Severe Hemorrhagic Pancreatitis Research Articles

The vicissitudes of pancreatic surgery

Using Senn's treatise as the benchmark from which to measure the advances of pancreatic surgery during the last century, it may be said that acceptable, if not totally successful, progress has been achieved in a number of areas. Injuries to the head of the pancreas, particularly those combined with duodenal trauma, continue to pose difficult operative and management problems. Persistent pancreatic and intestinal fistulas and infection substantially increase morbidity and prolong the hospital stay of some patients with injuries of the body and tail of the gland. Means to control or eliminate the effects of extravasated activated pancreatic juice are needed. Severe hemorrhagic gangrenous pancreatitis, with its excessive morbidity and mortality, offers numerous opportunities for improvement in management. The role of peritoneal lavage and of early resection have not been completely settled and require further carefully controlled evaluation. Why in one case of acute pancreatitis does the mild edematous variety develop and in the next the devastating gangrenous type? Although the majority of patients with chronic pancreatitis can be successfully treated, surgery often falls short of complete rehabilitation. Careful selection of patients and procedures as well as collaboration with colleagues in the psychologic and rehabilitative fields are essential to achieve optimal results. What are the important events within the pancreas that lead to the pathologic changes of chronic pancreatitis? Cancer of the pancreas remains one of the most discouraging problems of pancreatic surgery, and unfortunately, major surgical therapeutic break-throughs do not appear at hand. Earlier diagnosis or technical improvements may add a few percentage points to the survival rate, but our greatest hope for improvement may lie in adjunctive therapies that will help to control the basic biologic aggressiveness of this tumor. What accounts for the biologic aggressiveness of this tumor and how might this characteristic be modified? Of the endocrine tumors the best surgical results by far have been achieved with insulinomas. Diagnosis, localization, and excision are usually successful although occult and multiple tumors still pose a problem. Malignancy is rare (10 percent) in insulinomas, common in vipomas (35 percent), and frequent (66 percent) in gastrinomas and glucagonomas. Although the incidence of malignancy in the latter three tumors diminishes the efficacy of surgical excision, prolonged palliation and occasional cures are achieved. Operation is once again assuming an important role in the management of gastrinoma. Symptoms produced by congenitally misplaced pancreatic tissue, such as annular pancreas, can be quite successfully managed by appropriate surgical procedures. The clinical significance of pancreas divisum and ampullary or septal duct obstruction of the duct of Wirsung is not clear at present, and the selection of patients for operation is still a difficult and imprecise task. Surgical treatment should be recommended with caution. Thus, a review of this partial list of common as well as some uncommon pancreatic surgical problems indicates that the accomplishments of the last century have been considerable, but the vicissitudes of pancreatic surgery leave us with certain major difficulties that thwart any feeling of complacency, and a long list of important and exciting problems are waiting to be answered by the aggressive, innovative research efforts of the future.

Lack of sensitivity and specificity of the renal clearance of amylase/clearance of inulin ratio in experimental acute rat pancreatitis with a study on the renal handling of amylase.

As there are controversies about the specificity and the sensitivity of the amylase clearance/inulin clearance ratio (Cam/Cin) in the diagnosis of pancreatitis, this ratio has been calculated: (a) in rats with induced pancreatitis with histologically proven lesions; (b) in toxic induced tubulopathy rats with lesions demonstrated histologically and biologically (enzymuria). Hyperamylasaemia was found in 86% of the pancreatitis rats at 24 h, 50% at 48 h and 25% at 60 h. The ratio Cam/Cin was elevated above 2 SD of the control values among 14% of the rats at 24 h, 50% at 48 h and 25% at 60 h. There were no changes in enzyme elimination rates in the urine as compared to control values. Renal histology remained normal. Histological scores expressing a severe haemorrhagic pancreatitis were identical at 24, 48 ad 60 h. In toxic induced tubulopathy rats, amylasaemia remained normal. but the Cam/Cin ratio only increased when the glomerular filtration rate was diminished by 90%. The diagnosis could only be made by hyperamylasaemia in 50% of the histologically proven pancreatitis in the rat. The use of the ratio Cam/Cin does not increase the frequency of a correct diagnosis. Finally, amylase must be only filtered by the kidney as no tubular enzymes appeared in the urine of pancreatitis rats. Furthermore, this ratio is not specific for pancreatitis as it could be elevated in other pathologic states such as severe renal failure.

The effect of experimental pancreatitis and diabetes on the microvasculature of the rat pancreas.

Experimental diabetes was produced in 59 rats by intravenous injection of streptozotocin, and the rats were studied from 9 days to 4 months later. Experimental pancreatitis was produced in 28 rats by injecting sodium taurocholate, 3% or 6% solution in saline, into the pancreatic duct. These rats were studied with microangiography from 2 h to 4 days later. Experimental diabetes caused atrophy of the islets of Langerhans but did not cause any changes in the vessels of the exocrine pancreas, liver, or kidney up to 4 months. Capillary filling of the young, long-term diabetic rats was poor in all the examined organs, and the muscle arterioles showed variation of caliber. A 3% sodium taurocholate solution produced mild pancreatitis and little or no changes in the vasculature, whereas a 6% solution caused severe hemorrhagic pancreatitis with local extravasations and poor capillary filling. It is concluded that diagnostically useful vascular changes appear in the pancreas only if severe pancreatitis is present.

Sequestrectomy and hyperalimentation in the treatment of hemorrhagic pancreatitis

Surgical treatment has been used in those patients with hemorrhagic pancreatitis who deteriorate after several days of intensive medical therapy, or in those patients in whom the diagnosis cannot be established early in the course of treatment. Initial therapy consisted of: cholecystostomy or T-tube drainage in those patients who have gallstones, jaundice, or distended biliary tree; gastrostomy for prolonged gastric decompression; jejunostomy to provide a portal for enteroalimentation; and appropriate soft rubber drainage of the pancreatic bed as a simple, safe, and effective means of treating severe hemorrhagic pancreatitis. Adjunctive daily hyperalimentation and later sequestrectomy of necrotic pancreatic tissue provided a mortality of 20 per cent and complete rehabilitation of sixteen of thirty patients so treated. Delaying the initial approach to necrotic pancreas allows precise delineation of necrotic material so that sequestrectomy, leaving behind normal pancreas, can be carried out to avoid exocrine and endocrine deficiencies after the acute episode has passed.

Treatment of acute pancreatitis with albumin and whole blood.

Experience with acute pancreatitis over a 10-year period has been analyzed to evaluate the results of current therapy, and particularly the addition of concentrated albumin to customary treatment. During the same period blood volume determinations have shown marked deficits, in patients with pancreatitis, resulting in earlier and more liberal administration of whole blood. The results indicate that albumin together with whole blood has become the only important addition to the treatment of acute pancreatitis in this hospital during the past 10 years. The administration of concentrated albumin to patients with pancreatitis followed the success reported from this treatment by Kenwell and Wels in February, 1953. 1 They gave 300 to 500 cc. per day, for three to five days, to 11 patients operated on for severe hemorrhagic pancreatitis without a fatality. They attributed the benefit from albumin therapy to the inhibition of trypsin by concentration of the normal plasma trypsin