Management of internal and external pancreatic fistulas

A pancreatic fistula is an uncommon and challenging problem for the general surgeon. Protean in presentation, the underlying pathophysiology of a pancreatic duct disruption is consistent. Several basic principles, when followed, simplify management. These tenets include medical stabilization and nutritional optimization, definition of the underlying duct disorder, and, finally, definitive management with or without surgery. With appropriate prompt care, patients can achieve good outcomes.     

Clinical and secretory differences in pancreatic cancer and chronic pancreatitis.

The differential diagnosis between chronic pancreatitis and pancreatic cancer can be very difficult. In 60 patients with either of these conditions, who had satisfactory ERCP study, clinical features were correctly matched with the final diagnosis by discriminant analysis in 44 (73%). The sensitivity of ERCP radiographic findings in pancreatic cancer was 80% and sensitivity of cytology was 54%. To see if exocrine function was specific for cancer, fresh pancreatic secretions were aspirated in 27 patients at the time of ERCP. By isoelectric focusing, a pattern of extreme zymogen depletion was observed in chronic alcoholic pancreatitis (Group 1), pancreatic cancer (Group 2), and chronic nonalcoholic pancreatitis (Group 3). The three groups were not distinguishable. By contrast, significant changes in albumin, IgG and IgA concentrations were seen in Group 2. The albumin level was over ten-fold greater than in Groups 1 and 3 (p less than 0.02 and less than 0.05). The IgG was seven-fold and two-fold greater (p less than 0.01 and greater than 0.2) and the IgA was 15-fold and six-fold greater (p less than 0.002 and less than 0.05) than in Groups 1 and 3, respectively. The two groups of pancreatitis had similar concentrations of albumin and IgA. The ratio of albumin to IgG was also different in Group 2 from the other groups, suggesting different mechanisms for the appearance of proteins in pancreatic secretions. Nonzymogen protein levels can distinguish chronic pancreatitis from pancreatic cancer, and further study of them may identify useful tumor-specific markers.     

Combined internal and external drainage of pancreatic cysts

The results of combination of the internal and external drainage of pancreatic cysts in 9 patients are presented. Four variants of the external drainage of cysts after cysto-gastrocystojejunostomy are described. A prolonged washing of the cyst in early postoperative period results in the rapid diminishing of the cyst and in prevention of complications and recurrence of the disease.     

Endoscopic measurement of pancreatic juice secretory flow rates and pancreatic secretory pressures after secretin administration in human controls and in patients with acute relapsing pancreatitis,chronic pancreatitis,and pancreatic cancer

Secretory flow rates were measured inside the main pancreatic duct during endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute relapsing pancreatitis, chronic pancreatitis, and pancreatic cancer and in controls after intravenous administration of secretin. Peak secretory flow rates in these groups were 5.04 ± 1.74, 0.71 ± 1.28, 0.60 ± 1.37, and 4.13 ± 0.88 ml/min, respectively. Peak secretory pressures were also measured intraductally in patients with acute relapsing pancreatitis and pancreatic cancer and in controls and were 402 ± 69, 75 ± 161, and 403 ± 99 mm pancreatic juice, respectively. Peak secretory flow rates and pressures measured in controls during constant administration of secretin were similar to those measured when secretin was administered as a bolus.     

Changes in serum pancreatic enzymes and pancreatic secretory trypsin inhibitor in patients with severe acute pancreatitis

Serum pancreatic enzymes (amylase, trypsin, pancreatic elastase 1, pancreatic phospholipase A2) and serum pancreatic secretory trypsin inhibitor (PSTI) were measured in 22 patients with moderate or severe acute pancreatitis. Serum levels of all pancreatic enzymes were elevated at the initial determination, but they fell rapidly to normal in both moderate and severe pancreatitis. In contrast, PSTI in severe pancreatitis increased after admission and reached the maximum on the second to the forth day after onset. There was a significant positive correlation between the level of PSTI and that of acute phase reactant (fibrinogen, alpha 1-antitrypsin), and serum PSTI in severe acute pancreatitis changed as if it was one of acute phase reactants. There was also a significant negative correlation between the level of serum PSTI and that of alpha 2-macroglobulin.     

Value of exhaled air acetone level in assessing the impairement of secretory pancreatic function in acute destructive pancreatitis]

For the first time, a semiconductor gas sensor of original construction was employed to measure acetone level in the biologic liquids and gases in patients with acute destructive pancreatitis. A statistically significant difference in acetone level in the exhaled air of the healthy subjects, patients with edematous and destructive forms of acute pancreatitis and diabetes mellitus has been established.     

Relationship between pancreatic function and pain in chronic pancreatitis

The association between pain and exocrine pancreatic function was re-evaluated in 56 patients with chronic pancreatitis to see if residual function of the gland may evoke outflow obstruction resulting in pain. No significant differences were found in the degrees of pancreatic dysfunction among three groups with different degrees of pain (no pain, n = 7; moderate pain, n = 21; and severe pain, n = 28), but patients with more impairment of exocrine pancretic function tended to have less pain. In patients with no pain the mean (SD) peak serum concentration of fluorescein was 2.0 (0.2) micrograms/l, in those with moderate pain it was 2.6 (0.1), and in those with severe pain it was 3.4 (0.1). No significant differences were found between the degree of pain and the duration of the disease, which was 5.5 (0.3) years in the group with no pain, 3.5 (0.2) in patients with moderate pain, and 3.8 (0.1) in those with severe pain. We conclude that outflow obstruction may affect some patients, but is not the only cause of pain. Patients with severe pancreatic dysfunction and steatorrhoea often present with pain, so either obstruction of the residual secretions, or inflammatory activity impinging on nerve endings in fibrotic tissue, may also cause pain. The causes vary, and there is often more than one, so optimal management implies thorough investigation of each patient and long term follow up.     

Change in pancreatic exocrine function in acute appendicitis

In order to study changes in the functional state of the pancreas 1572 investigations of the blood and urine amylase, atoxylresistant lipase of the blood serum before operation were performed in different postoperative periods in 131 patients with acute appendicitis. The enzyme activity was established to increase, especially in destructive forms of appendicitis and in elderly patients.     

急性坏死性胰腺炎胰腺泡细胞功能变化的实验研究

目的　探讨急性坏死性胰腺炎 (acutenecrotizingpancreatitis,ANP)胰腺腺泡细胞氨基酸摄取、酶蛋白合成及细胞的分泌功能情况。方法　采用 5 %牛磺胆酸钠胰管逆行注射制备ANP动物模型。SD雄性大鼠 70只 ,随机分为模型组和对照组。采用L 3 H 苯丙氨酸作为同位素示踪剂和放射自显影技术观察胰腺腺泡细胞氨基酸摄取、酶蛋白合成和细胞外分泌功能。结果　呈点状出血坏死病理学改变的模型组ANP胰腺腺泡细胞氨基酸摄取放射性含量为 (186± 17)dpm/mg ,对照组为 (145±12 )dpm/mg(P >0 0 5 ) ;对照组酶蛋白合成的放射性含量在 30、6 0、90min时分别为 (2 2 81± 16 6 2 )dpm/mg、(30 17± 978)dpm/mg和 (2 5 44± 110 8)dpm/mg,而模型组分别为 (2 2 73± 6 2 7)dpm/mg、(2 840± 82 8)dpm/mg和 (2 6 2 8± 6 0 4)dpm/mg(P >0 0 5 ) ;放射自显影图像提示模型组腺泡细胞间质中可见大量酶原颗粒积聚 ,而对照组细胞间质中未观察到酶原颗粒。结论　ANP呈点状出血坏死时胰腺腺泡细胞氨基酸摄取及酶蛋白合成功能无下降 ,但腺泡细胞分泌途径发生了改变 ,出现了底膜及侧膜的异位分泌。     

犬急性水肿型胰腺炎胰液外引流模型的制备及胰腺外分泌功能的观察

目的建立犬急性水肿型胰腺炎胰液外引流模型,观察胰腺外分泌的功能。方法健康杂种犬12只,分为对照组和胰腺炎组,每组6只。制备犬胰液外引流模型后24h,5%牛磺胆酸钠(0.5mL/kg)1mL/min胰管逆行注射制备急性水肿型胰腺炎模型。每12h收集胰液一次,测定胰液的分泌量,胰液中淀粉酶、脂肪酶、总蛋白、pH值和主要电解质含量。制模后在不同时段采血,检测血中的淀粉酶、脂肪酶的浓度。取胰腺组织行病理学检查。结果成功建立犬急性水肿型胰腺炎胰液外引流模型。胰腺炎组胰液分泌量,胰液中淀粉酶、脂肪酶、总蛋白、HCO3-含量和pH值低于对照组(P0.05),Cl-高于对照组(P0.05)。胰液中的Na~+、K~+、Ca~(2+)、Mg~(2+)胰腺炎组与对照组差异无统计学意义(P0.05)。结论本模型适用于急性水肿型胰腺炎胰腺外分泌功能的研究。     

腹腔镜序贯外内引流术治疗胰腺假性囊肿的疗效观察

目的:探讨腹腔镜序贯外内引流术治疗胰腺假性囊肿的临床价值。方法:回顾分析2008年7月至2018年6月收治的56例胰腺假性囊肿患者的临床资料,分为腹腔镜序贯外内引流组(观察组)与经皮穿刺组(对照组),观察两组手术时间、出血量、住院时间、术后带管时间、并发症发生率、短期影像学缓解率、长期影像学缓解率及复发率等情况,评价两种术式的疗效。结果:两组均顺利完成操作,无围手术期死亡,观察组4例同时行腹腔镜胆囊切除术。观察组术后带管时间[(32.69±2.46)d vs.(34.56±2.60)d]、术中出血量[(23.33±5.92)mL vs.(28.69±4.24)mL]、并发症发生率(3.0%vs.26.1%)、长期影像学缓解率(100.0%vs.73.9%)及复发率(0 vs.17.4%)优于对照组,差异有统计学意义。两组短期影像学缓解率(100%vs.91.3%)、住院时间[(8.45±1.06)d vs.(9.95±4.18)d]差异无统计学意义。结论:腹腔镜序贯外内引流术安全、可靠,效果肯定,可作为治疗胰腺假性囊肿的合理术式。     

慢性胰腺炎胰,胆管梗阻的处理：附6例报告

在３７例慢性胰腺炎病人中，８例合并胆道梗阻（２２％），４例合并主胰管梗阻（１１％）；６列同时或异时合并胰、胆管梗阻（１９％）。其中１例在发现胰管扩张１年后，出现胆管梗阻；２例同时发现胰、胆管梗阻。３例因黄疸在外院先行胆道手术，术后腹痛持续，影像检查证实尚伴有胰管梗阻，而再次行胰管减压手术。未合并胆石和（或）胆管炎的单纯胆道梗阻一般不引起严重的腹痛。对腹痛症状较重，而又无胆管结石的慢性胰腺炎病人应特别警惕是否同时合并胰管梗阻。     

重症急性胰腺炎iNOSmRNA对大鼠内分泌功能影响

目的探讨重症急性胰腺炎大鼠胰腺内分泌功能变化，研究iNOSmRNA在胰腺内分泌功能损伤中的作用。方法制作大鼠重症急性胰腺炎动物模型，对胰腺病理损伤评分；检测血清脂肪酶，血糖水平；分离胰岛，进行葡萄糖刺激胰岛素分泌试验；应用逆转录聚合酶链反应技术，检测胰岛iNOSmRNA的表达情况。结果重症急性胰腺炎大鼠病理学评分、血糖、血清脂肪酶升高，葡萄糖刺激胰岛素分泌量较对照组明显减少，差异有显著性；逆转录聚合酶链反应提示重症急性胰腺炎组胰岛的iNOSmRNA表达增强，差异有显著性。结论重症急性胰腺炎对胰腺内分泌有较大影响，重症急性胰腺炎iNOSmRNA对胰腺内分泌功能可能发挥作用。     

带连接线的鼻胆胰内外引流管在困难性胆管插管中的应用价值

目的 探讨带连接线的鼻胆胰内外引流管在困难性胆管插管中的应用价值。方法 回顾性分析同济大学附属东方医院胆石病中心2019年1月至12月实施困难性胆管插管术的患者临床资料,分为观察组（带连接线的鼻胆胰内外引流管）与对照组（鼻胆管+单猪尾胰管支架）,每组47例,比较两组术中胆管插管及引流管置入时间,术后急性胰腺炎及高淀粉酶血症发生率,胰管支架早期脱落及晚期未脱落率。结果 观察组与对照组在胆管插管时间[（13.89±2.43）min vs（14.28±2.53）min,t=0.747,P=0.457]、术后急性胰腺炎[0 vs 4.3%（2/47）,χ2 =2.816,P=0.495]和高淀粉酶血症发生率[10.6%（5/47）vs 12.8%（6/47）,χ2 =0.103,P=0.748]方面差异无统计学意义。观察组引流管置入时间明显较对照组长[（4.30±0.83）min vs（2.15±0.66）min,t=13.885,P＜0.001],胰管支架早期脱落率[0 vs 12.8%（6/47）,χ2 =8.727,P=0.026]及晚期未脱落率[0 vs 12.2%（5/41）,χ2 =7.984,P=0.019]均低于对照组。结论 困难性胆管插管术中使用带连接线的鼻胆胰内外引流管其置入难度较大,但是具有移位率低、易取出的优点。     

Experience on the pancreatic function after an episode of acute biliary oedematous pancreatitis

The authors have examinated 35 patients 4 - 5 years after a previous episode of acute oedematous biliary pancreatitis. 20 patients had been cholecystectomized while 15 had not been operated. The patients of the first group didn't show any impairment of the endocrine or exocrine pancreatic function while the patients who were not cholecystectomized in 4 cases on 15 showed an impairment of the exocrine pancreatic function valued with the elastase-1 test in the stools. In 2 patients there was also a slight impairment of the glucose metabolism. The authors suppose that the persistance of a biliary disease can affect the pancreatic function.