Absence of pancreatic duct dilation in chronic pancreatitis: surgical significance

Of 22 patients treated surgically for intractable pain from chronic alcoholic pancreatitis, eight did not show notable dilation of the main pancreatic duct by endoscopic retrograde cholangiopancreatography (ERCP), operative pancreatography, and/or operative and microscopical studies of the pancreas after subtotal pancreatectomy. In all patients, far advanced parenchymal pancreatitis was evident at operation and by microscopical study of the removed portion of the pancreas. These findings indicate that the basic problem in a considerable number of patients with symptomatic alcoholic chronic pancreatitis is not related primarily to obstruction with dilation of the major pancreatic duct, but to intrinsic changes in the parenchymal pancreas. The preoperative use of ERCP and individualization of operative procedures with a preference for subtotal or partial pancreatectomy for symptomatic chronic alcoholic pancreatitis are supported.     

Early derivation operation can restore the pancreas histology and function in chronic obstructive pancreatitis in the cat

BACKGROUND/AIMS: Obstruction of the main pancreatic duct leads to progressive obstructive and atrophying pancreatitis in the cat. The question remains whether "early" derivative procedures can halt the destructive process or not? METHODOLOGY: Twelve cats submitted to total obstruction of the main pancreatic duct developed chronic obstructive pancreatitis as documented by histopathology. After 5 weeks, five animals underwent a caudal pancreaticojejunostomy, the others served as controls. Pancreatic histopathology and ductography was conducted in both groups, as well as tests of endocrine and exocrine functioning. RESULTS: Three of the five cats that underwent a derivation operation died 3-5 weeks following the second operation mainly due to infection, but 2 cats could be followed-up for up to 52 weeks. The histological signs of inflammation and early fibrosis gradually disappeared and the pancreas returned to normal as assessed by histology, radiology and pancreatic function tests. In contrast, cats not submitted to the derivation procedure developed an atrophic chronic pancreatitis. CONCLUSIONS: A desobstructive operation, carried out 5 weeks after total obstruction of the main pancreatic duct in cats, can halt the progression of chronic obstructive pancreatitis and leads to restitution of the pancreas as assessed by histology, radiology and function tests.     

Longitudinal changes of plasma pancreatic enzymes and hormones in experimental pancreatolithiasis in dogs

Plasma pancreatic enzymes and hormones were longitudinally observed after producing partial obstruction of the major pancreatic duct in dogs to study an initial state of chronic pancreatitis or pancreatolithiasis. Fasting plasma immunoreactive cationic trypsin was elevated during the first six months and then decreased in a subgroup with pancreatic calculi, marked fibrosis, or duct dilatation when compared with the corresponding opposite at the end of the 12-month period. Similar but less prominent changes were found in fasting plasma immunoreactive pancreatic polypeptide (IRPP). Plasma amylase, glucose, or immunoreactive insulin or glucagon (IRG) show no significant variation. Plasma IRG and IRPP responses to intravenous insulin were reduced in the subgroups with marked pancreatic changes towards the end of the 12-month period. These results suggest that plasma pancreatic enzymes and hormones remain elevated as long as pancreatic damage is mild and then start to decline as the damage progresses in chronic pancreatitis or pancreatolithiasis.     

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.     

The behavior of mucopolysaccharide in the pancreatic juice in chronic pancreatitis

In order to study whether or not mucosubstance increases occur in the pancreatic juice of patients with chronic pancreatitis, hexosamine was measured in duodenal aspirates during the secretin phase (S-40) following pancreozymin-secretin stimulation in 16 normal subjects, 37 patients with chronic pancreatitis, 6 patients with alcoholism, 13 patients with gallstones, and 11 patients with peptic ulcer. The hexosamine concentrations in the pancreatic secretions showed a negative correlation with the bicarbonate concentrations and volume output. Rises in hexosamine concentration were seen in alcoholism and chronic pancreatitis, especially in alcoholic pancreatitis. This is probably intimately related with the repeated ingestion of large amounts of alcohol over long periods of time. Since high hexosamine values are noted in the relapsing type of chronic alcoholic pancreatitis, increases in viscosity due to mucosubstance increases in the pancreatic juice are probably related with the recurrence of acute attacks accompanying ductal stenosis or obstruction.     

Endoscopic therapy of pancreas divisum

Pancreas divisum is the most frequent congenital ductal anomaly of the pancreas: it occurs in 5-10% of the population. In the majority of patients, this congenital anomaly is of no clinical importance. In a certain subset of patients, however, pancreas divisum is clinically important as a cause of abdominal pain, acute recurrent pancreatitis or chronic obstructive pancreatitis. The authors, experience on endoscopic drainage of the minor papilla is reported. In the history of patient 1., three episodes of recurrent pancreatitis and permanent upper abdominal pain were explored. ERP revealed a pancreas divisum and a mild irregularity and dilation of the dorsal pancreatic duct. A 7 F stent (length: 6 cm) was implanted in the dorsal pancreatic duct following a papillotomy on the stenotic minor papilla. A repeated Lundh test revealed a 58% improvement in the exocrine pancreatic function. No recurrence of pancreatitis has been observed in spite of the moderate continuous abdominal pain. In patient 2., ERP demonstrated a pancreas divisum and a severely dilated dorsal pancreatic duct as causes of the previous permanent abdominal pain. An 8 F stent (length: 5 cm) was inserted through the minor papilla without endoscopic sphincterotomy. A significant improvement in exocrine pancreatic function (70%) ensued. No abdominal pain has since been observed. In conclusion, dorsal pancreatic duct stenting (mainly in cases involving a dilated pancreatic duct) seems to have a beneficial effect in patients with both recurrent acute pancreatitis or chronic obstructive pancreatitis evoked by pancreas divisum.     

Linked markers and age at diagnosis

AIMS: To determine the clinical, biochemical, and/or morphological features which could predict the need for treatment of pseudocysts at diagnosis in a homogeneous population of patients with alcoholic chronic pancreatitis. METHODS: Between January 1983 and December 1993, all patients followed for alcoholic chronic pancreatitis complicated by pseudocysts and confirmed by computed tomography (CT) scan at diagnosis were studied retrospectively. Two groups of pseudocysts were considered according to their pattern of evolution and the therapeutic requirements. Group I included 45 pseudocysts that regressed spontaneously (25 patients) or that persisted without symptoms (20 patients). Group II included 45 pseudocysts with persisting symptoms or complications, requiring surgical or non-surgical treatment. The evolution of pseudocysts was monitored by CT scanning or abdominal ultrasound. Initial CT scans of all patients were reviewed by an experienced radiologist. For each patient with pseudocysts, the following morphological parameters were recorded: number of pseudocysts, maximal diameter, location, intrapancreatic or extrapancreatic development, complications related to the pseudocyst, pancreatic calcifications, enlargement of the main pancreatic duct, and signs of recent acute pancreatitis. Univariate analysis, and then multivariate analysis with all significant variables on univariate analysis were performed. RESULTS: On univariate analysis, location of pseudocysts in the pancreatic head and intrapancreatic development of pseudocysts were significantly more frequent in group I than in group II (78% versus 55%, p < 0.02 and 89% versus 60%, p < 0.001, respectively). The median diameter of pseudocysts was significantly smaller in group I than in group II (25 (10-110) mm and 40 (10-120) mm respectively, p < 0.001). No differences between groups I and II were found for the clinical or biochemical parameters. Multivariate analysis showed that the intrapancreatic development of pseudocysts and a diameter less than 4 cm were the only independent factors associated with a spontaneous and favourable outcome. These factors accounted for 20% of the total variance. CONCLUSIONS: Pseudocysts larger than 4 cm and extrapancreatic development can be considered independent predictive factors of persisting symptoms and/or complications in patients with pseudocysts and alcoholic chronic pancreatitis.     

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.     

Prevalence of Helicobacter pylori infection and gastric mucosal abnormalities in chronic pancreatitis

OBJECTIVE: Chronic pancreatitis is often associated with abnormal gastric acid secretion. However, previous studies have taken into consideration neither the potential role of Helicobacter pylori (H. pylori) infection nor histological features of the gastric mucosa in this context. The aim of this study was to analyze the prevalence of H. pylori infection as well as the pattern of gastritis in patients with chronic pancreatitis. METHODS: Forty patients with chronic alcoholic pancreatitis were included in the study: 40 patients with alcoholic liver cirrhosis and normal exocrine pancreatic function and 40 asymptomatic nonalcoholic subjects matched for age and sex used as control subjects. Endoscopy was performed in all patients, and five biopsy specimens from the antrum (three from the gastric body and two from the cardia) were taken for histological grading of gastritis and H. pylori assessment. RESULTS: Prevalence of H. pylori infection was similar in subjects with chronic pancreatitis (38%), asymptomatic subjects (28%) and liver cirrhosis (30%). Topography and expression of H. pylori-associated chronic gastritis was also not different among the three groups of subjects. In H. pylori-negative subjects, the presence of moderate to severe chronic antral gastritis was significantly more common in patients with chronic pancreatitis (40%) than in subjects with liver cirrhosis (18%) and in asymptomatic subjects (14%) (p < 0.05). No difference was found among the three groups of patients with regard to gastritis activity, atrophy, and intestinal metaplasia in the various gastric regions. The chronicity grade of gastritis did not correlate with the severity of pancreatic insufficiency. CONCLUSION: Prevalence of H. pylori infection is not different in patients with chronic pancreatitis as compared with subjects alcoholic liver cirrhosis and asymptomatic subjects. A severe H. pylori-negative chronic gastritis is more common in patients with chronic pancreatitis. This chronic inflammation of the gastric mucosa could contribute to determining the changes in gastric physiology described in patients with chronic pancreatitis.     

Endoscopic therapy of chronic pancreatitis

BACKGROUND/AIMS: Endoscopic therapy of chronic obstructive pancreatitis is an indubitable contribution to patients which brings immediate pain relief, enables an increased caloric food intake and improves the quality of patient's life. The authors describe their experience in a set of 42 subjects, in whom endoscopic papillotomy of the pancreatic duct was carried out after diagnosis of chronic obstructive pancreatitis. MATERIAL AND METHODS: Endoscopic papillotomy was performed in 42 patients. In 17 patients, papillotomy was followed by the drainage of the pancreatic duct. RESULTS: The treatment led to disappearance or significant decrease of the epigastric pain in 85.7% patients shortly after the treatment; in 47.1% of patients the painless period lasted for further 24 months after the therapy. Increase in body weight of about 2 kg occurred in 53% of treated subjects during the 2 years since the therapy. Complications in treatment, such as acute pancreatitis in 3 patients and bleeding in 2 were mastered conservatively. CONCLUSION: Endoscopic therapy of chronic pancreatitis is an alternative approach of managing the algic form of chronic obstructive pancreatitis. Changes in the area of Vater papilla, pathological content of pancreatic duct, structure or complications of chronic pancreatitis could be solved endoscopically with a minimum burden on patient. According to the experience of the authors, endoscopic papillotomy of pancreatic duct with contingent drainage led to the pain disappearence nearly in 50% of patients in the set of 42 subjects 24 months after the performance. This fact was followed with an increase in body weight in more than 50% of treated subjects. Minimum of complications put the endoscopic therapy among relatively safe and at the same time effective approach to chronic pancreatitis.     

Chronic pancreatitis: a cause of cholestasis

The bile ducts were visualised using endoscopic retrograde cholangiopancreatography (ERCP), percutaneous or intravenous cholangiography in 38 patients with non-gallstone chronic pancreatitis. Stenosis of the intrapancreatic portion of the distal common bile duct was demonstrated in 11 patients. Ten of the 11 developed transient cholestasis during exacerbations of their chronic pancreatitis. In six cholestasis eventually persisted requiring surgical relief. Secondary biliary cirrhosis was present in one patient. No evidence of pancreatic carcinoma was found in the patients explored surgically. Ten of the patients are alive more than one year after diagnosis. Chronic pancreatitis was of alcoholic aetiology in 10 of the patients with biliary stenosis. Cholestasis and biliary stricture are common but poorly recognised complications of non-gallstone chronic pancreatitis, especially when pancreatitis is severe and due to alcohol.     

Epithelial anomalies in chronic pancreatitis as a risk factor of pancreatic cancer

BACKGROUND/AIMS: The relationship between chronic pancreatitis and the development of pancreatic cancer is still a matter of dispute. Our aim was to determine the frequency of hyperplastic, metaplastic and dysplastic epithelial anomalies in the course of chronic pancreatitis and the potential steps in their development to malignancy. METHODOLOGY: The study was based on biopsy material of 70 patients with clinically diagnosed advanced chronic pancreatitis, who underwent partial or total pancreatectomy, as well as other operations. The patients were assigned to 2 groups: Group I (n = 41) with calcifying chronic pancreatitis; Group II (n = 29) with other forms of the disease. Histological sections were stained with hematoxylin-eosin, Mallory-azan, Gomori's silver method, and glycosaminoglycans (PAS and Alcian blue staining). Special interest was focused on the type and incidence of epithelial ductal and acinar cell anomalies, and on the degree of parenchymal scarring. RESULTS: Hyperplasia of the ductal epithelium was present in 31.4%, focal squamous metaplasia in 21.4%, mucous metaplasia in 11.1%, cellular dysplasia in 8.6%, dysplastic acinar cell nodules in 21.4%, and "tubular complexes" in 30.0% of all cases. The differences in the frequency of these changes, except for ductal epithelial hyperplasia, were not statistically significant in two comparable groups. Advanced pancreatic fibrosis was associated with epithelial anomalies in 65.7% of all cases. CONCLUSIONS: From the morphological point of view, the adequate prerequisites for the consideration of advanced forms of chronic pancreatitis, independent of type, as a risk factor of pancreatic cancer exist, necessitating the surgical removal of pathological lesions.     

Effect of recombinant platelet-activating factor acetylhydrolase on two models of experimental acute pancreatitis

BACKGROUND & AIMS: Recent reports suggest that platelet-activating factor (PAF) plays a role in pancreatitis and pancreatitis-associated lung injury. In this study, the effects on these processes of termination of PAF action by recombinant PAF-acetylhydrolase (rPAF-AH) were investigated. METHODS: Rats were given rPAF-AH and then infused with a supramaximally stimulating dose of cerulein to induce mild pancreatitis. Opossums underwent biliopancreatic duct ligation to induce severe pancreatitis, and rPAF-AH administration was begun 2 days later. RESULTS: In mild, secretagogue-induced pancreatitis, rPAF-AH given before the cerulein reduced hyperamylasemia, acinar cell vacuolization, and pancreatic inflammation but did not alter pancreatic edema or pulmonary microvascular permeability. In severe, biliopancreatic duct ligation-induced pancreatitis, rPAF-AH delayed and reduced the extent of inflammation and acinar cell injury/necrosis and completely prevented lung injury even though the rPAF-AH administration was begun after the onset of pancreatitis. CONCLUSIONS: PAF plays an important role in the regulation of pancreatic injury but not pancreatic edema or increased pulmonary microvascular permeability in mild, secretagogue-induced pancreatitis. PAF plays a critical role in the regulation of progression of pancreatic injury and mediation of pancreatitis-associated lung injury in severe biliary pancreatitis. Amelioration of pancreatitis and prevention of pancreatitis-associated lung injury can be achieved with rPAF-AH even if treatment is begun after pancreatitis is established.     

Effects of glycosaminoglycans on the glomerular changes induced by Adriamycin

BACKGROUND: A model of moderate acute necrotizing pancreatitis is essential for the study of the pathophysiology of the disease and novel therapies. We tried to establish a model of bile salt-induced acute necrotizing pancreatitis in rats. METHODS: Acute pancreatitis was induced by retrograde infusion of bile salt into the cannulated pancreatobiliary duct. Twenty-six rats wee divided into 3 groups. Group I (n = 8) received 0.2 ml of glycodeoxycholic acid (GDOC) 10 mmol/l; group II (n = 10) 0.2 ml of 2.5% sodium taurodeoxycholate (NaTDC); group III (n = 8) the mixture of 0.2 ml GDOC 10 mmol/l and 10 U enterokinase. Serum levels of amylase and lipase, hematocrit, mean arterial pressure and heart rate were determined at baseline and 5 hours later. Then the pancreas was removed for histopathology and grading (0-3; absent-severe) with regard to leukocyte infiltration, edema, necrosis, hemorrhage and acinar cell vacuolization. RESULTS: Serum levels of amylase and lipase increased significantly in 5 hours in all the groups. Serum amylase levels were significantly lower in group III than in group II. No significant difference of serum lipase was found among the groups. Group II had the highest scores of necrosis and acinar cell vacuolization, whereas group III had the highest scores of leukocyte infiltration and edema. The degree of necrosis was significantly more severe in group II than in group I. The hematocrit increased significantly in 5 hours in groups I and II. The mean arterial pressure in 5 hours decreased significantly in group I. There was no significant difference of the changes of heart rate in 5 hours among 3 groups. CONCLUSIONS: Intraductal infusion of NaTDC was a good method to induce moderate acute necrotizing pancreatitis in rats. GDOC caused mild pancreatitis, and pancreatic injury was aggravated when enterokinase was added. The severity of pancreatic histopathology was not correlated with the changes of serum levels of pancreatic enzymes, hematocrit or mean arterial pressure at the early stage of pancreatitis.     

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.     

Compartment syndrome in experimental chronic obstructive pancreatitis: effect of decompressing the main pancreatic duct

Chronic pancreatitis is characterized by persistent and severe pain, which can be relieved by decompression of the main pancreatic duct (MPD). Both ductal and interstitial pressures have been shown to be increased in chronic pancreatitis in patients. A study was carried out of pancreatic interstitial pressure and pancreatic blood flow in normal cats and those in which chronic obstructive pancreatitis had been induced 5 weeks earlier to determine the effect of decompression of the MPD. In the normal pancreas, median(interquartile range (i.q.r.)) basal interstitial pressure was 0.05(1.2) mmHg and median(i.q.r.) basal pancreatic blood flow 58.3(24.3) ml per min per 100 g. Secretory stimulation did not change the interstitial pressure significantly, but was associated with a 40 per cent increase in median(i.q.r.) blood flow to 81.8(45.8) ml per min per 100 g. In contrast, in chronic obstructive pancreatitis, the median(i.q.r.) basal interstitial pressure was 2.0(1.5) mmHg, which was significantly higher than in the normal gland, and median(i.q.r.) pancreatic blood flow was 38.3(9.8) ml per min per 100 g, significantly lower than in the normal pancreas. Furthermore, secretory stimulation was associated with a significant increase in median(i.q.r.) interstitial pressure to 3.3(1.6) mmHg and a simultaneous decrease in median(i.q.r.) blood flow to 31.5(13.7) ml per min per 100 g. After decompression of the MPD in cats with chronic obstructive pancreatitis, the median(i.q.r.) basal interstitial pressure was 2.0(1.4) mmHg and on secretory stimulation 1.8(1.5) mmHg. Decompression thus prevented the increase in interstitial pressure seen in the animals with obstruction. In contrast, ductal decompression improved the median(i.q.r.) basal pancreatic blood flow to 45.9(38.4) ml per min per 100 g and, furthermore, this increased significantly on secretory stimulation to a median(i.q.r.) of 81.4(47.8) ml per min per 100 g. Decompression thus restored the normal pattern of secretory hyperaemia. Within the confines of this model, these observations demonstrate that chronic obstructive pancreatitis exhibits a compartment syndrome that is relieved by duct drainage.     

Attitudes towards pelvic examination in a random sample of Swedish women

In acute pancreatitis, particularly in severe cases, polymorphonuclear neutrophil (PMN) elastase induces tissue damage in remote organs such as the lung, as well in the pancreas itself. Therefore, we examined the therapeutic effect of a specific synthetic inhibitor of PMN elastase (ONO-5046: Ono Pharmaceuticals, Osaka, Japan) on the lung, liver, and kidney, as well as pancreas, in severe hemorrhagic pancreatitis in dogs. Acute hemorrhagic pancreatitis was induced by the injection of a mixture of autologous bile and porcine trypsin into the main pancreatic duct. Lipopolysaccharide (LPS) was administered intravenously as a septic challenge. Two animal groups were used. In one group, continuous infusion of ONO-5046 was started prior to the injection of LPS (ONO group). In the other group (control), saline was infused instead. At the end of the experiment (330 min after the injection of bile and trypsin), the pancreas revealed severe hemorrhagic pancreatitis, and a large amount of bloody ascites had accumulated in the peritoneal cavity. The white blood cell count was markedly reduced in response to the induction of pancreatitis, and was decreased further by the septic attack, irrespective of the administration of ONO-5046, although the count increased again in the ONO group. Serum levels of amylase and alpha2-macroglobulin-trypsin complex increased similarly in both groups following administration of bile and trypsin. Serum Ca levels decreased in both groups. At the end of the experiment, the wet weight of the lung was slightly higher in the control group (without ONO-5046). Microscopically, the pancreas showed severe hemorrhage accompanied by extensive interstitial edema in both groups. The lung and liver demonstrated mild infiltration of inflammatory cells in the interstitium in both groups, although the inflammatory change in the liver was slightly milder in the ONO group. These findings indicate that severe hemorrhagic pancreatitis cannot be alleviated by the administration of a specific inhibitor of PMN elastase alone, although this may lessen damage to remote organs such as the liver and lung. The white blood cell count decreased markedly after the induction of acute pancreatitis, and much more after a septic challenge. This seems to be closely related to the accumulation of bloody ascites in the peritoneal cavity.     

Solid phase synthesis of a biased mini tetrapeptoid-library for the discovery of monodentate ITAM mimics as ZAP-70 inhibitors

BACKGROUND: Clinical evaluation of intraoperative endoscopy with electrohydraulic lithotripsy (EHL) in the management of 13 patients with pancreatobiliary lithiasis was undertaken. METHODS: Ten patients with chronic pancreatitis with intraductal lithiasis in the head and three with biliary lithiasis (one choledochal, one cystic, one right intrahepatic) underwent intraoperative endoscopy with EHL. Shock waves were applied by visual contact with a 3-Fr gauge EHL probe until all stones were fragmented and irrigated free. All pancreatitis patients had failed ERCP attempts to stent their pancreatic ducts secondary to ductal lithiasis. Patients with pancreatic stones underwent lateral pancreatojejunostomy. Biliary stone patients underwent laparoscopic cholecystectomy with common duct exploration (two cases) and open cholecystectomy with choledochoduodenostomy (one case). RESULTS: Intraductal stone eradication was successful in all patients. Transampullary visualization of the duodenum was achieved in eight cases. Average EHL time was 65 min. There was no evidence of postoperative pancreatitis, cholangitis, or retained common duct stones. CONCLUSION: Intraoperative pancreatobiliary endoscopy with EHL is safe and effective in the eradication of pancreatic and bile duct stones. This novel technique represents a valuable adjunct in the management of chronic fibrocalcific pancreatitis with ductal lithiasis in the head region and in the open and laparoscopic management of intra- and extrahepatic bile duct stones.     

Vascular permeability induced by pancreatic exudate formed during acute pancreatitis in dogs

Acute pancreatitis was produced in five dogs by injecting bile into the pancreatic duct. The capillary permeability effects of the exudate formed within the peritoneal cavity were studied by injecting the exudate intradermally into puppies. The amount of radioactively labeled albumin escaping from the circulation and appearing at the intradermal injection site was used as a measure of capillary permeability. It was observed that the peritoneal exudate, especially that produced in the early stage of bile induced pancreatitis, contains one or more substances which result in an increased capillary permeability when injected intradermally into puppies.     

Occlusion of the pancreatic ducts with "Ethibloc" injections. Experimental study in the dog

"Ethibloc" is a zeine-alcohol suspension which polymerizes in an aqueous medium after approximately 15 minutes. The product was injected in the pancreatic duct of 20 dogs. The procedure was free from complications, apart from the development of edematous pancreatitis without clinical manifestations. Healthy pancreases were transformed into fibrous organs within ten days or so, as is found in advanced stages of chronic pancreatitis. No effect occurred on the islets of Langerhans and a diabetes of the experimental type did'nt develop. "Ethibloc" would therefore appear to be of value in humans for the treatment of chronic pancreatitis, in order to reduce the period for transformation of the lesions without increasing the incidence of complications, and also for pancreatic fistulae of various origins, as a result of the rapid sclerosis of exocrine tissue that it provokes.