Thomas Taylor White

Results of surgical treatment of chronic pancreatitis. Report of 142 cases.

The authors report on 142 patients treated surgically for chronic pancreatitis. They had an average age of 43.5; 34.5% were calcific; 62.7% were alcoholics; 28.9% had cysts; 19% had diabetes; 16.9% had steatorrhea; and all had pain. A follow-up of 55 patients undergoing pancreaticojejunostomy showed that, 4–21 years following operation 16 had marked improvement, 11 had some relief, four were not relieved from pain, and 24 had died, three within one month postoperatively and 21 later. Eighty to ninety-five per cent pancreatectomy was more effective in relieving pain in the 9 patients subjected to this type of resection than was the 50–80% pancreatic resection used in 16 patients. Pancreaticoduodenectomy was of some value in three of five patients so operated. Celiac ganglionectomy, used in 22 patients, and sphincteroplasty, used in 35 patients, were less effective in relieving symptoms than the other procedures.

Cholangiography and small duct injury

Eighteen instances of bile duct injury over the past 25 years have been reported. Manipulation of a minute cystic duct where the common bile duct was 3 mm in diameter or less was responsible for the division of the duct in eight cases. Most of the commercial catheters are sharp, about 2 mm in diameter, and can easily divide the bile duct if pushed too far. Since manipulation of the duct with a mosquito or tonsil clamp to insert other smaller catheters can also divide a small bile duct, we have decided to discontinue obtaining cholangiograms under these circumstances. Longitudinal splitting of two additional 3 mm ducts with a 3 mm dilator was another major source of injury. Overclipping of the cystic artery to involve the hepatic duct and overmobilization of the bile duct were other sources of injury. We have ceased attempting to obtain cholangiograms in patients with small cystic ducts because of the availability of endoscopic sphincterotomy, the low yield of the films under these circumstances, and fear of damaging the ducts. We use hepaticojejunostomy with Silastic tube stenting for repair of bile duct injuries.

Sequestrectomy and hyperalimentation in the treatment of hemorrhagic pancreatitis.

Surgical treatment has been used in those patients with hemorrhagic pancreatitis who deteriorate after several days of intensive medical therapy, or in those patients in whom the diagnosis cannot be established early in the course of treatment. Initial therapy consisted of: cholecystostomy or T-tube drainage in those patients who have gallstones, jaundice, or distended biliary tree; gastrostomy for prolonged gastric decompression; jejunostomy to provide a portal for enteroalimentation; and appropriate soft rubber drainage of the pancreatic bed as a simple, safe, and effective means of treating severe hemorrhagic pancreatitis. Adjunctive daily hyperalimentation and later sequestrectomy of necrotic pancreatic tissue provided a mortality of 20 per cent and complete rehabilitation of sixteen of thirty patients so treated. Delaying the initial approach to necrotic pancreas allows precise delineation of necrotic material so that sequestrectomy, leaving behind normal pancreas, can be carried out to avoid exocrine and endocrine deficiencies after the acute episode has passed.

Potentially curable masses in the pancreas

Twenty patients with intraabdominal non-Hodgkins lymphoma localized to the peripancreatic area were reviewed. Appropriate diagnosis and staging required exploratory laparotomy and biopsy. With appropriate chemotherapy and radiotherapy, 40 percent of these patients were alive 3 years after diagnosis without evidence of disease. It is for this reason that we have adopted an aggressive approach in obtaining histologic diagnoses for all pancreatic masses.

Central hepatic resection and anastomosis for stricture or carcinoma at the hepatic bifurcation.

Ten cases of central hepatic resection for benign and malignant strictures are reported. Reconstruction was by hepaticojejunostomy with placement of a transhepatic silastic stent across the anastomosis. Four patients had carcinomas at the hepatic bifurcation. Four had high biliary stricture and two had intrahepatic stones and strictures. Follow-up ranged from six to 30 months. Two patients died in the postoperative period at two months and 18 months, both with widely patent hepaticojejunostomies. Satisfactory results have been obtained in seven of the eight remaining patients. These seven are symptom-free and without jaundice.

Trypsins In Human Pancreatic Juice–Their Distribution as Found in 34 Specimens. Two Human Pancreatic Trypsinogens

Trypsinogen I was found in 33 of 34 patient pancreatic juice specimens and trypsinogen II was found in 11 patients. Trypsinogen I was found in ten of the latter patients. The trypsinogen 1 band represented 13.4 ± 11.5 per cent of the total protein found in the juice, while trypsinogen II represented 1.4 ± 3.4 per cent. The isoelectric point of trypsinogen I was 7.0 and that of trypsinogen II was 4.7–5.0.

Electrophoretic analysis of twenty-four specimens of human pancreatic juice

Abstract An analysis of pancreatic juice from 24 patients on celluloseacetate strips has shown a consistent order of migration of lipase, amylase, ribonuclease, trypsin inhibitor, procarboxypeptidase, chrymotrypsinogen, and trypsinogen bands. In addition to the bands found in duodenal juice by Silberberg and Hadorn 18 we have located two ribonucleases and a second trypsinogen similar to that found by Figarella et al. 19 . In addition albumin appears to have leaked into the pancreatic juice in patients with pancreatitis.

Indications for sphincteroplasty as opposed to choledochoduodenostomy

On the basis of a study of 129 sphincteroplasties, 28 choledochoduodenostomies, and 26 choledochojejunostomies, sphincteroplasty is believed to be the best approach to decompression of the bile duct in patients in whom the intrapancreatic portion of the bile duct is not compressed. It was not adequate therapy in alcoholics, but it was effective in patients with gallstones. Choledochoduodenostomy was used in older, sicker patients because it is safer. Choledochojejunostomy was preferred in patients with cancer of the lower part of the bile duct, an inflammatory lesion involving the duodenum, or a compromised circulation to the bowel, so that the duct could be removed from an area of potential breakdown, obstruction, or tumor.

Insulinoma in seattle: 39 cases in 30 years☆

Abstract (1) Surgical rather than medical treatment is preferred for insulinoma. (2) Resection rather than enucleation is the treatment of choice. (3) An immunoreactive insulin-glucose ratio of over 0.35 is diagnostic of insulin tumor. (4) Computed axial tomographic scans, ultrasound and arteriography are useful in diagnosing large insulinomas but not small ones. (5) Percutaneous catheterization of the portal and pancreatic veins will be useful in the future in localizing small tumors of the pancreas.

Pancreaticojejunostomy: Report of a 25 year experience☆

Surgical therapy for 88 patients operated on between 1958 and 1982 has been reviewed. Ninety-three operative procedures were performed including pancreaticojejunostomy in 56, pancreaticocystojejunostomy in 12, pancreaticojejunostomy with resection of less than 10 percent of the pancreas in 16, and pancreaticojejunostomy with resection of more than 50 percent of the pancreas in 9. Operative mortality was 7.5 percent and operative morbidity was 25 percent. Overall, 63 percent of the patients had an excellent or good result in the postoperative follow-up period which averaged 4 years. In the nonalcohol-induced pancreatitis group, ductal diameter was a good predictor of postoperative success, whereas in the alcoholic patient population, abstinence from further alcohol intake was a more accurate predictor of the success of pancreatic drainage.