Management and outcome of hemorrhage due to arterial pseudoaneurysms in pancreatitis

BACKGROUND: Arterial pseudoaneurysm formation in pancreatitis is a rare complication. The optimal treatment modality is controversial. Operative treatment and interventional treatment, either alone or as a temporizing method with a later operation, are options. METHODS: In this single-center, patient-based cohort study, we managed 35 patients (8 with necrotizing pancreatitis and 27 with chronic pancreatitis) with bleeding pseudoaneurysms treated over a period of 10.5 years with a median follow-up of 4.6 years. Angiography was performed depending on the patient's hemodynamic condition. RESULTS: Angiography had a sensitivity of 96% for 26 patients. Angiographic embolization as primary treatment was performed in 16 patients (61% embolization rate); there were 2 rebleeding complications. No patients required intervention for embolization complications after discharge. Nineteen patients (54%) underwent an operation, 9 urgently without angiographic evaluation. The overall mortality rate for the 35 patients was 20% (19% for embolization, 21% after an operation). For necrotizing pancreatitis, an advantage of angiographic embolization was observed (mortality in 2/5 vs 2/3 after surgery). Ligation or repair of the bleeding vessel was complicated by higher rebleeding rates (6/13) than partial pancreatectomy (1/6). CONCLUSIONS: Concerns that angiographic embolization is unable to provide definitive hemostasis in both acute and chronic pancreatitis are unfounded. In the operative treatment of chronic pancreatitis, partial pancreatectomy is superior to vessel ligation, depending on the patient's general condition and degree of pancreatic inflammation. We propose an algorithm for the management of arterial pseudoaneurysms in the setting of pancreatitis.     

The significance of sinistral portal hypertension complicating chronic pancreatitis

BACKGROUND: Sinistral portal hypertension, a localized (left-sided) form of portal hypertension may complicate chronic pancreatitis as a result of splenic vein thrombosis/obstruction. AIM:To determine appropriate surgical strategy for patients with splenic vein thrombosis/obstruction secondary to chronic pancreatitis. METHODS: We reviewed our experience with operative management of 484 consecutive patients with histologically documented chronic pancreatitis treated between 1976 and 1997. The diagnosis of sinistral portal hypertension was based on clinical presentation, preoperative endoscopic and radiographic imaging, and operative findings. "Symptomatic," herein defined, denotes those patients with sinistral hypertension and either gastrointestinal bleeding or hypersplenism. "Asymptomatic" patients were those with sinistral hypertension alone. RESULTS: Sinistral portal hypertension was present in 34 of the 484 patients (7%). Gastric or gastroesophageal varices were confirmed in 12 patients (35%), of whom 6 had variceal bleeding and 4 had hypersplenism (25%). All symptomatic patients were treated by splenectomy alone or in conjunction with distal pancreatectomy. Splenectomy at the time of pancreatectomy for primary pancreatic symptoms was also performed in 15 patients with (asymptomatic) sinistral portal hypertension. None of the 23 patients who had splenectomy rebled in mean follow-up of 4.8 years. In contrast, 1 of the 11 patients with asymptomatic sinistral portal hypertension who underwent pancreatic surgery without splenectomy died of later variceal bleeding 3 years after lateral pancreatojejunostomy. CONCLUSIONS: Symptomatic sinistral portal hypertension is best treated by splenectomy. Concomitant splenectomy should be strongly considered in patients undergoing operative treatment of symptomatic chronic pancreatitis if sinistral portal hypertension and gastroesophageal varices are also present.     

Operative treatment of pseudocysts in patients with chronic pancreatitis

BACKGROUND: Pseudocysts associated with chronic pancreatitis are generally intrapancreatic and associated with parenchymal disease. They tend to persist and cause complications. Minimally invasive methods of treatment challenge the traditional techniques of operative management. Surgical operation allows definitive treatment of the pseudocyst with the option of dealing appropriately with the diseased pancreas and excluding a neoplastic process. The aim of this study was to review the safety and efficacy of a surgical approach to the management of pseudocysts associated with chronic pancreatitis. METHODS: A personal series of 112 consecutive patients operated for pseudocysts in the setting of chronic pancreatitis was reviewed. Chronic pancreatitis was confirmed by imaging studies in association with exocrine and/or endocrine failure. Cysts were multiple in 31 patients and presented with complications other than pain in 47. Data were collected prospectively regarding the clinical presentation, the nature of the operation and its outcome. RESULTS: Forty-eight patients (43 per cent) underwent drainage procedures, 56 (50 per cent) had a resection and eight (7 per cent) had a combination. Larger cysts and those located in the head and neck tended to be drained, while smaller and distal cysts were more often resected. The morbidity rate was 28 per cent and the operative mortality rate was 1 per cent. The cyst recurrence rate was 3 per cent and pain was relieved in 74 per cent of patients. CONCLUSION: Operative management of pseudocysts associated with chronic pancreatitis is effective with low morbidity and mortality rates. The introduction of newer minimally invasive techniques will have to withstand comparison to this traditional approach.     

Evaluation of positron emission tomography with 2-[18F]fluoro-2-deoxy-D-glucose for the differentiation of chronic pancreatitis and pancreatic cancer

BACKGROUND: The clinical presentation of patients with pancreatic cancer may resemble the clinical picture of chronic pancreatitis. A definitive preoperative diagnosis is not always obtained in patients with a history of chronic pancreatitis despite the use of modern imaging techniques. Operative strategy therefore remains unclear before operation in these patients. METHODS: Positron emission tomography (PET) with 2-[18F]fluoro-2-deoxy-D-glucose (FDG) was introduced recently into clinical oncology because of its ability to demonstrate metabolic changes associated with various disease processes. The impact of FDG-PET on the differentiation of chronic pancreatitis and pancreatic cancer was investigated. FDG-PET was performed in 48 patients with chronic pancreatitis (n = 12), acute pancreatitis (n = 3) and pancreatic cancer (n = 27), and in controls (n = 6). Histological examination was undertaken in all cases except controls. The FDG-PET results were obtained without knowledge of results of other imaging procedures. The results were then compared with those of computed tomography, ultrasonography, endoscopic retrograde cholangiopancreaticography, operative findings and histology. PET images were analysed semiquantitatively by calculating a standard uptake value (SUV) 90-120 min after application of the tracer. RESULTS: Cut-off values were validated as follows: SUV greater than 4.0 for pancreatic cancer, SUV of 3.0-4.0 for chronic pancreatitis, and SUV of less than 3.0 for controls. Sensitivity and specificity of PET imaging were 0.96 and 1.0 for pancreatic cancer, and 1.0 and 0.97 for chronic pancreatitis. In five cases only FDG-PET led to the correct preoperative diagnosis. CONCLUSION: The results give further evidence that FDG-PET is an important non-invasive method for the differentiation of chronic pancreatitis and pancreatic cancer. Delayed image acquisition in the glycolysis plateau phase permits improved diagnostic performance. This imaging technique is extremely helpful before operation in patients with an otherwise unclear pancreatic mass, despite its costs.     

Progressive loss of pancreatic function in chronic pancreatitis is delayed by main pancreatic duct decompression. A longitudinal prospective analysis of the modified puestow procedure.

OBJECTIVE: This study evaluated the effect of operative drainage of the main pancreatic duct (MPD) on functional derangements associated with chronic pancreatitis (CP). SUMMARY BACKGROUND DATA: The author previously reported delayed functional impairment in an evaluation of the impact of operative drainage in patients with CP. The author now reports on a prospective study of 143 patients with this diagnosis. METHODS: Each patient underwent 1) ERCP, 2) the Bentiromide PABA, 3) 72-hour fecal fat test, 4) oral glucose tolerance test (OGTT) and 5) fat meal (LIPOMUL)--stimulated pancreatic polypeptide release (PP). All patients were stratified as mild/moderate (M/M) or severe CP on the basis of a 5-point system that was developed by the author. Patients were studied at 16-month intervals. RESULTS: All 143 patients underwent initial and follow-up evaluations in a mean follow-up of 47.3 months; 83 of 143 patients had M/M grade at initial evaluation. Eighty-seven patients underwent (MPD) decompression to relieve abdominal pain. In a separate prospective 17 patients with a diagnosis of CP, a grade of M/M and non-disabling abdominal pain were randomized to operative or non-operative treatment; 9 of these randomized patients were operated upon and 8 were not. No patient improved their grade during follow-up; 47 of 83 M/M patients had operative drainage and 36 did not. This grade was preserved in 41 of 47 (87%) operated patients but in only 8 of the 36 non-operated patients (22%). In the randomized trial, seven of nine operated patients retained their functional status in follow-up, whereas only two of eight patients (25%) randomized to non-operation preserved their functional grade. CONCLUSIONS: These data in this large study as well as among a previous randomized sample, support a policy of early operative drainage before the development of irreversible functional impairment in patients with chronic pancreatitis and associated dilation of the main pancreatic duct.     

Postobstructive chronic pancreatitis: results with distal resection

HYPOTHESIS: For most patients with chronic obstructive pancreatitis, distal pancreatectomy confers pain relief. DESIGN: Retrospective case series. Follow-up was complete in 80% of study subjects (mean follow-up, 6.7 years). SETTING: Tertiary care center. PATIENTS: Among 484 patients with chronic pancreatitis undergoing operation from 1976 to 1997, 40 with postobstructive chronic pancreatitis were identified. Criteria for selection included an isolated, dominant major pancreatic duct stricture or cutoff, changes of chronic pancreatitis in the distal pancreas, and ostensibly normal parenchyma without calcification in the proximal gland. The patients were reviewed with regard to operative procedure, postoperative course, and outcome. MAIN OUTCOME MEASURES: Outcome measures included degree of pain relief, morbidity and mortality of operation, survival, rates of endocrine and exocrine insufficiency, and ability to return to work and/or normal activities. RESULTS: All but 1 of the 40 patients had abdominal pain, and 20 (50%) had recurrent episodes of acute pancreatitis. Suspicion of malignancy was a concern in 16 patients (40%). Thirty-eight patients underwent distal pancreatectomy; 1 had a central resection and another a Roux-en-Y cystojejunostomy. There was no operative mortality, but significant morbidity occurred in 15%. Among 31 patients with preoperative pain in whom long-term follow-up was available, complete or significant pain relief was achieved in 25 (81%); 74% returned to normal social function, but about half had some element of pancreatic insufficiency. CONCLUSIONS: Distal pancreatectomy is a safe procedure and achieves pain relief and good quality of life in a large percentage of patients (80%) with presumed postobstructive chronic pancreatitis. However, some of these patients with chronic pancreatitis involving the entire gland have disease masquerading as postobstructive chronic pancreatitis secondary to an ostensibly isolated dominant pancreatic ductal stricture.     

Duct drainage alone is sufficient in the operative management of pancreatic pseudocyst in patients with chronic pancreatitis

OBJECTIVE: To test a hypothesis that definitive management of pseudocyst associated with chronic pancreatitis is predicated on addressing pancreatic ductal anatomy. SUMMARY BACKGROUND DATA: The authors have previously confirmed the impact of pancreatic ductal anatomic abnormalities on the success of percutaneous drainage of pancreatic pseudocyst. The authors have further defined a system to categorize the pancreatic ductal abnormalities that can be seen with pancreatic pseudocyst. The authors have published, as have others, the usefulness of defining ductal anatomy when managing pancreatic pseudocysts associated with chronic pancreatitis. METHODS: Beginning in 1985, all patients with pseudocyst who were candidates for intervention (operative, percutaneous, or endoscopic) have undergone endoscopic retrograde cholangiopancreatography (ERCP). An associated diagnosis of chronic pancreatitis was established by means of ERCP findings. Patients were candidates for longitudinal pancreaticojejunostomy (LPJ) if they had a pancreatic ductal diameter greater than 7 mm. In a nonrandomized fashion, patients were managed with either combined simultaneous LPJ and pseudocyst drainage or with LPJ alone. RESULTS: Two hundred fifty-three patients with pseudocyst have been evaluated. Among these there have been 103 patients with chronic pancreatitis and main pancreatic duct (MPD) dilatation (>7 mm). Among these 103 patients, 56 underwent combined LPJ/pseudocyst drainage and 47 had LPJ alone. Compared to combined LPJ/pseudocyst drainage, the patients undergoing LPJ alone had a shorter operative time, slightly less transfusion requirement, slightly reduced length of hospital stay, and slightly reduced complication rate. Long-term pain relief was achieved in 90%, and pseudocyst recurrence was less than 1%. Rates of each of these long-term outcomes were nearly incidental among the two groups. CONCLUSIONS: Ductal drainage alone (LPJ) is sufficient in patients with chronic pancreatitis (MPD > 7 mm) and an associated pseudocyst. Simultaneous drainage of pseudocyst is not necessary.     

Surgery for chronic pancreatitis. Drainage versus resection.

A retrospective study of 49 patients with chronic obstructive and chronic calcific pancreatitis is presented. All patients were operated upon and underwent either a partial pancreatectomy or internal drainage of the ductal system into a Roux-en-Y loop of jejunum. The criteria for selection of operation are discussed, and the follow-up of the two operative groups is given. In patients selected as described, internal drainage provided better relief of pain and was accomplished with a lower operative mortality and morbidity and with less postoperative pancreatic insufficiency.     

Results of surgical treatment for acute pancreatitis

The results following the surgical treatment of acute pancreatitis in 67 patients are presented. The male:female ratio was 1.5:1; the average age for all patients was approximately 54.5 years. From an etiological viewpoint, biliary pancreatitis was found in 50.7% of the cases, followed by alcoholic (32.8%), idiopathic (7.5%), postoperative (6%) and traumatic (3%) pancreatitis. In most cases drainage operations were performed (92.5%) in conjunction with necrosectomy, whilst resectional techniques were used in five patients (7.5%). The perioperative mortality for all patients was 30%; it was higher among patients operated upon in the first week (44%) than in those whose operation was delayed (12.9%). The extent of organ necroses and the presence of extrapancreatic necroses were of decisive prognostic significance. The findings are compared with data given in the literature.     

Operative management of chronic pancreatitis: longterm results in 372 patients

BACKGROUND: Operative treatment of chronic pancreatitis is indicated for patients with intractable pain after failed medical and endoscopic treatment, or for the presence of complications of the disease. This study evaluates a single-center experience with operative management of chronic pancreatitis. STUDY DESIGN: The records of 372 consecutive patients who underwent lateral pancreaticojejunostomy (n = 184), pancreaticoduodenectomy (n = 97), or distal pancreatectomy (n = 91) for chronic pancreatitis between 1995 and 2003 were retrospectively reviewed and analyzed. Longterm outcomes were assessed by patient survey, with a median followup of 5.5 +/- 0.2 years. RESULTS: Primary indication for operative treatment included intractable pain (n = 215), pancreatic duct disruption (n = 109), inflammatory mass (n = 42), or biliary obstruction (n = 6). Perioperative morbidity was 22%, 51%, and 29% after lateral pancreaticojejunostomy, pancreaticoduodenectomy, and distal pancreatectomy, respectively, with a perioperative mortality rate of 1%. Two hundred twenty-eight patients were available for longterm followup. Fifty-eight patients (25%) died in the followup period. Twenty-four percent of the remaining 170 patients were pain free, and 25% had good pain control after the procedure. On multivariate analysis, risk factors for poor pain control were pancreaticoduodenectomy (p < 0.01), preoperative narcotic dependence (p < 0.02), earlier abdominal operations (p < 0.02), and an absent history of gallstone pancreatitis (p < 0.05). Sixty-two percent returned to work. Quality of life assessed by SF-36 version 2 questionnaire showed norm-based scores between the 35th and 46th percentile and slightly below, but not substantially different from, a general population. New onset of endocrine and exocrine insufficiency was present in 35% and 29% of patients, respectively. CONCLUSIONS: Operative management of chronic pancreatitis can be performed with low mortality and acceptable morbidity. Surgical treatment can provide good pain control, return patients to work, and achieve a satisfactory quality of life in the majority of patients. Longterm mortality is high in a subset of patients.     

Peroperative cholangiography in cholelithiasis. Results of a multivariate analysis]

This study was done to select patients with a low risk of common bile duct (CBD) stones in whom operative cholangiography could be avoided. Operative cholangiography was performed upon 511 patients. Two different groups of patients were identified: patients with CBD stones visualized by CBD exploration (n = 90) and patients with no CBD stones at the time of operative cholangiography (n = 42). Multivariate analysis (stepwise logistic regression) showed that five variables were correlated with the presence of CBD stones: size of CBD equal to or greater than 12 millimeters, gallstones equal to or less than 10 millimeters, advanced age, chronic or acute cholecystitis and pas history of biliary colic. Using a scoring system, a group of patients with a low risk (less than 2%) of CBD stones could be easily determined. In this group of patients, operative cholangiography may be avoided.     

On-table pancreatography: importance in planning operative strategy

We describe our experience with 124 on-table pancreatograms performed during 117 operative procedures on 112 patients in a wide variety of clinical settings. Endoscopic retrograde cholangiopancreatography (ERCP) was performed on 84 occasions with a 73 per cent success rate for visualization of the main pancreatic duct. On-table pancreatography (OTP) was performed by one of five different techniques: retrograde, prograde or ambigrade ductography, cystography and ascending loopography after pancreaticojejunostomy. OTP provided important information about the main pancreatic duct when endoscopic visualization was unsuccessful (n = 23), incomplete (n = 17) or not performed (n = 33); there was a failure rate of 4 per cent. In 35 patients either the additional information or discrepancies between ERCP and OTP findings resulted in a change of operative plan (19 extra procedures, 16 altered procedures). Complete ductography was especially helpful in the 63 patients with chronic pancreatitis. OTP is technically simple, free from complications and invaluable for planning operative strategy.     

A modern review of the operative management of chronic pancreatitis

Chronic pancreatitis is a debilitating disease resulting in pain, intestinal malabsorption, endocrine dysfunction, and poor quality of life (QoL). Our aim was to analyze surgical outcomes for patients with chronic pancreatitis. Data for patients undergoing operations for chronic pancreatitis between 1990 and 2009 were reviewed. Demographics, operative and perioperative data, and survival were catalogued. QoL was determined (Short Form 36 and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire + PAN-26) and compared with historical controls. The mean age was 51 +/- 2 years, 38 patients were male (53%), the most common indication was pain (71%), the etiology of pancreatitis often was alcohol, and most patients underwent a Whipple procedure (56%). Operative time was 316 +/- 17 minutes and blood loss was 363 +/- 75 mL. There were 34 complications in 30 patients (42%) and one death. QoL surveys were administered for 25 of 55 (45%) surviving patients at a mean follow-up of 72 +/- 16 months. Mean survival was 99 +/- 9 months, whereas 5- and 10-year survival were 86 and 75 per cent. QoL scores were uniformly better than historical controls. Our data demonstrate that operations for chronic pancreatitis can be performed with acceptable morbidity and mortality. Patients have excellent survival and improved QoL compared with historical controls. Surgery is an effective and durable treatment option for patients with chronic pancreatitis.     

Change of external and internal secretory pancreatic function in pancreatitis

In 49 patients with an acute pancreatitis and 91 - with chronic pancreatitis were studied external and internal secretory pancreatic function in remote terms after the treatment. In 48 (52.7%) patients, suffering chronic pancreatitis, the investigated indexes were studied in dynamic before and after the operation. There was established the disorders of external secretory pancreatic function in an acute pancreatitis of severe stage and noninfected pancreonecrosis in patients, to whom direct operative pancreatic interventions were not performed. Indications for conduction of internal drainage of the pancreatic ducts, taking into account data of preoperative instrumental examination and initial activity of fecal elastase-1, were substantiated. The advantages of Beger and Frey operations, in comparison with resecting procedures, were proved because of lesser occurrence of the pancreatic functions disorders.     

Wall stent-enhanced lateral pancreaticojejunostomy for small-duct pancreatitis

HYPOTHESIS: The purpose of this study was to see if a small (<7 mm) pancreatic duct could be dilated to an acceptable diameter, allowing lateral pancreaticojejunostomy to decompress the pancreatic duct and relieve pain, while preserving pancreatic endocrine and exocrine function. DESIGN: Patients with chronic pancreatitis who had a small main pancreatic duct underwent progressive trans-ampullary dilation of the duct and subsequent placement of an expandable metallic wall stent (wallstent; Boston Scientific Microvasive Division, Natick, Mass). Approximately 14 days later, a lateral pancreaticojejunostomy was done. SETTING: A 400-bed university referral center hospital in an urban setting. PATIENTS: Thirty-five patients were selected from a large group with chronic pancreatitis. Thirty-one had pancreas divisum. All patients had undergone transendoscopic sphincterotomies and stenting before being accepted into the study. All had endoscopic retrograde cholangiopancreatography-proven chronic pancreatitis, and all ducts were observed to be 7 mm or smaller. INTERVENTIONS: Patients were selected after endoscopic sphincterotomy and stenting failed. Progressive transendoscopic duct dilation with plastic stents was carried out, and a 10-mm expandable metallic wall stent was placed prior to surgical decompression. Lateral pancreaticojejunostomy was performed. MAIN OUTCOME MEASURES: Patients were observed for pain relief, postoperative symptoms, analgesic use, glucose intolerance, and quality of life. All patients were seen or contacted by telephone, and their results were recorded. RESULTS: There were no operative deaths, but 26% of patients had complications. Seventy-one percent of patients reported that their pain was better than preoperatively. Three patients had subsequent pancreatic surgery. No new cases of diabetes occurred except in the 2 patients who underwent total pancreatectomy. CONCLUSIONS: In general, most patients feel that their lives were improved by the procedure. A quarter of the patients no longer take narcotics, and many have been able to resume a relatively normal lifestyle. Although this procedure is not a panacea for all patients with chronic pancreatitis and a nondilated duct, it is a reasonable alternative to resection.     

Preoperative endoscopic retrograde cholangiopancreatography (ERCP) in patients with pancreatic pseudocyst associated with resolving acute and chronic pancreatitis.

Experience with patients with pancreatic pseudocysts has led the authors to the hypothesis that preoperative evaluation of the pancreatic and bile ducts by ERCP will define those patients who may be inadequately treated by pseudocyst drainage alone without attention to associated pancreatic and biliary ductal abnormalities. In patients with certain ductal abnormalities, the pseudocyst operation was combined with a definitive operative drainage of the pancreatic duct and/or of the biliary tree where appropriate. A prospective evaluation of routine preoperative ERCP was undertaken over a 36-month period in all patients scheduled for operative treatment of pseudocyst of the pancreas. From an initial group of 44 patients with pseudocysts, three patients who had spontaneous regression of the pseudocyst were excluded. ERCP was successful in 39 of the remaining 41 patients. Among 41 operated patients, 24 were admitted with a diagnosis of pseudocyst that arose after an episode of acute pancreatitis, and 17 had chronic pancreatitis with pseudocyst. Nine patients, initially assumed to have acute pancreatitis, were recognized to have chronic pancreatitis on the basis of ERCP findings. Communication with the main pancreatic duct (MPD) was demonstrated in 18 of 41 pseudocysts, and the rate of communication was similar in patients with acute and chronic pancreatitis. Dilatation of the MPD was seen in 23 of 41 patients and was associated with chronic pancreatitis in 21. Dilatation of the common bile duct was found in 12 patients with chronic pancreatitis. The operative plan was altered by ERCP findings in 24 of 41 patients; 22 of the 24 patients had chronic pancreatitis. There were no complications of ERCP. These data suggest that ERCP should be performed in all patients with pseudocysts to establish correct diagnosis and to allow optimal choice of operation.     

Hemosuccus pancreaticus complicating chronic pancreatitis: an obscure cause of upper gastrointestinal bleeding

Background: Hemosuccus pancreaticus, a rare form of upper gastrointestinal bleeding, may complicate chronic pancreatitis and pose a significant diagnostic and therapeutic dilemma. Aim: To present our experience with this potentially life-threatening complication of chronic pancreatitis. Methods: We reviewed our experience with management (both operative as well as angiographic embolization) of patients with hemosuccus pancreaticus complicating histologically documented chronic pancreatitis between 1976 and 1997. Diagnosis of hemosuccus pancreaticus was based on clinical presentation, preoperative endoscopic and radiographic imaging, operative findings, and pathologic evaluation. Results: During the period, we managed eight patients with hemosuccus pancreaticus (1.5% of all patients with chronic pancreatitis treated surgically). Gastrointestinal bleeding presented as hematemesis in three and hematochezia in three, but all had recent melena and were anemic; three of these patients were hemodynamically unstable. Abdominal pain was present in six. When performed, angiography (n=6) was diagnostic of a pseudoaneurysm; computed tomography (n=7) showed a pseudoaneurysm in two and a pseudocyst in five. Endoscopy (n=8) revealed blood issuing from the ampullary papilla in two patients. Operative management (n=6) involved distal pancreatectomy, pancreatoduodenectomy, or total pancreatectomy in two patients each. Angiographic embolization was successful in one patient, but the other died from uncontrollable hemorrhage. Conclusions: Hemosuccus pancreaticus is rare, but should be considered in patients with chronic pancreatitis and gastrointestinal bleeding. In the absence of pancreatitis-related indications for surgery, angiographic embolization can be definitive treatment. If there are pancreatitis-related indications for operation, angiographic embolization may allow an elective operative procedure based on structural changes of the pancreas. If embolization fails, pancreatic resection is usually required, often on an emergent basis. Received: 23 August 1999 Accepted: 27 December 1999     

Chronic pancreatitis combined with obliterative arterial disease

We performed a prospective study at the 1st Surgical Department, Semmelweis University Budapest between 1996 and 2000, in which we examined the common occurrence of chronic pancreatitis and obstructive vascular disease in patients admitted to our department because of either of these illnesses. There were 37 patients suffering from both diseases, all are included in our trial. Control groups were set up of 50 consecutive chronic pancreatitis patients and 50 consecutive vascular patients. In all patients with two disease chronic pancreatitis developed earlier than vascular disease. Occurrence of vascular disease is twice as common among patients with chronic pancreatitis as in normal population. Risk factors like smoking, coffee-abuse and alcohol, which might trigger both diseases, didn't vary in the three groups. This combination of diseases usually starts in the young, and causes severe and progressive deterioration in the quality of life. In four patients after operations performed because of chronic pancreatitis, peripheral arterial operation was also necessary. Operative mortality rate in the chronic pancreatitis group was 2%, in vascular patients 4% and in the group with both diseases it was 16%. We found in our study that there is relation between chronic pancreatitis and peripheral obstructive vascular disease. Further examinations are necessary to examine the etiology. In patients with chronic pancreatitis we must always think of the possibility of later obstructive vascular disease.     

The value of operative pancreatography

Between 1978 and 1982 operative pancreatography was undertaken in 39 patients (mean age 47 years) using 1 of 4 different techniques. Final diagnoses were chronic pancreatitis (15), isolated dorsal pancreas (10), carcinoma head of pancreas (3), acute pancreatitis (3) and miscellaneous pancreatic conditions (8). Retrograde (transduodenal) pancreatograms were successfully obtained in 10 of 12 patients, including 3 via the minor papilla. Prograde cannulation was achieved after distal pancreatectomy in 15 of 16 patients, 10 of whom had an isolated dorsal pancreas. 'Ambigrade' pancreatography was performed after direct puncture of a palpable duct in 6 patients and cystography in another 5 patients with pseudocysts. No complications of pancreatography were seen and the radiological findings modified the operative procedure in 16 patients (41 per cent).     

Efficacy of feeding tube placement during pancreaticoduodenectomy for chronic pancreatitis

Malnutrition, intestinal dysmotility, and gastroparesis are frequent problems in patients with chronic pancreatitis who undergo pancreaticoduodenectomy. This has led to the practice of operative placement of enteral feeding tubes. The purpose of this study is to examine the efficacy of feeding tubes placed during pancreaticoduodenectomy in patients with chronic pancreatitis. The records of 78 consecutive patients who underwent pancreaticoduodenectomy for chronic pancreatitis were retrospectively reviewed and analyzed. Forty-nine patients who received feeding tubes at the time of operation were compared with 29 who did not have feeding tubes placed. Both groups had similar disease progress measured by duration of symptoms and preoperative nutritional status. During the observation period, there was a trend toward not using operative feeding tubes (first 6 years 84 per cent versus last 2 years 33%). The overall complication rate after pancreaticoduodenectomy was 54 per cent. Placement of a feeding tube was associated with an increase in intra-abdominal morbidity from 34 per cent to 57 per cent (P < 0.03). None of the patients had a complication directly related to placement of the feeding tube. Eighty-eight per cent of the placed feeding tubes were used. Despite feeding tube placement, 49 per cent of patients with feeding tubes required postoperative use of total parenteral nutrition compared with 55 per cent of patients without feeding tubes (P > 0.05). Length of hospital stay and hospital readmission during the first postoperative year were not affected by feeding tube placement. In conclusion, simultaneous feeding tube placement along with pancreatic head resection for chronic pancreatitis can be performed safely. The majority of the feeding tubes are used in postoperative care, but they do not prevent the need for total parenteral nutrition and do not shorten length of hospital stay.