Clinical and pathologic prognostic factors for curative resection for pancreatic cancer

BACKGROUND

Pancreatic cancer is the fifth leading cause of cancer-related deaths in the world. Operative resection is the only therapeutic option with curative potential for this disease.

OBJECTIVE

The aim of the present study was to correlate clinical and pathologic parameters with survival in patients submitted to pancreatic resection for pancreatic adenocarcinoma.

METHODS

Surgical resection with curative intent (R0 and R1 resections) was performed in 65 pancreatic cancer patients between 1990 and 2006. The overall results of surgical treatment were retrospectively analyzed and compared with the clinicopathologic features of these patients.

RESULTS

Pylorus-preserving pancreatoduodenectomy was performed in 37 patients (56.9%), classic resection in 35.4%, distal pancreatectomy in 4.6% and total pancreatectomy in 3.6%. The inhospital mortality was 5% (three patients). Postoperative complications occurred in 28 patients (43%). Mean survival and five-year survival rate after curative resection were 27 months and 9.0%, respectively. Sex, TNM stage, tumor differentiation, neural invasion, tumor size and involvement of resection margin were significant prognostic factors on univariate analysis. Multivariate analysis showed tumor differentiation and neural invasion as prognostic factors.

CONCLUSION

Patients with pancreatic cancer, even those with poor prognostic factors should be given the opportunity of surgical resection with curative intent.

Surgical and interventional treatment of chronic pancreatitis

The management of patients with chronic pancreatitis (CP) remains a challenging problem. Main indications for surgery are intractable pain, suspicion of malignancy, and involvement of adjacent organs. The main goal of surgical treatment is improvement of patient quality of life. The surgical treatment approach usually involves proximal pancreatic resection, but lateral pancreaticojejunal drainage may be used for large-duct disease. The newer duodenum-preserving head resections of Beger and Frey provide good pain control and preservation of pancreatic function. Thoracoscopic splanchnicectomy and the endoscopic approach await confirmatory trials to confirm their efficiency in the management of CP. Common bile duct obstruction is addressed by distal Roux-en-Y choledochojejunostomy but when combined with dudodenal obstruction must be treated by pancreatic head resection. Pancreatic ascites due to disrupted pancreatic duct should be treated by internal drainage. The approach to CP is multidisciplinary, tailoring the various therapeutic options to meet each individual patient's needs.

Pancreatic head tumors with portal vein involvement: an alternative surgical approach

BACKGROUND/AIMS

One of the determining factors for the unresectability of pancreatic head tumors is the involvement of the portal venous system. Recent reports show that the resection of tumors with portal vein involvement has similar results to lesions with same stage without portal vein invasion. The aim of this study is to present a technique that allows the resection of portal vein segments without the use of grafts and with a shorter period of intraoperative venous occlusion.

METHODOLOGY

Fifteen patients with pancreatic head tumors and portal vein involvement were submitted to pancreaticoduodenectomy according to this technique. The main feature of the technique is starting the pancreatic dissection at the posterior aspect of the head of the pancreas. The superior mesenteric artery is completely dissected from the pancreatic tissues leaving the section of the pancreas and the resection of the portal vein to the last step.

RESULTS

Portal vein flow occlusion did not exceed 10 minutes. There were no major postoperative complications or mortality.

CONCLUSIONS

This maneuver allows an easier resection of the mobilized portal vein with a shorter period of venous clamping and reconstruction without the need of venous graft.

Insulinoma: diagnostic strategies and surgical treatment. A 22-year experience

BACKGROUND/AIMS

The efficacy of preoperative localization methods and the results of the surgical treatment of insulinoma were studied.

METHODOLOGY

Fifty-nine patients referred for surgical treatment were studied and the results of the diagnostic tools for tumor localization were compared with findings at surgical intervention. The influence of the type of surgical procedure in the immediate and late postoperative course was also studied.

RESULTS

Ultrasonography had a sensitivity of 30%, computed tomography 25%, angiography 54%, portal vein sampling 94%, endoscopic ultrasonography 27% and magnetic resonance 17%. Intraoperative palpation localized 98.2% of the tumors and by the addition of intraoperative echography, all lesions were identified. In 55 patients with benign lesions, 22 enucleations, 25 distal pancreatectomies, 7 pancreatectomies plus enucleation and one duodenopancreatectomy were performed. Malignant tumors were treated by pancreatic resection, postoperative hepatic artery embolization and systemic chemotherapy. There was no postoperative mortality. Pancreatic fistula was the most common complication. Three patients who underwent distal pancreatectomy developed late diabetes (9.3%).

CONCLUSIONS

Extensive preoperative investigation, mainly with invasive methods, is not indicated and by combining intraoperative palpation and echography most of the cases can be adequately dealt with. Preservation of pancreatic tissue with enucleation and preservation of the spleen are the best choice for treatment of benign insulinomas.

A new technique of gastroenterostomy for palliative treatment of pancreatic head carcinoma

BACKGROUND/AIMS

Most of the patients with pancreatic cancer can be only palliatively treated. Although 30% of the patients submitted to palliative biliary bypass will require further treatment for duodenal obstruction, prophylactic gastric bypass still remains a controversial issue in the management of unresectable pancreatic head carcinoma. The main disadvantage of current techniques of gastrojejunostomy is postoperative vomiting due to impaired gastric motility and circulus vitiosus through the nonobstructed duodenum. A new technique of prophylactic gastrojejunostomy is described herein as an attempt to obviate these complications.

METHODOLOGY

An antecolic isoperistaltic gastrojejunostomy was fashioned at the gastric mid-body above the angulus. The afferent limb was partitioned close to the gastrojejunostomy and a Braun type entero-enterostomy constructed joining the afferent and the efferent limbs. Following the gastrojejunostomy a Roux-en-Y choledochojejunostomy was performed.

RESULTS

In 19 patients consecutively submitted to this procedure no postoperative mortality or complications occurred. Nasogastric suction was interrupted at postoperative day 3 and oral feeding resumed on the next day. Neither early nor late postoperative vomiting was observed.

CONCLUSIONS

These encouraging preliminary results suggest that this procedure may have its place in the palliative treatment of pancreatic head carcinoma.

Preoperative diagnosis of pancreatic leiomyosarcoma

BACKGROUND

The low incidence of pancreatic leiomyosarcoma is responsible for the small number of cases correctly diagnosed preoperatively, the tumor being frequently confused with benign pancreatic lesions.

RESULTS

We describe a symptom free 52-yr-old male bearing an abdominal mass incidentally found at physical examination. Imaging techniques revealed a nonhomogenous large mass at the head of the pancreas that dislodged the portal vein and the superior mesenteric vein. Increased metabolic activity in the tumor area demonstrated by 18F-fluorodeoxyglicose positron emission tomography scan allowed the diagnosis of a malignant lesion. The patient was operated on and a pylorus preserving pancreatoduodenectomy performed. The pathology diagnosis was a low grade leiomyosarcoma. Immunohistochemistry revealed positivity for vimentin and smooth muscle specific actin. The clinical course was uneventful after 2 yr follow-up.

CONCLUSION

Pancreatic leiomyosarcoma may be preoperatively diagnosed by image techniques and differentiated from benign lesions by means of fluorodeoxyglicose positron emission tomography scanning (FDGPET).

Distal pancreatectomy without splenectomy and with preservation of splenic vessels

BACKGROUND/AIMS

Conventional distal pancreatic resection routinely involves splenectomy. The awareness that spleen removal may lead to postoperative septic and hematological complications motivated the development of spleen-preserving procedures. Successful distal pancreatectomy with splenic conservation has been reported for treatment of benign pancreatic diseases of the distal pancreas. This report presents the results of spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein.

METHODOLOGY

Ten patients underwent distal pancreatectomy with splenic vessel preservation. In all cases, both splenic vessels were separated from the pancreas towards the spleen after transecting the body of the pancreas.

RESULTS

The indications for the procedure were: neuroendocrine pancreatic tumors (n = 4), cystic neoplasm of the pancreas (n = 4) and cystic-papillary pancreatic tumors (n = 2). Four patients developed pancreatic fistulas with spontaneous healing and there was no mortality.

CONCLUSIONS

Spleen-preserving distal pancreatectomy with splenic vessel conservation can be safely performed and should be indicated in the surgical management of benign pancreatic diseases of the distal pancreas.

Surgical treatment of cicatricial biliary strictures

BACKGROUND/AIMS

Cicatricial biliary strictures are usually associated with high morbidity and mortality rates, frequently related to technical difficulties of their surgical repair, mainly in hilar lesions. Interference with bile duct blood supply during surgical attempts for correction is a major factor for unsuccessful results. The aim of this study is to evaluate, after an extended follow-up period, the results obtained with a modified technique for surgical correction of cicatricial biliary strictures.

METHODOLOGY

The medical records of 57 patients surgically treated for cicatricial biliary strictures between January 1984 and July 1995 were reviewed and the immediate and long term results retrospectively analyzed. Patients consisted of 46 females and 11 males. The average age was 43 years. The etiology of the biliary lesion was: cholecystectomy alone (23); cholecystectomy with duct exploration (8); T tube CBD drainage (6); Biliary-enteric anastomosis stricture (16); choledochoplasty (2) and trauma (2). In 28 cases (49.1%) the stricture was located in the upper third of the bile duct, in 28 (49.1%) in the middle third and in one case (1.7%) it was low. All patients were submitted to longitudinal Roux-en-Y hepaticojejunostomy with mucosa apposition after dissection of the anterior aspect of the biliary tract. No transanastomotic stents were used.

RESULTS

Ten patients (17.5%) presented 11 postoperative complications: biliary fistula (4), duodenal fistula (1), wound infection (5), and acute pancreatitis (1). Average hospital stay was 11 days and there were no postoperative mortalities. The follow-up study was possible in 54 patients and ranged from one to ten years, with an average of 2.9 years. Four patients of 28 (14%) with hilar lesions developed stricture recurrence and cholangitis episodes, whereas no patients bearing lesions below the biliary junction had such complications.

CONCLUSION

Roux-en-Y hepaticojejunostomy with mucosa apposition without transanastomotic stent performed after minimal dissection of the biliary duct, thus avoiding major interference with the bile duct blood supply, is a safe and efficient method for the surgical repair of cicatricial biliary strictures. Using this technique excellent results can be obtained in the lesions below the biliary junction and acceptable results may be achieved in patients with hilar lesions.

[Surgical treatment of insulinoma: study of 59 cases]

After establishing the diagnosis of an insulinoma the next step is its localization in order to perform the most suitable management approach.

PURPOSE

To evaluate the methods used for the diagnosis of insulinoma and the localization of its site as well as the results of the surgical treatment.

METHODS

Fifty nine consecutive patients with pancreatic insulinomas were studied. The discriminative power of the preoperative investigations in the localization of insulinomas was analysed. Special attention was focused to the intra operative methods of tumor localizations. The early and late results of the surgical treatment were also investigated.

RESULTS

There were 55 benign cases and 4 malignant tumors. Preoperative localization was attempted by using ultrasonography (positive in 28.1%) CT imaging (positive in 25%), selective arteriography (positive in 54.1%), endoscopic ultrasonography (positive in 27.2%) and assay of portal plasma insulin levels (positive in 94.4%). In 54/55 cases (98.2%) the tumors were identified intraoperatively by palpation. By addition of intraoperative ultrasonography all lesions were identified and successfully removed without mortality. Five patients had multiple endocrine neoplasias all with multiple lesions in the pancreas. In patients with benign lesions 29 enucleations and 32 resections were performed. Pancreatic fistulas were the most common complication (29/59). Excluding the patients with malignant lesions the recovery rate was 98.1%. Three patients who underwent corporo caudal pancreactectomy developed diabetes.

CONCLUSIONS

The preoperative localization is not necessary, since a combination of palpation and intraoperative ultrasonography can deal with most cases. Enucleation when possible is the best choice for benign lesions.

[Laparoscopic cholecystectomy in a patient with sickle-cell anemia]

Laparoscopic cholecystectomy has recently become a popular alternative to traditional laparotomy and cholecystectomy in the management of patients with gallbladder disease. Elective surgical treatment of cholelithiasis in patients with sickle cell anemia has been followed by frequent postoperative complications. We present a case of elective laparoscopic cholecystectomy in a patient with sickle cell anemia followed by severe postoperative complications related to the hematological disease.

[Duodenal duplication in adult simulating pancreas pseudocyst]

An adult patient with clinical and radiologic evidence of pancreas pseudocyst was undergone at laparotomy and a diagnosis of duodenal duplication was made. Due to the rarity of this case, a review of the literature is presented and the authors discuss the treatment of duodenal duplication.

[Complications of chronic pancreatitis in São Paulo (Brazil)]

Chronic Pancreatitis (CP) presents distinctive characteristics in different geographical areas. With the purpose of evaluating the clinical characteristics, particularly in relation to the frequency and etiopathogeny of the complications in São Paulo, in comparison to other centers, 545 patients with this disease were analyzed, retrospectively, 493 (90.5%) of these patients were males and 52 (9.5%) females, with ages ranging from 8 to 88 (38.2 +/- 9.3 years). The diagnosis of CP was based on criteria previously adopted by the Pancreas Group of Gastroenterology Studies of the Medical School of São Paulo. The principal etiologic factors were represented by: chronic alcoholism in 509 of the 545 patients (93.4%), hereditary factors in four (0.7%), malnutrition in three (0.5%), metabolic alterations in three (0.5%) and obstruction to the pancreatic flow in two patients (0.3%). In 24 (4.4%) of the 545 patients, the etiologic factor could not be established, due to the idiopathic nature of the disease. Of the 509/545 patients (93.4%) presenting chronic ethylism, alcoholic consumption was characterized by: a) mean age alcoholic consumption was initiated: 19.5 +/- 6.5 years; b) mean daily alcoholic consumption in grams of pure ethanol: 358.6 +/- 282.0 g/d; c) mean time of alcoholic consumption: 19.8 +/- 8.8 years, and d) mean age of the appearance of clinical symptoms: 34.9 +/- 9.8 years. The clinical complications were always investigated in accordance with the pre-established protocol; the principal complications observed were represented by: gastrointestinal compression (3.3%), jaundice (24%), cysts (35.9%), cavity effusions (13.3%), pancreatic necrosis (4.7%), abscesses (3.6%), digestive hemorrhage of pancreatic origin (2.3%) and fistulae (1.1%). The incidence of these complications, particularly cysts, cavity effusions and pancreatic necrosis, was greater in the patients studied than in those observed in other regions, probably due to the presence of more intense and frequent anatomopathologic lesions found in these patients, possibly resulting from the greater consumption of alcohol compared to patients with this disease in other centers. The etiopathogenic mechanisms for the complications were individually analyzed and interpreted.

[Early adenocarcinoma of the duodenum--report of a case]

The early duodenal carcinoma is a very rare type of neoplasia, usually asymptomatic, its surgical treatment remains a controverse issue. In the present case an early duodenal carcinoma was incidentally found at the pathological specimen after a gastrectomy with BII reconstruction for a gastric adenoma unressectable by endoscopy. The patient is now alive for two years, without evidence of recurrence on follow-up.

[Biliary fistula after elective conventional cholecystectomy]

The use or not of drainage after elective cholecystectomy has been recently studied, and we will discuss the real incidence of the subhepatic biliary collection and its clinical significance. In this sense, we studied 20 patients with a mean age of 45 years (4 male and 16 female), submitted to elective cholecystectomy according to selective techniques patterned by our group, where we realized ligature of all vessels of the gallbladder bed, and subhepatic drainage. These patients receibed 99 mTc-DISIDA at the moment we closed the abdomen, and in a period of 24 and 48 hours we studied its presence in the subhepatic bed and in the drainage material. All the patients had not post-operative complications and none biliary drainage or subhepatic collection scanned. We concluded that using our preconized techniques, the subhepatic drainage is unnecessary after elective cholecystectomy.

[Distal pancreatectomy with conservation of the spleen]

Conventional resection of the body and tail of the pancreas usually involves splenectomy. There are evidence that spleen removal can lead to septic and hematological complications and should, therefore, be avoided when possible. Distal pancreatectomy with spleen conservation has been described by specialized centers with good results. This report describes our experience in 8 cases with conservation of the spleen during the resection of the body and tail of the pancreas. The technique has been applied in patients with pancreatic neuroendocrine tumors (n = 4), cystic tumors (n = 3) and cystic-papillary tumor (n = 1) with no complications and good late results in all cases.

[Results of conventional cholecystectomy. Experience in a university hospital]

The experience with open cholecystectomy in an university affiliated hospital is documented in this report. We studied retrospectively 221 patients operated between 1987 and 1992, type of surgery, morbidity and mortality were analyzed. There were 171 (77.3%) cholecystectomy alone and 50 (22.7%) cholecystectomy with other biliary surgery (BS). Pulmonary, urinary and wound complications were the most common. Overall incidence of complications was 7.2%. For patients with cholecystectomy alone morbidity was 3.5% and for patients with BS morbidity was 20% (p < 0.002). There were no mortality in this group of patients.

Surgical treatment of pancreatic ascites and pancreatic pleural effusions

BACKGROUND/AIMS

Massive ascites and pleural effusions are uncommon but well-documented complications of chronic pancreatitis. The present study reviews the results of surgical management of pancreatic ascites and pleural effusions of pancreatic origin.

PATIENTS AND MATERIALS

From forty-nine patients with chronic pancreatitis presenting with ascites and/or pleural effusion of pancreatic origin, 31 were surgically treated.

RESULTS

Nineteen had ascites only, ten pleural effusions and two presented with both conditions. Diagnosis of the internal pancreatic fistula was based on the findings of high amylase levels and elevated albumin content of the peritoneal and pleural exudates. Failure of medical therapy was the indication of surgical treatment in all patients. Thirteen were submitted to internal pancreatic drainage, 17 to external drainage and one to distal pancreatic resection. Eight of 17 externally drained patients were reoperated for intraperitoneal abscesses (2), infected pseudocyst (1), pain recurrence (3) and pancreatic fistula (2); whereas reoperation occurred in only one of the 13 patients submitted to internal drainage (p < 0.05).

CONCLUSIONS

Internal pancreatic drainage was the ideal surgical treatment for patients with pancreatic ascites and/or pleural effusion that did not respond to medical treatment. When this was not feasible external drainage was successfully used as an alternative to pancreatic resection.

[Prognostic value of the sites of pancreatic necrosis determined by computed tomography of the abdomen]

Correlations between tomographic findings and the outcome of the disease was made in 49 patients with necrotizing pancreatitis submitted to surgical treatment. Mortality rate was 20.40% resulting mostly from sepsis and multiple organ failures. There was no correlation between APACHE II index and number of necrotic areas diagnosed by abdominal computed tomography although they were closely related with mortality. These findings suggest that different necrotic areas have different prognostic values. The root of the superior mesenteric artery and retropancreatic area were related to worst prognosis with 100% mortality rate. Incomplete necrotic tissue removal is the possible explanation for the high mortality rate.

[Internal biliary fistula: study of 13 cases and review of the literature]

Between 1986 and 1994 13 patients with spontaneous internal biliary fístula were operated at the Hospital das Clínicas of the University of São Paulo. Ten were patients women and three were men. Their mean age was 55.2 years (range 30 to 87 years). The etiology was cholelithiasis in all cases and the most frequent type of fístula was cholecystoduodenal. There was no mortality. A review of literature of this condition and a discussion about the diagnosis, treatment and etiopathogenesis are presented.

[Bouveret's syndrome: a case report]

A patient with duodenal obstruction resulting from passage of a gallstone through the wall of the gallbladder into the duodenum is reported. The patient was successfully treated by removal of the gallstone. A review of literature concerning the diagnosis, treatment and etiopathogenesis is presented.

[Cystic neoplasm diagnosed as pancreatic pseudocyst: report of 5 cases and review of the literature]

The majority of cystic lesions of the pancreas are pseudocysts. Nine to thirteen per cent of pancreatic cyst are neoplastic, benign or malignant. Failure to recognize neoplastic nature of a cyst leads to an improper management. The authors present five cases of cystic tumors mistaken for pancreatic pseudocysts, including three mucinous cystadenomas and two mucinous cystadenocarcinomas. Four were drained by cystojejunostomy and one cystogastrostomy. One patient with no metastases at first operation had metastatic spread at reoperation. In the other four cases, subsequent resection was possible and probably curative. Review of the literature and guidelines are given for the purpose of differential diagnosis between theses entities.

[Cystic neoplasm of the pancreas: analysis of 24 cases]

Cystic neoplasms are an uncommon group among pancreatic tumors. These lesions are seen more frequently in recent surgical practice, probably because of advances in diagnostic and surgical techniques. We report 24 patients with cystic tumors of the pancreas, including twelve patients with serous cystadenoma, ten with mucinous cystadenoma and two patients with mucinous cystadenocarcinoma. Twenty-two patients were women and two were man. The median age of patients was 53.5 years (range, 21 to 80 years). Mild abdominal pain was the main symptom; in 71% of patients and weight loss in 29% of patients. The lesions were incidental findings 8% of patients. The mean size of the cysts was 7.8 cm (range, 2.3 to 15cm). Eleven cystic neoplasms were located in the head, three in the neck, five in the body, two in the tail of pancreas and three in the body and tail. All patients underwent surgical exploration. There was no perioperative mortality. Total tumor resection provides the best chance of cure and may remove the risk of malignant transformation of the cystadenomas, particularly of the mucinous type.

[Duodenal ulcer clinically simulating pancreatic neoplasm]

A small fraction of solid mass in the head of the pancreas are inflammatory rather neoplastic in origin. The failure to recognize the true nature of a solid tumor in the head of pancreas may lead to an incorrect treatment strategy. This is a report of a patient with clinical history of pancreatic cancer which computed tomography showed a mass in the head of the pancreas with radiologic characteristics of malignancy. The patient underwent exploratory laparotomy with the finding of a mass in the head of the pancreas. The inflammatory palpable characteristic of the mass led to a intraoperative biopsy to confirm the preoperative diagnosis. With the benign result of the biopsy, the final diagnosis was duodenal ulcer which penetrates in the pancreatic parenchyma.

[Frantz's tumor (papillary epithelial and cystic neoplasms of the pancreas): report of 3 cases]

Three cases of Frantz tumor, a papillary and cystic tumor of the pancreas, are discussed and compared with other cases reported in the literature. The neoplasm behaved in these three cases as a benign tumor. Pancreaticoduodenectomy was performed in one patient and distal pancreatectomy in the other two. C T scan and ultrasonography are useful for the diagnosis of these tumors. Cut surfaces show mostly well encapsulated tumors with the characteristically solid and hemorrhagic-necrotic patterns. Usually they are of a very low-grade malignancy so the complete surgical removal is the treatment of choice.

[Duodenal perforation following endoscopic papillotomy: report of 3 cases]

Duodenal perforation is a rare complication of endoscopic sphincterotomy and its treatment is controversial. The authors report three cases of duodenal perforation by endoscopic sphincterotomy. In two cases with history of a previous biliary infection, surgical treatment had to been performed because of a peripancreatic abscess.

Massive infestation by Ascaris lumbricoides of the biliary tract: report of a successfully treated case

This is a report of a 25 years old black woman from the city of São Paulo, Brazil, who developed acute obstructive cholangitis of Ascaris lumbricoides with septicemia and multiple hepatic abscesses. The patient had sickle cell trait and normal delivery 3 months ago. Massive infestation of the biliary tract by Ascaris lumbricoides was diagnosed by abdominal ultrasonography and endoscopic retrograde cholangiography. Sixty worms were removed from the common bile duct and hepatic abscesses were drained by surgery. The infectious process was polymicrobial. The patient's recovery was complete after a long evolution with a wide spectrum antibiotic therapy. New surgeries were needed to remove residual worms in the biliary tract. The diagnostic methods, clinical-biochemical features and also the clinical and surgical management are presented. The biliary ascariasis pathophysiology is commented.

[Carcinoid tumor of the duodenal papilla]

Carcinoid tumor of the duodenal papilla is very rare. The authors report the case of a 17 years old male with a carcinoid tumor at this site in whom a partial pancreatoduodenectomy was performed and who is well and asymptomatic 13 years after the surgical intervention. A review of literature of this unusual condition and a discussion about the treatment are presented.

[Focal nodular hyperplasia of the liver observed in a patient undergoing prolonged therapy with ketoconazole]

The authors report on a 44 year old man presenting focal nodular hyperplasia of the liver associated with prolonged ketoconazole therapy in the absence of known intake of either estrogens of androgens as well as of any factor that could cause hyperproduction of estrogens. It seems possible the existence of an etiopathogenic relationship between prolonged ketoconazole therapy and focal nodular hyperplasia of the liver since ketoconazole inhibits steroidogenesis and can also increase the estradiol-testosterone ratio (E/T). This hormonal alteration is known to play an important role in the pathogenesis of several hepatic neoplasms, including focal nodular hyperplasia.

[Surgical treatment of ascites and pleural effusion in patients with chronic pancreatitis]

Pleural effusion and ascites are now recognized as possible complications of chronic pancreatitis. Diagnosis of these conditions can be made by the finding of high amylase levels in the pleural or ascite fluid. Out of 31 of our patients with this complications 19 had ascites, 10 pleural effusions and two both pleural effusion and ascites. In 19 patients, presenting poor clinical conditions, the treatment was external drainage. Remaining patients were treated by internal drainage or resection. Eight out of the 19 patients treated by external drainage and one of the 13 patients with internal drainage had to be reoperated. There was no mortality. Though external drainage is followed by high incidence of reoperations this technique should be used in patients with poor conditions.

Surgical treatment of biliary complications from calcifying chronic pancreatitis

Obstructive jaundice in patients with chronic pancreatitis still constitutes a surgical problem deserving the attention of many specialized centers throughout the world. Out of a series of 149 patients operated upon for chronic pancreatitis, 45 (30.2%) with common duct stricture secondary to pancreatic disease have been studied in this series. Eleven patients (24.4%) had transient jaundice, eleven (24.4%) persistent cholestasis and six patients (13.3%) presented cholestasis with cholangitis. Seventeen patients (37.7%) were considered to have asymptomatic biliary tract stenosis. In 37 patients, pancreatic and biliary tract surgery were performed at the same time. There were two postoperative deaths (4.4%) and the late mortality was 9.3%. Choledochojejunostomy was preferred in the treatment of biliary stricture associated with pancreatitis. Cholecystojejunostomy provides inadequate biliary decompression and should not be used in the treatment of these patients. When a pancreatojejunostomy needs to be performed in association with biliary tract decompression, a double intestinal loop technique should be used because it is associated with less morbidity and mortality.