Kenneth W. Warren

Results of radical resection for periampullary cancer.

This report concerns 348 pancreatoduodenectomies, including 13 total pancreatectomies. Operative mortality over 30 years was 15%, operative mortality since 1962, 10%. Precise factors influencing operability, mortality, morbidity, and long-term palliation or cure are emphasized. The necessity for making a distinction among tumors arising in the ampulla of Vater, the intrapancreatic portion of the common bile duct, and the duodenum surrounding the papilla of Vater and carcinomas arising in the head of the pancreas is the most important factor in the approach to periampullary malignant tumors. Even with this large experience, the impression of the operating surgeon at the time of resection was incorrect in 10% of the patients in whom a reons who do not resect carcinomas arising in the head of the pancreas and who may have had less experience in this specialized field may be rejecting an even larger per cent of patients with more favorable periampullary malignant tumors. The influence of previous exploration, manipulation, and biopsy on morbidity, mortality, and survival is discussed. The significance of nodal involvement and residual tumor at the neck of the pancreas and the point of division of the common bile duct and the uncinate process is discussed. These data justify continued selective application of pancreatoduodenectomy for periampullary cancer and identify areas where further improvement can be made.

Primary sclerosing cholangitis. A study of forty-two cases.

Abstract Forty-two patients with primary sclerosing cholangitis were studied in four groups: twelve patients who also had ulcerative colitis; fifteen who had had biliary surgery, with gallstones found in fourteen; four who had severe periportal inflammation; eleven who had no other intra-abdominal or general disease. Study of the clinical material supports the hypothesis of bacterial etiology of the disease. The diagnosis is usually made at operation from the characteristic gross appearance of the bile ducts, namely, thickening and induration of the duct wall and narrowing of the ductal lumen, involving the entire extrahepatic biliary tract in the majority of cases. The resemblance of the gross pathologic changes of primary sclerosing cholangitis to those of cholangiocarcinoma is pointed out, and the importance of differential diagnosis of these two diseases at operation is emphasized. Surgical treatmentm is limited to decompression of the biliary tree by external or internal drainage, removal of stones if present, and total colectomy if the primary sclerosing cholangitis is associated with ulcerative colitis. The disease carries an unfavorable prognosis, progressing in the majority of cases to biliary cirrhosis and death from liver failure or bleeding esophageal varices within several years from its onset.

Ductal drainage or resection for chronic pancreatitis

We report a 10 year review comparing the results of pain relief after three procedures for chronic pancreatitis: Whipple pancreatoduodenectomy, modified Puestow side-to-side longitudinal pancreaticojejunostomy and distal pancreatic resection. Results of follow-up review at 6 months, 2 years and 5 years were tabulated. Five year follow-up data were available on more than 80 percent of patients. The proportion of good results for pain relief decreased with the passage of time regardless of the procedure performed. Although equally good results are obtained after either pancreatoduodenectomy or pancreaticojejunosotomy, we conclude that in the presence of a dilated duct, the procedure of choice is pancreaticojejunostomy. If the duct is not dilated, we then favor pancreatoduodenectomy, after which the pain relief is significantly better (p = 0.05) than after distal resection. Our data show that, for all factors evaluated, the poorest pain relief was obtained after distal resection. Therefore that procedure has limited value when used specifically for relief of pain in chronic pancreatitis, except in the uncommon circumstance when the disease is confined to the distal part of the gland. Our study also shows that patients who have more radical distal resection have no better pain relief than those who have 50 percent distal resection.

Management of Strictures of the Biliary Tract

The best treatment of biliary stricture is prevention by education of surgeons in safe techniques for cholecystectomy and other biliary tract operations, and in the awareness of the various congenital abnormalities in the region of the gallbladder. Treatment should include a mucosa-to-mucosa anastomosis and insertion of an internal stent.

Surgical management of chronic relapsing pancreatitis

Abstract Review of the thirty year experience at the Lahey Clinic with 530 cases of chronic pancreatitis shows that the clinical, physiologic, and pathologic manifestations of the disease are extremely varied and indicates that the most significant feature in the treatment of these patients is the choosing of the appropriate operation for each individual patient after careful exploration of the pancreas. The progressive and irreversible structural changes include fibrosis, atrophy, cystic degeneration, patchy necrosis, abscess formation, and pancreaticolithiasis, often with complete or partial obstruction of the pancreatic ducts. Because duct obstruction is the main pathophysiologic change, early operations directed to the biliary tract, stomach, and autonomic nervous system were generally unsatisfactory, especially in patients with advanced chronic pancreatitis. In contrast, satisfactory longterm results were obtained in 70 per cent of patients who had operations directly on the pancreas. These procedures included drainage of associated pancreatic cysts and abscesses, transduodenal decompression of pancreatic ducts, transpancreatic ductal decompression, distal pancreatectomy, pancreaticoduodenectomy, and total pancreatectomy. Unsatisfactory results were related to choice of an inappropriate operation, inability of the patient to free himself from alcoholism, and persistence of residual pancreatic inflammatory disease. The clinical antecedents of the disease, the metabolic consequences, and the results of various operations are discussed.

Progress in biliary stricture repair

Between 1967 and 1970 inclusive, 119 patients underwent 158 operations for the relief of benign bile duct stricture. During this time hepaticojejunostomy was favored for biliary reconstruction, since eighty procedures were of this type. Thirty-eight were end to end repairs and the remainder were a variety of other types. Of the cases evaluated, 58 per cent of the hepaticojejunostomies and 61 per cent of the end to end repairs produced satisfactory results. This experience is an improvement over a previously reported earlier series from this institution. Only three patientd died postoperatively, a significant reduction over an earlier mortality. Further experience with the use of the modified Y tube has been gained in forty-two cases, and it suggests that the benefits might be statistically significant in hepaticojejunostomy if the number of cases were increased. We have begun to evaluate the transhepatic circle tube which can be replaced, when obstructed, on an outpatient basis, thus allowing longer use of stents. Analysis of obstructive biliary sludge in five stents suggests that the sludge is a polymer of bile pigment that is insoluble in both aqueous and organic solutions and therfore not preventable or dissolvable by the administration of chenodeoxycholic acid.

Periampullary and duodenal carcinoid tumours

2 60 M Duodenum, Ist part 56 M Duodenum, Ist part 1 45 M Ampulla 1 41 F Duodenum, 2nd part 2 Unspecified 1 46 F Duodenum, 3rd part 3 64 F Unspecified 63 M Duodenum, 1st part 60 F Duodenum, Ist part 1 42 F Unspecified 1 36 F Unspecified 1 65 F Duodenum, Ist part 3 64 M Duodenum, Ist part 63 M Duodenum, Ist part 70 F Duodenum, 1st part 1 Unspecified 2 49 F Duodenum, 2nd part 70 F Duodenum, Ist part 3 80 M Duodenum, Ist part 78 M ?Duodenum, 2nd part 60 M Duodenum, 2nd part 2 72 M Duodenum, Ist part 47 M Duodenum, 1st part 8 All unspecified 2 57 M Ampulla 69 M Ampulla 3 62 M Duodenum, Ist part 61 M Ampulla 57 M Duodenum, 1st part 1 Unspecified 1 63 M ?Duodenum, Ist part 1 38 F Duodenum, 2nd part 2 63 M Unspecified Unspecified 1 64 F Unspecified 1 49 M Duodenum, 1st part 1 56 F Unspecified 2 49 F Ampulla 70 F Ampulla 1 46 M Ampulla 1 40 M Duodenum, Ist part

Sphincterotomy or sphincteroplasty in the treatment of pathologically mild chronic pancreatitis

We reviewed 67 patients with a mild to moderate degree of chronic pancreatitis, 33 of whom had sphincterotomy and 34 of whom had sphincteroplasty of the sphincter of Oddi and the sphincter of the pancreatic duct. The cause of the pancreatitis was idiopathic in 35 and probably alcoholic in 32. Initial relief of symptoms at 6 months was acceptable in both groups (mean, 64 percent), but thereafter decreased at 2 years and 5 years postoperatively to significant relief in only 48 and 44 percent of patients, respectively. The more complex sphincteroplasty appears to offer no advantage over the simpler sphincterotomy in the management of patients with pain of pancreatitis. In the patients who were alcoholics, avoidance of alcohol seems to be a much more important determinant of the outcome of the operation than the operation itself.

The Choice of Therapeutic Measures in the Management of Chronic Relapsing Pancreatitis and Pancreatolithiasis

Summary The difficulty of selecting the proper surgical procedure in the treatment of chronic relapsing pancreatitis is stressed. The clinical and pathologic features of the disease are discussed. Our experience with, and preference for, the various surgical maneuvers commonly employed in the management of the disease are detailed. Thoracolumbar sympathectomy appears to offer temporary relief. Pancreatoduodenectomy offers the best chance for permanent relief.

Changing Patterns in Surgery of the Pancreas

In pancreatic surgery, exact diagnosis is sometimes impossible, the operation is intricate, and complications are frequent. However, new diagnostic measures that complement the old ones have been developed and offer promise in detecting early, treatable disease.