Edward L. Bradley

The natural history of splenic vein thrombosis due to chronic pancreatitis: indications for surgery.

SummaryEleven patients with angiographically demonstrated splenic vein thrombosis associated with chronic pancreatitis were followed for an average of 6.5 yr to determine the natural history of this condition. Repeat angiography was performed in five patients. Significant gastric or gastroesophageal varices were noted in six cases. In another patient, peri-colonic varices and spleno-portal collaterals were demonstrated. Two patients bled massively during follow-up; one from gastric varices and one from colonic varices. Another patient, with known gastric varices, intermittent hematochezia and iron deficiency anemia, underwent surgery. All three patients responded well to splenectomy. Since three of the seven patients with splenic vein thrombosis and significant varices eventually required surgical correction, it may be that the long-term risk of gastrointestinal bleeding exceeds the risks of elective splenectomy in these patients.

Complications of Chronic Pancreatitis

The most common complication of chronic pancreatitis is pain, which in many cases seems related to pancreatic ductal obstruction with ductal hypertension. Longitudinal pancreaticojejunostomy is indicated in patients with a dilated (larger than 7 mm) duct and pain that requires narcotic analgesics for relief. Chronic pseudocysts may be corrected surgically without the usual 6-week wait, and asymptomatic pseudocysts less than 4 cm in diameter may not require surgery at all. The relative efficacy and risks of percutaneous drainage of pseudocysts versus the standard surgical approaches need to be studied. Pancreatic fistulas may be external or internal, where pancreatic ascites or hydrothorax can be the clinical manifestation. The pharmacologic suppression of pancreatic secretion (e.g., with somatostatin) may be useful in their management, but surgery may be required. Pancreatic resection or internal drainage is usually effective. Persistent jaundice should be relieved surgically by choledochoduodenostomy to avoid the development of secondary biliary cirrhosis. Obstruction at various levels of the gastrointestinal tract (duodenum, small bowel, colon) may require bypass (gastrojejunostomy) or resection. Hemorrhage from major arteries is an infrequent but often lethal complication of chronic pancreatitis, especially associated with pseudocysts. Angiography is invaluable for diagnosis and occasionally for treatment (embolization). Surgery is preferred in good-risk patients, with suture ligation (resection) of the bleeding source. Chronic pancreatitis is the most common cause of splenic vein thrombosis. The resultant hemorrhage from gastric varices is managed effectively by splenectomy.

Mesenteric venous infarction in acute pancreatitis

SummarySegmental intestinal necrosis is a rare complication of acute pancreatitis. The pathogenesis of intestinal necrosis in acute pancreatitis has previously been attributed to arterial thrombosis, but we have observed an unusual case of segmental small intestinal infarction associated with pancreatitis that could not be explained by this mechanism. In our patient, the clinical, gross, and microscopic features were compatible with mesenteric venous infarction. A search of the literature revealed three previous cases of small intestinal infarction in patients with acute pancreatitis with similar clinical and histologic findings. Mesenteric venous infarction of the colon has also been described in association with acute pancreatitis. It seems clear that mesenteric venous infarction represents an additional cause of intestinal necrosis in patients with acute pancreatitis, and may result from changes in clotting mechanisms known to be induced by acute pancreatitis.

The mechanics of pancreatic pseudocyst

Abstract The mechanical properties of normal and pancreatic pseudocyst tissues were studied in one-dimensional stress tests. The resulting load-unload cycles were analyzed assuming elastic, homogeneous, isotropic, incompressible behavior for which a strain energy density function exists. Results were in good agreement with a modified form of the familiar Mooney strain energy density function characterizing rubber elasticity. No statistically significant differences were observed between the normal and pseudocyst samples. A lower bound on the ultimate stress was also obtained. A simplified model for pseudocyst behavior, in which the cyst was assumed to behave as a thin membrane stretched over a hole and inflated, was also considered.

Surgery in acute pancreatitis

SummaryConsiderable controversy has existed in the United States regarding the operative management of acute pancreatitis. Recently, areas of consensus have begun to form regarding necrotizing pancreatitis and biliary pancreatitis. However, the role of surgery and endoscopy for the prevention of recurrent acute pancreatitis in patients with pancreas divisum has not as yet been established.In the United States, few areas of contemporary surgery have remained as controversial as the operative approach to patients with acute pancreatitis. Recently, however, newer methodologies have appeared that seem capable of addressing those current surgical disputes that exist in necrotizing pancreatitis, biliary pancreatitis, pancreas divisum, and in the various complications of acute pancreatitis.

Obstruction from Brunner’s Adenoma

Duodenal hamartoma (Brunner’s adenoma) is a rare tumor and uncommonly symptomatic. We describe 2 cases presenting as obstruction; in one case, ampullary obstruction mimicking carcinoma, and in the oth