Surgical treatment of pancreatitis
RICHARD T. CALEEL, De., FACOS Olympia Fields, Illinois RICHARD J. WOREL, De Norton Shores, Michigan
Osteopathic Hospital and Olympia Fields Os- teopathic Medical Center by one senior member Excluding patients with proved (R.T.C.) of the surgical faculty. (Surgeries per- metastatic or localized carcinoma formed by other faculty members were not included involving the pancreas, 75 pancreatic in this report.) Twenty-two patients had histo- surgeries were performed on 68 logically proved primary or metastatic carcinoma patients by one author (R.T.C.) that involved the pancreas. These patients, as well between 1970 and 1981. Multiple as 1 whose chart could not be located, were excluded diagnostic procedures, including from the series. Five patients were operated on clinical history taking, determination twice at our institutions, and 1 additional patient of amylase and lipase values, and underwent surgery 3 times. The series, therefore, plain and contrast radiography, is composed of 75 operations on 68 patients. ultrasonography, endoscopic Consistent with recent trends, the majority of retrograde choledochopancreatography, our patients (53 patients, 77.9 percent) had clinical and angiography were utilized. The histories of significant alcohol abuse. Four patients majority of patients (77.9 percent) had (5.9 percent) had long-term histories of peptic ulcer a significant history of ethanol abuse. disease. Gallbladder disease was identified in 37 Gallstones were present in over half patients (54.4 percent); however, cholelithiasis or of the patients. Multiple surgical ampullary stenosis could be implicated as the sole procedures were performed and are etiologic factor in only 6 patients. enumerated. The major complication Thirty-one (45.6 percent) of our patients were rate was 9.3 percent, and there were 3 female, and 37 (54.4 percent) were male. The me- deaths (4.4 percent) in the series. The dian age was 42.8 years, with a range of 20-80 improvement rate was 87.7 percent. years. The duration of postoperative hospitaliza- Current pancreatitis therapy and the tion ranged from 7 to 50 days, with 17 days being authors surgical recommendations average. are presented. Diagnostic procedures Serum amylase and lipase levels were determined routinely. Consistent with the differences in the duration of the pancreatic disease, the extent of the endocrine reserve, and use of or abstinence from In 1963, the Marseille International Symposium on alcohol, the laboratory values were quite variable. Pancreatitis classified two distinct forms of the dis- A similar lack of correlation was noted by Adson.2 ease—acute and chronic.1 Chronic pancreatitis in- This lack of direct correlation of the disease with volves irreversible changes in the macroscopic and enzyme levels should alert the surgeon to the mul- microscopic structure of the gland, including cal- tifactorial nature of these variables. cification and altered texture and anatomy, as well Patients with a history of ethanol or drug abuse as both endocrine and exocrine dysfunction, the were interviewed by a psychiatrist or social worker extent of which reflects the severity of the disease. preoperatively, and arrangements were made for The purpose of this paper is to share our surgical postoperative social support for these individuals. experiences and to review the operative treatment All were informed of the increased danger should of pancreatitis. they resume drinking or drug use postsurgically. Multiple radiographic procedures were em- Report of series ployed throughout the series. Plain and contrast Between 1970 and 1981, 98 pancreatic operations radiography, ultrasonography, endoscopic retro- involving 91 patients were performed at Chicago grade choledochopancreatography (ERCP), and
Surgical treatment of pancreatitis 490/59 TABLE 1. SEVENTY-FIVE PRIMARY SURGICAL PROCEDURES IN 68 TABLE 2. MAJOR COMPLICATIONS IN SERIES OF 68 PATIENTS (75 PATIENTS. OPERATIONS). Category Procedure No. Complication No. Bile drainage Cholecystectomy, common Diabetes mellitus 2 bile duct exploration, and Diabetes mellitus and pneumonia 1 choledocholithectomy 4 Pneumonia 1 Cholecystectomy, common Upper gastrointestinal hemorrhage bile duct exploration, and secondary to sepsis and stress 1 sphincteroplasty 2 Disseminated intravascular coagulopathy and (6) adult respiration distress syndrome 1 Ductal drainage Pancreaticocystojejunostomy 1 Subphrenic abscess Pancreaticocystogastrostomy 11 Pancreaticocystoduodenostomy 2 TABLE 3. MINOR COMPLICATIONS IN SERIES OF 68 PATIENTS (75 Jejunopancreatostomy 1 OPERATIONS). Revision of Duval to Puestow Complication No. procedure 1 Puestow jejunopancreatostomy 1 Wound infection 5 (17) Urinary tract infection 4 Intestinal drainage Gastrojejunostomy 1 Left pleural effusion 3 Gastroduodenostomy and vagotomy 1 Bile stasis 1 (2) Suture granuloma 1 Pulmonary edema 1 Ablation Subtotal resection with: Pancreatic cutaneous fistula closure of duct 4 (resolved spontaneously) 1 pancreaticocystojejuritistomy 11 Duval procedure 5 Puestow procedure 2 pancreaticogastrostomy 1 Resection of pseudocyst 1 Indications for surgery Whipple procedure 9 Detailed clinical history taking and physical exam- Childs procedure 3 inations were performed for all patients, and find- Total resection 3 Resection of pseudocyst abscess 1 ings were consistent with chronic forms of (40) pancreatitis in 64 (94.1 percent). Pain, the most Miscellaneous Exploration with lysis of adhesions 3 common symptom, was present in 64 patients (94.1 Evacuation of intraperitoneal clots secondary to disseminated percent). Pancreatic pseudocysts were noted on intravascular coagulopathy 1 physical and diagnostic examinations in 25 pa- Marsupialization of abscess 2 tients (36.8 percent). Primary biliary disease was Ligation of gastroduodenal and splenic vessPls 1 the sole etiologic factor in 6 cases (8.8 percent). Six Drainage of abscess 2 patients (8.8 percent) had gastrointestinal obstruc- Ligation of the body of the tions, pancreatic abscess or pseudocyst abscess was pancreas and splenic vessels (massive hemorrhage into present in 5 patients (7.4 percent), and massive pseudocyst) 1 hemorrhage was the indication for surgical inter- (10) vention in 2 patients (2.9 percent). Total 75