Marion C. Anderson

Outcome after lateral pancreaticojejunostomy for chronic pancreatitis.

ObjectiveTo assess the outcome of lateral pancreaticojejunostomy in patients with chronic pancreatitis. Summary Background DataSummary Background Data fibrocalcific pancreatitis associated with pancreatic ductal dilation and chronic pain has been managed successfully with lateral pancreaticojejunostomy. Early results, measured by pain relief and postoperative morbidity and mortality, have been excellent; however, long-term follow-up and overall outcome has been less clearly defined in these patients. MethodsThe outcome of 85 patients who had lateral pancreaticojejunostomy was assessed by reviewing hospital inpatient and outpatient records and conducting patient telephone interviews. ResultsResults 62 patients who were alive at follow-up, health status was characterized as good in 24%, fair in 31%, and poor in 45%. Alcohol abuse continued in 42% of patients, whereas narcotic use continued in 35%, insulin use continued in 23%, and pancreatic enzyme supplementation continued in 34%. Rehospitalization for recurrent attacks of pancreatitis and pain was necessary in 40% of patients. Six patients required subsequent operations for complications of chronic pancreatitis. Death occurred in 22 patients (26%) and resulted from continued alcohol abuse, progression of chronic pancreatitis, or late complications of the operation in more than one half the cases. ConclusionsConclusions lateral pancreaticojejunostomy provided pain relief, had a low morbidity rate, and no early postoperative deaths, long-term outcome was poor based on the patients health status, continued alcohol and narcotic use, employment status, subsequent hospitalization to treat recurrent pancreatitis or its complications, subsequent operations required for complications of chronic pancreatitis, and postoperative deaths related to comorbid medical conditions or complications of chronic pancreatitis.

Percutaneous catheter drainage compared with internal drainage in the management of pancreatic pseudocyst.

The records of 92 patients with symptomatic pancreatic pseudocysts referred for surgical management over a 27-year period were retrospectively reviewed to compare outcome in 42 patients managed with operative internal drainage procedures (group I) with that in 52 patients managed with computed tomography-directed percutaneous catheter drainage (PCD) (group II). The two groups were similar for patient age, sex, pseudocyst location, and cause. The frequency of antecedent pseudocyst-associated complications was less in group I (16.7 versus 38.5%, p less than 0.05). Seven group I patients and four group II patients had major complications (16.7 versus 7.7%, not significant). Group II mean duration of catheter drainage was 42.1 days, and the drain track infection rate was 48.1%. The frequency of antecedent operative cyst drainage was similar (14.2 versus 13.5%), as was the frequency of subsequent operations for complications related to chronic pancreatitis (9.5 versus 19.2%, not significant). Mortality rate was greater in group I (7.1% versus 0%, p less than 0.05). Pseudocysts can be effectively managed either by open operation with internal drainage or by PCD. Drawbacks of PCD include the controlled external pancreatic fistula and the risk of drain track infection. Percutaneous catheter drainage has the following advantages: (1) low mortality rate, (2) does not require a major operation, (3) does not violate the operative field in cases when subsequent retrograde duct drainage procedures are required. Neither PCD nor internal drainage is definitive, and with either technique subsequent correction of underlying pancreatic pathology may be necessary.

Microcirculatory dynamics in the normal and inflamed pancreas

Abstract When an India ink solution was infused into the main pancreatic duct of the dog, the particles were shown to pass between the cells of the acinar unit without apparent ductal rupture. The ink accumulated in a well defined space immediately adjacent to the basilar aspect of the acinus. This periacinar space appeared to communicate directly with terminal ramifications of the local lymphatic circulation. When the lymphatic system was patent, an ink solution introduced into the periacinar space was removed by this route, and the ink particles were deposited in the lung. When the lymphatic system was obstructed by ligation of the thoracic duct, much of the ink remained in the periacinar spaces; however, there was also a considerable concentration of the particulate material in the liver. The latter suggested that the periacinar spaces also communicated directly with the local capillary (portal) circulation. During acute pancreatitis the periacinar spaces became acutely distended, and congestion and stasis were present in both the lymphatic and capillary components of the circulation. Ultimately, erythrocytes filled the periacinar spaces, suggesting the communications between the capillaries and periacinar spaces became pervious to both the fluid and cellular components of the blood. The latter may in part explain the development of hematochylia during acute experimental pancreatitis. The existence of a periacinar space which communicated with both the lymphatic and the capillary circulation of the pancreas was supported by the distribution of ink when it was infused directly into the local lymphatic, venous, or arterial systems during acute pancreatitis.

Microcirculation of the normal and inflamed canine pancreas.

Pancreas of normal dogs and the inflamed gland of experimental pancreatitis were studied by intra-arterial injection of Microfil, a silocone-rubber compound especially suited for study of the microcirculation. Duodenal vasculature and labular vessels of the pancreas were studied as were those supplying the duct. Interlobular vessels were well visualized in the normal pancreas and intralobular vessels formed a fine reticular pattern throught the cleared lobules. A complex network of vessels in the pancreatic duct was observed using this technique, apparently derived from the interlobular vessels. The blood supply of each layer of the duodenum was evaluated.Intraductal trypsin injection produced focal areas of pancreatitis associated with edema, poor vascular filling and spastic changes of the lobular vessels. Extravasation of Microfil, although not aparent on normal specimens, was prominent in inflamed specimens and suggested vascular weakness and disruption. Pancreatic lobules adjacent to inflammatory areas showed definite evidence of dilatation. The inflamed pancreatic ducts were markedly edematous, thickened, and showed incomplete vascular filling. When the duodenum adjacent to pancreatitis was injected with Microfil, edema and vasoconstriction were especially prominent in the duodenal muscular layes.

Thoracic esophageal diverticula

SummaryA review of intrathoracic esophageal diverticula has been presented. Diverticula are considered either epibronchial or epiphrenic by their point of origin in the intrathoracic esophagus. The pathogenesis, symptomatology, complications, and methods of diagnosis of each has been presented. The surgical treatment of epibronchial diverticula is indicated for complications. Small, asymptomatic epiphrenial diverticula are treated conservatively; diverticula that are symptomatic or large and retain barium should be removed surgically. The treatment of choice is a transpleural diverticulectomy. The technical details of this procedure as performed by the authors has been recorded.

Pancreatic enzyme levels in bile of patients with extrahepatic biliary tract disease

A total of ninety three patients with biliary tract disease were studied to determine the concentration of the pancreatic enzymes, amylase and lipase, in bile obtained from the gallbladder and/or common bile duct. Of seventy gallbladder bile samples, amylase levels were higher than actual or predicted serum levels in 87 per cent, while bile lipase were higher than serum lipase values in 66 per cent. Bile obtained from the common bile duct had enzyme concentrations which fluctuated from values similar to those in serum to remarkably high levels. This suggests that pancreatic enzymes enter the biliary system through a common terminal ampulla which is known to exist in 60 to 90 per cent of human subjects. The premise is advanced that pancreatic enzymes may initiate inflammatory changes in the gallbladder and could play a role in gallstone formation by altering the constituents which maintain cholesterol in a soluble state. Biliary reflux of pancreatic enzymes could play a role in the pathogenesis of some cases of cholecystitis can cholelithiasis.

Role of the lymphatic system in the pathogenesis of inflammatory disease in the biliary tract and pancreas.

Abstract The role of the lymphatic system in the passage of inflammatory products between the biliary tract and pancreas is reconsidered. Our findings indicate that in the dog lymphatic communications do exist between biliary tract and pancreas. Under normal conditions lymphatic drainage from the pancreas and biliary tract passes through a group of paraduodenal nodes located near the termination of the common bile duct, from which lymph flow is upward to the cisterna chyle and thoracic duct. The paraduodenal nodes appear to serve as a common lymphatic outflow pathway for the pancreas and biliary tract. India ink infused into the lymphatics of either the pancreas or gallbladder could be demonstrated to pass retrograde, presumably via the paraduodenal nodes, to the other side of the system. Ink infused into the pancreatic lymphatics by ductal injection was demonstrated in lymphatics along the common bile duct. Ink infused into the lymphatics of the gallbladder has been shown to enter lymphatics in the interlobular spaces of the pancreas. When acute cholecystitis was produced, either by an injection of staphylococcus toxin into the gallbladder lymphatics or by injection of lipase into the lumen of the gallbladder, an associated acute pancreatitis was observed in a high proportion of animals. Conversely, lipase-induced pancreatitis resulted in a high incidence of acute cholecystitis. Usually these inflammatory changes could be increased by ligation of the thoracic duct. All of this evidence indicates that the lymphatic system may well be involved in the transmission of inflammatory disease from one organ to another in the pancreatobiliary system.

Extrahepatic biliary obstruction associated with pancreatitis.

A total of 40 patients with pancreatitis had associated extra-hepatic biliary obstruction. Eighteen had biliary-induced pancreatitis. Comprehensive correction of the biliary tract disease, including cholecystectomy, common duct exploration and, when indicated, transduodenal sphincteroplasty, resulted in a high recovery rate (83%) with no recurrence of pancreatitis. Twenty-two patients had chronic pancreatitis with involvement of the terminal biliary tract by a long tapering stenosis. Nineteen of these patients had chronic fibrocalcific pancreatitis secondary to chronic alcohol abuse. In five patients, the stenosis produced a high grade obstruction which required biliary bypass with choledochoduodenostomy (four) or cholecystoduo-denostomy (one). The remaining 14 patients maintained patency of the biliary tract following correction of the underlying pancreatic pathology. The latter consisted of drainage (nine) or resection (five) of 14 associated pseudocysts (present in 64% of the 22 patients), combined with side-to-side pancreaticoje-junostomy to decompress an obstruction of the major pancreatic duct. In assessing the degree of terminal bile duct stenosis, calibration of the duct with Bakes dilators or rubber catheters was a useful aid. Two of the 22 patients ultimately proved to have carcinomas, producing obstruction of the pancreatic duct in the head of the gland. Both were treated initially with choledochoduodenostomy. This possibility must be considered in the management of these patients.

A review of experimental pancreatitis.

Abstract It is apparent from this review that a great deal of effort has been devoted to problems related to the pathophysiology of pancreatic inflammation. It is equally obvious that many aspects of the disease deserve further study. It can be said that a foundation has been laid; some of the stones will collapse under the weight of additional knowledge, while others will be replaced because they fail to conform to the structure which evolves. A beginning has been made, but much remains to be learned.

An Evaluation of the Common Channel as a Factor in Pancreatic or Biliary Disease

An Evaluation of the Common Channel as a Factor in Pancreatic or Biliary Disease Marion Anderson;W. Mehn;Harold Method; Annals of Surgery