The surgical treatment of pancreatic disease

Periampullary carcinoma and chronic pancreatitis are the most frequent indications for operations on the pancreas. Exploration and resection by pancreaticoduodenectomy is the preferred method of treatment for carcinoma of the periampullary region when the malignancy is localized to this area and when it does not invade the superior mesenteric vein. A direct anastomosis of the remaining pancreatic duct to the side of the jejunum is performed when possible. Total pancreatectomy has been utilized for extensive carcinomas of the pancreas and for early lesions with an essentially normal pancreatic parenchyma to avoid the hazards of the pancreaticojejunal anastomosis. Chronic pancreatitis has been treated by various operative procedures. Duct stenosis and calculi, fibrosis and inflammation, and occasional pseudocyst formation commonly occur in the head of the gland. This area seems to act as a site of origin and perpetuation of the disease process. Proximal pancreatic resection by pancreaticoduodenectomy is being performed more frequently with anastomosis of five to 15 per cent of the pancreatic tail to the jejunum. Diabetes may be prevented and some external pancreatic enzyme function may thereby be preserved. In any pancreaticoduodenectomy, preservation of the entire stomach and first portion of the duodenum and intact pylorus should be considered. Preliminary observations suggest that the presence of an intact stomach and a functioning pylorus tend to lessen the digestive disturbances following this resection. After total pancreatectomy, further efforts should be made to extract and regraft the patient's viable islet of Langerhans cells from the excised pancreas. A reliable method of restoring insulin production would extend the use of total pancreatectomy for both malignant and benign pancreatic disease.