Charles F. Frey

Pancreatectomy for Chronic Pancreatitis

Of one hundred and forty-nine patients (101 male and 48 female) 4–67 years of age, 117 were alcoholics and underwent pancreatectomy because of episodic or continuous abdominal pain or complications or chronic pancreatitis. Nineteen patients underwent pancreaticoduodenectomy, seventy-seven 80–95% distal resection, and fifty-three 40–80% distal pancreatic resection. There were 3 operative deaths and 30 late deaths 6 months to 11 years post pancreatectomy. Twenty-one patients were lost to followup, I to 11 years post pancreatectomy. Ninety-five patients are known to be alive, 4 of whom are institutionalized. Indications for pancreatectomy in addition to abdominal pain include recurrent or multiple pseudocysts, failure to relieve pain after decompression of a pseudocyst, pseudoaneurysm of the visceral arteries associated with a pseudocyst, recurrent attacks of pancreatitis unrelieved by non-resective operations, duodenal stenosis and left side portal hypertension. The choice between pancreaticoduodenectomy or distal resection of 40–80% or 80–95% of the pancreas should be based on the principle site of inflammation whether proximal or distal in the gland, the size of the common bile duct, the ability to rule out carcinoma, and the anticipated deficits in exocrine and endocrine function. The risk of diabetes is very significant after 80–95% distal resection and of steatorrhea after pancreaticoduodenectomy. When the disease process can be encompassed by 40–80% distal pancreatectomy this is the procedure of choice.

Pancreatic Pseudocyst—Operative Strategy

The experience with 131 patients with 157 pseudocysts is reported. One hundred and twenty patients with 146 pseudocysts underwent 165 operations. There were ten operative deaths (8.3%) three of which were not attributable to the pseudocyst or its operative management. Sixteen patients died six months to 14 years after operation. Deaths in six of the 16 patients were in part attributable to pancreatitis or complications of pseudocyst management. The operative mortality was highest in patients undergoing incision and drainage and cystoduo-denostomy. Other factors influencing mortality unfavorably included postoperative gastrointestinal hemorrhage from a pseudocyst; rupture or flstulization of the cyst into the gastrointestinal tract if associated with hemorrhage, and evidence of common duct obstruction, or the location of cysts in the head or uncinate process of the pancreas. Visceral angiography should be performed on all patients with pseudocysts. The risk of massive gastrointestinal or intra-abdominal hemorrhage is highest in the 10% of patients having pscudoaneurysms associated with their pseudocysts. Incision and drainage of pseudocysts is associated with a high rate of recurrence of the cyst and continued pain. Incision and drainage should only be used if the cyst is infected, or the cyst wall is not mature enough to hold sutures. Cystogastrostomy and cystojejunostomy are the procedures of choice for mature cysts. The presence of a pseudo-aneurysm visualized on preoperative visceral angiography is an indication for an cxcisional operation as are the presence of multiple cysts, compression of the common duct or duodenum by the cyst, evidence of left sided portal hypertension, recurrent cysts or evidence of chronic pancreatitis.

A novel method for the separation and identification of bile acids and phospholipids of bile on thin-layer chromatograms

Cholesterol gallstone disease, so common in the western world, ‘has consider&le medical and economic importance. Under normal physiological conditions, cholesterol is held in solution in the bile. If the solubility of cholesterol in bile is changed, cholesterol crystals will precipitate and lead to the formation of gallstones. The solubility of cholesterol in bile depends on three major lipid components of bile: conjugated bile salts, phospholipids and cholesterol’. Knowledge of bile lipid composition is important in our understanding of the mechanism of gallstone formation. Paper chromatography2 and silicic acid column chromatography3 have been used for the analysis of the composition of bile lipids. However, the latter technique has been found less satisfactory for routine bile analysis or to experiment on small animals because of the limited quantity of the bile samples. Although thin-layer chromatographic separation of bile lipids4 can be performed using three successive solvent systems, it takes as long as 8 h and does not delineate the free bile acids one from the other. Since bile contains a variety of compounds, different plates and different solvent systems must be used for the separation of each class of compounds. Various solvent systems have been proposed to achieve the separation of bile acids and their conjugates5*6 on thin-layer chromatograms. Our method successfully accompiishes the separation of severai ciasses of biie iipids on a singie piate which makes a direct comparison possible between different bile lipid components such as cholesterol, free and conjugated bile acids, lecithin and lysolecithin. The solvent system and the spray reagent used in our technique, not previously described, are satisfactory for a routine check of bile lipid composition and may be used for the skparation of individual bile acids, both free and conjugated, in biological fluids on the same plate.

The role of phospholipase A in gallstone formation

Abstract Gallbladder bile of patients with gallstones having acute or chronic cholecystitis were examined for phospholipase A activity. None of the specimens tested showed any sign of this enzyme. It is unlikely that the mechanism of gallstone formation in patients with acute and chronic cholecystitis involves phospholipase A.

A method for the separation of glycine-conjugated bile acids as a group from taurine-conjugated bile acids.

Abstract A thin-layer chromatographic method for bile acids has been described which separates glycine conjugates, taurine conjugates, and free bile acids into three separate bands. The solvent system used for this purpose is ethanol-isopropyl alcohol-isooctane-ethyl acetate (25:10:10:10). This method is time saving and very simple for quantitative estimation of the glycine:taurine ratio in biological specimens.

Evaluation of balloon tamponade of the abdominal aorta : An adjunct to the treatment of hemorrhagic shock

Abstract Intra-aortic balloon tamponade of the infra-diaphragmatic aortic is an effective means of reducing intra-abdominal hemorrhage. However, its therapeutic use when preceeded by hypotension and in the face of persistent hypovolemia, often results in death or hind limb paralysis in dogs.

Hematin formation and pancreatitis

Abstract Production of hematin from hemoglobin in vitro is augmented by a mixture of powdered pancreatic enzymes and human pancreatic juice. Those enzymes which most affected the rate of conversion of hemoglobin to hematin were lipase, elastase, and trypsin. These same enzymes were also most active in hematin production from red cells.

A guideline for the organization of an emergency department in the university setting

An emergency d e p a r t m e n t associated with a medical school is pa r t of a teaching ins t i tu t ion and mus t provide the atmosphere , faci l i t ies and s taff for the educat ion of s tudents , phys ic ians and al l ied hea l th professionals. I t also has the respons ib i l i ty for developing new knowledge in emergency medical care th rough research because of i ts academic set. t ing. The commi tmen t to educat ion and research is often in conflict wi th the commi tment to pa t i en t care. These must be brought into h a r m o n y if the emergency depa r tmen t is to run smoothly.

Cholelithiasis in mice: Effects of different chemicals upon formation and prevention of gallstones

CHOLECYSTITIS AND GALLSTONE formation in the mouse can be induced by a lithogenic diet containing 1% cholesterol and 0.5% cholic acid by weight [20]. Gallstones formed more rapidly and frequently in conventional than germ-free mice fed the lithogenic diet, although the development of cholecystitis was similar in onset and degree in both cases [12]. This finding and the inability to culture bacteria from the gallbladder wall or bile of conventional mice fed the lithogenic diet makes it unlikely that bacteria have any major role in gallstone formation in the mouse [13].

Curriculum for the 2nd career physician in emergency medicine

Recommendations for a three week refresher course for physicians seeking a new career in emergency medicine are made. The skills to be mastered during the course, each of which should be checked by an instructor, are listed. The recommendations made are based on: (1) a survey of the incidence of 50 disease categories in four different kinds of hospitals; and (2) a survey of 90 physicians who worked in an emergency department either full or part-time. An additional 13 residents in medicine were also surveyed. The survey of the physicians was done in an attempt to determine their level of confidence in managing 50 disease categories.