Major Duct Research Articles

Surgery for chronic relapsing pancreatitis.

Eight cases of chronic relapsing pancreatitis are reviewed. It is re-emphasized that at this stage of the disease the major duct is involved in multiple strictures and cannot be drained by terminal anastomosis. The advantages of longitudinal pancreatico-jejunostomy are outlined, particularly in regard to the preservation of pancreatic function. The outstanding result in this series has been the relief of pain and the considerable gain in weight and well-being, even though no patient has apparently stopped drinking.

Rupture of small ducts and acini in the pancreas of the rat and guinea pig following major duct obstruction.

SummaryObstruction of the pancreatic duct system in the rat and the guinea pig leads to the rupture of pancreatic acini and ductules, consistently demonstrable by the periodic acid‐Schiff (PAS) technique.In the rat with pancreaticobiliary obstruction ruptured acini and ducts can also be revealed by interposing an ink‐filled tube between the hepatic and common ducts.A study has been made of the time course of pancreatic histological changes following pancreatic duct obstruction in the rat with and without common‐channel biliary obstruction. The addition of common‐channel biliary obstruction only slightly modified the picture causing haemorrhage in the wall of the common duct and more frequent and severe fat necrosis in the first 18 hr.Preliminary studies in the dog suggest that the periodic acid‐Schiff (PAS) technique may be useful in detecting ruptured acini in that species also.The occurrence and significance of increased mucus concentration within the obstructed pancreatic duct system is discussed.

MULTICENTRIC SIALOANGIECTASIS: AN INTERESTING CONGENITAL MALFORMATION.

SIALOANGIECTASIS—dilatation of salivary ducts, terminal ductiles, and even terminal alveoli 1 involving the parotid glands has often been reported. Although sialoangiectasis is found in later stages of many inflammatory lesions of the parotid, 2 it may be considered a primary disease in the specific group of cases where the pathology is generalized and frequently bilateral. Thus it is apparent that sialoangiectasis may be the basic underlying factor in the development of the clinical inflammatory picture. 3 Review of the literature reveals only rare reports of sialoangiectasis of the submaxillary glands, and only in cases secondary to obstruction, with the ectasia limited to the major ducts. Sialoangiectasis involving both parotids and both submaxillary glands simultaneously has not been demonstrated noi reported previously. It seemed important to report the case of a patient in whom th( presence of sialoangiectasis was demonstrated concurrently in both parotids anc both submaxillary glands. Report of Case

MALIGNANT OBSTRUCTION OF THE MAJOR HEPATIC DUCTS.

MALIGNANT OBSTRUCTION OF THE MAJOR HEPATIC DUCTS.

Excision of Major Duct System of the Breast

Excision of Major Duct System of the Breast

Excision of the major duct system of the breast.

Excision of the major duct system of the breast.

Maximum alkaline (bicarbonate) output of the dog pancreas.

By cannulation of the major pancreatic duct in six dogs with chronic Thomas type duodenal fistulas, dose-response curves have been obtained for the volume and bicarbonate output of pancreatic secretion stimulated by secretin (Vitrum). With single rapid intravenous injections (0.5–15 U/kg) or continuous intravenous infusions (1–16 U/min), increased doses of secretin produced increased volumes of pancreatic juice and bicarbonate outputs up to a maximum. This maximum alkaline output of the pancreas was reached at doses ranging from 7.5– 12.5 U/kg for single injections, and 4–16 U/min for infusions. In each dog supramaximum doses led to a fall in juice volume and bicarbonate output, unaccompanied by side effects. With supramaximum doses or intravenous infusions lasting longer than 30–90 min, bicarbonate concentration fell independently of juice volume. The chloride concentration consistently varied inversely with bicarbonate concentration. The sodium, potassium, and amylase concentrations were unaffected by rate of flow. Repeated measurements of basal secretion showed considerable variation. Coefficients of variation were low for repeated measurements of secretin-stimulated secretion, the most repeatable measurement being the maximum output of pancreatic juice in the first 15 min after a single injection which, in each of the six dogs, was almost identical to the plateau 15 min during infusion.

Role of the liver in secretin inactivation.

In order to determine the effect of the liver on the action of secretin on the pancreas, secretin was infused alternately into the femoral and portal veins of adult mongrel dogs for 15-min periods, using a constant infusion pump. The major pancreatic duct was cannulated transduodenally and pancreatic juice was continuously collected in a graduated centrifuge tube. Injection of Evans blue dye through the main pancreatic duct at the conclusion of each experiment confirmed the ligation of all ducts, other than the major one, so that collections represented total flow of pancreatic juice. In each pair of infusions (portal and systemic) the volume of pancreatic juice obtained was always greater when secretin was given by the systemic route, and this increase in volume was highly significant statistically ( P < .005). These observations indicate that the effect of secretin on the pancreas is partially inactivated by the liver.

Experience with ligation of the pancreatic ducts in the treatment of chronic relapsing pancreatitis

I T is the purpose of this paper to present experience with six patients suffering from chronic reIapsing pancreatitis who were treated by Iigation of the pancreatic duct or ducts. Experience at Wadsworth HospitaI in the past has indicated that for the most part none of the surgica1 procedures advocated for the relief of symptoms of chronic reIapsing pancreatitis in the absence of biliary tract disease, short of actuaI excision of the pancreas, has been invariabIy effective. Procedures most commonty advocated alone or in combination incIude: vagotomy, sympathectomy, sphincterotomy, gastroenterostomy with or without gastric resection, transpIantation of the common biIe duct, and caudaI pancreatico-dochojejunostomy. The fact that so many procedures are advocated for the reIief of this disease wouId seem to indicate that none is particuIarIy effective. AI1 of the surgica1 measures so far devised, short of excision, have had as their aims relief of assumed major duct obstruction, suppression of exocrine activity, or interruption of nerve fibers bearing pain impuIses. Neither the actua1 cause nor the pathoIogic physioIogy of chronic reIapsing pancreatitis is well understood. It is probably safe to say, however, that breakdown of the ductal system with the consequent reIease of activated enzymes into the pancreatic stroma is essentia1 to the production of the disease. In chronic reIapsing pancreatitis it is the presence of episodes of severe pain which make the disease subject to surgica1 intervention. It wouId appear that the pain is the resuIt of stroma digestion and irritation by activated enzymes which have escaped from the ducta system. Rich and Duff’ have reported the most

Pressures in the pancreatic and common ducts; values during fasting, after various meals, and after sphincterotomy; an experimental study.

Normal physiologic pressures in the pancreatic and common bile ducts have proved difficult to measure. Various methods of recording pressures have been described,* but all the methods have involved either producing a fistula or occlusion of the major duct by the recording cannula. The preliminary objective of the present investigation was to develop a method whereby the pressures could be recorded without producing a fistula or occluding the ducts and without interfering with any sphincteral mechanism which might control the flow of bile or pancreatic juice from the ducts into the duodenum. A method was developed which satisfactorily met these criteria, a method by which simultaneous recordings of pressures in the pancreatic duct, in the common bile duct, and in the duodenal lumen could be made from cannulae placed in these organs. The experiments were carried out on trained dogs which had fully recovered from the operative procedures of placing

Studies on the Therapy of Pancreatic Insufficiency

Summary Fat and nitrogen balance studies have been carried out on dogs deprived of most of their external pancreatic secretion by ligation of the major ducts. Enteric-coated pancreatin and Viokase administered at 21% of the nitrogen intake have a marked and equal effect in reducing the excessive fecal nitrogen and fat loss. Papain, purified for manufacturing purposes, when fed at a level of 2% of the dietary nitrogen, results in a considerable improvement in the creatorrhea and sometimes in the steatorrhea. Higher levels of supplementation have no greater effect. Papain is not as effective as pancreatin or Viokase. Tween 80 or aureomycin under the conditions of this study did not reduce the fecal loss of nitrogen or fat.

Reflux into the Major Pancreatic Duct During Cholangiography

Reflux into the Major Pancreatic Duct During Cholangiography