts

Between 1966 and 1980, 54 patients (40 men and 14 women) with a mean age of 38 years were operated on for a pancreatic pseudocyst at the Department of General Surgery, University of Göttingen. The aetiology of the cysts was alcohol abuse in 35 patients, biliary diseases in 8, blunt abdominal trauma in 4, virus-induced in 2 and unknown in 5. With the exception of those who had had trauma, all patients were suffering from chronic pancreatitis. Surgical therapy included in all cases a cystojejunostomy (52 with a Roux-Y-limb and 2 with an omega loop). The mean follow-up period was 13 years (range 6 to 20 years). The late mortality was 15 per cent (8 of 52 patients). Recurrent cysts occurred in two patients (5 per cent) and relapse of pancreatitis in one third of the patients. Deterioration of carbohydrate metabolism was observed in 20 per cent of the patients. After drainage operation stool fat content became normal in 20 per cent and deteriorated in 13 per cent. Persistence or cessation of alcohol intake influenced the long-term results. From these data we conclude that both alcohol withdrawal and sufficient drainage of the pseudocyst are important factors in the prognosis of pseudocyst.

Adenocarcinoma of the ampulla of Vater. Diagnosis and treatment

Fifty-one patients underwent operation for adenocarcinoma of the ampulla of Vater. Seven patients underwent palliative bypass, with an operative mortality of 28.6%; 44 additional patients underwent potentially curative pancreaticoduodenal resection (PDR), with an operative mortality of 15.9%. Postoperative complications occurred in 63% of patients. Postoperative gastrointestinal bleeding was observed in 11 of 44 patients who underwent PDR (25%). Although anastomotic ulcers (AU) were directly implicated in five cases (45%), the 12% incidence of AU-related bleeding among 33 patients who underwent PDR without truncal vagotomy (TV) was not significantly different from the 9% incidence observed in 11 patients who underwent PDR plus TV. However, performance of TV appeared to result in a higher incidence of postoperative pulmonary complications. Five patients who underwent curative resection survived for five years (11%). Only one of seven patients who underwent palliative bypass survived three years (14%), and none survived to five years. Acceptable survival rates following resectional therapy warrant an aggressive approach to this tumor. Further, our experience suggests that TV may increase postoperative patient morbidity without actually providing any protection from anastomotic ulceration.

Pseudocysts of the pancreas after blunt abdominal trauma in children

Of 6 children with posttraumatic pancreatic pseudocyst, 5 had been transferred from other hospitals. Three of the 5 had undergone laparotomy but in only 1 had the pancreatic injury been noted. All 5 had elevated serum amylase activity on admission here, but in only 2 had this been measured in the referring hospital. Three were seriously ill at the time of transfer, and all 6 patients required prolonged hospitalization (1.3--5.5 mo). The lesion resolved spontaneously in 1, and was drained externally in 3 and by cystogastrostomy alone i 1. One child required multiple surgical procedures, terminating in subtotal pancreatectomy. The seriousness of this lesion demands constant alertness to the possibility of pancreatic pseudocysts in children who have suffered upper abdominal trauma, however minor.

[Is total pancreatectomy still responsible treatment for chronic pancreatitis? (author's transl)]

A total of 61 pancreatectomies for chronic pancreatitis are reported. The operative mortality rate was 21% and the later mortality rate 29%, although caused by diabetes. The results are so poor that this method should only be performed in extreme situations. Left or right resection of the main inflammation site is proposed as an alternative. To prevent recurrence of the pancreatitis, the in situ remaining part of the pancreas should be sclerosed by occlusion of the pancreatic duct system.