Appraisal of Operative Treatment for Chronic Pancreatitis

With Special Reference to Side to Side Pancreaticojejunostomy

Toshio Sato, MD, Sendai, Japan

Yoichi Saitoh, MD, Sendai, Japan

Noboru Noto, MD, Sendai, Japan

Koki Matsuno, MD, Sendai, Japan

The ever increasing use of modern diagnostic

methods, such as pancreatic exocrine function

testing, selective angiography, and others, is ap-

parently linked to the recently noted higher inci-

dence of chronic pancreatitis, even in Japan where

such patients, particularly those requiring opera-

tive treatment, were long believed to be very rare.

In a previous publication [I], we reported on the

results of surgical treatment for chronic pancreati-

tis in our clinic. The present report evaluates the

various operative procedures, with special refer-

ence to side to side pancreaticojejunostomy, from

an analysis of the results. The number of subjects, although not necessarily statistically significant, is

the largest series from a single institution in

Japan.

Material and Methods

A total of seventy-one patients with chronic pancrea- titis were treated up to March 1973 at the First Depart-

ment of Surgery, Tohoku University School of Medi- cine, Sendai, Japan. Of these seventy-one patients,

forty-eight were men and twenty-three were women.

The forty-eight men, except for one in his twenties, were all older than thirty years of age (mean, 47.3 years), whereas the twenty-three females included seven youn-

ger than twenty years (mean, 40.7 years). (Table I.) Pan- creatic calculi were found in forty patients (56.3 per

cent), thirty in men, all older than thirty years (mean,

45.1 years), and ten in women, including seven younger

than twenty years (mean, 27.3 years).

Alcohol was predominant among the suspected causes of chronic pancreatitis in. these patients, occurring in

twenty-one (29.6 per cent); other causes included pro-

From the Department of Surgery. Tohoku University School of Medicine, Sendai. Japan.

Reprint requests should be addressed to Toshio Sate, MD. Department of Surgery. Tohoku University School of Medicine, Sendai, 980. Japan.

gression of acute pancreatitis in twelve (16.9 per cent), cholelithiasis in eight (11.3 per cent), and pancreatic in-

jury in three (4.2 per cent); and the cause was unknown

in twenty-seven patients (38.0 per cent). All the patients

with suspected alcoholic pancreatitis had been drinking

for more than ten years. Of the eight patients with cho-

lelithiasis, gallstones were found in the gallbladder in

six, in the bile duct in one, and in both the gallbladder

and bile duct in one. The main constituent of the stone

was cholesterol in seven patients and calcium bilirubi-

nate in one. Of the forty patients with associated pan- creatic calculi, in nineteen the cause was alcohol, but in

the remaining twenty-one patients the cause could not

be determined. Among the clinical symptoms in these patients at ad-

mission, epigastric pain was predominant, occurring in

fifty-three patients, followed by bilateral upper abdomi- nal pain in thirty-one patients. Other symptoms includ-

ed nausea, vomiting, jaundice, fever, and weight loss.

Jaundice, occurring as the main clinical symptom in thirteen patients, was traced to carcinoma of the head of

the pancreas in two, cholelithiasis in two, and stenosis of

the bile duct with advanced fibrosis of the pancreas in

nine. Severe pain occurred in thirty-seven patients and

pain radiating to back in forty-four, both symptoms noted predominately in patients with pancreatic calculi.

The episodes occurred more than once a month in

twenty-five patients and more than once a year in forty- six. These episodes of epigastric pain had been noted for less than one year in nineteen patients, one to five

years in nine, and ten years or more in twenty-one.

Secretin tests carried out in sixty-four patients to evaluate the pancreatic exocrine function revealed se-

vere impairment in twenty-nine patients (45.3 per cent), including twenty-one with pancreatic calculi, moderate impairment in seventeen, and mild impairment in fif- teen. Results of fat absorption study performed by the method of Van de Kamer in twenty-nine patients were normal in seventeen and abnormal in twelve. The twelve patients with abnormal results all had pancreatic calcu-

li.

Volume 129, June 1975 621

Sat0 et al

TABLE I Age and Sex Distribution in Seventy-One Patients with Chronic Pancreatitis

-__ Number of Patients

Age (YO Males Females

<19 2 m* 20-29 1 5 (5) 30-39 13 (7) 5 (2) 40-49 16 (10) 5 (1) 50-59 8 (5) 2

>60 10 (4) 4 Total 48 (30) 23 (10)

* Parentheses indicate the number of patients with pan-

creatic calculi.

TABLE II Surgical Procedures for Chronic Pancreatitis in Sixty Patients

Number of

Procedure Patients Mortality

Side to side pancreaticojejunostomy 24 (23)* . . . Caudal pancreatectomy 10 (2) . . .

Pancreaticoduodenectomy 6 (4) 1 Total pancreatertomy l(1) 1 Pancreaticolithotomy 4 (4) 1 Cystojejunostomy 2

Biliary tract procedures 12 (3) ‘;’ Drainage of abscess l(1) ..* Exploratory laparotomy l(1) . . .

* Parentheses indicate the number of patients with pan-

creatic calculi.

Glucose tolerance tests carried out in sixty-three pa- tients to evaluate the pancreatic endocrine function showed a diabetic curve in thirty-three (52.3 per cent) and a decreased glucose tolerance curve in thirteen (20.6 per cent), thus revealing glycoregulation disorders in forty-six of sixty-three patients (73.0 per cent). Diabetes of a more than moderate level was found in fourteen of thirty-nine patients (35.9 per cent) with pancreatic cal-

Figure 1. Surgical specimen after resection of head and tail of the pancreas, showing dilated pancreatic duct with calculi at the head and cyst at the tail.

culi, which was more frequent than in five of twenty- four patients (20.8 per cent) without calculi. Cancer of the pancreas was associated with pancreatic calculi in four patients.

The indications for operation in our patients with chronic pancreatitis were (1) severe pain uncontrolled by conservative management, (2) pancreatic calculi, (3) pancreatic cyst, abscess, or fistula, (4) stenosis of the bile duct and other biliary tract disease, and (5) suspect- ed carcinoma of the pancreas.

In sixty of the seventy-one patients with chronic pan- creatitis, a total of sixty-one operative procedures were performed. (Table II.) Side to side pancreaticojejunos- tomy was used in twenty-four patients, twenty-three of whom had pancreatic calculi. Caudal pancreatectomy was performed in ten patients with the main lesion or cyst limitkd to the body or tail of the pancreas. Pancrea- ticoduodenectomy was carried out in six patients with the main lesion or cyst in the head of the pancreas, in- cluding one who also had resection of the tail because of cysts identified there. (Figure 1.) In one patient with far advanced diffuse fibrosis accompanying multiple cysts in the pancreas, total pancreatectomy was performed as a last resort. Simple removal of pancreatic calculi limited to the head of the pancreas was carried out in four patients, transduodenally in two and trans- parenchymally in the other two. Procedures in the biliary tract were performed in twelve patients, includ- ing cholecystectomy with T tube drainage in two, chole- cystectomy only in two, cholecystojejunostomy in one, choledochoduodenostomy in two, and choledocholitho- tomy with T tube drainage in one. One patient had only simple drainage because of a pancreatic abscess but un- derwent side to side pancreaticojejunostomy one year and four months later. Nothing other than exploratory laparotomy was carried out in one patient with compli- cating cancer of the pancreas. One patient with the Kimmelstiel-Wilson syndrome was excluded because of our indications for operation.

Results

Immediate Results of Operation. Operative fa- tality occurred in six patients. One of the six pa- tients undergoing pancreaticoduodenectomy died of postoperative pneumonia. The only patient subjected to total pancreatectomy, who had ac- companying parathyroid cancer, died of acute renal failure postoperatively. Of those who under- went pancreaticolithotomy, one died soon after operation from cancer of the pancreas. Among the patients who had procedures in the biliary tract, one with associated carcinoma of the head of the pancreas underwent cholecystojejunostomy but died soon after operation. One patient subjected to choledocholithotomy and another who had hepati- coduodenostomy, both with jaundice, died from hemorrhage. There was no operative mortality

622 The American Journal of Surgery

Chronic Pancreatitis

among the t,wenty-four patients undergoing side to

side pancreaticojejunostomy; however, in two a

pancreatic fistula developed postoperatively but soon closed spontaneously. Massive bleeding from

a peptic ulcer was encountered postoperatively in

two of these patients. Long-Term Results. The results of operation

were followed up in fifty-three patients surviving

operation, excluding the one with only exploratory

laparotomy. (Table III.) Of the twenty-four pa-

tients undergoing side to side pancreaticojejunos-

tomy. pain disappeared in twenty-two but some

remained in the other two. Of the two patients

with continued pain, one with alcoholic pancreati-

tis continued drinking for two years and four

months and the other had slight epigastric pain for

one year and eight months postoperatively. Of the

ten patients who underwent caudal pancreatec- tomy, pain was relieved in all, whereas of the five

survivors after pancreaticoduodenectomy, one with carcinoma in the head of the pancreas had

continued pain. Of three survivors after only pan-

creaticolithotomy, two continued to have pain. No

pain remained in the two patients who had cysto-

jejunostomy or in eight of the nine survivors who

had biliary tract procedures. Thus, in reference to

relief of pain, our operative procedures showed satisfactory results in forty-seven of fifty-three pa-

tients (88 per cent). Among the patients surviving operation, ten had

died at follow-up study. Of the twenty-four pa-

tients undergoing side t.o side pancreaticojejunos-

tomy, six died, three from diabetes and one each

from hepatitis, pneumonia, and rectal cancer. One

patient each died from recurrent cancer (pancrea-

ticoduodenectomy), cirrhosis of the liver (caudal

pancreatectomy), and senescence (choledocholi-

thotomy with T tube drainage). One patient who had only exploratory laparotomy because of cancer

of the pancreas died three months later.

Therefore, since eight patients died of the forty-

seven who had relief of pain among the fifty-two surviving operation (fifty-four minus the two who

already had complicating carcinoma of the pancre-

as at the time of operation), follow-up results were

satisfactory in thirty-nine of fifty-two patients (75

per cent j. Side to Side Pancreaticojejunostomy. Postop-

erative elimination of pain was obtained, as al-

ready described, in twenty-two of the twenty-four patients undergoing side to side pancreaticojeju-

no&my. Since six patients died from diabetes and other

diseases and two survivors continue to have pain, follow..llp study for periods of five months to nine

Volume 129, June 1975

TABLE III Relief of Pain in Patients Surviving Operation

Number Pam

01

Procedure Patients Relieved Persisted ~_____..~~~~~. ~~ ~~ __~~

Side to side pancreaticojejunostomy 24 22 2

Caudal pancreatectomy 10 10

Pancreaticoduodenectomy 5 4 1

Pancreaticolithotomy 3 1 2

Cystojejunostomy 2 2

Biliary tract procedures 9 8 1

YEARS AFTER Ol’ERATlOii

I 2 3 4 _s 6 7 II ‘) 10

6

Figure 2. Follow-up period of patients with side to side pancreaticojejunostomy.

E + 10” c. z . . c .

w .

2 0 = I’r*“prrarlur Lrvrl-

YEARS AFTER

Figure 3. Postoperative change in body weight in pa-

l .

tients with side to side pancreaticojejunostomy.

years and six months showed results evaluated as

satisfactory in sixteen of twenty-four patients

(66.7 per cent). (Figure 2.) All survivors, including

the two with mild pain, have resumed normal ac- tivity.

Changes in body weight between pre- and post- operative levels were observed in the eighteen sur- vivors including the two with pain. A postopera- tive loss of less than 10 per cent occurred in seven, the weight was unchanged in two, and a gain was noted in eleven, including five who gained more than 10 per cent. (Figure 3.) However, fat absorp-

623

Sat0 et al

Figure 4. Retrograde pancreatography showing contrast medium flowing rapidly from the original duct (arrows) into the jejunum, indicating a patent anastomosis.

tion study by the method of Van de Kamer in these eighteen patients revealed that in four who had had normal values preoperatively and in ten who had had abnormal values results were not af- fected by operation, whereas four who had had normal values preoperatively had abnormal results postoperatively. These results indicate that this procedure does not contribute significantly to an improvement in digestion and absorption.

The following two case reports show the patency of anastomosis and histologic features of the pan- creas after side to side pancreaticojejunostomy.

Case I. The patient, a twenty-six year old woman, had had severe pain in the upper abdomen several times a year for fifteen years. Plain film examination revealed evidence of numerous calculi in the upper abdomen. Be- cause of dilatation evident in the pancreatic duct, she was subjected to side to side pancreaticojejunostomy. At five years and nine months postoperatively, retrograde pancreatography revealed contrast medium flowing rap- idly from the original duct into the jejunum, indicating a patent anastomosis. (Figure 4.) Another abdominal plain film examination showed the pancreatic calculi to be fewer than noted immediately after operation. At six

years and three months after operation, she is well and living with her two children. There were two other pa- tients in whom a patent anastomosis was confirmed by retrograde pancreatography.

Case II. The patient, a fifty-nine year old man, had had dull pain in the upper abdomen usually once a month for eight years. There was evidence of a calculus in the pancreas on plain film examination. Because of evident dilatation in the pancreatic duct, he was subjected to side to side pancreaticojejunostomy. At the time of operation, the histologic appearance was of ex- tensive inter- and intralobular fibrosis. (Figure 5.) Pain disappeared postoperatively, and he resumed normal ac- tivity but died from rectal cancer four years and eleven months after operation. At autopsy, there was histologic evidence of pancreatic fibrosis remarkably milder than that at operation. (Figure 6.) The 8 cm anastomotic opening created at operation remained patent at autop- sy but had decreased to only 1 cm. (Figure 7.)

Comments

Operations for chronic pancreatitis currently available consist of pancreatectomy, decompres- sion of the pancreatic duct, procedures in the bil- iary tract, and splanchnicectomy.

For chronic pancreatitis, very few investigators positively favor pancreatectomy. Performing pan- creaticoduodenectomy in eighty-two patients, Warren and Mountain [2] reported successful re- sults in 68 per cent; however, they commented that this procedure should only be performed in pa- tients with advanced chronic relapsing pancreati- tis with multiple points of obstruction within the proximal pancreatic ductal system and particular- ly when more limited operations have proved un- successful. When chronic pancreatitis is still at an early stage or accompanies severe pancreatic in- flammation, they believe treatment should be sim- pler and less radical whenever possible. Of their patients, 81 per cent had undergone previous pan- creatic procedures, and postoperative diabetes de- veloped in 15 per cent of all. Guillemin et al [3] also performed pancreaticoduodenectomy in sixty-

624 The Amerban Journal of Surpry

Chronic Pancreatitis

three patients, and reported results of three years’

follow-up study. Fifteen patients died and six were

lost to follow-up study; of the remaining forty-two,

the postoperative course was good in thirty-one, fair in six, poor in two, and bad in three. According

to these authors, pancreaticoduodenectomy should

only be performed when clinical findings indicate

an urgent need for relief of severe and rapid weight

loss, jaundice, duodenal stenosis, portal hyperten-

sion with hemorrhage, diarrhea, or diabetes. They

also maintain that this procedure should be car-

ried out only when other less radical procedures have proved unsuccessful. Of their sixty-three pa-

tients, twenty-three had undergone a total of

thirty-nine operations previously. Pancreaticoduo- denectomy was mentioned briefly by White and

Keith [4] with a comment on the postoperative

frequency of recurrent inflammation in the re-

maining segment of the pancreas. We performed this procedure in six patients in whom the main le-

sion (cysts, calculi, or carcinoma) was confined to

the head of the pancreas.

Caudal pancreatectomy was performed in ten

patients with a cyst or the main lesion in the distal

segment of the pancreas. This procedure was used

by Warren and Mountain [2] in seventy-three pa-

tients with chronic pancreatitis, of whom thirty- nine had distal pancreatitis, fifteen had post-trau-

matic distal pancreatitis, fourteen had severe pan-

creatitis, and five had a pancreatic fistula. They

reported satisfactory results in 78 per cent of these seventy-three patients, although diabetes devel-

oped postoperatively in fourteen patients.

Total pancreatectomy may be unavoidable in

those patients with severe pancreatic changes such

as multiple cysts or an abundance of calculi. In our

series one patient was subjected to this procedure

as a last resort. Warren and Mountain [2] reported

that seven of their eight patients had satisfactory

results after this radical procedure. However, they

comment that total pancreatectomy should be

avoided unless partial resection has failed to re-

lieve pain. Certainly, as the resultant deterioration of both endocrine and exocrine functions causes

extreme difficulty in postoperative management,

this radical procedure should be postponed as long

as possible. There are no available reports of a large series of patients undergoing total pancrea-. tectomy. An alternative 95 per cent distal pancrea- tectomy was performed by Child, Frey, and Fry [5] in thirty-seven patients; twenty-three of thirty-

two patients (72 per cent) surviving one year or more had satisfactory results. However, according to Warren and Mountain [2], 95 per cent distal

Figure 7. Case II. Autopsy specimen showing patent anastomosis (arrows) 1.0 cm in size four years and elev- en months after side to side pancreaticojejunostomy.

pancreatectomy could not be performed in many patients with far advanced chronic pancreatitis

without jeopardizing the blood s’upply of the duo-

denum. White and Keith [4] suggest that this pro-

cedure be performed in patients who have had fail-

ure of previous surgical procedures or in those

with nerve-cutting procedures ineffective for the

diffusely fibrosed and shrunken gland with a nor-

mal ductal system. We have no experience with this type of operation.

Surgical decompression of the pancreatic duct is

designed to preserve, in place of pancreatectomy,

as much pancreatic function as possible. Sphinc-

terotomy was first used by Doubilet and Mulhol- land [6] in 190 patients with recurrent pancreati-

tis, with good results in 88 per cent. Many other

authors, however, question the effects of this tech-

nic. White [7], for instance, considers this method

useful only for pancreatography in cases of chronic

pancreatitis. It is also our opinion that only specif-

ic conditions in an extremely limited group of pa-

tients with chronic pancreatitis may indicate this

procedure. Another method of ductal decompres- sion was preferred by Warren and Mountain [2] in

cases of mild or moderate pancreatitis with ductal

stenosis within a few centimeters of the duodenal

papilla; the opening of the duct of Wirsung was

exposed after transduodenal sphincteroplasty,

sphincteroplasty of the duct of Wirsung was per- formed and any other stricturea were incised or di-

lated with removal of any intraductal calculi, and then a ureteral catheter was inserted through the area of stricture and brought out through the duo- denal wall to the exterior. Satisfactory results were reported in 72 per cent of their 155 patients. This surgical technic seems useful in some cases. As an-

Volume 129. June 1975 625

Sat0 et al

other method of ductal decompression, DuVal and Enquist [8] attempted caudal pancreaticojejunos- tomy. However, the disadvantage of caudal pan- creaticojejunostomy is that it is ineffective in the presence of obstruction or calculi in the remaining pancreatic duct.

Side to side anastomosis between the pancreatic duct and jejunum was thus introduced by Peustow and Gillesby [9] as an improved technic for ensur- ing adequate ductal drainage. It was suggested that side to side pancreaticojejunostomy be per- formed after incising the pancreatic duct longitu- dinally and removing the calculi from within the lumen. With subsequent modification of technical details, the method was applied by Thal [IO], Par- tington and Rochelle [II], and White and Keith [4], with fairly favorable results. In contrast, anas- tomosis of the pancreatic duct and the stomach in- stead of the jejunum was advocated by Warren and Mountain [2] for the same purpose. Because of our interest in the significance of side to side pancreaticojejunostomy, we have used this proce- dure in a total of twenty-four patients with chronic pancreatitis, all of whom had prominent dilatation in the pancreatic duct and twenty-three of whom had pancreatic calculi.

Operations in the biliary tract include cholecys- tectomy or choledocholithotomy in patients with cholelithiasis, sphincteroplasty in patients with stenosis at the papilla of Vater, and cholecystoje- junostomy or choledochoduodenostomy in pa- tients with jaundice. Generally, however, these procedures are effective only in patients with mild pancreatitis or complicating jaundice [2].

As a surgical procedure for the nervous system, Mallet-Guy and de Beaujeu [12] advocate left splanchnicectomy and celiac ganglionectomy. Applying this procedure in seventy patients, they reported favorable results in 84 per cent. White, Lawinski, and Stacker [13] favor this procedure in patients in whom the pancreas is shrunken by se- vere fibrosis with ducts of small caliber.

The rationale of vagotomy and antrectomy was discussed in the report of Richman and Colp [Id]. Recently, this procedure was used by Pradhan et al [25] in fourteen patients with alcoholic pancrea- titis, with favorable results in eleven. In some cases of chronic pancreatitis associated conditions may indicate such procedures.

We performed a total of sixty-one operations in sixty of seventy-one patients with chronic pan- creatitis, with six operative deaths. Excluding one patient who underwent only exploratory laparot- omy due to cancer of the pancreas, forty-seven of

the remaining fifty-three survivors (88 per cent) had relief of pain. Specifically, the pain-free pa- tients included twenty-two of twenty-four with side to side pancreaticojejunostomy, all ten with caudal pancreatectomy, four of five with pancre- aticoduodenectomy, one of three with removal of pancreatic calculi only, both with cystojejunos- tomy, and eight of nine with biliary tract proce- dures. With eight later deaths among the forty- seven pain-free patients, the follow-up results were evaluated as favorable in thirty-nine of fifty- two patients (75 per cent) (excluding the two who already had complicating cancer of the pancreas at the time of operation from the fifty-four surviving operation). In the large series of Warren and Mountain [2] with 546 operations in 530 patients with chronic pancreatitis, satisfactory results were shown in 421(79 per cent).

White and Keith [4] recommended pancreatico- jejunostomy, splanchnicectomy, and 95 per cent distal pancreatectomy in descending order of choice for the treatment of chronic pancreatitis. We also favor side to side pancreaticojejunostomy as the first procedure when chronic inflammation and fibrosis are accompanied by dilatation of the pancreatic duct. To date, we have used this proce- dure in twenty-four patients with no operative deaths. White and Keith [4], applying this type of procedure in fifty patients, found that a pancreatic or intestinal fistula developed postoperatively in ten. Pancreatic fistula also developed in two of our patients but spontaneously closed in a short time.

Side to side pancreaticojejunostomy was effec- tive in relieving pain in twenty-two of our twenty- four patients. Of these twenty-two patients, six had died at follow-up study, including three from aggravated diabetes after neglecting the medical regimen and one from acute pneumonia after re- suming alcoholic intake postoperatively. White and Keith [4] also cite alcohol and cancer of the pancreas as predominant factors affecting the re- sults of this type of operation. Taking into account the two patients who had continued pain and the six who were pain-free but died later, follow-up re- sults were satisfactory in sixteen of our twenty- four patients (66.7 per cent). In the experience of White and Keith [4], of fifty patients treated with this surgical procedure, 46 per cent were symp- tom-free after 4.41 years (average follow-up peri- od), 35 per cent showed improvement but had in- termittent pain after 4.38 years, and 19 per cent remained unimproved after 4.42 years. Warren and Mountain [2], performing pancreaticogastros- tomy, reported satisfactory results in fifteen of

626 The American Journal of Surgery

Chronic Pancreatitis

twenty-five patients (60 per cent). In summary,

current results of surgical treatment of chronic

pancreatitis by transpancreatic ductal decompres- sion are in the range of results just described.

As already mentioned, the survivors of side to

side pancreaticojejunostomy followed up for five

months to nine years and six months showed the

following changes in body weight between pre- and

postoperative levels: postoperative loss of less than 10 per cent in seven, absence of change in two, and

postoperative gain in eleven, including five with

more than 10 per cent gain. However, no improve-

ment in results of fat absorption examination was

observed postoperatively, in agreement with the

observations of White [7] and Cox and Gillesby

[16], implying that this type of procedure is rather

ineffective in improving digestion and absorption.

The postoperative weight gain may be explained

by the increased food intake due to relief of pain.

The surgical treatment of chronic pancreatitis

by side to side pancreaticojejunostomy anticipates

the problems of anastomotic patency and histolog-

ic changes in the pancreas after operation.

Evident relief of pain in almost all of our pa-

tients undergoing side to side pancreaticojejunos- tomy suggested continued patency of the anasto-

mosis, which was confirmed by endoscopic pancre-

atography in three patients. Moreover, in one pa-

tient who died four years and eleven months post-

operatively, postmortem examination revealed a

patent anastomosis. In this patient, the 8 cm anas-

‘tomotic opening created at operation had de-

creased to 1 cm at autopsy, supporting the view of

White and Keith [4] that an anastomotic opening

of 10 cm or more is necessary to prevent failure of

patency. Opinions are divergent as to whether or not fi-

brosis of the pancreas can be improved by means of pancreatic ductal decompression. Hill, Stone,

and Baker [17] presented one case suggesting im-

proved pancreatic endocrine and exocrine function

after side to side pancreaticojejunostomy. Based on the results of secretin tests and histologic evi-

dence, Doubilet [18] pointed out that the pancreas

often can regenerate when sphincterotomy has ef-

fected pancreatic ductal decompression, thereby

suppressing attacks. In canine experiments, Car- nevali [19] reported that side to side pancreatico- jejunostomy could improve fibrosis of the pancre- as. In one of our patients who died from rectal can- cer four years and eleven months after side to side pancreaticojejunostomy, histologic findings at au-

topsy showed pancreatic fibrosis markedly milder than that observed at operation. The findings in

this single instance, of course, cannot be generally

applied to all cases of chronic pancreatitis since

chronic pancreatitis is not always diffuse; never- theless, these findings at least suggest. the absence

of histologic deterioration about five years after side to side pancreaticojejunostomy.

Summary

A total of sixty-one operations were performed in sixty of seventy-one patients with chronic pan-

creatitis, with the following results.

1. The procedures used were side to side pan-

creaticojejunostomy in twenty-four patients, caud-

al pancreatectomy in ten, pancreaticoduodenec-

tomy in six, total pancreatectomy in one, removal

of pancreatic calculi in four, cystojejunostomy in

two, biliary tract procedures in twelve, and drain-

age of pancreatic abscess in one. Operative fatality

occurred in six patients, with fifty-four surviving

operation.

2. Of fifty-three patients surviving operation

(excluding the one who underwent only explorato- ry laparotomy), forty-seven (88 per cent) had relief

of pain. With the exception of two patients with

complicating cancer of the pancreas at the time of operation, of fifty-two patients surviving opera-

tion, thirty-nine (75 per cent) had satisfactory re-

sults at follow-up study.

3. Sixteen of twenty-four patients (66.7 per

cent) undergoing side to side pancreaticojejunos-

tomy had satisfactory follow-up results. 4. Comparison of pre- and postoperative body

weight levels in twenty-one patients undergoing

side to side pancreaticojejunostomy showed a

postoperative loss of less than 10 per cent in seven,

unchanged weight in two, and a gain in eleven pa-

tients, including five with more than 10 per cent

gain. However, fat absorption examination in

these patients showed no distinct postoperative

improvement in digestion and absorption.

5. Histologic evidence in one patient at autopsy four years and eleven months after side to side pancreaticojejunostomy indicated improvement in fibrosis of the pancreas as compared with the find- ings at operation.

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Volume 129, June 1975 627

Sat0 et al

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