Hypoparathyroidism after total thyroidectomy

The aim of the study is to describe the last advances (2000-2007) in the management of hypoparathyroidism secondary to total thyroidectomies. This systematic review was conducted according to recently presented guidelines on the argument. A comprehensive literature search was performed in August 2007 consulting PubMed MEDLINE for publications, matching the terms of hypoparathyroidism/ hypocalcaemia AND parathyroid glands, total thyroidectomy, thyroid surgery, postoperative complications, and risk factors. Hypoparathyroidism remains a frequent and challenging complication following total thyroidectomy. A meticulous surgical technique with an excellent anatomical knowledge of the neck compartment are mandatory to restrain its appearance. The application of lens magnification and of parathyroid glands autotransplantation (PTAT) during thyroid surgery contribute to preventing definitive hypoparathyroidism and also to decrease the postoperative incidence of transient hypocalcaemia. Consequently, the reduction of complications rate determines the decrease of the hospitalization length, costs, and patient discomfort due to a fear of clinical manifestations, and facilitates the return to work. The microsurgical approach and the PTAT are effective and easily learnable procedures, also adaptable in less favoured areas without additional cost. We believe that these performances represent a real aid in association with an operative strategy aiming always to the preservation of parathyroid glands in situ.

The Impact of Single Parathyroid Gland Autotransplantation During Thyroid Surgery on Postoperative Hypoparathyroidism: A Multicenter Study

BACKGROUND

We compared the surgical outcomes in patients undergoing bilateral thyroid surgery with or without parathyroid gland autotransplantation (PTAT).

METHODS

One thousand three hundred nine patients underwent surgery for treatment of various thyroid diseases at three Academic Departments of General Surgery and one Endocrine-Surgical Unit throughout Italy. A nonviable gland or difficulties in dissection of the parathyroid glands were encountered in 160 (13.7%) patients. The subjects were divided into two groups: (1) patients undergoing PTAT during thyroidectomy (n = 79) versus (2) control group (n = 81), patients not undergoing PTAT.

RESULTS

Clinical manifestations occurred in 5.0% of PTAT patients and in 13.6% of control patients (P = NS). Total postoperative hypocalcemia was less among PTAT than control patients (17.7% and 48.1%, respectively; P = .0001). There was no significant difference between the two groups in terms of definitive hypocalcemia (0% vs 2.5% in PTAT and control, respectively). Transient postoperative hypocalcemia was less among PTAT than controls (17.7% vs 45.7%; P = .0002). PTAT was associated with decreased occurrence of hypocalcemia in the two subgroups of patients operated for benign euthyroid disease (P < .0001), as compared with the control group.

CONCLUSIONS

PTAT is an effective procedure to reduce the incidence of permanent hypoparathyroidism. Transient hypoparathyroidism appears to not be influenced by PTAT. Moreover, we observed that damage to one parathyroid gland has more side effects (ie, transient hypocalcemia) among patients who were preoperatively at low rather than at high risk of postoperative hypocalcemia.

[Urgent ulcerative colitis: our experience]

The authors refer their experience in Urgent Ulcerative Colitis. They define the various clinical maniferstations and then specify the necessary elements for a corrent nosological arrangement. About diagnosis, their confirm the inconvenience of clinical examination like as colonscopy or an opaque clysma, giving their choice to other parameters, like as clinical, hematic (PCR), microscopic and cultural of the faeces, radiological (direct abdomen radiography; abdomino-pelvic echography; abdomino-pelvic TC, better if spiral), endoscopic (rectoscopy with minimal insufflation). They explain their guideline about medical therapy, the strategy adopted in relation to its duration, the protocol of evaluation during the administration period and the predictive sighs of its possible failure. After having precised the surgical indications, they stop a little about the timing of a surgical interventation, underlining its primary importance. In the range of a surgical strategy. They give their choice to the total colectomy with associated ioleostomy for its less incidence of complications and mortality versus proctocolectomy, reserving this last one to that cases with irreprensible rectal hemorragy, with preservation of the anal canal for a possible delayed ileo-anal anastomosis. They also think, at last, that after an Urgent Total Colectomy, the immediate ileo-rectum anastomosis could have an high risk of dehiscence of the anastomosis itself and so it must be reserved only to that selected cases which offer local and general guarantees of solidity of the anastomosis and it must be preferably done joinly whit a loop ileostomy at the bottom of the anastomosis itself.

Second harmonic imaging improves trans-abdominal ultrasound detection of biliary sludge in 'idiopathic' pancreatitis

BACKGROUND

Recently, biliary sludge has been strongly correlated with 'idiopathic pancreatitis'. It is often diagnosed by trans-abdominal ultrasonography, despite the low sensitivity of this investigation. New scanners, using second harmonic imaging, may improve the quality of the echographic picture.

AIM

To verify the impact of this methodology on the detection of biliary sludge in patients with 'idiopathic' pancreatitis.

METHODS

Fifty patients with 'idiopathic' pancreatitis observed over a 18-month period entered the study. Exclusion criteria were gall-bladder stones, polyps, clinical conditions related to biliary sludge development and haemolytic disorders. Patients were assessed blind by two operators using either conventional ultrasonography or second harmonic imaging. The parameters of diagnostic quality of both examinations were evaluated using, as the gold standard, microscopic examination of the gall-bladder content collected at endoscopy after cholecystokinin infusion.

RESULTS

An improvement in sensitivity, specificity, efficiency and negative predictive value was obtained by second harmonic imaging compared with conventional ultrasonography.

CONCLUSIONS

Second harmonic imaging, in our experience, is a reliable non-invasive tool for the diagnosis and follow-up of biliary sludge in the course of 'idiopathic' pancreatitis.

One-day vs standard thyroidectomy. A perspective study of feasibility

BACKGROUND

The aim of this randomized controlled trial is to evaluate the feasibility of one-day thyroidectomy, comparing the results of this method vs standard thyroidectomy.

METHODS

From June 2000 to June 2001, 110 patients underwent total thyroidectomy under general anesthesia for thyroid disease. The patients were randomized into 2 groups: in group A (40 patients) we used the one-day thyroidectomy; in group B (70 patients) we employed standard thyroidectomy. In both groups postoperative mobilization was immediate and the mean postoperative hospitalization stay was 21 hours (range: 18-24) in group A and 60 hours (range: 21-120) in group B. The mean follow-up was 10 months (range: 6-18 months).

RESULTS

The patients of group A showed hypoparathyroidism with temporary hypocalcaemia in 3 cases (7.5%) vs 5 (7.1%) of group B; this finding was not statistically significant. No cases of definitive hypoparathyroidism, nor lesions of RLN, of the external branches of the superior laryngeal nerve, nor postoperative hemorrhage were observed in either group.

CONCLUSIONS

The one-day thyroidectomy was found to be a safe, feasible and cost effective procedure, it is convenient for both the patient and the surgeon, and offers the same immediate and long-term results as the standard thyroidectomy in selected patients.

Typhlitis complicating induction therapy in adult acute myeloid leukemia

In a retrospective analysis of 161 consecutive adult patients with de novo acute myeloid leukemia undergoing induction therapy, including cytarabine, etoposide and anthracyclines, seven patients (4.3%) developed typhlitis. All presented severe neutropenia, fever, abdominal pain and tenderness within 16 days from starting chemotherapy (median 11 days; range 5-16). Three patients underwent surgery and survived, four were treated only with supportive therapy: two recovered and two died. In our experience early recognition of typhlitis and rapid recovery of the neutrophils are the most important determinants of the results of surgical and/or medical approaches. The management of typhlitis, a life-threatening condition, is controversial and depends on many factors characterizing each patient, which must be evaluated in collaboration between the surgeon and the hematologist.

[Right abdominal colonic masses. Recent diagnostic and therapeutic advances: personal experience]

The authors, referring to their experience, make a review of colic pathological features presenting as right abdominal mass. Despite of modern diagnostic means--specially radiological investigations: ultrasonographic and CT scanning--accurate clinical examination still plays a role in the initial assessment and to address diagnostic procedures. Diagnosis may be difficult as the right colon is hardly accessible even to present investigative means. US scanning has proved to be useful, in the surgeon's hands, for timely detection of the lesion and in monitoring its evolution. Many diseases must be considered in the diagnosis of a right colon mass and a few rare too: Meckel diverticolitis, carcinoid, vermiform appendix pseudomyxoma, amebic granuloma, Kaposi's sarcoma. Treatment is still an intriguing question, depending on many factors: site, kind and variety of the diseases showing as right abdomen mass, difficulty in early diagnosis, risk of misdiagnosing, shortage of series reported in literature and the absence of multicenter studies.

[Early colorectal reoperation: risk factors]

The aim of the study was to analyse the risk factors in colorectal reoperation. Over the period from January 1987 to December 1999, 371 patients (191 male and 180 female, aged from 16 to 88 years) underwent colorectal surgery. Eighteen reoperations (12 male, 6 female, aged from 20 to 74 years; median age: 52.6 years) were performed. These included reoperations performed within 30 days of the first operation (or patient admission). The overall incidence of reoperation after colorectal surgery was 4.8% (18/371). In 14 of 18 patients (77%) anastomotic dehiscence was the indication for reoperation. In our experience, the mortality rate was 16.6% (3/18), in agreement with other reports in the literature. Analysis of risk factors in colorectal reoperation poses several methodological problems because we have no randomized multicentre studies that analyse risk factors in colorectal reoperation and the related surgical mortality.

Ultrasound duplex as a sole exam for surgical purposes in lower limb arterial obstructive disease

BACKGROUND

The aim of the research is to value the efficacy of ultrasound duplex as a sole preoperative exam in peripheral Arterial Obstructive Disease (PAOD). Angiography is undoubtedly known as the gold standard, though its risks and complications. In the last decades duplex scanning and its variant, has proven to be an irreplaceable tool in the diagnosis of these disease.

METHODS

We evaluated five previous studies that compare angiography to duplex scanning.

RESULTS

Out of 273 cases, 207 (73.8%) had a good correspondence between the two methods; besides if we consider each arterial tract duplex reliability is better in distal diseases (159 cases out of 200, 79.5%) than in proximal (48 out of 73.65%) contrasting with an other meta-analytic evaluation made by Koelemay et al. Moreover we wanted to verify our personal experience, by the intention to treat method, if the surgical operation selected for our patients would have been the same based only on pre-operative echo-duplex scanning. After the analysis of about 20 files the research was interrupted because there was a perfect correspondence between the two exam only in three cases, all of them re-operation for graft branches obstruction. The lacks of duplex has been: 1) non identification of important lesions on the aorto-iliac tract; 2) insufficient location of distal disease.

CONCLUSIONS

The angiography results the fundamental choice in the treatment of PAOD particularly in the distal tracts. Debatable is the role of echography in aorto-iliac portion, where a number of lesions may be effectively treated by endovascular procedures.

Management of narrower anastomotic colonic strictures. Case report and proposal technique

Management of narrower (<5-mm) colonic anastomotic stricture mainly is performed endoscopically by repeated balloon dilation often ineffectively. The use of metal self-expanding stents in the malignant and benign stricture of the large bowel has been suggested only recently, and is still being debated. In this report we propose a single-stage procedure that we developed to manage narrower anastomotic colonic stricture. A 60-year-old man 2 years previously had undergone surgery for perforated sigmoid diverticulitis by means of Hartmann's procedure. He was submitted to two mechanical recanalization attempts, both of which failed with dehiscence of anastomoses. He reached us with a significant stricture of the colorectal anastomoses (smaller than 5 mm in diameter) and a diversion ileostomy. After two endoscopic balloon dilations, we observed the relapse of the anastomotic stricture, so we decided to draw up another strategy. We performed a dilation with a TTS balloon, leaving a metallic self-expanding covered stent in situ for 3 months. The aim was to achieve the definitive healing of the anastomotic scar tissue at the desired diameter. We removed the stent during the ileostomy closure. At the time of this writing, 18 months of follow-up evaluation, the patient defecates without any problem

Surgery of abdominal aorta in octogenarians. Can indications be extended?

BACKGROUND

This paper describes the authors' experience with the management of the abdominal aorta in patients aged over 80 years.

METHODS

Ten urgent procedures were performed on patients older than 80 years during a 2 year period. In 4 cases surgery was performed because of a ruptured aneurysm of the subrenal abdominal aorta, in 2 cases for active symptomatic aneurysms, in 3 cases for severe lower limb ischemia (occlusion of the iliac and femoral arteries) and in 1 case for a secondary aortoenteric fistula.

RESULTS

The operative mortality rate was 20% (2 cases with a ruptured aneurysm). Five patients are still alive in good health conditions (one of them had been operated twice for two different diseases). Even if our findings refer to a small number of patients, although similar series on emergency operations found in the literature are not substantially larger, the results do not advise against operative treatment of the abdominal aorta in cases requiring a direct approach, even in patients over 80 years of age.

CONCLUSIONS

If this treatment strategy is obviously adopted in emergency conditions, as with the patients we are reporting on, since the alternative to operation is usually death, it should also be carefully considered in elective circumstances, where alternative treatments such as endovascular stents did not to date obtain better results. In the elective scenario all the necessary biological and physical parameters as well as the patient's age should be taken into proper account in deciding whether to operate. This is specially true now that the average life spans of an individual is longer so that patients, who may incur serious problems if left untreated, may be offered a better quality of life.

[Traumatic retroperitoneal lesions]

The presence of lesions on the retroperitoneum generally worsens the prognosis in traumatic pathology; it implies more attention and skills from both the medical and surgical aspect. All type of trauma, blunt or open, may involve retroperitoneal structures and organs; specifically there may be lesions on the great vessels, pancreas, duodenum, oesophagus and genitourinary apparatus. Mortality is high, compared to abdominal traumatic lesions confined within the peritoneal sac. Treatment of single or associated lesions requires a multidisciplinary approach, as the surgical repair implies a specific knowledge and experience on different organs, whose habitual pathology lies on the hands of more surgical specialists. Lesions of great vessels are immediately life-threatening; moreover the choice to "open" a patient for a retroperitoneal hematoma has to be taken upon a careful estimation. It could be better in more than a situation leave such hematoma in its place, specially in the iliac region, waiting for the spontaneous resolution of the hemorrhagic source and of the hematoma itself. The involvement of oesophagus, duodenum or pancreas determines instead a poorer prognosis at a distance. In conclusion retroperitoneal traumatic lesions are among the most challenging and serious emergencies, and necessitate a maximum of attention and expertise by the surgical team involved. Only with a careful judgement about the tactics and the procedures to carry on it is possible to obtain valid results, which often means to safe the patients life.

Insulin-like growth factor-1 and insulin-like growth factor receptor in thyroid tissues of patients with Graves' disease

Growth factors are frequently involved in the regulation of mitosis and differentiation of several cell types and insulin-like growth factor-1 (IGF-1) is actively involved in the thyroid stimulating hormone-mediated proliferation of thyrocytes. In view of the pivotal role of IGF-1 in thyrocyte proliferation and of the still unsettled role of this growth factor in the pathogenesis of hyperplastic thyroid lesions, we investigated the expression of IGF-1 and of its corresponding receptor, by means of immunohistochemistry, in the surgical specimens obtained from six patients with Graves' disease. Moreover, IGF-1 mRNA expression was analysed in one such case by means of Northern hybridisation. All samples showed consistent intracytoplasmic immunoreactivity for both IGF-1 and IGF-1 receptor; the vast majority of hyperplastic thyrocytes were strongly decorated by the two antibodies used in this study whereas stromal cells displayed IGF-1 immunoreactivity only. IGF-1 mRNA was markedly overexpressed in Graves' disease in comparison with normal thyroid tissues. The results of this study suggest that IGF-1 and IGF-1 receptor may be actively involved in the pathogenesis of Graves' disease; furthermore, IGF-1 and IGF-1 receptor apparently act by different mechanisms (paracrine vs. autocrine) as suggested by their differential expression in epithelial and stromal cells.

An unusual complication resulting from surgical treatment of periampullary tumours

BACKGROUND AND METHODS

The authors describe the rising of four postoperative pancreatic pseudocysts in a series of 20 patients treated for periampullary tumours by pancreaticoduodenectomy (PDT), with the closure of pancreatic stump, between 1989-1996. The operation was always performed by the pylorus-preserving technique according to Traverso-Longmire.

RESULTS

In four patients (20%) 3, 4, 4, and 8 months after PDT with closure of the pancreatic stump, the authors observed the development of pseudocysts (PPC) in the pancreatic remnant. All these patients previously had a pancreatic fistula. Three symptomatic patients underwent surgical drainage of the pseudocyst in a jejunal loop (2) or in the stomach (1); in the asymptomatic patient, the clinical feature and the size of the cyst allowed for conservative treatment. In 2 cases PPC was the consequence of a pancreatic fistula evolved in acute pancreatitis of the stump. The PPC drained by cystogastrostomy appeared 4 months after the closure of the pancreatic fistula: the pancreatic stump was completely substituted by a cyst presenting a communication with the pancreatic duct.

CONCLUSIONS

The authors conclude that PPC is a rare complication of the pancreatic resection that results from acute or chronic pancreatitis; sometimes pathogenesis is due to a cyst resulting from the pancreatic duct occlusion by phlogistic tissue as a consequence of the surgical suture.

[Preliminary experience with the surgical treatment of inguinal hernias with the Shouldice procedure]

The authors report their recent experience on the surgical treatment of inguinal hernias according to Shouldice Canadian repair, used for the undiscussed advantages. The least pre-operational preparation, the early mobilization of the patient, the reduction of the hospitalization and the almost total absence of relapses, support the application of this technique of which we auspicate a wider use.

Surgical treatment of chronic pancreatitis. Report of 134 cases treated by resection or drainage

One hundred thirty-four patients (123 men and 11 women) were operated on for chronic pancreatitis (69 pancreaticojejunostomies, 20 cytopancreaticojejunostomies, 22 left pancreatectomies, and 23 Whipple operations). Half of these patients were followed up for 5 years or more. Four patients died from cancer of the pancreas. The operative mortality rate was 4.2 percent after anastomosis, 13.5 percent after pancreatectomy, and 8.7 percent after a Whipple operation. Relief of pain was the main aim of operation. The rate of good results after pancreaticojejunostomy (85 percent) was higher than after resection (71 percent after right pancreatectomy or Whipple operation and 66.6 percent after left pancreatectomy). The mortality rate after 5 years 26 percent after anastomosis, 30 percent after Whipple operation, and 45 percent after left pancreatectomy. Alcoholic intake did not appear to influence the operative result but improved the quality of life of the patient. Postoperative complications are more common and more serious after resection than after anastomosis. If dilated, the common bile duct must be drained as well as the pancreatic duct after anastomosis. Whenever the pancreatic duct is dilated more than 8 mm it must be drained rather than resected.

Action of gastrointestinal hormones on the myoelectric activity of the sphincter of Oddi in living rabbit

The aim of this work was to compare the action of gastrointestinal (GI) hormones on the myoelectrical activity of the sphincter of Oddi. Using an experimental design previously described, we studied the electrical activity of the sphincter of Oddi and compared the percentage variation in the number of spikes before and after injection of hormones. Increasing doses of the following hormones were injected i.v. at random: CCK, OP-CCK, caerulein, bombesin, gastrin, secretin and glucagon. CCK and caerulein (as previously found), and also bombesin, OP-CCK and gastrin increased the spikes activity of the sphincter of Oddi. Secretin had no effect and glucagon decreased this activity. There was no tachyphylaxis, but a good dose-effect relationship for each hormone. Compared on a molar basis caerulein is 8 times more effective than CCK and OP-CCK which in turn are more potent than bombesin. Gastrin acts only at pharmacological doses.

An interesting case of pancreaticoduodenal trauma

A case of severe duodenal trauma is described in which duodenal rupture occurred but relative integrity of the pancreas was maintained. Conservative surgical management with construction of a new papilla of Vater and with anastomotic protection by a gastrojejunostomy proved successful and obviated the need for pancreaticoduodenectomy.

The parotid and the pancreas. V. Effects of a synthetic prostaglandin analog on parotid gland secretion

Effects of a synthetic prostaglandin analog--16,16-dimethyl prostaglandin E2 methyl ester (16-diMe-PGE2)--on parotid secretion were evaluated in eight dogs under anesthesia. Graded doses of 16-diMe-PGE2 (0.3, 0.5, 1.0 and 2.5 microgram./kg.) were administered intravenously with the parotid in the resting state or in response to urecholine (intravenous infusion or subcutaneous injections). Profound and prolonged inhibition of volume occurred. Amylase concentration was increased but output was unchanged. Bicarbonate concentration was increased but output was decreased. Nonsteroid inhibitors of endogenous prostaglandin synthesis did not alter these effects. Although these studies do not establish a physiologic role for prostaglandins in the regulation of salivary secretion, they do demonstrate a wide-ranging effect of prostaglandins on the gastrointestinal tract.

The parotid and the pancreas

Parallel studies in parotid and pancreatic function and histology were carried out in Thomas fistula dogs with irradiation-induced chronic pancreatitis. After completion of base line studies of parotid and pancreatic secretion, four dogs were subjected to 2,400 rads tumor dose over two weeks (with a nominal single dose of 1,175 rets); two additional dogs served as control. Sequential studies were performed on pancreatic secretion in response to secretin and on parotid secretion in response to urecholine. After a short-lived period of hypersecretion. There was a progressive reduction in pancreatic secretory rate, bicarbonate and enzyme outputs (greater than 90% after three months). Parotid secretion increased over this period but subsequently decreased, so that at eight months there was a marked reduction both in pancreatic and parotid function. Whereas pancreatic histology showed diffuse interstitial fibrosis and reduction of acinar tissue, no histologic changes were noted in the parotid glands. Although the mechanisms are unclear, alterations in parotid secretion may be of value in the diagnosis of chronic pancreatitis, in the evaluation of its severity, and may yield information on the duration of the disease.

The diagnostic significance of the immunoglobulin A to M and A to total ratios in the pancreatoduodenal fluid of patients with benign and malignant pancreatic diseases

Immunoglobulins A, M and G in the pancreato-duodenal fluid (PDF) of 35 pancreatic disease-free individuals and 48 patients with chronic pancreatitis (25), hypersecretory disorders (10), renal transplanted (4) and with pancreatic cancer (9), were determined by a single radial immunodiffusion method. Although a trend of immunoglobulin hypersecretion in benign diseases and hyposecretion in malignancies was present, individual levels of Ig-A and Ig-M differed statistically only between cancer and other groups. Calculating the ratios of Ig-A to Ig-M (A/M) and Ig-A to total immunoglobulin contents (A/T) in the PDF of patients with chronic pancreatitis or cancer, however, a significantly higher or lower ratio, respectively, was found compared to control group. Differences in A/M ratios could not be detected between patients with benign diseases, but were constantly present when these patients were compared to pancreatic cancer. The underlying mechanism(s) of the disturbed immunosecretory system in pancreatic diseases remains speculative. Nevertheless, immunoglobulin measurements in the PDF of patients with pancreatic diseases offer a simple diagnostic aid in clinical differentiation of pancreatic pathology.

The effect of Imuran on pancreatic secretion. A preliminary report

The acute administration of Imuran and hydrocortisone significantly decrease pancreatic flow and protein output in canines. This observed phenomenon may explain the gastrointestinal side reactions encountered in clinical usage of these potent immunosuppresants.

[Criteria of evaluation of hemorrhagic portal hypertension and surgical indications]

Massive, active bleeding of the oesophageal varices in cirrhotics requires immediate, comprehensive and continuing appraisal of determining risk parameters (liver function and morphology, hyperdynamic syndrome, renal function, dynamic angiography of the splanchnic circulation). When survival is linked with stopping the haemorrhage, indications must not be looked at restrictively and operation has to be fast. Minor surgical measures aimed at temporary control of the haemorrhage are not satisfactory. Side-to-side portacaval anastomosis is effective in terms of reducing portal pressure and controlling the haemorrhage. Mesenterico-caval shunt with H-dacron graft interposition is sufficient dynamically and has less effect on porto-hepatic flow. Long-term results with this technique requires further study.

Effects of duodenal alkalinization on pancreatic secretion

Effects of duodenal alkalinization on pancreatic secretion were evaluated in seven dogs including two antrectomized dogs with chronic duodenal fistulas. Continuous intravenous injection of secretin or secretin plus CCK PZ was administered as a stimulus for the pancreatic secretion. Intraduodenal infusion of alkaline solutions such as pancreatic juice (pH 8.6), bile (pH 8.1), bicarbonate solution (160 mEq./I., pH 8.6) and TRIS buffer solution (0.3 M, pH 9.5) caused a moderate increase in protein output and a modest or no increase in flow but no change in bicarbonate output. During infusion of pancreatic juice, varied doses of secretin (0, 0.015, 0.03, 0.06 u./kg./min.), or secretin (0.03 u./kg./min.) plus CCK-PZ (0.05 u./kg./min.) were administered intravenously. For example, under the stimulation of secretin (0.03), flow increased modestly (17.7%), an increase which was of statistical significance. Protein output also showed a significant increase of 35.7%. There was, however, no response of the pancreas to the infusion of pancreatic juice when the gland was stimulated by secretin plus CCK-PZ. Antrectomy did not alter the effect of alkaline intraduodenal infusions on pancreatic secretion.

Effect of irradiation on the canine exocrine pancreas

Effects of irradiation on the pancreas was studied in 6 dogs receiving a dose equivalent to the biologic effect of 4000 R/6 weeks (with a nominal stnadard dose of 1175 rets) given to patients with Hodgkins disease. After control secretory, histologic and pancreatographic studies, 6 Thomas fistula dogs were subjected to 2400 R tumor dose over two weeks. There was a biphasic response to secretin alone or secretin with cholecystokininpancreozymin. An initial hypersecretion occurred at 2 weeks --volume was increased, but bicarbonate and enzyme output remained unchanged. Thereafter there was a progressive reduction in volume, bicarbonate and enzyme outputs ( greater than 90% after 3 months). Histology showed early ductal reduplication but with progressive fibrosis, features compatible with chronic pancreatitis. Pancreatic insufficiency may contribute to post-irradiation gastrointestinal symptomatology. Close field irradiation of the pancreas results in actual destruction of the parenchyma.