Segmental occlusion of the pancreatic duct with prolamine to prevent fistula formation after distal pancreatectomy.

OBJECTIVE: The authors used prolamine (Ethibloc, Ethicon GmBH, Norderstedt, Germany) for segmental obstruction of the pancreatic duct to prevent pancreatic fistula development after distal pancreatectomy combined with total gastrectomy for gastric malignancies. SUMMARY BACKGROUND DATA: Although the initial clinical application of prolamine was pancreatic duct obstruction for patients with pancreatitis and undergoing pancreatic transplantation and pancreaticoduodenectomy for pancreatic cancer, there are no reports on prevention of pancreatic fistula formation after distal pancreatectomy. METHODS: Prolamine (0.2 mL) was injected into the distal segment of the main duct in the remaining pancreata of 51 patients. Small pancreatic ducts on the cut surface, from which prolamine extravasates, were closed by ligation, the main duct was ligated doubly, and the transected pancreatic margin was closed 15 minutes after phenylpropanolamine hydrochloride injection. RESULTS: No patient developed a pancreatic fistula or the complication of arterial bleeding due to prolonged infection. CONCLUSION: Segmental obstruction of the pancreatic duct with prolamine is useful for preventing pancreatic fistula development after distal pancreatectomy.     

Experimental pancreatic duct occlusion with polyurethane

Pancreatic transplantation requires an effective method to manage exocrine secretion. A new technique to eliminate the exocrine function of the pancreas by obstruction of the duct with polyurethane was investigated in terms of function, outcome and morphology. Polyurethane is an alcoholic solution of block copolymers with the property of polymerizing within 5-10 min. In this study the in-situ pancreatic tail model in dogs was utilized, the pancreatic duct was cannulated and injected with 2-3 ml of polyurethane. As a result, complete atrophy and fibrosclerosis of the exocrine tissue was obtained leaving islets well vascularized and functioning for the entire experimental periods. All animals remained normoglycemic and showed normal K-values. Amylase levels were found to be maximally elevated at 24 h and returned to normal within 2 weeks after duct occlusion. Insulin, glucagon and somatostatin levels remained normal. Because of its ability to effect a complete occlusion of the pancreatic ducts with subsequent atrophy of the exocrine gland and without notable disturbance of endocrine function, we feel that polyurethane solution is superior to previously used materials for this purpose.     

Retrograde pancreatic duct imaging and surgical tactics in hemorrhagic necrotizing pancreatitis. Preliminary report

In patients with haemorrhagic necrotizing pancreatitis who are scheduled for surgery we have been carrying out a preoperative retrograde investigation of the pancreatic duct system for the past months. The results in, to date, ten patients revealed four different morphological findings of importance for the surgical tactic: 1. A normal pancreatic duct system with no signs of fistulae: only peripancreatic necrosectomy is required. - 2. Contrast medium leaks via a ductal fistula: left resection including the removal of the fistulous area must be done. - 3. Normal duct system with complete segmental parenchymal staining, representing total necrosis in this region: left resection of the pancreas. - 4. Duodenoscopically demonstrable perforation into the duodenum of a necrotic cavity in the head of the pancreas: conservative management only, no surgery, since this lesion resulting in drainage of the necrotic cavity into the bowel permits self-healing, while the site of the perforation within the necrotic wall cannot be dealt with by surgery. - The experience gained so far indicates that the surgical tactic can be determined with greater selectivity by the use of ERP.     

The clinical and histopathological effects of pancreatic duct occlusion in experimental acute pancreatitis in dogs

A continuous production of significant pancreatic enzymes, which are thought to be responsible for the maintenance of the digesting process, is frequently found in fulminant necrotizing pancreatitis. Since the medical therapies known to be effective are based upon the rationale of slowing pancreatic secretion, a simple measure which permits the "burning out" of residual pancreatic tissue might therefore have a therapeutic value. In this study, 2 hr after the induction of acute hemorrhagic pancreatitis, 5 dogs (Group I) were treated with 1.5 ml Ethibloc injected into the pancreatic duct; 5 other animals (Group II) were given 1.5 ml saline; Group III (5 dogs) had no treatment. All animals in Group II and 4 of the 5 animals in Group III expired within 8 days postoperatively. In contrast, 4 of 5 animals from Group I survived. Although some of the biochemical parameters showed significant changes after the induction of acute pancreatitis, no differences were seen between the three groups. In the expired animals, the picture of histological examination was that of a fulminant acute hemorrhagic pancreatitis of the left lobe. In the survival dogs although normal pancreatic tissue was present in the right lobe at necropsy at intervals, there was always a pancreatic atrophy of the left lobe and striking adhesions with the surrounding tissues suggesting the severity of the disease in the acute phase. These findings suggest that pancreatic duct occlusion causing the exocrine secretion to stop may have beneficial effects in the treatment of acute fulminant pancreatitis in the acute phase and may improve the survival rate.     

Delayed occlusion of the pancreatic duct

Seventy six delayed occlusions of the main pancreatic duct were fulfilled during the period from 1978 to 1985. No severe complications or lethal outcomes due to performing a delayed occlusion of the duct were noted.     

Severe chronic cephalic pancreatitis: Use of partial duodenopancreatectomy with occlusion of the pancreatic duct in 289 patients

Partial duodenopancreatectomy and occlusion of the remaining ductal system by Ethibloc^® to induce rapid exocrine atrophy for treatment of severe chronic cephalic pancreatitis was introduced in our department in January of 1978. Since then, this surgical procedure has been performed in a total of 289 patients. Postoperative morbidity was 12.2%, 5 pancreatic and 3 biliary fistulas occurred. Postoperative mortality was 1% and relapses of pancreatitis occurred in only 2.2% due to incomplete filling of ducts with Ethibloc^®. A total of 88.2% of patients became pain-free and symptomless, 10.8% voiced minor complaints, and 85.9% gained an averaged of 7.8 kg weight postoperatively.We conclude that Ethibloc^® occlusion is highly effective in inducing complete exocrine atrophy, thus abolishing the inflammatory process and preventing relapses of chronic pancreatitis and preserving the endocrine function from further impairment. This was demonstrated by biochemical assays during a 36-month follow-up in a prospective study in 23 of 289 patients.Our results compare favorably with and are superior to results from any other operative procedure for chronic cephalic pancreatitis. We consider partial duodenopancreatectomy combined with Ethibloc^® occlusion of the pancreatic duct the procedure of choice in the surgical treatment of severe chronic cephalic pancreatitis.

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Resumen La duodenopancreatectomía con oclusión del sistema ductal remanente con Ethibloc^® (para inducir la rápida atrofia del tejido exocrino) como modalidad de tratamiento de la pancreatitis crónica cefálica, fue introducida en nuestro departamento en enero de 1978. A partir de esa época este procedimiento ha sido realizado en un total de 289 pacientes. La tasa de mortalidad postoperatoria fue de 12.2%; se presentaron 5 fístulas pancreáticas y 3 biliares. La tasa de mortalidad postoperatoria fue de 1% y la de recurrencia de la pancreatitis de sólo 2.2%, debida a llenamiento incompleto de los canales con Ethibloc^®. El 88.2% de los pacientes quedó libre de dolor y de sintomatología, y 10.8% manifestó quejas menores. El 85.9% ganó peso, 7.8 kg en promedio, en la fase postoperatoria.Hemos concluído que la oclusión con Ethibloc^® es altamente efectiva para inducir atrofia exocrina completa, con lo cual queda abolido el proceso inflamatorio y se logra la prevención de relapsos de la pancreatitis crónica y la conservación del tejido endocrino. Esto fue demostrado mediante determinaciones bioquímicas realizadas en un estudio prospectivo sobre 23 de 289 pacientes, en el curso de un período de seguimiento de 36 meses.Nuestros resultados se comparan favorablemente, y realmente son superiores, a los de cualquier otro procedimiento operatorio utilizado en el tratamiento de la pancreatitis crónica cefálica. Nosotros consideramos la duodenopancreatectomía parcial combinada con oclusión de los canales pancreaticos con Ethibloc^®, el procedimiento de escogencia en el tratamiento de la pancreatitis crónica cefálica severa.

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Résumé La duodénopancréatectomie céphalique complétée par 1'occlusion du canal de Wirsung avec la colle Ethibloc^® pour induire une atrophie exocrine rapide du parenchyme restant dans la pancréatite chronique a été introduite dans notre département dès janvier, 1978. Depuis nous avons réalisé cette intervention chez 289 patients. La morbidité postopératoire était de 12.2% (5 fistules pancréatiques et 3 fistules biliaires). La mortalité postopératoire était de 1%; la récidive de pancréatite chronique a été observée dans 2.2% des cas, attribuée à un remplissage incomplet des canaux. La douleur a disparu chez 88.2% des patients; 10.8% continuaient à se plaindre faiblement. Une reprise de poids de 7.8 kgs en moyenne a été observée chez 85.9% des patients après 1'intervention.Nous concluons que 1'occlusion par 1'Ethibloc^® est très efficace pour provoquer 1'atrophie exocrine du parenchyme pancréatique, mettant fin au processus inflammatoire du pancréas et prévenant des récidives de pancréatite chronique, tout en évitant une aggravation de la fonction endocrine. Ceci a été démontré par des tests biologiques faits pendant 36 mois dans une étude prospective chez 23 des 289 patients.Nos résultats sont similaires ou meilleurs qu'avec tout autre procédé chirurgical pour la pancréatite chronique de la tête du pancréas. Nous considérons que la duodénopancréatectomie céphalique avec occlusion du canal de Wirsung est un procédé de choix dans le traitement chirurgical de la pancréatite chronique céphalique.

     

Redrainage of the pancreatic duct in chronic pancreatitis

Recurrent pain after a drainage procedure for chronic pancreatitis is considered an indication for pancreatectomy. To evaluate whether redrainage might be a better alternative, 14 patients who underwent redrainage after a failed pancreaticojejunostomy were reviewed. Patients with previous pseudocyst drainage were excluded. Initial operations included five caudal, three longitudinal, and six side-to-side pancreaticojejunostomies. Nine patients treated since 1974 had ERCP, which showed obstructed segments of pancreatic duct in the head of the gland. Two caudal pancreaticojejunostomies and one longitudinal pancreaticojejunostomy were revised to longitudinal pancreaticojejunostomies. The other 11 were revised to side-to-side pancreaticojejunostomies. Operative findings confirmed undrained segments of the pancreatic duct in the pancreatic head. Postoperatively, one patient died from hemorrhage and four patients had complications. At most recent follow-up from 6 months to 20 years postoperatively, three patients were pain free and six had substantial relief from pain (71 percent). Of eight patients who were not diabetic before redrainage, diabetes developed in only two. Only one of seven patients without pancreatic exocrine insufficiency required pancreatic enzymes after redrainage. Patients with recurrent pain after pancreaticojejunostomy should undergo ERCP. If segments of the pancreatic duct are obstructed, redrainage can provide satisfactory pain relief with a minimal loss of endocrine and exocrine function. This problem is best avoided by initial complete drainage of the major and minor pancreatic ducts.     

Management of pancreatic pseudocysts in chronic alcoholic pancreatitis with duct dilatation

Twenty-one patients with pancreatic pseudocysts secondary to alcoholic pancreatitis were treated by cystojejunostomy (16), cystoduodenostomy (4) and external drainage (1). In all patients, the duct of Wirsung was drained into a defunctionalized loop of the jejunum at the same operation. There was no early or late mortality. Pseudocyst recurrence did not occur, and only one patient (4.7%) had light pain recurrence in the follow-up period. The importance of providing an outflow route for the obstructed pancreatic duct, and not just for the pseudocyst, is stressed due to this experience with patients affected by underlying chronic pancreatitis.     

早期胰管支架置入治疗急性坏死性胰腺炎的疗效：附57例报告

背景与目的 急性坏死性胰腺炎（ANP）的病情复杂多变，病理进展迥异，继发感染时病死率可达20%~30%。目前对于ANP的治疗主要是早期给予禁食、补液、镇痛、抑酸、抑酶等对症治疗，后期形成并发症时，进行外科干预的升阶梯治疗。而ANP后期局部并发症发生率和病死率较高，预后较差。相关研究表明，胰管高压和胰管梗阻在急性胰腺炎（AP）的发病过程中起着重要作用，AP合并胰液渗漏的概率可高达90%以上。因此，本研究探讨早期胰管支架置入治疗ANP的有效性和安全性。方法 回顾性收集宁夏医科大学总医院2019年6月1日—2021年12月30日期间入院后48 h之内行胰管支架置入术治疗的ANP患者临床资料。结果 按照纳入标准和排除标准，共纳入57例患者，其中中度重症34例，重症23例。所有患者入院到手术等待时间为8（3~21）h，均成功完成胰管支架置入。18例患者在手术中可见胰管蛋白栓，其中中度重症8例（23.53%）、重症10例（43.48%）。患者手术后腹痛、腹胀等症状均有不同程度的缓解；患者入院48 h后，白细胞、血淀粉酶、血脂肪酶、血糖水平及APACHE Ⅱ评分均较入院时明显降低（均P<0.05）。患者首次经口进食时间和住院时间的中位数分别为72（48~144）h和9（6~16.5）d。进一步分析显示，中度重症转入ICU患者数量、首次经口进食时间、住院时间、住院费用和CT严重程度指数方面均明显优于重症患者（均P<0.05）。大部分患者入院时有严重的胰周渗出，胰管支架置入后，胰周渗出都有不同程度的吸收。无严重手术相关不良事件发生，后期形成感染性坏死8例、包裹性坏死7例，其中5例通过胰管支架引流后治愈，其余10例行经皮穿刺置管引流，未进行开腹清创等其他外科干预。结论 早期胰管支架置入治疗ANP可以快速缓解患者的症状，降低局部并发症的发生率，减少后期反复的外科干预，是临床有效的治疗方法和策略。     

慢性胰腺炎合并胰管结石的的外科治疗(附7例报告)

慢性胰腺炎所致的胰管阻塞、胰管结石、顽固性疼痛、胰腺的内、外分泌功能障碍,常伴有胰管的全程扩张,特别是当阻塞位于胰腺头部时：有时胰管亦可以呈多数性的狭窄,临床表现多为持续性腹痛,可伴有胰腺内外分泌功能不全,病理改变为局部性或弥漫性硬化性改变和内、外分泌腺永久性的破坏。此类病人晚期常需手术治疗,手术方式以Puestow胰管-空肠吻合术为主要措施。作者1997～2002年共治疗7例,获得满意效果,报告如下。     

牛磺胆酸钠混合大肠杆菌逆行胰管注射法建立感染性坏死性胰腺炎大鼠模型

目的建立一个稳定可靠的感染性坏死性胰腺炎大鼠模型,为深入研究感染性坏死性胰腺炎的病理生理、病变转归以及探索新的治疗方法提供动物模型载体.方法46只SD大鼠随机分成5组：牛磺胆酸钠逆行胰管注射组、大肠杆菌逆行胰管注射组,牛磺胆酸钠混合不同浓度大肠杆菌（浓度分别为103个/ml、104个/ml和105个/ml,混合液为实验即时配制）逆行胰管注射组,注射量为0.1 ml/100 g体重,注射速度为0.2 ml/min.观察8 h,记录生存率;存活者8 h后活杀,抽血测定血清淀粉酶,并取胰腺组织行病理学检查和细菌培养.结果单纯牛磺胆酸钠逆行胰管注射能建立坏死性胰腺炎模型,其中胰腺组织细菌培养阳性率为12.5%（1/8）;单纯大肠杆菌逆行胰管注射不仅不能建立坏死性胰腺炎模型,而且胰腺组织细菌培养阳性率为0（0/8）;牛磺胆酸钠混合大肠杆菌逆行胰管注射能够建立感染性坏死性胰腺炎模型,大肠杆菌浓度为103个/ml组、104个/ml组、105个/ml组胰腺组织细菌培养率分别为60%、100%、100%,而8 h存活率分别为100%、100%、70%.结论（1）大肠杆菌浓度为104个/ml和牛磺胆酸钠浓度为5%的混合液,按0.1 ml/100 g体重的量经胰管逆行注射（注射速度为0.2 ml/min）可建立稳定可靠的感染性坏死性胰腺炎大鼠模型.（2）该方法导致感染性坏死性胰腺炎发生的可能机制为：牛磺胆酸钠导致胰腺组织发生出血、坏死,并引起胰腺组织抵抗细菌定植能力下降;同时,坏死的胰腺组织给细菌提供了良好的生长环境;此外,胰腺组织发生细菌感染与入侵的细菌量有正相关关系.     

慢性胰腺炎合并胰管结石的诊断和治疗

慢性胰腺炎是由于多种原因（酗酒、胆道系统疾病等）造成的胰腺组织结构和功能持续性损害,常合并胰管结石。疼痛是其最主要症状,同时常伴有消化不良、脂肪泻、糖尿病等并发症。结合多种影像学检查方法如B超、CT、ERCP和磁共振胰胆管造影（MRCP）等能明显提高慢性胰腺炎合并胰管结石的确诊率。慢性胰腺炎合并胰管结石应予以积极治疗,以控制症状、改善胰腺功能和治疗并发症为重点,强调以个体化治疗为原则的综合治疗。在体外震波碎石及内镜取石不彻底而症状不能控制或结石复发者应尽早手术治疗,根据结石分布范围选择相应的治疗方式,彻底去除病灶,取净结石,解除胰、胆管梗阻,充分引流胰液,同时注意尽量保存胰腺组织功能,可明显改善病人生存质量。     

内镜胰胆管引流治疗急性坏死性胰腺炎

目的探讨内镜胰胆管引流治疗急性胰腺炎的临床效果.方法将41例急性坏死性胰腺炎随机分为对照组(20例)和内镜胰胆管引流组(21例).结果21例内镜胰胆管引流均获成功.内镜胰胆管引流组与对照组平均住院时间为(28±12) d对(37±19)