Demonstration of the duct of Wirsung through a pancreatico-cutaneous fistula.

Abstract

Satisfactory demonstration of the pancreatic duct by injection of an opaque medium has been reported in the medical literature both as an accidental (1) and as a deliberate procedure (2, 3). In most cases the injection was achieved via a T-tube placed in the common duct following surgery on the gallbladder. When the sphincter of Oddi remained contracted, reflux of the dye into the duct of Wirsung could occur. Contraction of the sphincter, however, is only occasionally sufficient to prevent the medium from passing out into the jejunum before filling the pancreatic duct. To meet this objection, H. Doubilet (2) has used morphine to contract the sphincter of Oddi and thus permit filling of the pancreatic radicles. The material used for this procedure may be either sodium iodide, iodized oil, or a water-soluble opaque medium such as diodrast. All have been used successfully and without apparent harm to the patient. No cases of pancreatitis have been reported. Carter (3) states that the only untoward reaction has been shock secondary to pain from dilatation of the ducts. He therefore injects his medium under low pressure, using the gravity method. Both water-soluble and oil-soluble media have their advantages and disadvantages. The water-soluble media are miscible with the pancreatic and biliary secretions, thereby producing a homogeneous column of dye. On the other hand, mucus or other secretions within the duct system may fail to mix with oil-soluble agents and thus produce defects in the column. Water-soluble agents disappear rapidly, whereas oil-soluble agents can be visualized for long periods of time. P. C., a 58-year-old male, was admitted to Halloran Veterans Administration Hospital on April 15, 1948, complaining of jaundice, pruritus, cramping pain in the right upper abdominal quadrant, periodic in nature, extremely dark urine, and light stools. Laparotomy revealed granulation tissue obstructing the sphincter of Oddi. This was resected, and the patient was symptom-free until November 1949. In January 1950, he was readmitted to the hospital because of a recurrence of symptoms He showed jaundice, some cachexia, and a weight loss of 22 pounds Laboratory findings were as follows: Blood count normal; serum amylase, 176 Somogyi units; serum bilirubin, 2.3 mg. per cent (0.9 mg. per cent direct, and 1.4 mg. per cent indirect); serum alkaline phosphatase, 16.1 units; stool negative for occult blood. On Feb. 6, 1950, laparotomy was again performed, revealing a carcinoma of the ampulla of Vater. A partial pancreatico-duodenectomy and gastrojejunostomy were performed; a T-tube was left in the common duct, and a drain was inserted through a stab wound in the right hypochondrium. Fifteen days postoperatively the drain was removed. A fistulous tract formed at the site of the stab wound, intermittently secreting a clear serous fluid. Repeated examinations showed this to be almost pure pancreatic juice.