Duodenum-preserving resection of the head of the pancreas--modified procedures and long-term results-.

BACKGROUND/AIMS: Relief of chronic pancreatitis can be accomplished surgically or with medication. Surgical treatment of pancreatitis should preserve the endocrine and exocrine function of the pancreas. This paper details the results of our modified procedure for resecting the head of the pancreas. The advantage of this procedure is small resection, preservation of endocrine and exocrine function, complete relief of pain by the pancreatic duct drainage and maintenance of function of the duodenum and bile duct. PATIENTS AND METHODS: Duodenum-preserving resection of the pancreatic head with denervation of the body and tail of the pancreas was performed in 41 patients with severe chronic pancreatitis. RESULTS: Mortality after a median follow-up period of 36 months was 2.4%. Complete relief or alleviation of pain were found in 92% of patients and any other patients of recurrent pain due to postoperative pancreatitis was not found. Eighty-seven percent of patients had maintained more than preoperative body weight. Postoperative glucose tolerance was unchanged in 88% of patients. After long-term follow-up postoperative exocrine function had been maintained at preoperative condition. CONCLUSIONS: Our procedure can maintain endocrine and exocrine function of the pancreas, relieve pain well and prevent pain due to recurrent pancreatitis.

[Transendoscopic microvascular Doppler sonography for the assessment of hemodynamics of esophageal and gastric varices].

The importance of unravel hemodynamics at the stomach and esophagus in patients with portal hypertension has been described for understanding pathophysiology and treatment of varices associated with portal hypertension. Microvascular Doppler sonogrlaphy (MF20) is a pulse Doppler method with 20 MHz which is able to measure velocity and direction of blood flow in microvessel. We invented transendoscopic microvascular Doppler sonography (EMDS) by connecting a tiny probe of one mm in diameter with an endoscopy. We evaluated direction of blood flow in the esophageal and gastric varices by EMDS and angiography in 21 untreated and 26 shunt-operated patients with portal hypertension. In all of untreated patients direction of blood flow in the varices was toward the probe (forward). Results obtained with EMDS were consistent with angiographic results available in 13 patients. Direction of blood flow after shunt operation was away from the probe in 21 out of 26 patients. The comparison with angiography revealed that post-operative patients with "away" blood flow in varices had maintained satisfactory shunt selectivity without hepatofugal collateral and it proved that the direction of blood flow was toward the shunt at lower pressure. In conclusion EMDS is useful as an evaluation method for hemodynamics in varices of the esophagus and stomach.

[Clinical study on reoperation for recurrent pulmonary metastasis].

Ninety seven patients with metastatic lung tumors were treated surgically in our department. Second pulmonary resections were performed in 13 patients. They consists of 9 males and 4 females, their age ranged from 12 to 75 years old (average 54.4 years old). Tumors originate from sarcoma in 5 cases, laryngeal cancer, colorectal cancer, renal cell cancer in 2 cases respectively, oral cavity cancer and transitional cell cancer in 1 case respectively. No second pulmonary resection was performed in patients with metastatic lung tumors originating from lung cancer or breast cancer, because they metastatize not only lung but also general organs. No second pulmonary resection was required in patients with testicular tumor and choriocarcinoma, because chemotherapy take good effect on them.

Bleeding esophageal varices associated with pancreatic arteriovenous malformation.

Three cases of bleeding esophageal varices associated with arteriovenous malformation of the pancreas have been observed over the last 7 years. In 1 case, arteriovenous malformation (AVM) was the cause of the portal hypertension; thus, it was considered to be a "primary lesion." In the other cases, liver cirrhosis was the cause of the portal hypertension, and the AVM, which originally was a minor pathology, became significant as the portal hypertension progressed, thus making it a "secondary lesion." In the case of a "primary lesion," resection of the lesion is the preferred treatment for bleeding varices, but our case had multiple lesions, and excision was problematic. In the case of bleeding varices caused by liver cirrhosis, if liver function is normal, surgical treatment of both the varices and the AVM is recommended, while if the liver function is abnormal, repeated sclerotherapy is the best mode of therapy.

A case report of Zollinger Ellison syndrome and review of the literature.

There is much controversy concerning the mode of therapy for patients in whom Zollinger-Ellison syndrome is strongly suspected but a tumor can not be located. We recently experienced a patient with Zollinger-Ellison syndrome presenting with melena in whom an attempt to stop the bleeding by H-2 antagonists failed and an emergency operation had to be carried out. At laparotomy, no tumor was found in the pancreas, duodenum or stomach wall and there was no specific swelling in any of the lymph nodes. A total gastrectomy was thus done with lymphadenectomy and a histopathological examination revealed two gastrinomas in the lymph nodes of the gastrinoma triangle. Postoperative secretin tests with 2 u/kg of secretin have been negative even 6.5 years later, and the patient is now well and working as a full time teacher. In this case, an emergency total gastrectomy was performed for uncontrolled bleeding, but we want to stress the importance of lymphadenectomy based on the findings of the frozen section and changes in gastrin levels.

Chronic calcifying pancreatitis associated with primary hyperparathyroidism--report of a case and review of the literature.

A 34 year old male was hospitalized because of severe abdominal pain and diarrhea. An abdominal X-ray revealed multiple calculi in the head of pancreas and blood tests showed his serum calcium level to be high. He underwent surgery of the parathyroid gland and a parathyroid tumor was removed. Two months later, resection of the head of the pancreas was also performed. Eighteen months after his operation there has been no recurrence of abdominal pain or diarrhea and his serum calcium level is within the normal range. We report this case herein and also discuss the possible cause and effect relationship between primary hyperparathyroidism and pancreatitis, and the appropriate management, in relation to a review of the literature.

Cystadenoma and cystadenocarcinoma of the pancreas.

During the period 1963 to 1988, we treated 45 patients with cystic neoplasms of the pancreas. The patients were divided into group 1, which included 26 patients treated between 1963 and 1983, and group 2, which included 19 patients treated between 1984 and 1988. The rate of resection for cystadenoma was 67% for group 1 (n = 15) and 100% for group 2 (n = 11). The operative mortality rate was 0% for both groups. Pathologically, 17 patients (69%) had serous cystadenoma and nine (31%) mucinous adenoma. Except for 5 of the 15 patients from group 1 who died of other causes, all patients are healthy. The resection rate for cystadenocarcinoma was 36% for group 1 (n = 11) and 100% for group 2 (n = 8). In 2 patients from group 1 and 1 patient from group 2, the tumors had been diagnosed previously as benign by operative biopsy of the cyst wall. There was no operative mortality in either group. Cystic neoplasm was suspected from the results of ultrasonography and computed tomography in 70% of the patients in group 2. In 2 patients (25%), the preoperative diagnosis of pseudocyst associated with chronic pancreatitis was made. Adenocarcinoma was diagnosed in 3 patients by needle biopsy and cytologic examination of pancreatic juice. Eighty-two percent (9 patients) of group 1 died of recurrent carcinoma; 2 patients were alive without disease at 5 and 8 years. Thirty-eight percent (3 patients) of patients in group 2 died of recurrent carcinoma, two patients died of other causes, and 3 patients are still alive.(ABSTRACT TRUNCATED AT 250 WORDS)

Modified splenorenal shunt with splenopancreatic disconnection.

Distal splenorenal shunt with splenopancreatic disconnection is a difficult surgical procedure; therefore its use is not widespread. We present a modified technique that facilitates the procedure and also ensures maintenance of portal flow by adding gastric devascularization and gastric disconnection. Our results compare favorably with the standard distal splenorenal shunt.