Saturday, October 30, 2010

CASE: Perforated sigmoid diverticula with peritonitis

perforation peritonitis with sigmoid diverticula

sigmoid diverticula

perforated diverticula with peritonitis

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

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

CASE: chronic alcoholic pancreatitis pus in MPD (27.10.10) @ SURAT GENERAL

chronic alcoholic pancreatitis

MPD with pus discharge within

Longitudinally opened pancreatic duct with coring of head

completed LPJ

Thursday, October 21, 2010

Evidence-Based Pancreatic Head Resection for Pancreatic Cancer and Chronic Pancreatitis

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

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.

Vol. 236, No. 2, 137–148

Long-Term Results of Distal Pancreatectomy for Chronic Pancreatitis in 90 Patients

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

Tuesday, October 19, 2010

* Treatment of Re currant acute on chronic pancreatitis

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

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.
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).
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%).
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

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

* Treatment of chronic pancreatitis with pseudocyst in tail

"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

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.
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.
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.
Ductal drainage alone (LPJ) is sufficient in patients with
chronic pancreatitis (MPD 7 mm) and an associated
pseudocyst. Simultaneous drainage of pseudocyst is not

Vol. 237, No. 5, 614–622
© 2003 Lippincott Williams & Wilkins, Inc.

CASE : chronic pancreatitis with divism (14.10.10, SURAT,MAHAVIR)

a 28 years Boy with chronic pancreatitis with head mass, operated for Frey's procedure and Lateral pancreatico jejunostmoy done, patient discharged on Post Op day 7.

CASE 1: left hepatectomy (24.9.10, SURAT, MAHAVIR hospital)

giant hemangioma

highly vascular tumor

after resection of tumor and left lobe of liver

removed tumor