Surgical significance of vascular changes in chronic pancreatitis

To establish a rational approach to the diagnosis and management of pancreatitis complicated by vascular abnormalities, the records of 50 patients who underwent angiography because of pancreatitis were reviewed. The findings included splenic vein thrombosis in 11 patients, splanchnic arterial anomaly or occlusion in ten patients and arterial pseudoaneurysm in six patients. Disease duration and presence of associated splenic vein thrombosis were the only two significant predictors of pseudoaneurysm. The presence of a pseudocyst was not predictive. Gastroesophageal varices, splenomegaly, associated arterial pseudoaneurysm and chronic pancreatic disease were significant predictors of splenic vein thrombosis. Dynamic bolus computed tomography was 100 per cent sensitive in detecting arterial pseudoaneurysm and 71 per cent in detecting splenic vein thrombosis. Eight patients with splenic vein thrombosis underwent splenectomy and the remaining three patients have been observed without splenectomy. Variceal bleeding has not occurred in either group. Five of the six patients with arterial pseudoaneurysm underwent aneurysmectomy without operative mortality. We conclude that arterial and venous complications of pancreatitis are associated with long duration of disease, gastrointestinal tract bleeding, varices and splenomegaly. Dynamic bolus computed tomography will detect vascular complications in these high risk patients. In patients with chronic pancreatitis in whom an operation is indicated, preoperative knowledge of vascular abnormalities may change the planned operative approach.     

Isolated gastric varices due to focal splenic vein stenosis.

Left-sided portal hypertension due to splenic vein stenosis is a very rare disease. We report a case of this condition in a 21-year-old woman who suffered from a first episode of tarry stool passage with fresh blood vomiting. Panendoscopy showed isolated gastric varices while sonography showed a normal liver but the presence of splenomegaly with prominent collateral circulations. Further imaging studies, including abdominal computed tomography, splenoportography and percutaneous transhepatic portography, revealed a focal stenotic proximal splenic vein resulting in left-sided portal hypertension. The collateral circulation ran from the short gastric veins via the left gastric veins into the main portal vein. The intraportal venous pressure was within normal limits. Splenectomy was performed and near normal wedge liver biopsy pathology confirmed non-cirrhotic extrahepatic portal hypertension. The patient had no further variceal bleeding after surgery.     

Combined hepatic and pancreaticoduodenal procurement for transplantation

We have used a procurement method whereby both the liver and whole pancreas grafts are procured from the same donor and successfully transplanted. During the combined procurement, the hepatic artery is completely mobilized; the splenic artery is transected from the hepatic artery and the gastroduodenal artery is ligated from the hepatic artery. The portal vein is mobilized 2 centimeters from the head of the pancreas. The whole pancreas graft includes the splenic artery and the superior mesenteric artery, which are reconstructed. The hepatic graft includes the entire length of the hepatic artery with the celiac axis, and no further reconstruction is required. Using this technique, we have performed nine combined hepatic and whole pancreas procurements; only one liver was not transplanted because of technical complications. When a replaced right hepatic artery is identified from the superior mesenteric artery, we have abandoned the pancreatic retrieval. All combined retrievals have included successful renal retrieval, and the majority have been associated with cardiac retrieval also. Combined hepatic and whole pancreas procurement is feasible with minimal technical complications with the liver or the pancreatic graft and should be standard in most procurements.     

Technical considerations in distal pancreatectomy with splenic preservation

Splenic preservation may be attempted when distal pancreatectomy is performed for nonmalignant disease. The splenic artery and vein can be preserved with meticulous control of the multiple small, thin-walled branches that tether these vessels to the pancreas, allowing splenic salvage. Mobilization of the spleen into the operative field, ligation of the short gastric vessels and splenectomy are not performed. Thus, the operative procedure may be accomplished in carefully selected patients with little increase in operative time or blood loss over conventional distal pancreatectomy with splenectomy.     

Manifestations of carcinoma of the uncinate process by means of superior mesenteric arteriography

Identification of carcinoma arising in the uncinate region of the pancreas is difficult because of the peculiar topographic relationship of this lesion with adjacent structures. Among the various diagnostic procedures performed upon ten patients with this malignant lesion, superior mesenteric arteriography provided the most helpful information, including signs of invasion in the main trunk of the superior mesenteric artery and vein and in the proximal portion of the jejunal arteries. A clearer visualization of these vascular involvements was attained in the right posterior oblique projection rather than in the anteroposterior projection. On the contrary, the arterial and portal vessels belonging to the celiac territory, such as superior pancreaticoduodenal arteries, dorsal pancreatic artery, gastroduodenal artery, splenic vein and portal vein, were almost free of involvement. At laparotomy, almost all of the patients had direct extension of the tumor to the superior mesenteric vessels, forming a cancerous core in the root of mesentery. All died of cachexia within six months after a palliative surgical procedure. Serial roentgenograms of superior mesenteric artery, especially taken in the oblique projection, are the best means of confirming carcinoma of the uncinate process, for which only a few available methods have been established to evaluate the clinical aspects.     

The jugular vein as an interposition graft in the distal splenorenal shunt

The selective distal splenorenal shunt is the preferred portal decompression procedure for patients with refractory bleeding esophageal varices. An autogenous jugular vein interposition graft in the distal splenorenal position obviates the tedious struggle associated with mobilizing the splenic vein from the pancreatic substance, thereby lessening blood loss, avoiding postoperative pancreatitis and shortening operative time. An autogenous jugular vein interposition distal splenorenal shunt can, therefore, be performed with less morbidity while affording the same physiologic benefits as the standard distal splenorenal shunt.     

Deleterious effects of testicular venous occlusion in young rats

To determine the differences between testicular arterial and venous obstruction, the spermatic artery or vein, or both, were occluded for varying periods of time in young rats. Two months later, at the conclusion of the study, the testes were examined. Histologic degeneration after vascular obstruction was graded by a modified Johnsen's tubular biopsy score (TBS). The testicular concentrations of enzymes (lactic dehydrogenase and sorbitol dehydrogenase), known to decrease with testicular injury, were measured. TBS and seminiferous tubule diameter (STD) were found to decrease significantly after two hours of vascular occlusion and were similar regardless of whether the obstruction was produced by occlusion of arterial inflow or venous drainage, or both. Testicular concentration of enzymes decreased significantly after permanent ligation of the spermatic artery and vein, but decreased minimally when the vascular obstruction lasted less than 120 minutes. Testicular injury produced by venous occlusion was equally severe and occurred as rapidly as injury produced by arterial or combined arteriovenous occlusion. No significant injury was noted in the contralateral testes in any group.     

Experimental diminution fo splenci function by selective embolization of the splenic artery.

The splenic artery was occluded by the selective injection of Amicar-mixed clot or Gelfoam in 18 dogs. The dogs were sacrificed at 24 hours, two weeks and two months. Angiography was done before and after embolization, three hours after embolization and prior to sacrifice. White blood counts and hematocrit values were evaluated weekly in the dogs sacrificed at two months. The results of this study reveal differences in the effects of the two embolic materials. Because Amicar-mixed clot was partially lysed in the first several hours and also pushed peripherally, the depression of hematologic function seen with its use was transient and most spleens returned to a relatively normal gross and histologic appearance. With Gelfoam, although the embolic material was also pushed peripherally into the branches of the splenic artery in several of the dogs, the depression of hematologic function was prolonged, and moderate splenic parenchymal fibrosis was seen. The areas between the bands of fibrosis appeared normal. The results indicate that selective embolic occlusion of the splenic artery and its branches may offer a method of depressing splenic function in patients who are not candidates for splenectomy.     

A simple technique for resection of the uncinate process during pancreatectomy

Difficulty in resection of the uncinate process of the pancreas often results in significant hemorrhage. Partial vascular occlusion of the superior mesenteric vein with resection of the lateral wall allows complete removal of all pancreatic tissue with minimal blood loss.     

Resectional surgical procedures for carcinoma of the head of the pancreas

Of a total series of 103 patients with preoperatively diagnosed carcinoma of the head of the pancreas (including ampullary carcinoma, carcinoma of the distal part of the common bile duct and pancreatic duct and acinar cell carcinoma), 78 underwent pancreatic resection. The remaining 25 had palliative surgical treatment, either a gastric or biliary bypass, and are not included in the present study. Three of the 78 patients who underwent pancreatic resection died, and ten patients required early reoperation. Predictive criteria could be formulated for the prognosis and outcome of the patients with carcinoma of the head of the pancreas. The most reliable index for survival time of the patients proved to be the radicality of the resection, which was directly related to the differentiation of the primary tumor. Forty-three of 48 patients who underwent radical resection are alive, with a survival time ranging from three to 49 months. Eleven of 23 patients who underwent palliative resection are alive, with a survival time ranging from two to 29 months. Of 44 patients with well or moderately differentiated adenocarcinoma who underwent radical resection, 38 are alive, with a survival time ranging from six to 41 months (mean of 29 months).     

Endoscopic ultrasonography to study the causes of extragastric compression mimicking gastric submucosal tumor.

BACKGROUND AND PURPOSE: Many reports have confirmed that endoscopic ultrasonography (EUS) can differentiate gastric submucosal tumor from extragastric compression, but only a few specifically concentrated on EUS in identifying the causes of external compression. MATERIALS AND METHODS: From May 1993 to May 2001, we used EUS in 238 patients to diagnose gastric submucosal tumor or external compression. We excluded 183 patients who had submucosal tumors and analyzed the remaining 55 patients with extragastric compression. Malignant causes of external compression were proved by surgery or biopsy. Benign causes of external compression were proved by other imaging examinations (abdominal ultrasound, computerized tomography, angiography) or surgery. Patients with external compression caused by normal organs were followed up with repeated upper gastrointestinal endoscopy or EUS. RESULTS: The stomach was compressed by normal extragastric organs in 32 patients (spleen 10, splenic vessel 6, gall bladder 9, liver 3, pancreas 3, and intestine 1), by benign pathologic lesions in 12 patients (liver cyst 7, liver hemagioma 2, splenic cyst 1, pancreatic cyst 1, pancreatic cystadenoma 1) and by malignant tumors in 5 patients (hepatoma 1, liver metastasis from colon cancer 2, pancreatic cystadenocarcinoma 1 and lymphoma of spleen 1). In the remaining six patients, neither submucosal tumor nor external compression was found during EUS examination and the external compression was considered transient. CONCLUSION: When an extragastric compression mimicking submucosal tumor is detected by upper gastrointestinal endoscopy, EUS is indicated to identify the cause of extragastric compression.     

Endoscopic ultrasonography in the differential diagnosis of giant gastric folds.

Giant gastric folds (or large gastric folds) are found in both benign and malignant diseases, and differential diagnosis with either upper gastrointestinal X-ray or endoscopy is difficult. Sometimes, even endoscopic biopsy cannot establish a definitive diagnosis. Recently, endoscopic ultrasonography (EUS) has been used to study giant gastric folds. We performed EUS in 25 patients with giant gastric folds that had been detected with upper gastrointestinal X-ray or endoscopy. The definitive diagnoses were confirmed by histopathology, other examinations, or long-term follow-up. The final diagnoses of these 25 patients were gastric varices in eight, gastric lymphangiectasis in one, gastritis in four, gastric carcinoma (scirrhous type) in six, and gastric lymphomas in six. All patients with gastric varices had anechoic tortuous varicose veins in the submucosal layer. EUS images of gastric lymphangiectasis were similar to those of gastric varices. EUS revealed regular gastric wall thickening of the second (mucosa) and third (submucosa) layers in all cases of gastritis. The fourth (muscularis propria) layer was intact in the only case of mucosa-associated lymphoid tissue lymphoma (MALToma), but not in the other five cases of gastric lymphoma. The second and third layers of this MALToma were irregular in thickness and heterogenous in echogenicity, different from the characteristic EUS findings in gastritis. The fourth layer was markedly thickened only in malignant conditions. Differentiation of gastric cancer from lymphoma with EUS was difficult because of overlapping EUS findings. In conclusion, EUS is indicated for the differential diagnosis of giant gastric folds. In addition, it avoids the risk associated with biopsy of gastric varices.     

Early experience with the selective splenocaval shunt for variceal bleeding

Selective variceal decompression is the operative method of choice in the definitive management of recurrent hemorrhage from gastroesophageal varices. The distal splenorenal shunt is the recommended procedure for selective variceal decompression, but its use may be limited in patients who have undergone left nephrectomy, in patients with an anatomically aberrant relationship between the splenic and left renal veins and in patients with preoperative visceral angiographic findings suggesting that they are at risk for development of the postoperative syndrome of renal vein hypertension. In these clinical situations, selective variceal decompression can be obtained with a splenocaval shunt, constructed by directly anastomosing the splenic vein to the infrarenal vena cava. Seven patients who have undergone the selective splenocaval shunt are reviewed in this report. Early experience with these patients demonstrates the use of the selective splenocaval shunt when an alternative to the distal splenorenal shunt is needed.     

Endoscopic approaches in the diagnosis of obstructive jaundice--with special reference to endoscopic retrograde cholangiopancreatography.

Duodenofiberscopy with endoscopic retrograde cholangiopancreatography (ERCP) was performed in 102 patients with obstructive jaundice. Peritoneoscopy and peritoneoscopic cholecystocholangiography were done in patients whose ERCP was inconclusive. The causes of obstructive jaundice were carcinoma of the pancreas in 14 cases, carcinoma of the papilla of Vater in 12 cases, choledocholithiasis in 37 cases, carcinoma of the common bile duct in seven cases, hepatocellular carcinoma (HCC) in seven cases, intrahepatic cholestasis in three cases and miscellaneous causes in eight cases. No final diagnosis was made in 14 patients. The duodenofiberscopic examination with biopsy revealed the cause of obstructive jaundice directly in eight cases, when carcinoma of the pancreas or papilla of Vater extended to the duodenal mucosal surface. In 34 of the 37 patients with choledocholithiasis, ERCP alone was successful in making the diagnosis. Percutaneous transhepatic cholangiography and ERCP were used together to reach a diagnosis in the remaining three patients. We propose a classification for HCC on ERCP which may be useful for the study of icteric type HCC.     

Angiographic evaluation of hepatoma for surgical treatment.

Celiac and superior mesenteric arteriography of 60 patients with primary carcinoma of the liver was evaluated retrospectively to select patients properly for hepatic lobectomy, ligation of the hepatic artery or temporary occlusion of the hepatic artery. The angiograms were studied from the viewpoints of origin of the hepatic artery, location of hepatomas, macroscopic type of hepatomas, tumor supplying arteries, patency of the portal vein and coexistence of cirrhosis of the liver. It is stressed that an exact knowledge of these items before operation is important in performing any type of surgical treatment for patients with hepatomas. Resectability of the tumor in the present series of patients was possible in 11 patients, and in the recently seen patients with nonresectable hepatomas, ligation or repeated temporary occlusion of the hepatic artery or both have been performed with postoperative infusion chemotherapy.     

Observations during treatment of acute necrotizing pancreatitis with surgical ablation.

Seven patients with acute necrotizing pancreatitis were treated by surgical ablation. Immediate improvement was seen in six patients. Two patients died during the course of postoperative complications requiring reoperations. At operation, strikingly conforming lesions were found in the shape of a sharply limited necrotic portion of the gland. The body and tail of the pancreas constituted this necrotic portion in all patients. In a certain group of patients, the vascular anatomy infers a total infarction of the body and tail of the pancreas if a thrombosis of the transverse pancreatic artery occurs. In view of these observations, more interest should be directed toward the possibility of a vascular occlusion as a cause of pancreatic necrosis.     

Polytetrafluoroethylene vein composite grafts across the knee

Fifteen Gore-tex vein composite femoral-popliteal artery bypass procedures were performed during the four year period of December 1975 to December 1979. Nine were performed for salvage of the limb and six, for incapacitating claudication. Preoperatively, all patients had an arteriographic evaluation of the outflow tract. CPR by the life-table method was 63 per cent at six years. Early failures were three occlusions within two months in patients with poor outflow. One late occlusion occurred at 16 months, and the limb was salvaged with a femoral tibial bypass graft. Another late occlusion was treated by thrombectomy at 24 months with continued patency. Late revision was carried out in one patient at seven months. This consisted of repair of a stenosis of the distal popliteal artery with salvage of the graft. Only two of ten grafts available for evaluation beyond one year have become occluded. All patients operated upon for claudication or with good runoff have patent grafts. On the contrary, none of the grafts to an isolated popliteal segment remained patent. When there is not sufficient autogenous saphenous vein available for femoral-popliteal bypass, the ready availability of a synthetic graft makes it an attractive choice. Nevertheless, our 63 per cent CPR at six years strongly suggests that the composite graft is a durable option.     

Progress in reconstruction after resection of the head of the pancreas

Fistulas of the pancreas due to dehiscence of pancreaticojejunostomy after partial pancreaticoduodenectomy caused severe postoperative complications. Whereas various methods with and without anastomosis of the pancreas are recommended to deal with the pancreatic stump, mortality rates of 20 to 75 per cent have been reported. These different results prompted us to start a prospective, nonrandomized study in which three methods of reconstructing the remnant of the pancreas involving anastomosis were compared with pancreaticocutaneous drainage without anastomosis. One hundred and thirty-one patients with partial pancreaticoduodenectomy entered this trial, 54 female and 77 male patients with an average age of 55.9 years. The indications included: 42 instances of chronic pancreatitis, 44 instances of carcinoma of the pancreas and 45, periampullary carcinoma. We performed 33 end to side pancreaticojejunostomy procedures (four fistulas of the pancreas, a mortality rate of 15.0 per cent), 31 end to end anastomoses (three fistulas of the pancreas, a mortality rate of 6.5 per cent) and 48 double loops with anastomoses of the pancreatic and hepatic duct to separate jejunal loops (nine fistulas of the pancreas, a mortality rate of 2 per cent). Nineteen patients were operated upon using external drainage of the pancreatic stump by means of Penrose drains (five fistulas of the pancreas, a mortality rate of zero per cent). To reduce the fatal risks caused by combined fistulas of the pancreas and biliary tract, the use of separate intestinal loops for anastomoses of the pancreas and biliary tract offers the best solution, since no fatal complications of the pancreaticojejunostomy were observed. In contrast, pancreaticocutaneous drainage was performed upon patients with endangered pancreatic anastomoses due to local morphologic conditions, such as tender pancreatic parenchyma or thin pancreatic ducts. The total loss of exocrine function and the high morbidity rate of 37 per cent is justified in spite of the mortality rate of zero per cent. Total pancreaticoduodenectomy, for technical reasons, represents no acceptable alternative in view of higher mortality rates.     

Alpha-fetoprotein-producing pancreatic acinar cell carcinoma.

A 47-year-old man with chronic hepatitis B had progressive elevated alpha-fetoprotein of 2 years' duration. A pancreatic tail tumor, instead of liver tumor, was detected. He underwent elective distal pancreatectomy and splenectomy and the pathology turned out to be acinar cell carcinoma of the pancreas. Serum level of alpha-fetoprotein returned to normal soon after surgery. No cancer recurrence was noted after 3 years of follow-up. Alpha-fetoprotein is commonly used as a tumor marker to screen for hepatocellular carcinoma in high-risk patients. However, elevated alpha-fetoprotein could occur in a much rarer disease, acinar cell carcinoma of the pancreas.     

Evaluation and treatment of early hemorrhage of the alimentary tract after selective shunt procedures

The cause and treatment of early variceal bleeding in 15 patients who had undergone distal splenorenal shunt were reviewed. Eight of these patients were taken from a group of 91 who underwent selective shunts from July 1983 through June 1985 and had extensive preoperative and postoperative evaluation of shunt patency and pressure gradient. Seven patients operated upon before July 1983 were reviewed because they illustrate the cause, diagnosis, successful and unsuccessful management of bleeding after selective shunt. Urgent selective arteriography combined with shunt catheterization is the key diagnostic and therapeutic maneuver. Thrombosis of the shunt can be successfully managed by revising the anastomosis. Stenosis of the shunt can be successfully treated with balloon dilation or operative revision of the anastomosis. When renal vein hypertension (RVH) occurs, there might be inadequate decompression of the varices. A gradient of 10 millimeters of mercury or greater from left renal vein to vena cava is diagnostic. Measurements of 30 patients who had no bleeding and one patient with documented RVH show the gradient decreases over time. Treatment should be supportive until this adaptation occurs. Hemorrhage can also occur in patients with a patient shunt but without a significant pressure gradient. Inadequate decompression of the varices through the short gastric veins leading to the spleen has been proposed as one cause. Termed short gastric hypertension, this syndrome could be expected to parallel RVH because the venous collaterals will enlarge and eventually decompress the varices. Treatment should be aimed toward supporting the patient until this adaptation occurs. A small number of patients continue to bleed despite these therapeutic interventions but can sometimes be salvaged with a total shunt.