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Pancreatic Disease: Surgical Aspects Postgrad. med. J. (September 1968) 44, 737-741. Postgrad Med J: first published as 10.1136/pgmj.44.515.737 on 1 September 1968. Downloaded from Pancreatic disease: surgical aspects A. V. POLLOCK Consultant Surgeon, Scarborough Hospital Chronic pancreatitis abdominal symptoms. In November 1966 she was Chronic pancreatitis, that is chronic progres- perfectly well apart from bronchitis and sive replacement fibrosis of the pancreas, is a emphysema. rare disease in this country. I have collected The next patient is a man who was 60 in 1961. fifty-five cases (thirty-six women and nineteen He had a long history of rheumatoid arthritis men) who illustrate some aspects of the disease, on steroids and presented with mild epigastric but I have had to rely on the literature for most pain. Investigations were negative apart from of my information. diffuse pancreatic calcification. No treatment was The literature on chronic pancreatitis has been given and in November 1966 he had no abdom- very confused and one was never quite sure what inal complaints. disease an author was writing about. It was The third patient is a man who presented at Protected by copyright. clarified by the Marseilles symposium in 1963 the age of 45 in 1961 with steatorrhoea without and I have used Sarles' article. in Gut in 1965 pain. In 1966 he was perfectly well, and is still extensively in preparing this paper (Sarles et al., taking pancreatin. The enormous pancreatic duct 1965). Sarles and his colleagues make the point calculi are very unusual and have not changed that chronic alcoholism is the main cause of in the last 5 years (see Fig. 1). chronic pancreatitis in France, U.S.A. and South Africa, but that this is not so in Britain, Czech- slovakia, Switzerland or Argentine. Without the alcoholics we are at a great disadvantage in this country when it comes to experience of chronic pancreatitis. I will follow the classification of the Marseilles workers in their report on 205 cases of pancreat- itis. They first of all draw a sharp line between patients with acute pancreatitis and relapsing http://pmj.bmj.com/ acute pancreatitis (ninety cases), which with but a single exception did not evolve into chronic pancreatitis, and true chronic pancreatitis with or without calcification. Their group of acute and relapsing pancreatitis corresponds with our experience in this country. It is with their group of chronic that pancreatitis on September 28, 2021 by guest. we find ourselves with so little experience. Chronic pancreatitis with calcification In 8 years I have found only six cases of pancreatic calcification, and I am indebted to my colleague Mr Griffin for three of them. The first patient is a woman aged 47 in 1954 when she had a cholecystectomy for gall stones asso- ciated with a diffuse enlargement of the pancreas. I saw her in 1959 when she had a diabetic type GIT, normal secretin-pancreozymin test and no FiG. 1 Postgrad Med J: first published as 10.1136/pgmj.44.515.737 on 1 September 1968. Downloaded from 738 A. V. Pollock The fourth patient is a woman who was 67 drainage, choledochojejunostomy, cholecysto- in 1960 when she had a cholecystectomy for gall jejunostomy, sphincterotomy, caudal pancreatico- stones. Diffuse pancreatic calcification was seen jejunostomy, and thoraco-lumbar sympathectomy, on X-ray. She was well until 1965 when she fifty-four were rated as failures. developed a pseudopancreatic cyst in the lesser Du Val & Enquist (1961) followed twenty-eight sac and died after cystogastrostomy. patients with alcoholic pancreatitis treated by The last slide illustrates the slight pancreatic caudal pancreatic-jejunostomy for 8 years and calcification of a man of 52 whom I investigated found that only nine were still alive. last year with upper abdominal pain. All invest- igations are negative, he has settled down and I Chronic pancreatitis without calcification (secon- will follow his further progress. A year later he dary to obstruction in the duct of Wirsung) was symptom-free. This group according to Sarles has a similar The sixth patient died 6 years ago of a clinical picture to the first group (alcoholic carcinoma of colon and his X-rays have been pancreatitis with calcification) and histologically destroyed. He had heavy pancreatic calcification is characterized by a similar picture of paren- without upper abdominal symptoms. chymal atrophy and replacement fibrosis. In These few cases contrast with the wealth of Sarles' eight cases the causes of the Wirsung material from Sarles' clinic. They report 100 obstruction were: patients with pancreatic calcification. There were In three cases, stenosis at the ampulla of ninety-three men and seven women with an Vater. average age of 38. Only one patient did not In three cases, slow-growing carcinoma of the drink, and only five drank less than 50 g of pancreas. alcohol per day. In 1887 Friedreich (quoted by In one case, isthmic sclerosis following an at- Howard & Ehrlich, 1961) wrote: 'I am inclined tack of acute pancreatitis. Protected by copyright. to believe that general chronic interstitial panc- In one case, accidental ligation of the duct at reatitis may result from excessive alcoholism gastrectomy. (drunkard's pancreas)'. Birnstingl in 1959 found twenty-two patients The clinical picture is of increasingly frequent with a diagnosis of chronic pancreatitis in 16 recurrences of abdominal pain with progressive years at St Bartholomew's Hospital. In twelve of deterioration of general health, mental and phys- these the pathological picture of chronic panc- ical degradation, narcotic addiction, loss of reatitis was produced by a carcinoma of the weight, diabetes, steatorrhoea and attacks of pancreas obstructing the pancreatic duct. jaundice. One patient had cirrhosis of the liver In my series I have three patients with chronic and nine had portal hypertension. Splenography pancreatitis due to carcinoma. was performed in five and showed portal vein The first patient was a middle-aged man who compression in three, thrombosis in one. Pancreat- presented with a pseudo-pancreatic cyst which ography by direct puncture showed duct was drained externally. Abdominal pain and a dilatation in three-quarters of the cases, with pancreatic fistula persisted and some months later http://pmj.bmj.com/ stricturing of the main duct in the head of the a second laparotomy showed a diffusely enlarged pancreas, and in twenty-six patients single or hard nodular pancreas with an enormously multiple cysts either in or outside the pancreas, dilated pancreatic duct. Anastomosis of the side usually communicating with the main duct. of this duct to a Roux loop of jejunum was The histology of the pancreas was studied in followed by relief of pain and healing of the one post mortem, seventeen partial pancreatect- fistula, but within a few months the patient had omy specimens and twenty-nine biopsies. The developed obstructive jaundice and metastases in striking thing was the irregular distribution of the liver and died. on September 28, 2021 by guest. areas of sclerosis, parenchymal atrophy and The second patient was an elderly lady who had ductular dilatation and plugging, interspersed had her gall bladder removed many years before. with areas of normal pancreas. Calcification is She presented with recurrent severe upper always intraductal and never interstitial. abdominal pain without jaundice and biligrafin The conservative surgical treatment of chronic showed a somewhat dilated common bile duct. alcoholic pancreatitis is disappointing. Subtotal At operation I opened her common duct and or total pancreatectomy may be required. extracted several stones, encountering a stricture Howard and Ehrlich of Philadelphia reported on in the intrapancreatic part of the duct corres- 127 cases of alcohol pancreatitis in 1961. Of ponding to a firm nodular lesion in the head of sixty-five patients subjected to such operations the pancreas at this point. Pre-operative cholan- as cholecystectomy, cholecystostomy, T-tube giography confirmed this stricture. I opened the Postgrad Med J: first published as 10.1136/pgmj.44.515.737 on 1 September 1968. Downloaded from Surgical aspects of pancreatic disease 739 duodenum and did a choledocho-duodenostomy Treatment of chronic pancreatitis and acute which however lay below the stricture. Post- relapsing pancreatitis operatively she did very well, and was perfectly There is an atmosphere of therapeutic comfortable after her T-tube had been clamped nihilism about the treatment of chronic panc- off. A post-operative cholangiogram still showed reatitis, and this is likely to increase as more the stricture and it was my intention to repeat surgeons follow the Marseilles classification. It is the cholangiogram later. Unfortunately the T- probable that none of the ordinary operations on tube fell out and the wound immediately healed. the gall bladder, common bile duct, sphincter of Two months later I found a large fixed mass in Oddi or pancreatic duct will do good to more the epigastrium, strongly suggestive of carcinoma. than a very few patients, and therapy will prob- The third patient was a woman of 62 who pre- ably need directing towards the restoration of sented as an emergency with abdominal pain. exocrine and endocrine pancreatic secretions, the At operation I found a stone in the gall bladder avoidance of alcohol, and the symptomatic relief and a somewhat dilated common bile duct. There of pain. When complications such as pancreatic were no stones in the bile duct but the pancreas duct obstruction, common bile-duct obstruction, was diffusely enlarged, hard and nodular and or pseudopancreatic cyst occur they may be the tail of the pancreas was adherent to the back relieved by operation, and when pain is intract- of the stomach. I was doubtful whether this was able subtotal or total pancreatectomy may be the benign or malignant but decided it was probably only answer.
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