John H. C. Ranson

The timing of biliary surgery in acute pancreatitis.

The timing of biliary surgery remains controversial in patients with acute pancreatitis associated with cholelithiasis. Eighty hospital admissions for acute pancreatitis, occurring in 74 patients with cholelithiasis, have therefore been reviewed. Among 22 patients who underwent abdominal surgery during the first week of treatment, there were five deaths (23%) and four patients (18%) who required more than seven days of intensive care. Fifty-eight episodes of pancreatitis were managed non-operatively during the first week of treatment, with no deaths, although six (10%) required more than seven days of intensive care. Biliary surgery was undertaken later during the same admission in 37 patients, with no deaths. Twenty-one patients were discharged without biliary operation, but seven (33%) developed further pancreatitis. Previously reported prognostic signs were used to divide pancreatitis into 57 “mild” episodes (1.8% mortality) and 23 “severe” episodes (17% mortality). Karly (day 0–7) definitive biliary surgery was undertaken in 11 patients with “mild” pancreatitis, with one death (9%), and in six patients with “severe” pancreatitis, with four deaths (67%). In three recent patients with “severe” pancreatitis, early biliary surgery was limited to cholecystostomy, with no deaths. These findings suggest that although early correction of associated biliary disease may be undertaken safely in many patients with “mild” acute pancreatitis, early definitive surgery is hazardous in “severe” pancreatitis and should, if possible, be deferred until pancreatitis has subsided. In most patients biliary surgery should precede hospital discharge.

Optimal Management of the Pancreatic Remnant After Pancreaticoduodenectomy

ObjectiveThe authors evaluated methods of operative management of the pancreatic remnant after pancreaticoduodenectomy. Summary Background DataDespite reductions in mortality after pancreaticoduodenectomy, leakage from the pancreatic remnant still may cause significant morbidity. Patients with small, unobstructed pancreatic ducts or soft, friable pancreata are at particularly high risk. Although numerous surgical techniques have been described to avoid such complications, no single method is suitable for all patients. MethodsThe authors retrospectively reviewed the medical records of 114 consecutive patients who underwent pancreaticoduodenectomy. Sixty-nine patients were men (61%) and 45 were women (39%), with median age 66 years. Underlying disease was malignant in 87 (76%) and benign in 27 (24%). Patients were divided into groups based on risk for postoperative pancreatic fistula and on the operative management of the pancreatic remnant. Sixty-eight patients underwent end-to-side pancreaticojejunostomy, 13 of whom were high risk (group 1A) and 55 of whom were low risk (group 1B). Thirty-seven patients, all high risk, had either pancreatic duct closure by oversewing (N = 19, group 2) or end-to-end pancreaticojejunal invagination (N = 18, group 3). Nine patients underwent total pancreatectomy (group 4). Morbidity related to prolonged pancreatic drainage (PPD) of greater than 20 days was determined. ResultsOverall incidence of PPD was 17% and caused the only death. Patients considered high risk for postoperative pancreatic fistula had a 36% incidence of PPD compared with 2% in patients considered low risk (p < 0.0001). Prolonged pancreatic drainage frequency related to the method of pancreatic remnant management was as follows: group 1A, 15%; group 1B, 2%; group 2, 79%; and group 3,6% (p < 0.001 for group 2 vs. other groups). No serious sequelae followed PPD in 15 patients (79%); however, 4 patients required reoperation for pseudocyst or abscess drainage; one in group 1A (who died) and three in group 2. Multivariate analysis revealed that operative technique (oversewing of the pancreatic duct) and male sex were significant factors predisposing a patient to the development of PPD. ConclusionsAfter pancreaticoduodenectomy, pancreatic remnant management by end-to-side pancreaticojejunostomy appeared safe in low-risk patients. In high-risk patients, end-to-end

The Role of Peritoneal Lavage in Severe Acute Pancreatitis

Encouraged by reports of the therapeutic efficacy of peritoneal lavage in small series of five or six patients with acute pancreatitis, we have evaluated this treatment in 24 patients with “severe” pancreatitis. One hundred and three patients with “severe” pancreatitis (28% mortality) were separated from 347 with “mild” pancreatitis (0.9% mortality) by previously described early objective signs. Early treatment (Day 0–7) of “severe” pancreatitis included peritoneal lavage through catheters placed nonoperatively in 18 (Group A) and by catheters placed at laparotomy in six (Group C). Early treatment of nonlavaged patients with “severe” pancreatitis was by standard nonoperative measures in 61 (Group B) and included early operation in 18 (Group D). Lavage was continued for 48–96 hours, usually using 36–48 L/24 hours of balanced isotonic dialysate fluid, and was uncomplicated. Lavage led to striking immediate clinical improvement and no lavaged patient (Groups A and C) died during the first 10 days of treatment for pancreatitis. By contrast, 45% of deaths in nonlavaged patients (Groups B and D) occurred during this early period, usually from cardiovascular or respiratory failure. Although lavage reduced mortality in subgroups of patients, ultimate overall survival was not affected (Group A, 83%; B, 84%; C, 33%; D, 33%). Late peripancreatic abscesses caused most deaths in lavaged patients. These data show that peritoneal lavage is a highly effective adjunct to the treatment for early complications of severe acute pancreatitis and dramatically reduces early mortality. Lavage does not prevent the late local sequelae of peripancreatic necrosis.

Abdominosacral Approach for Retrorectal Tumors

The relative rarity and anatomical position of retrorectal tumors may lead to difficulty in diagnosis and surgical treatment. The clinical features and management of 20 such tumors (chordoma 8, neurilemmoma 3, teratoma 3, hemangiopericytoma 1, chondrosarcoma 1, osteosarcoma 1, dermoid 1, lipoma 1, and undifferentiated sarcoma 1) have therefore been reviewed. Low back or sacral pain was present in 18 patients and, although all tumors were palpable on rectal examination, pain had been present for a median of 12 months before diagnosis. Mean tumor size was 9.4 cm (range: 2.5–17 cm). Sacral bone destruction was demonstrated radiographically in all chordomas and three sarcomas, but in none of the benign tumors. Three patients had undergone previous partial removal of their tumors. Surgical resection was carried out using a combined abdominal and transsacral approach in 13, a transsacral approach in the right lateral position in four and transabdominally in three. There was one operative death following secondary operation for chordoma. Four of 12 patients with malignant tumors arc alive and well at seven months to eight years. One died of a myocardial infarct without recurrence at 11 years. For small benign tumors, the right lateral position permits maximal flexibility for resection either by the transsacral, transabdominal or a combined approach. For bulky or malignant tumors, a combined abdominal transsacral approach in the right lateral position permits vascular control and provides good exposure for protection of vital structures and wide resection.

Diagnostic standards for acute pancreatitis

An accurate history and thorough physical examination will often raise clinical suspicion of acute pancreatitis in the differential diagnosis of a patient presenting with acute abdominal pain. An accurate diagnosis is needed to eliminate etiologies of acute abdominal pain and to appropriately direct therapy. Confirmation of the diagnosis is most often made by evaluation of serum amylase and lipase levels. Although hyperamylasemia is found in the majority of patients with acute pancreatitis, other nonpancreatic acute abdominal conditions may be present with hyperamylasemia. CT scanning provides an accurate confirmation of clinical and laboratory findings and offers excellent anatomic and morphologic representation of the pancreas and peripancreatic tissue. The following article, written by the late John H.C. Ranson, presents a discussion of the modalities available for diagnosing acute pancreatitis.RésuméLa pancréatitc aiguë est une maladie relativement fréquente dont l’incidence est en hausse. Son diagnostic est difficile. Dans une étude présentée par Bockus à partir de 94 admissions pour pancréatite aiguë, le diagnostic était inexact chez 43 % des cas. La pancréatite a été prise le plus souvent pour une cholécystitc aiguë (20%), une perforation de viscère creux (7%) ou une occlusion intestinale (5%). Chez le patient ayant une pancréatite aiguë fatale, le diagnostic correct n’a pas été fait avant l’autopsie dans 41.6% des cas. Il n’existe aucun critère clinique ou biologique qui permette le diagnostic certain de pancréatite aiguë à tous les coups. Les données opératoires ou autopsiques ne sont disponibles que chez un faible pourcentage des patients. Les données de la tomodensitométrie sont parfois diagnostiques, mais cet examen peut être normal chez le patient ayant une forme mineure de la maladie. Les critères diagnostiques de la pancréatite aiguë sont passés en revue. Il faut souligner que le diagnostic initial dépend principalement d’un interrogatoire précis ainsi que d’un examen physique soigneux.ResumenLa pancreatitis aguda es una entidad común, con frecuencia de dificil diagnóstico, cuya incidencia es creciente. En un estudio realizado por Bockus en 94 pacientes hospitalizados por pancreatitis aguda, el diagnósti co inicial resultó incorrecto en 43% de los casos. Comúnmente se confundio la pancreatitis aguda con colecistitis aguda (20%), víscera perforada (7%) u obstructión intestinal (5%). En los casos de pancreatitis aguda letal, el diagnóstico correcto solo es establecido en el momento de la autopsia, lo cual ocurre en 41.6% de los casos. Desafortunadamente no existen criterios clínicos o de laboratorio que permitan un diagnóstico certero de pancreatitis aguda en la totalidad de los pacientes. Los hallazgos operatorios o de necropsia están disponibles sólo en una pequena minoría de los casos. Los hallazgos radiológicos en tomografia computadorizada pueden ser diagnósticos de la entidad, pero el estudio puede aparecer normal en los pacientes con enfermedad leve. Es por ello que en el presente artìculo se revisan las características diagnósticas. Debe hacerse énfasis en que el diagnóstico inicial depende, primordialmente, de una bien orientada historia clìnica y de un meticuloso examen fisico.

Resection of the perforated segment: A significant advance in treatment of diverticulitis with free perforation or abscess☆☆☆

As a result of improved medical management of chronic diverticular disease, perforation has become the most common indication for surgical intervention. During the past five years sixty-three patients underwent operation for colonic diverticular disease, of which forty-six were for perforation (generalized peritonitis in 8, abscess in 30, and fistula in 8). The eight patients with generalized peritonitis underwent emergency exploration for spreading peritoneal signs and were managed by resection of the perforated segment, end colostomy, and mucous fistula or Hartmanns pouch. Treatment of thirty-eight patients with abscess or fistula has also stressed primary resection of the perforated segment of colon. Resection and end colostomy without anastomosis was performed in three. Primary anastomosis with proximal diverting colostomy was performed in four. Primary anastomosis alone was done in thirty-one patients. There were no deaths. These results support primary resection of the involved colon with immediate or delayed anastomosis in the operative management of perforated diverticular disease.

The role of surgery in the management of acute pancreatitis.

Surgical intervention in acute pancreatitis may have varied goals. Early laparotomy may be required for diagnostic purposes. There is, however, no convincing evidence that attempts to reduce the morbidity of severe pancreatitis by early operative pancreatic drainage, early formal pancreatic resection, or early biliary procedures have been effective. In fact, they may be harmful. Peritoneal lavage by catheter induced under local anesthesia may ameliorate early cardiovascular and respiratory complications in some patients. Preliminary experience suggests that early operative debridement of devitalized pancreatic tissue with postoperative lavage may be helpful in selected patients. Patients with infections of devitalized pancreatic or peripancreatic tissue require operative debridement and drainage or packing. Other complications such as colonic necrosis or pseudocysts also require operative treatment. Rarely do patients require operation to relieve protracted pancreatitis. Patients with gallstone-associated pancreatitis should usually undergo surgical correction of their cholelithiasis as soon as their pancreatitis has subsided.

Long peritoneal lavage decreases pancreatic sepsis in acute pancreatitis.

Late infection of devitalized pancreatic and peripancreatic tissue has become the major cause of morbidity in severe acute pancreatitis. Previous experience found that peritoneal lavage for periods of 48 to 96 hours may reduce early systemic complications but did not decrease late pancreatic sepsis. A fortunate observation led to the present study of the influence of a longer period of lavage on late sepsis. Twenty-nine patients receiving primary nonoperative treatment for severe acute pancreatitis (three or more positive prognostic signs) were randomly assigned to short peritoneal lavage (SPL) for 2 days (15 patients) or to long peritoneal lavage (LPL) for 7 days (14 patients). Positive prognostic signs averaged 5 in both groups but the frequency of five or more signs was higher in LPL (71%) than in SPL (47%). Eleven patients in each group had early computed tomographic (CT) scans. Peripancreatic fluid collections were shown more commonly in LPL (82%) than in SPL (54%) patients. Longer lavage dramatically reduced the frequency of both pancreatic sepsis (22% LPL versus 40% SPL) and death from sepsis (0% LPL versus 20% SPL). Among patients with fluid collections on early CT scan, LPL led to a more marked reduction in both pancreatic sepsis (33% LPL versus 83% SPL) and death from sepsis (0% LPL versus 33% SPL). The differences were even more striking among 17 patients with five or more positive prognostic signs. In this group the incidence of pancreatic sepsis was 30% LPL versus 57% SPL and of death from sepsis 0% (LPL) versus 43% (SPL) (p = 0.05). In these patients, overall mortality was also reduced (20% LPL versus 43% SPL). When 20 patients treated by LPL were compared with 91 other patients with three or more positive prognostic signs who were treated without lavage or by lavage for periods of 2 to 4 days, the frequency of death from pancreatic sepsis was reduced from 13% to 5%. In those with five or more signs, the incidence of sepsis was reduced from 40% to 27% (p = 0.03) and of death for sepsis from 30% to 7% (p = 0.08). These findings indicate that lavage of the peritoneal cavity for 7 days may significantly reduce both the frequency and mortality rate of pancreatic sepsis in severe acute pancreatitis.

Hepatic resection for metastatic colon and rectal cancer. An evaluation of preoperative and postoperative factors.

Hepatic resection for metastatic colorectal cancer has been reported in over 700 patients. However, approximately 5000 patients each year are candidates for surgical excision. Since 1972, 25 patients have undergone hepatic resection for colorectal metastases at New York University. Potentially curable synchronous lesions were detected by preoperative liver chemistries and operative palpation. Patients were screened for metachronous lesions by serial liver chemistries and carcinoembryonic antigen (CEA) determinations; when clinical findings or laboratory findings were either positive or equivocal, then scanning techniques were used. Most patients had solitary lesions (20). Thirteen of 25 lesions were synchronous; 12 were metachronous. Anatomic lobectomy was performed in 13 patients (6 extended resections); and wedge resection was performed in 12. The operative mortality rate was four per cent; the 2-year survival rate, 65%; the 5-year survival rate, 25%. Hypertonic dextrose solutions were administered during and after operation. Post-operative albumin requirements ranged from 200 to 300 grams/day. Coagulation factors II, V, VII, and fibrinogen decreased after surgery to 30 to 50% of their preoperative levels. Subsequent elevation of these factors correlated with increased bile production and improvement in liver chemistries 10 to 14 days after operation. At present, hepatic resection for colorectal metastases provides the only potential method of salvage, offering a 20 to 25% long-term survival rate.

Perforated diverticula of the jejunum and ileum

Over a ten year period, four patients with inflammation or perforation of non-Meckelian, small intestinal diverticula were treated on the surgical services of Bellevue Hospital. This entity remains uncommon but may be increasing in incidence. The patients presented with a short history of severe abdominal pain, usually accompanied by nausea and vomiting. Each patient also gave a longer preceding history of less well defined abdominal symptoms. The pathogenesis of the small intestinal diverticula is uncertain but may be related to disturbed muscular peristalsis in the small bowel analogous to the changes implicated in esophageal and colonic diverticular disease. The diverticulum may be difficult to demonstrate at operation, and careful exploration for this possibility should be carried out at the time of operation for peritonitis of obscure origin. Segmental resection and end-to-end anastomosis is the treatment of choice.