Duodenum preserving resection of the head of the pancreas: a standard procedure in chronic pancreatitis

Duodenum-preserving resection of the head of the pancreas was developed 25 years ago by Beger. This procedure is indicated in patients suffering from chronic pain in combination with inflammation of the head of the pancreas, common bile duct obstruction, pancreatic duct obstruction and/or obstruction of the retropancreatic vessels. At the Inselspital in Berne, 74 patients underwent this operation between 1993 and 1996. The median length of the operation was 380 min, with the need for transfusion in a median of 0 units (0-6). There was no postoperative mortality. Total postoperative morbidity was 13%. One patient needed relaparotomy on day 17 for small bowel obstruction. Median length of hospital stay was 11 days. Postoperatively, two patients developed diabetes. Duodenum-preserving resection of the head of the pancreas represents an organ-preserving principle of surgery. This procedure treats the complications of chronic pancreatitis and provides long-term pain relief in more than 80% of patients.     

Acute myocardial infarction in a young woman with systemic lupus erythematosus

A 49-year-old diabetic patient with abdominal pain was found upon ultrasonography and computed tomography to have a cystic mass in the head of the pancreas with dilation of the main pancreatic duct. The head of the pancreas and duodenum were removed surgically. Examination of the operative specimen showed chronic pancreatitis, dilation of the main pancreatic duct, and impacted mucus in the secondary ducts with villous proliferation of the ductal epithelium, establishing the diagnosis of intraductal adenomatosis. There was no evidence of malignancy. The resection margin was involved, and consequently the remainder of the pancreas was removed six months after the initial surgical procedure. A review of the literature showed that intraductal adenomatosis tends to spread and carries a high risk of malignant transformation. Surgery is required because of the risk of pancreatic duct obstruction and pancreatic cancer. Intraductal adenomatosis of the pancreas shares many characteristics with other adenomatous proliferations of the gastrointestinal tract (colorectal villous adenoma, bile duct adenomatosis), including presence of villous structures with increased mucus production, a tendency to spread massively, and a high risk of malignant transformation.     

Modified duodenum-preserving resection of the head of the pancreas

A modified procedure of duodenum-preserving resection of the head of the pancreas was used in treating three patients with benign lesions in the head of the pancreas. Compared with Beger's procedure, the modified procedure was simpler, and pancreaticojejunostomy on duodenal side was not necessary because of less remaining pancreas attached to the conjunction of the pancreatobiliary duct. The patients, recovered and ate food from 4 to 6 days after operation without symptoms of duodenal obstruction. The patient's digestive function was normal, and the pre- and postoperative pancreatic endocrine function was almost identical. This procedure can be used as the first-choice surgical procedure for benign lesions in the head of the pancreas. Problems in how to protect blood supply of the duodenum were also discussed.     

Ultrasonographic findings of diseases in peripheral lung fields using transtracheobronchial endoscopic ultrasonography (TUS)

Cystic neoplasms of the pancreas constitute about 9% of all cystic lesions of the pancreas and less than 1% of all pancreatic neoplasms. The case of a 70 years-old woman with microcystic cystadenoma is reported. CT-scan of the abdomen diagnosed a 5 cm multilocular septated cyst, with calcifications in the context, localized in the head-uncinate process of the pancreas. The mass was well separated by a sharp cleavage plane with portal vein and superior mesenteric vessels. An ERCP showed cephalic symmetrical stenosis (diameter 3 mm) of the main pancreatic duct (MPD), mildly dilated in the remaining tract (diameter 6 mm). An intraoperative biopsy of the cystic wall was performed. Therefore, it was decided to proceed with a duodenum-preserving resection of the head of the pancreas (DPPHR), including the stenosis tract of the MPD in the surgical specimen. The reconstructive procedure consisted, by i.v. jejunal loop transposition, in a side-to-side pancreatico-jejunostomy, including in the anastomosis both corpocaudal stump and the resection cavity of the pancreatic head, and an end-to-side Roux-en-Y jejuno-jejunostomy. With respect to long-lasting pain relief and preservation of the endocrine and exocrine functions of the pancreas, DPPHR is a highly effective surgical procedure with a low early and late morbidity and mortality due to limited surgical resection. This technique, introduced into surgical practice by Beger, is indicated in patients with chronic pancreatitis with an inflammatory mass in the head of the pancreas. The authors conclude that this procedure can be performed also in case of pancreatic benign tumors, as microcystic cystadenoma. Advantages of this technique makes DPPHR an attractive alternative to Pylorus-Preserving-Pancreatico-Duodenectomy (PPPD).     

Five-year follow-up of a prospective randomised multi-centre trial of weekly chemotherapy (CAPOMEt) versus cyclical chemotherapy (CHOP-Mtx) in the treatment of aggressive non-Hodgkin''s lymphoma. Central Lymphoma Group

Benign tumors of the pancreatic head are normally treated by a partial duodenopancreatectomy. This operation has been developed for the treatment of malignant alterations in the pancreatic head and includes resection of the gastric bowel, duodenum and common bile duct. The aim of this study was to evaluate whether the less radical duodenum-preserving pancreatic head resection is a suitable surgical procedure in the treatment of benign pancreatic head tumors. From May 1982 to December 1996, seven patients underwent surgical treatment for benign pancreatic head tumors. Two patients suffered from gastrinoma of the pancreatic head, four exhibited a serous or mucinous cystadenoma, and one patient suffered from an intraductal papillary-mucinous tumor in this region. All patients were treated by duodenum-preserving pancreatic head resection. The operation was easily performed with little blood loss and a low rate of complications. None of the patients had to be reoperated upon due to postoperative surgical complications. After a follow-up period of a median 3 years, six of seven patients were had no recurrence of the disease and were symptom-free. One patient who had initially been operated on for gastrinoma still exhibited high gastrin values postoperatively. The endocrine and exocrine pancreatic function was not impaired in the early and late postoperative phase as compared to the preoperative assessment. From our results, it is concluded that duodenum-preserving pancreatic head resection is an adequately radical, yet organ-preserving procedure for the treatment of benign tumors of the pancreatic head without compromising endocrine and exocrine function.     

Extrahepatic peribiliary glands express alpha-amylase isozymes, trypsin and pancreatic lipase: an immunohistochemical analysis

We examined expression of alpha-amylase isozymes (pancreatic and salivary), trypsin and pancreatic lipase on the epithelium of extrahepatic peribiliary glands immunohistochemically using 53 autopsied normal extrahepatic bile ducts. Three parts of the extrahepatic bile duct (common bile duct, intrapancreatic bile duct and bile duct at the ampulla of Vater) were examined in each case. Histologically, the extrahepatic bile duct harbored branched tubular glands (extrahepatic peribiliary glands). Extrahepatic peribiliary glands were few in the common bile duct and intrapancreatic bile duct and numerous in the bile duct at the ampulla of Vater. Immunohistochemically, pancreatic alpha-amylase was expressed in the epithelium of extrahepatic peribiliary glands in 42 cases (79%). Salivary alpha-amylase was expressed in the epithelium of the glands in 38 cases (72%). Trypsin was expressed in the epithelium of the glands in 32 cases (60%). Pancreatic lipase was expressed in the epithelium of the glands in 45 cases (85%). The immunoreactivity of these enzymes was granular and located in the supranuclear cytoplasm (corresponding to the Golgi apparatus) of the epithelium of the glands. We confirmed the specificity of the immunoreactivity of these enzymes with various methods. These results suggest that extrahepatic peribiliary glands produce alpha-amylase isozymes, trypsin and pancreatic lipase and secrete these enzymes into lumens of the extrahepatic bile duct. The secreted enzymes may play an important role in the physiology of the extrahepatic bile duct and bile.     

Pancreatic mucin-producing adenocarcinoma associated with a pancreatic stone: report of a case

We present an autopsy case of an 83-year-old Japanese man with a mucin-producing adenocarcinoma accompanied by pancreatolithiasis in the head of the pancreas. He suffered from obstructive jaundice and died of disseminated intravascular coagulation. He did not normally drink alcohol and had no history of chronic pancreatitis. The autopsy findings revealed a mucinous cystic tumor, composed of multiple dilatated branches, in the head of the pancreas. Histological examinations showed papillary adenocarcinoma, which scirrhously infiltrated the distal common bile duct with perineural invasion and lymph node involvement. He was thus diagnosed to have mucin-producing branch-type cancer in the head of the pancreas. The main pancreatic duct was dilated, and the residual pancreatic tissue showed moderate fibrosis and parenchymal atrophy. A stone was observed in a dilated branch of the primary lesion. To the best of our knowledge, there have only been five previously reported cases of mucin-producing tumor associated with pancreatolithiasis. Intraductal calcification is a major characteristic of chronic pancreatitis, but it is clinically important not to misdiagnose cancers associated with pancreatolithiasis such as chronic pancreatitis.     

Chronic pancreatitis: nutrition and pain therapy

Therapy of chronic pancreatitis rests on five arms: Avoidance of alcohol, treatment of pain, replacement therapy for exocrine and endocrine insufficiency and adequate nutrition. Alcohol withdrawal improves pain and the patient's compliance. It also seems to retard the chronic inflammatory process. Therapy of pain depends on the pathomechanism of pain. There is a lack of prospective, controlled studies comparing various treatment regimens. Thus, treatment options are partly dependent on the experience of the physician taking care of the patient and include i.e. for pseudocysts: surgical vs percutaneous or endoscopic drainage; for stenosis of the main pancreatic duct close to the papilla: surgical vs endoscopic drainage (stents); for distal bile duct stenosis: endoscopic stents vs biliodigestive anastomosis vs pancreatic head resection; for pancreatic stones: extracorporal shock wave lithotripsy followed by endoscopic stone extraction vs surgery (pancreaticojejunostomy), finally for inflammatory tumor of the pancreatic head combined with pain with or without compression of the distal bile duct or duodenum: duodenum-preserving pancreatic head resection vs Whipple resection. Patients with pain resistant to medical treatment may be candidates for a transcutaneous blockade of the plexus coeliacus or for epidural nerve blockade before one choses a surgical procedure. Application of pancreatic enzymes does not seem to have a major beneficial effect on pancreatic pain. Modification of nutrition has become less restrictive. Thanks to improved substitution with acid resistant porcine pancreatic extracts with high lipase activity, fat restriction is no longer of paramount importance. However, supply with sufficient calories is still difficult due to pain, inadequate compliance and hypermetabolism.     

Spontaneous rupture of the left hepatic duct

A previously well 24-year-old man complained of persistent epigastric pain after a session of intensive muscle building exercise especially of the abdominal muscles. The abdomen was diffusely tender without guarding. There was an increased concentration of bilirubin (64.7 mumol/l), GOT (117 U/l), GPT (529 U/l) and alkaline phosphatase (150 U/l). Ultrasound examination showed a widening of the choledochal duct to 11 mm without signs of gallstones. Endoscopic retrograde cholangiography additionally revealed contrast-medium extravasation from the left hepatic duct. Computed tomography, performed immediately afterwards, confirmed the extravasation, while liver and pancreas were unremarkable. Laparoscopy revealed a 5 mm tear in the left hepatic duct, close to the hepatic duct bifurcation with bile effusion into the peritoneal cavity. The latter was rinsed endoscopically with Ringer's solution and drains were placed in the omental bursa and subhepatically in the region of the bile leak. To relax the sphincter Oddi glycerol trinitrate was administered postoperatively, for the first five days 72 mg/24 h intravenously, then for nine days twice daily 20 mg by month. No more bile drained as early as the second postoperative day and the patient was free of symptoms 2 weeks later.     

Characteristics and treatment of mucin-producing tumor of the pancreas

BACKGROUND/AIMS: There has been no thorough clinicopathological analysis of a large number of cases with mucin-producing tumor of the pancreas. The aim of this study was to investigate the clinicopathological features of and therapeutic strategy for this ailment. METHODOLOGY: Two hundred and fifty-nine cases of mucin-producing tumor of the pancreas were analyzed clinicopathologically. RESULTS: Mucin-producing tumor of the pancreas was found in 177 males and 82 females (M:F=2.2:1). The mean age was 65.5 years. Jaundice, diabetes mellitus and a past history of pancreatitis were found in 15-19% of the cases. The tumor was most frequently (62%) found in the head of the pancreas. Pathologically, hyperplasia or adenoma was found in 58 cases, and adenocarcinoma in 160 cases. Five-year survival rate by the Kaplan-Meier method was 82.6% in all of the cases, and the post-operative survival curve was much better in cases with this type of carcinoma than in cases with ordinary pancreatic duct cell carcinoma (5-year survival rate: 17.3%). Organ-function preserving procedures, such as duodenum preserving subtotal resection of the head of the pancreas or spleen preserving distal pancreatectomy, might be recommended for this disease without infiltration. CONCLUSIONS: Mucin-producing tumor has unique clinicopathological characteristics, such as the dilated main pancreatic duct or branches, dilatation of the orifice of the papilla of Vater, or a good prognosis. Organ-function preserving procedures should be recommended in some cases with this ailment.     

A normal pancreatogram in three cases of pancreatic carcinoma

Three patients with carcinoma of the head of the pancreas were examined by endoscopic pancreatography and retrograde cholangiography. In each case the pancreatic duct appeared normal. Abnormalities of the common bile duct were found in each case and are described. The use and value of endoscopic pancreatography and other methods of examination are discussed.     

Dissemination of pancreatic carcinoma following endoscopic sphincterotomy

Endoscopic sphincterotomy (ES) is sometimes advocated for the temporary decompression of an obstructed bile duct by a periampullary tumor. We report a 27-year-old woman with a small carcinoma of the pancreatic head who developed acute pancreatitis and a pseudocyst following ES. At operation, malignant spread was virtually confined to the walls of the resolving pseudocyst cavity. Despite radical resection, she died from recurrent carcinoma 7 months postoperatively.     

Laparoscopic distal resection of the pancreas with the preservation of the spleen

Management of the pancreatic diseases is still a challenge to the laparoscopic technique. Some experience has been gained in the laparoscopic exploration of the pancreas and staging in cancer. Anatomically the accessibility of the distal pancreas provides the laparoscopic approach technically feasible. Patient and method: A case of insuloma in the tail of the pancreas is presented, where distal pancreatic resection was performed laparoscopically with the preservation of the spleen. In a 55 years old female patient with typical clinical symptoms of hyperinsulinism CT identified a 3 cm large solid tumor in the tail of the pancreas. Complete mobilization of the distal pancreas was enhanced by the use of an ultrasonic dissector (UltraCision). The pancreas is detached from the splenic hilum after dividing the spleen vessels. The pancreas is transected proximally by laparoscopic linear stapler. Preservation of the short gastric vessels provides the necessary blood supply of the spleen following division of the splenic artery and vein. Thus removal of the spleen is not a necessary step in this procedure. The operation was carried out within 4.5 hours. Postoperative course was uneventful, the patient left the hospital on the 5th postoperative day. Advantages of the procedure were the earlier mobilization and shorter recovery time, less postoperative pain. The procedure can be safely performed with a good experience in both pancreatic and laparoscopic surgery.     

Ventral duct pancreaticolithiasis in pancreas divisum

Pancreas divisum, partial or nonfusion of the dorsal and ventral pancreatic ductal systems, affects up to 10 per cent of the population. Approximately 25 per cent of patients with pancreas divisum will develop complications such as recurrent pancreatitis as a consequence of stenosis of the minor papilla with altered dorsal duct drainage. Surgical and endoscopic therapy usually include minor papilla sphincterotomy or sphincteroplasty to facilitate drainage of the dorsal ductal system. The following case represents an unusual complication of pancreas divisum with primarily ventral duct disease and pancreaticolithiasis.     

Duodenal obstruction from chronic pancreatitis

The fibrosclerosing process of the pancreas in the chronic pancreatitis may constrict not only the pancreatic duct but also the bile duct, splenoportal venous system and duodenum. In our retrospective study we analysed 24 patients with duodenal obstruction associated with chronic pancreatitis. Duodenal obstruction was suspected whenever repeated vomiting occurred or large volumes of nasogastric aspirate were obtained. The diagnosis was confirmed by barium meal and endoscopic examination. Duodenal obstruction was relieved by gastrojejunostomy in eight patients, gastrojejunostomy and vagotomy in eight patients, gastroduodenostomy and vagotomy in two patients, vagotomy with Finney pyloroplasty in one patient, duodenoplasty with vagotomy in one patient and Whipple procedure in four patients. We concluded that vagotomy and gastroenterostomy are the procedures of choice. Bypass surgery is helpful to relieve the obstruction of the common bile duct and pancreatic duct. Whipple procedure should be reserved for the small duct form of chronic pancreatitis and for the cases in which there is high suspicion of malignancy.     

Simple reconstructive method in cases of duodenum-preserving subtotal resection of the head of pancreas

BACKGROUND/AIMS: Surgical treatment of chronic pancreatitis is either by ductal decompression, or resection of the pancreas. Among various resection operations the duodenum preserving resection of the head of pancreas is the newest surgical technique. This paper describes substances of our modified reconstructive method following resection of the pancreatic head, and the results of this procedure. METHODOLOGY: Duodenum preserving resection of the head of pancreas with a simple modified reconstruction was performed in 21 patients with chronic pancreatitis. Early and late results are herein evaluated. RESULTS: There was no mortality. The rate of complication was 28.5%. Considering late results, complete pain relief was achieved in 80% of patients. Body weight was unchanged in 50%, decreased in 15% and gained in 35% of patients. Progression of endocrine dysfunction (rate of diabetes mellitus and glucose tolerance impairment) was observed to a small degree two years (average follow-up) after the operation. CONCLUSION: Our procedure can be applied in the treatment of chronic pancreatitis, with low risk and relatively good late results.     

Intraductal ultrasound of the pancreas--a procedure with diagnostic prospects? Initial preclinical experiences

For the first time, human pancreas specimens (18 autopsy specimens, three resection specimens) were examined with high-resolution, flexible ultrasound catheters (20 MHz; 3.5 F, 4.8 F, 5.0 F and 6.0 F external diameters; mechanical and electronic systems). The ultrasound catheter was easily inserted into the pancreatic duct in all specimens. The sonographic tissue texture was correlated with its histological picture at defined positions. A high resolution was thus achieved in the sonomorphological differentiation of blood vessels, duct system elements, fibrotic tissue, fatty tissue and pancreas tissue with varying lipomatous composition. In a radius of an average of 5.5 mm, structures 0.1 mm large were recognised. Contrast media studies of the ductal system were carried out before and after ultrasound examination. No evidence of trauma due to catheterisation was found either with these studies or by histology. In one case, a 15 mm serous microcystic adenoma of the pancreatic head was found at intraductal examination of the resection specimen. Clinical examinations within the framework of endoscopic retrograde pancreaticography must clarify if the intraductal ultrasonography technique presented here can truly enlarge the diagnostic, repertoire used in the search of tiny focal pancreatic lesions.     

Unusual indication for 2/3 gastroduodenopancreatectomy in ulcer of the papilla, acute pancreatitis and massive ascites

A 32-year-old worker, an alcoholic with a history of duodenal ulcer for 2 years, was admitted because of weight loss, severe pain in the upper abdomen, and ascites. Serum lipase was 1200 mU. X-ray showed a possible postbulbar ulcer. Laparotomy was performed, and 10 1 ascitic fluid were evacuated, the latter caused by a peripancreatic callosity compressing the portal vein. Findings: multiple necrotic areas in the pancreas; sequestrum cavity in the head of the pancreas connected with a callous ulcer at the duodenal papilla (histology: no malignancy). Two-thirds gastric resection, subtotal duodenopancreatectomy, extirpation of the gallbladder and common bile duct, splenectomy, gastroenteroanastomosis, and antecolic hepatojejunostomy were performed. After a transitory cerebrovascular incident, the patient was discharged on the 34th postoperative day. The patient has gained 11 kg, and works in the construction business. The pathogene development, frequency of complications, and therapy of postbulbar ulcer are described.     

Ampullary and periampullary tumors

Ninety-eight consecutive patients with ampullary and periampullary carcinoma diagnosed between 1983-1993 were studied retrospectively. Among these patients, 66 had a carcinoma of the head of the pancreas, 10 a carcinoma of the papilla of Vater, 8 a carcinoma of the duodenum, and 14 a carcinoma of the distal common bile duct. Resectability rate ranged from 12% to 90% according to the tumor location and histologic type. Palliative procedures such as laparotomy, biopsy and bilio-digestive bypasses were performed in 27 patients. Curative resections were performed in 24 cases: 20 pancreatoduodenectomies, 2 total pancreatectomies, 1 duodenectomy, 1 common bile duct resection. The results of the surgical treatment as well as mortality and morbidity rates were compared with those of different and larger series.     

A rare case of severe acute pancreatitis complicated with pancreatic pseudocysts, obstructive jaundice and intraperitoneal hemorrhage

A 58-year-old man visited our hospital because of back pain. Blood examinations revealed the presence of acute inflammation and an increase of pancreatic enzymes. Abdominal computed tomography indicated pseudocysts in the pancreas. The patient was diagnosed as having acute pancreatitis with pseudocysts formation. During the course of the disease, a newly formed pseudocyst in the pancreatic head compressed the common bile duct, leading to the obstructive jaundice. In addition, the rupture of a pseudocyst in the pancreatic tail caused intraperitoneal hemorrhage. This is an interesting case of acute pancreatitis with pseudocysts in which two rare complications developed.