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post op with end colostomy

Thursday, October 28, 2010

CASE: chronic alcoholic pancreatitis with pseudocyst in tail of pancreas & splenic vein thrombosis (PHT) (28.10.10) @ MAHAVIR^-www.drkeyurbhatt.in*

completed surgery with LPJ

Chronic pancreatitis with pseudocyst in tail
and multiple calculi in duct

opened duct till head and
pseudocyst drained into duct only

inferior layer of anastomosis of LPJ

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CASE: chronic alcoholic pancreatitis pus in MPD (27.10.10) @ SURAT GENERAL^-www.drkeyurbhatt.in*

chronic alcoholic pancreatitis

MPD with pus discharge within

Longitudinally opened pancreatic duct with coring of head

completed LPJ

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Thursday, October 21, 2010

Evidence-Based Pancreatic Head Resection for Pancreatic Cancer and Chronic Pancreatitis^-www.drkeyurbhatt.in*

From the *Department of Surgery and †Division of Gastroenterology, University of Zu¨ rich, Zu¨ rich, Switzerland

Conclusions
Pancreatoduodenectomy and its main modifications are safe
and effective treatment modalities, especially in experienced
centers with a high patient volume. For chronic pancreatitis,
surgical resection provides major relief of pain and thus increased
quality of life. Overall survival for patients with pancreatic
cancer is determined predominantly by the pathology
within the resected specimen.

ANNALS OF SURGERY

Vol. 236, No. 2, 137–148

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Long-Term Results of Distal Pancreatectomy for Chronic Pancreatitis in 90 Patients^-www.drkeyurbhatt.in*

From the *Department of Surgery, Hammersmith Hospital, London, United Kingdom, and the †Department of Biochemistry and

Molecular Biology, Royal Free and University College Medical School, London, United Kingdom

Distal pancreatectomy for chronic pancreatitis from any etiology
can be performed with low mortality and a good outcome
in terms of pain relief and return to work in approximately
60% of patients. Little effect is seen on exocrine function of
the pancreas, but there is a diabetic risk of 46% over 2 years.
Pseudocyst disease is associated with the best outcome, but
other manifestations of this disease, including strictures, calcification,
and limited concomitant disease in the head of the
pancreas, can still be associated with a good outcome.

ANNALS OF SURGERY Vol. 236, No. 5, 612–618

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Tuesday, October 19, 2010

* Treatment of Re currant acute on chronic pancreatitis^-www.drkeyurbhatt.in*

Analysis of Surgical Success in Preventing
Recurrent Acute Exacerbations in
Chronic Pancreatitis

William H. Nealon, MD, and Sina Matin, MD

From the Department of Surgery, The University of Texas Medical Branch, Galveston, Texas

Objective

To determine whether surgical intervention prevents recurrent

acute exacerbations in chronic pancreatitis (CP).

Summary Background Data

The primary goal of surgical intervention in the treatment of

CP has been relief of chronic unrelenting abdominal pain. A

subset of patients with CP have intermittent acute exacerbations,

often with increasing frequency and often unrelated to

ongoing ethanol abuse. Little data exist regarding the effectiveness

of surgery to prevent acute attacks.

Methods

From 1985 to 1999, all patients identified with a diagnosis of

CP were recruited to participate in an ongoing program of

serial clinic visits and functional and clinical evaluations. Patients

were offered surgery using standard criteria. Data were

gathered regarding ethanol abuse, pain, narcotic use, and

recurrent acute exacerbations requiring hospital admission

before and after surgery. Patients were broadly categorized

as having severe unrelenting pain alone (group 1), severe pain

with intermittent acute exacerbations (group 2), and intermittent

acute exacerbations only (group 3).

Results

Two hundred fifty-nine patients were recruited. One hundred

eighty-five patients underwent 199 surgical procedures (124

modified Puestow procedure [LPJ], 29 distal pancreatectomies

[DP], and 46 pancreatic head resections [PHR; 14 performed

after failure of LPJ]). There were no deaths. The complication

rate was 4% for LPJ, 15% for DP, and 27% for PHR.

Ethanol abuse was causative in 238 patients (92%). Mean

follow-up was 81 months. There were 104 patients in group 1

(86 who underwent surgery), 71 patients in group 2 (64 who

underwent surgery), and 84 in group 3 (49 who underwent

surgery). No patient without surgery had spontaneous resolution

of symptoms. Postoperative pain relief (freedom from narcotic

analgesics) was achieved in 153 of 185 patients (83%)

overall: 106 of 124 (86%) for LPJ, 19 of 29 (67%) for DP, and

42 of 46 (91%) for PHR. The mean rate of acute exacerbations

was 6.3 6 2.1 events per year before surgery in group 2

and 7.8 6 1.8 events per year in group 3. After surgery, no

acute exacerbations occurred in 42 of 64 (66%) group 2 patients

and in 40 of 49 (82%) group 3 patients. The mean number

of episodes of acute exacerbation after surgery was

1.6 6 2.3 events in group 2 and 1.1 6 1.9 events in group 3.

Only four patients in group 2 and one patient in group 3 had

an equal or increased frequency of attacks after surgery. Preventing

attacks was most effective with LPJ (58/64, 91%) and

least effective for DP (6/18, 33%).

Conclusions

Surgical intervention prevents recurrent acute exacerbations.

The overall frequency of events was reduced in nearly all patients.

Therefore, surgical intervention is indicated in patients

with CP whose disease is characterized by recurrent acute

exacerbations.

ANNALS OF SURGERY

Vol. 233, No. 6, 793–800
© 2001 Lippincott Williams & Wilkins, Inc.

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* Treatment of chronic pancreatitis with pseudocyst in tail^-www.drkeyurbhatt.in*

"Duct Drainage Alone is Sufficient in the Operative
Management of Pancreatic Pseudocyst in
Patients With Chronic Pancreatitis"

William H. Nealon, MD, and Eric Walser, MD
From the Department of Surgery, The University of Texas Medical Branch, Galveston, Texas

Objective

To test a hypothesis that definitive management of pseudocyst

associated with chronic pancreatitis is predicated on addressing

pancreatic ductal anatomy.

Summary Background Data

The authors have previously confirmed the impact of pancreatic

ductal anatomic abnormalities on the success of percutaneous

drainage of pancreatic pseudocyst. The authors have

further defined a system to categorize the pancreatic ductal

abnormalities that can be seen with pancreatic pseudocyst.

The authors have published, as have others, the usefulness of

defining ductal anatomy when managing pancreatic pseudocysts

associated with chronic pancreatitis.

Methods

Beginning in 1985, all patients with pseudocyst who were

candidates for intervention (operative, percutaneous, or endoscopic)

have undergone endoscopic retrograde cholangiopancreatography

(ERCP). An associated diagnosis of chronic

pancreatitis was established by means of ERCP findings. Patients

were candidates for longitudinal pancreaticojejunostomy

(LPJ) if they had a pancreatic ductal diameter greater

than 7 mm. In a nonrandomized fashion, patients were managed

with either combined simultaneous LPJ and pseudocyst

drainage or with LPJ alone.

Results

Two hundred fifty-three patients with pseudocyst have been

evaluated. Among these there have been 103 patients with

chronic pancreatitis and main pancreatic duct (MPD) dilatation

( 7 mm). Among these 103 patients, 56 underwent combined

LPJ/pseudocyst drainage and 47 had LPJ alone. Compared

to combined LPJ/pseudocyst drainage, the patients

undergoing LPJ alone had a shorter operative time, slightly

less transfusion requirement, slightly reduced length of hospital

stay, and slightly reduced complication rate. Long-term pain relief was achieved in 90%, and pseudocyst recurrence was less than 1%. Rates of each of these long-term outcomes

were nearly incidental among the two groups.

Conclusions

Ductal drainage alone (LPJ) is sufficient in patients with

chronic pancreatitis (MPD 7 mm) and an associated

pseudocyst. Simultaneous drainage of pseudocyst is not

necessary.

ANNALS OF SURGERY

Vol. 237, No. 5, 614–622