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Surgical Treatment of Pancreatitis 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 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 liver 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, colectomy, 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) gastrostomy 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 laparotomy 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
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