Surgical treatment of

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. ( per- metastatic or localized carcinoma formed by other faculty members were not included involving the , 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 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 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. disease was identified in 37 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 , 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 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 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 , common Diabetes mellitus 2 exploration, and Diabetes mellitus and pneumonia 1 choledocholithectomy 4 Pneumonia 1 Cholecystectomy, common Upper gastrointestinal hemorrhage bile duct exploration, and secondary to and stress 1 sphincteroplasty 2 Disseminated intravascular coagulopathy and (6) adult respiration distress syndrome 1 Ductal drainage Pancreaticocystojejunostomy 1 Subphrenic 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 5 (17) Urinary tract infection 4 Intestinal drainage Gastrojejunostomy 1 Left pleural effusion 3 Gastroduodenostomy and 1 Bile stasis 1 (2) Suture granuloma 1 Pulmonary edema 1 Ablation Subtotal resection with: Pancreatic cutaneous 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

Five patients underwent surgery twice, while 1 patient had 3 opera- Surgical procedures tions. A list of the primary surgical procedures performed on our patients is presented in Table 1. Of the 75 procedures, 25 involved drainage, 40 were ablative, and 10 were categorized as miscellaneous. angiography were all utilized, with their use tai- In addition to the primary procedures, multiple lored to each individual patient. Ultrasonography secondary procedures were performed. Cho- and ERCP were performed with greater frequency lecystectomy was the most common (31 patients, in the more recent cases. Plain and contrast radi- 45.6 percent). Splenectomy was required in 25 pa- ography were highly suggestive or diagnostic in 56 tients (36.8 percent). Needle biopsy of the and patients (82.3 percent), and ultrasonography of the pancreas were performed in 9 (13.2 percent) and 3 pancreas yielded positive studies in 40 patients (4.4 percent) patients, respectively. One patient (58.8 percent). ERCP was diagnostic in 38 cases each underwent nephrectomy, , tubal (55.9 percent); 2 additional attempts at ERCP were ligation, or para-aortic node biopsy. Temporary unsuccessful in cannulation of the duct. Angiogra- tube (Stamm) was utilized in an in- phy, which was used selectively, was utilized for creasing number of patients. This afforded long- only 3 patients (4.4 percent). Angiographys great- term gastric decompression without the discomfort est value is in determining the origin of the hepatic and morbidity associated with nasogastric intuba- artery. tion.

491/60 August 1986/Journal of ADA/vol. 86/no. 8 Complications Pancreatic enzyme supplements were the most Surgical complications were noted in 23 of 75 oper- commonly required medication, with 26 patients ations (30.7 percent). Of these, only 7 (9.3 percent) (40 percent) discharged on such supplements. Two were considered major complications (Table 2). patients had required them preoperatively. Doses Three patients (4.4 percent) developed glucose in- were titrated to patient response. tolerance during the postoperative period; these patients were adequately controlled with diet and Discussion insulin. Several patients suffered from more than Etiology one complication. One patient each developed As Cooperman3 states, "The etiology of chronic pneumonia, urinary sepsis with secondary gastric pancreatitis is one of association with exogenous stress ulceration, disseminated intravascular co- and endogenous toxins, rather than clearly defined agulopathy, and, secondarily, adult respiratory pathophysiologic mechanisms...." distress syndrome, and subphrenic abscess. Minor Alcohol abuse is implicated in approximately 75 complications are listed in Table 3. percent of cases. Cholelithiasis is becoming less Three deaths (4.4 percent) occurred in the series. frequently involved with chronic pancreatitis be- A 57-year-old patient underwent emergency ex- cause of earlier recognition and surgical interven- ploratory for ruptured hemorrhagic tion. pseudocyst and suffered intraoperative cardiac ar- Blunt abdominal trauma is implicated in chronic rest. This patient eventually succumbed to car- pancreatitis secondary to pseudocyst formation diopulmonary failure. A 52-year-old patient and distal duct obstruction. Congenital anomalies suffered cardiopulmonary arrest 6 days of the sphincter are also associated with pan- postoperatively. A 44-year-old patient died follow- creatitis. In addition, hyperparathyroidism and ing circulatory collapse and cardiopulmonary ar- protein calorie malnutrition have been related to rest with disseminated intravascular coagulopa- the disease. Administration of calcium, par- thy. This patient had undergone pancreaticoje- ticularly in hyperalimentation solutions, has been junostomy 2 times to repair anastomotic leakage associated with acute exacerbations of pan- following conversion of a Duval to a Puestow pan- creatitis. creaticojejunostomy. Diagnosis Results Chronic pancreatitis is diagnosed most accurately Sixty-five of 68 patients were discharged from the by endoscopic, radiographic, and ultrasonographic hospital, with 57 (87.7 percent) requiring no criteria. Depending on the functional reserve of the anodynes by the time of discharge. The other 8 (12.3 gland during relapses, the amylase and lipase lev- percent) were sent home on nothing stronger than els may range from subnormal to markedly ele- compounds containing 1/2 grain of codeine; these vated. tended to be the same patients who had displayed Ultrasonography is valuable in monitoring the narcotic dependence preoperatively. One patient size and consistency of the as well had prostatic carcinoma, which was metastatic to as pseudocysts. Low level resolution is approx- bone. (We are currently completing long-term fol- imately at 1.0 cm. At our institution, a high correla- low-up studies on the duration of pain relief follow- tion (76 percent) between ultrasonographic and ing surgery. These results will be published at a ERCP findings in moderate-to-severe pancreatitis later date.) has been reported.4 Of the 65 patients who were discharged, 10 (15.4 ERCP was performed preoperatively in 40 (58.8 percent) had demonstrated glucose intolerance percent) of our patients, and with increasing fre- preoperatively, while 11 patients required insulin quency for our more recent patients. The procedure postoperatively. Of the 55 patients who did not was found to be invaluable in defining ductal pa- need insulin prior to surgery, only 3 (5.5 percent) thology. Its limitations include inability to cannu- did afterwards. Interestingly, 2 patients who had late the pancreatic duct (2 patients, 5.0 percent), required insulin prior to surgery were controlled nondiagnostic studies in early chronic pan- with diet alone, despite their having undergone creatitis, and age-related variability of the duct. major (Whipple, subtotal) resections. The 3 Possible complications include perforation of a vis- postsurgical diabetics were controlled on 10 units cus, exacerbation of pancreatitis, and infection of a (2 patients) or 15 units of single-dose NPH insulin. . These complications were Only 2 patients required split-dose insulin re- not encountered in our series. gimens, and these patients had required insulin Computerized tomography (CT) has been uti- preoperatively. lized to a lesser degree in the diagnostic workup.

Surgical treatment of pancreatitis 492/61 CT is valuable in defining mass lesions as well as support in the postdischarge period should be ar- pseudocysts and . ranged. Abstinence is a preoperative requisite un- Angiography is especially helpful when pan- less surgery must be performed for an emergent creatic carcinoma is suspected, or when a major complication. resection is planned. In our series, angiography Total parenteral alimentation is instituted pre- was utilized for 3 patients (4.4 percent). Visualiza- operatively in patients with a negative nitrogen tion of the celiac and superior mesenteric axes balance. A positive nitrogen balance is essential to provides information not only on the presumptive adequate wound healing, especially in the body diagnosis, but also on location, extent, vascular depleted by ethanolism. The level of serum al- anatomy, and likelihood of resectability. An unex- bumin is a reliable indicator of nitrogen balance. plained fall in the hemoglobin level in a patient Albumin is secreted as 1.26 percent of normal pan- with a pseudocyst may indicate intracystic hemor- creatic protein; this is increased to 8.16 percent in rhage, and preoperative angiography is recom- patients with chronic pancreatitis. 5 Marked trans- mended. If a Whipple procedure is planned, udation of serum is noted to occur via damaged angiography is indicated to locate the origin of the pancreatic ductal epithelium. We routinely admin- hepatic artery. Origin from the superior mesen- ister salt-poor albumin (100 gm. in 4 divided doses) teric artery contraindicates the Whipple pro- during the first 24 hours postoperatively. Dosage is cedure. Digital subtraction angiography offers a decreased by 25 gm. in each succeeding 24-hour possibility for simplified vascular evaluation in the period. future. Pulmonary preparation via incentive spirometry is started several days preoperatively. Aerosols are Surgical indications added to the regimen of smokers and patients with The indications for surgical intervention in pan- histories of bronchitis or asthma. These serve not creatitis can be of either a chronic or emergent only as a pulmonary toilet but also acquaint the nature. Intractable pain is an indication in pa- patient with techniques for preventing tients who have documented chronic, relapsing postoperative pulmonary complications. pancreatitis. Pseudocysts that do not present as an Deep-vein thrombosis prophylaxis is achieved emergent problem should be observed for a suffi- with pneumatic boots whenever possible. An ante- cient period (generally 6-8 weeks) to assure their cedent alcoholic history with makes maturity. Many acute pseudocysts will begin to minidose heparinization a less desirable alter- resolve during this period. In these cases, medical native. In these cases, heparinization should be management should be continued unless complica- avoided if possible. tions ensue. Pseudocystal abscess and hemorrhage Preoperative broad-spectrum are require immediate surgical intervention. routinely administered to patients with suspected Primary biliary disease is an indication for cho- abscess and in cases where the biliary tree will be lecystectomy and common duct exploration. Sec- manipulated. Our choice of is a ondary biliary obstruction, in our experience, cephalosporin unless it is contraindicated. A sec- requires enteric bypass. Peripancreatic fibrosis in ond bolus is administered in cases lasting over 4 this form of obstruction may prevent adequate bili- hours. Antibiotics are usually continued for 4 doses ary drainage despite achievement of adequate pan- in the postoperative period. creatic drainage. Pancreatic fibrosis and pseudocysts of the head and uncinate process Surgical procedures of choice should be treated by combined resection, biliary The operative procedure should always be designed and pancreatic drainage, and enteric bypass. to fit the patient and the anatomy of his/her dis- Pancreatic ascites should be treated medically ease. This is an especially important truism in initially with parenteral hyperalimentation, pancreatic surgery. The goals of pancreatic surgery nasogastric suctioning, and anticholinergic are as follows: (1) pancreatic, biliary, and intestinal agents. If medical management fails, which it does drainage; (2) preservation of adequately function- in approximately 50 percent of cases, enteral drain- ing structures; (3) pain relief; and (4) the smallest age or excision of the pseudocyst should be consid- possible rates of morbidity (complications and re- ered.3 currence) and mortality. As previously mentioned, the recalcitrant alco- Preoperative preparation holic must be excluded from surgery unless he or Adequate preoperative preparation is essential to she is suffering from an emergent complication. successful operative results. Alcoholic patients Functional pancreatitis tissue should be drained must receive psychiatric counseling, and continued and excised only to the extent where adequate

49362 August 1986/Journal of AOA/vol. 86/no. 8 drainage can be assured. The surgeon must be tive when the pancreatic duct is markedly dilated. mindful of partial biliary obstruction; the biliary A longitudinal drainage procedure, as that de- tree should be drained when there is proximal pan- scribed by Puestow, 9 is preferable to caudal drain- creatic involvements age in cases of multiple alternating strictures and dilations (Chain of Lakes or string of pearls effect). Also, the gland is preserved with longitudinal Drainage procedure. Multiple surgical pro- drainage. Variations with and without splenec- cedures are available for the treatment of chronic tomy have been described. The gland may be intus- pancreatitis, with the procedure of choice depend- sucepted into a Roux-en-Y limb, or a precise ing on the general condition of the patient, the anastomosis of ductal epithelium to jejunal mucosa presence of concomitant disease, and the nature may be performed. Excellent results with pan- and extent of the pancreatic disease or its complica- creaticogastrostomy have been reported.1° tion. Emergent problems in a compromised patient require the surgical treatment to be concise in ex- Resection. Pancreatic resection is reserved for pa- tent and duration. tients who have recurrent symptomatology follow- and are sometimes ing drainage and/or resection, and for symptomatic seen with rapid enlargement of a pseudocyst or patients without dilatation of the pancreatic duct. pancreatic abscess. Immature pseudocyst wall and Resective procedures must be planned carefully— pseudocyst abscess are not reliably sutured to the sequelae of endocrine and exocrine deficiency, effect internal drainage. These cases are best the risk of mortality, and the psychologic makeup treated with external drainage or excision when of the patient must be considered. Also, the surgeon feasible. This has recently been accomplished by must know the precise extent of the pancreatic Karlson and associates, 7 who performed per- involvement. cutaneous drainage under sonographic and/or fluo- Subtotal distal is indicated for roscopic guidance, which may prove to be the patients with symptoms of chronic pancreatitis procedure of choice in the compromised patient who have normal caliber ductal systems. It is also unless hemorrhage ensues. The procedure is inade- indicated for patients with dilated ductal systems quate, however, in cases that involve loculated cav- who have remained symptomatic following less ex- ities or additional ductal pathology; in these cases, tensive procedures. Pseudoaneurysm associated formal surgical marsupialization may be required. with a pseudocyst requires resection. Stenosis of In Karlson and associates series, 25 percent of the the or secondary to patients subsequently developed pan- involvement of the head or uncinate process re- creaticocutaneous . In our series, only 1 pa- quires pancreatic duodenectomy. tient formed such a fistula, which resolved spon- If there is any question of partial common bile taneously. duct obstruction or duodenal obstruction, we favor Internal drainage to an adjacent hollow viscus initial choledochoenteric anastomosis with pan- also may be employed. All cysts should be aspirated creatic duodenectomy, because stenotic changes prior to anastomosis to rule out abscess or hemor- may become progressive. Nonresective procedures rhage, and cyst walls should be biopsied to search may be indicated in the occasional case of ampul- for cystadenoma and cystadenocarcinoma. Distal lary stenosis. Sphincteroplasty should be followed pseudocysts may be approached by distal resection; by operative pancreatography to eliminate the however, the incidence of morbidity is higher than need for further drainage or resection. with drainage. Bilateral splanchnicectomy or ablation with al- In general, pancreatic pseudocysts should be cohol is useful in cases of recalcitrant pain. Candi- drained into an adjacent hollow viscus when this is dates are determined on the basis of their response anatomically feasible. Cystojejunostomy via a de- to preoperative nerve block. functionalized Roux-en-Y limb is an alternative procedure. Additional techniques can be utilized New techniques. Several new drainage pro- for drainage of the dilated pancreatic ductal sys- cedures have been proved to be useful in cases of tem. The Duval pancreaticojejunostomy is useful pseudocyst, pancreatic abscess, and pseudocyst ab- in distal pancreatic disease when proximal scess.3 Under CT or sonographic guidance, the cav- obstruction of the duct is not deemed to be resecta- ities are entered with a skinny needle. If aspiration ble. Taylor and coworkers8 reported comparable reveals no evidence of hemorrhage, the tract is long-term results with ductal drainage and pan- dilated with progressively larger catheters. These creatic resection in the presence of dilated ductal are left in place until resolution is confirmed by systems. One complication, however, is ana- contrast studies. The success of this procedure is stomotic stenosis. For this reason it is most effec- limited in cases with multiple loculations; in these

Surgical treatment of pancreatitis 494/63 instances, multiple aspirations or direct surgical the best results, while those without dilated ducts intervention may be required. Percutaneous aspi- who presented with pain as the indication for sur- ration is most promising for those patients with gery seemed to do the worst. Anodynes were re- single cavities that are adjacent to a hollow viscus, quired by only 8 patients (12.3 percent) at the time as well as for those who are too debilitated to un- of discharge. Only 3 patients who had not required dergo formal laparotomy. insulin preoperatively developed glucose intol- Injection of the pancreatic duct with a synthetic erance. Our major complication rate was 9.3 per- polymer, such as Neoprene, produces results that cent, and the mortality incidence was 4.4 percent. seem to be consistent with those from ductal liga- Both rates are within acceptable range. tion. It has been anticipated that preservation of endocrine function and obliteration of exocrine function would ensue following these procedures. 1. Sarles, H.: Proposal adopted unanimously at International Sym- However, these procedures have been generally posium on Pancreatitis, Marseilles, France, 1963 unsuccessful due to sclerosis of the gland and even- 2. Adson, M.A.: Surgical treatment of pancreatitis. Review of a series. tual loss of remaining endocrine function. At this Mayo Clin Proc 54:443-8, Jul 79 3. Cooperman, A., ed.: Chronic pancreatitis. Surg Clin North Am time, it appears to be more advantageous to per- 61:71-83, Feb 81 form ductoenteric anastomosis to deal with ex- 4. Grant, T.H., and Efrusy, M.E.: Ultrasound in the evaluation of chronic ocrine secretions and preserve exocrine function. pancreatitis. JAOA 81:183-8, Nov 81 Patients with severe chronic pancreatitis often 5. Howat, H.T., and Sarles, H., eds.: The endocrine pancreas. W.B. Saun- ders Co., Philadelphia, 1979, p. 112 will not have sufficient endocrine function to war- 6. Kim, U., Shen, H., and Romeuj, J.: Biliary obstruction associated with rant distal preservation. In these cases allografts chronic pancreatitis. Surgical approaches. Mount Sinai J Med 46:489-93, Sep-Oct 79 been attempted with minimal success. Com- have 7. Karlson, K.B., et al.: Percutaneous abscess drainage. Surg Gynecol plications include rejection, anastomotic leakage, Obstet 154:44-8, Jan 82 and thrombosis of the vascular anastomosis. 8. Taylor, R.H., et al.: Ductal drainage or resection for chronic pan- creatitis. Am J Surg 141:28-33, Jan 81 Pure islet cell transplantation has been more 9. Puestow, C.B., and Gillesby, W.G.: Retrograde surgical drainage for promising. After collagenase digestion and density chronic relapsing pancreatitis. Arch Surg 76:898-907, 1958 gradient separation, the islet cell preparation is 10.Schwartz, S., ed.: Maingots abdominal operations. Ed. 7. Appleton- Century-Crofts, Norwalk, Ct., 1980, p. 866 implanted into the spleen or is injected into the 11.Broe, P.J., et al.: Pancreatic transplantation. Surg Clin North Am portal vein. Allograft islet cell preparations, 61:85-98, Feb 81 however, have been indicated only for "diabetic pa- Cooperman, A., and Hoerr, S.O.: Surgery of the pancreas. A text and atlas. tients who are prone to the morbid life-threatening C.V. Mosby Co., St. Louis, 1978 complications of their disease, and who already Hutson, D.G., et al.: Pancreatic duct ligation in the therapy of chronic pancreatitis. Am J Surg 45:449-52, Jul 79 require maintenance immuno-suppressives follow- ing a renal allograft." 3 Great progress is also being made in pancreatic transplants at this time. Accepted for publication in April 1985. Updating, as necessary, Conclusion has been done by the authors. Successful surgical treatment of pancreatitis must provide pancreatic, intestinal, and biliary drain- Dr. Caleel is a professor of surgery and vice-chairman of the age, relief from pain, preservation of functioning Department of Surgery at the Chicago College of Osteopathic Medicine. Dr. Worel was a general surgery resident at CCOM at tissue, and the lowest possible rates of morbidity the time this paper was written. He is now in the private practice and mortality. Our series, which utilized a large of surgery in Norton Shores, Michigan. variety of procedures, has accomplished these Dr. Caleel, Olympia Fields Osteopathic Medical Center, 20201 goals. Patients with drainage of dilated ducts had Crawford Avenue, Olympia Fields, Illinois 60461.

495,64 August 1986/Journal of AOA/vol. 86/no. 8