Potentially curable masses in the pancreas.

Twenty patients with intraabdominal non-Hodgkin's lymphoma localized to the peripancreatic area were reviewed. Appropriate diagnosis and staging required exploratory laparotomy and biopsy. With appropriate chemotherapy and radiotherapy, 40 percent of these patients were alive 3 years after diagnosis without evidence of disease. It is for this reason that we have adopted an aggressive approach in obtaining histologic diagnoses for all pancreatic masses.

Primary sclerosing cholangitis.

Primary sclerosing cholangitis was seen in only 7 of 6,494 biliary operations performed between 1948 and 1979. Fifteen more cases were seen in 1,467 biliary operations performed over a recent 5 year period. Surgery was directed primarily towards the differential diagnosis between cholangiocarcinoma and primary sclerosing cholangitis of the upper bile duct and the need for decompression (nine patients), accompanying gallstones (4 patients), and focal distal bile duct stricture with a question of cholangiocarcinoma (two patients). Invasive radiologic dilatation of the bile ducts was not possible in most instances. Two patients have had successful liver transplants and two more were pending at last follow-up.

Pancreatic lymphoma, diagnosis and management.

Eleven cases of non-Hodgkin's lymphoma were referred as patients thought to have pancreatic cancer. It was impossible to make the diagnosis in this particular group of patients preoperatively, by imaging techniques and needle biopsy. For this reason we favor laparotomy for staging followed by Roux-en-Y choledochojejunostomy for those patients with obstructive jaundice because this approach both rapidly resolves the jaundice and enables a more accurate diagnosis. We do not feel that non-surgical means of decompression of the biliary tree by transhepatic or endoscopically placed stents are as safe or effective for patients who are potentially curable because the diagnosis may not be made early enough. We call this group of patients to your attention because recent reports indicate that over 30% of such patients can be cured by chemotherapy. Thus these lesions should be differentiated from others at this location.

Cholangiography and small duct injury.

Eighteen instances of bile duct injury over the past 25 years have been reported. Manipulation of a minute cystic duct where the common bile duct was 3 mm in diameter or less was responsible for the division of the duct in eight cases. Most of the commercial catheters are sharp, about 2 mm in diameter, and can easily divide the bile duct if pushed too far. Since manipulation of the duct with a mosquito or tonsil clamp to insert other smaller catheters can also divide a small bile duct, we have decided to discontinue obtaining cholangiograms under these circumstances. Longitudinal splitting of two additional 3 mm ducts with a 3 mm dilator was another major source of injury. Overclipping of the cystic artery to involve the hepatic duct and overmobilization of the bile duct were other sources of injury. We have ceased attempting to obtain cholangiograms in patients with small cystic ducts because of the availability of endoscopic sphincterotomy, the low yield of the films under these circumstances, and fear of damaging the ducts. We use hepaticojejunostomy with Silastic tube stenting for repair of bile duct injuries.

Human pancreatic secretory protein profiles in pancreas cancer and chronic pancreatitis.

Pancreatic secretory protein profiles differed significantly between patients with chronic pancreatitis (CP) and pancreatic carcinoma (CA). Specific regions of the patterns were altered when CP versus CA and when CP versus normals were compared. Bands isoelectric in the region of pH 9-11 were elevated in CP. The possible identification of this band as lactoferrin is discussed.

Human pancreatic secretory protein profiles in the search for tumor markers.

Pancreatic cancer secretory protein profiles were shown to be different from normals by a microcomputer-assisted analysis of isoelectric focusing patterns. Two acidic protein band regions (pI 3.0 and 4.5) of the pancreatic carcinoma profiles were significantly increased, and eight protein bands (pI 3.7, 5.0, 5.5, 6.5, 6.9, 7.3, 8.0, greater than 10.0) were significantly decreased. Highly significant decreases occurred at pH 7.3 (chymotrypsinogen) and at pH 5.0 (procarboxypeptidase Al, DNase I) in nonactivated specimens. The ratio between the absorbance points at 2.08 and 2.63 cm from the anode in each protein pattern differentiated the pancreas cancer specimens from the control group. Profiles found for the control group gave pI values similar to those found in the literature. The potential value of these findings in the search for tumor markers warrants further investigation as to whether these specimens can be differentiated from those from chronic pancreatitis patients.

TIBIAS--a microcomputer-based analysis system for isoelectric focusing and electrophoretic patterns.

A program is described for a computer-aided analysis system for isoelectric focusing (IEF) patterns. This system is primarily aimed at comparing and statistically analyzing large numbers of one-dimensional electrofocusing patterns in the search for specific tumor markers in pancreatic ductal secretions. It is designed to collect raw densitometric data, allow interactive processing, matching and statistical tests, and prepare high-quality plots of data at various stages.

Pancreaticojejunostomy. Report of a 25 year experience.

Surgical therapy for 88 patients operated on between 1958 and 1982 has been reviewed. Ninety-three operative procedures were performed including pancreaticojejunostomy in 56, pancreaticocystojejunostomy in 12, pancreaticojejunostomy with resection of less than 10 percent of the pancreas in 16, and pancreaticojejunostomy with resection of more than 50 percent of the pancreas in 9. Operative mortality was 7.5 percent and operative morbidity was 25 percent. Overall, 63 percent of the patients had an excellent or good result in the postoperative follow-up period which averaged 4 years. In the nonalcohol-induced pancreatitis group, ductal diameter was a good predictor of postoperative success, whereas in the alcoholic patient population, abstinence from further alcohol intake was a more accurate predictor of the success of pancreatic drainage.

Obstructive biliary tract disease.

The techniques that have come into general use for diagnosing problems of obstructive jaundice, particularly in the past ten years, have been ultrasonography, computerized tomography, radionuclide imaging, transhepatic percutaneous cholangiography using a long thin needle, transhepatic percutaneous drainage for obstructive jaundice due to malignancy, endoscopic retrograde cannulation of the papilla (ERCP), endoscopic sphincterotomy and choledochoscopy. It is helpful to review obstructive jaundice due to gallstones from a clinical point of view and the use of the directable stone basket for the retrieval of retained stones, choledochoscopy for the same purpose using the rigid versus flexible choledochoscopes and dissolution of stones using various fluids through a T tube. The use of dilation of the sphincter for the treatment of stenosis or stricture of the bile duct is now frowned on; rather, treatment choices are between the use of sphincteroplasty versus choledochoduodenostomy and choledochojejunostomy. Any patient with obstructive jaundice or anyone undergoing manipulation of the bile ducts should have prophylactic antibiotic therapy. The current literature regarding treatment of cancer of the bile ducts is principally devoted to the new ideas relative to treatment of tumors of the upper third, especially the bifurcation tumors that are now being resected rather than bypassed. Tumors of the distal bile duct are still being resected by focal operations. Finally, it is now felt that early operation for congenital biliary atresia and choledochal cysts gives the best prognosis, with preoperative diagnosis now possible with the use of ultrasonography and ERCP.

Management of duodenal diverticula.

Duodenal diverticula are not uncommon. Uncomplicated diverticula require no treatment. In the period 1970 to 1980, 104 patients with symptoms presented at the Vancouver General Hospital and the Swedish Hospital in Seattle. Of these, 26% presented with pain and 24% with anemia. Malabsorption and benign tumours were noted infrequently. Fifteen patients were treated surgically for pain, perforation, hemorrhage, tumour, blind loop syndrome and obstruction of the duodenum, biliary tract or pancreatic duct. Two patients died. The second part of the duodenum was involved in 82% and the third part in 10%. Anatomical variations are common in the area of the ampulla; these should be anticipated before operation. Surgical procedures in the area may be technically demanding and associated with high mortality and morbidity. The choice of procedure depends on the urgency and nature of the complication of the diverticulum. Endoscopic retrograde cholangiopancreatography can play a role in evaluating the possible significance of the diverticulum and the anatomy of the area. In some cases endoscopic sphincterotomy may be possible. In some situations diverticulectomy is contraindicated.

Protein secretions in hamsters with pancreatic carcinoma.

Pancreatic secretions from the hamster model for pancreatic ductal adenocarcinoma were analyzed to determine whether alterations had occurred in the protein composition. CCK-and secretin-stimulated secretions were collected from 13 animals with cancer and 16 normal controls. Subsequent separation of the proteins by isoelectric focusing showed the following: (1) Significant changes occurred in the protein composition from animals with carcinoma. An unusually dark band was present at pH 7.5 just below amylase (pH 7.65); two unidentified bands, present in the normals at pH 6.9 and 7.0, were missing; and marked decreases occurred in the cathodic proteins with isoelectric points above pH 9, (2) CCK provided the optimal stimulus for differentiating specimens from animals with carcinoma from the normal controls. (3) The protein concentrations of CCK-stimulated secretions of animals with carcinoma were significantly lower than the controls. We have concluded that the protein alterations which have occurred in the hamster model for pancreatic ductal adenocarcinoma warrant further investigation.

Cloning and sequence of cDNA coding for alpha 1-antitrypsin.

Recombinant plasmids containing human and baboon cDNA have been screened for alpha 1-antitrypsin, a major serine protease inhibitor present in blood. One plasmid, designated pBa alpha 1a2, was found to contain a cDNA insert of 1352 base pairs coding for the baboon inhibitor. It included 45 nucleotides that code for 15 amino acids present in the amino-terminal signal sequence of the protein, 1182 nucleotides that code for 394 amino acids in the mature protein, a stop codon, and a noncoding region of 76 nucleotides. Comparison of the amino acid sequences of baboon alpha 1-antitrypsin, human antithrombin III, and chicken ovalbumin indicated that these three proteins are about 230% homologous. A second plasmid, designated pH alpha 1a1, was found to contain a human cDNA insert of 306 base pairs. This plasmid coded for 69 amino acids present in the carboxyl-terminal region of human alpha 1-antitrypsin. The human and baboon cDNAs and their amino acid sequences are greater than 96% homologous.

Ampullary disconnection during the course of biliary and duodenal surgery.

Ampullary disconnection is fortunately rare. As this experience indicates, the long-term salvage rate is good but demands immediate recognition, precise repair and frequently reoperation to obtain a satisfactory result. One should be aware that the ampulla may be located very proximally in patients with long-standing peptic ulceration. The common duct should be catheterized while reoperation is required in this area in cases of obscured anatomy of the distal bile and pancreatic ducts.

Choledochal cysts presenting in late childhood and adulthood.

Primary excision is well accepted in children. Although the length of follow-up is inadequate, our review of the literature and experience with five patients suggests primary excision as the procedure of choice in older children and adults. Although the number of cases is too small and the follow-up too sporadic to draw statistically valid conclusions, excision has a lower morbidity, mortality and reoperation rate than internal cyst drainage, and definitive removal of tissue at risk for malignant degeneration seems intuitively more appealing.

Surgical treatment of chronic pancreatitis--report of 227 cases.

In our series, long pancreaticojejunostomy appears to be the most effective treatment of chronic pancreatitis in the alcoholic, with 87% good to fair results, and with 90% good results in the non-alcoholic. The Whipple operation is the second most effective treatment for alcoholics with 45% good results, as opposed to 100% in non-alcoholics. Less than 40% good and fair results were achieved for alcoholics with 80-95% resection, sphincteroplasty, 40-80% resection, and total pancreatectomy. These operations were much more effective in non-alcoholics. The main differences between patients seen in Japan and in the United States seems to be a much lower incidence of alcohol-induced pancreatitis in the Japanese. Our findings in cases of congenital and non-alcoholic pancreatitis are similar to those reported in the case of chronic pancreatitis among Japanese, except that biliary trace procedures such as sphincteroplasty seem to have been more effective for the Japanese patients.