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Management of chronic pancreatitis is mainly palliative. Most patients with chronic pancreatitis require surgical evaluation and intervention when there is suspicion of pancreatic malignancy, evidence of intractable pain, or development of pancreatitis-related local complications. The ideal operation for chronic pancreatitis, therefore, should be designed to exclude the existence of malignancy, provide long-lasting pain relief, and correct the local complications. It should be as simple and safe as possible and should preserve the remaining endocrine and exocrine functions of the pancreas.

Sixty-seven of 207 patients with pancreatic and peripancreatic malignancies underwent preoperative fine needle aspiration cytology (FNA), and 24 patients underwent intraluminal endoscopic biopsies. All patients had confirmation of the diagnosis of malignancy either at operation, autopsy, or by clinical follow-up. FNA of liver metastases was positive for malignancy in 12 of 12 patients. FNA of the pancreas was performed on 44 patients with pancreatic adenocarcinoma and 11 patients with other pancreatic or peripancreatic malignancies. The diagnosis of cancer was established by FNA in 32 of 44 (72.4%) patients with pancreatic adenocarcinoma and 1 of 11 patients (9.1%) with other pancreatic or peripancreatic malignancies. In the patients with pancreatic adenocarcinoma, 17 of 18 patients (94.4%) who had no operative intervention, 12 of 18 (66.7%) patients who had palliative bypass procedures, and 3 of 8 (37.5%) patients resected had positive FNA. Eighteen of 24 patients (75%) who underwent intraluminal endoscopic biopsies, and 11 of 15 (73.3%) with ampullary carcinoma were positive. We believe that FNA is of limited value in the diagnosis of small resectable tumors of the pancreas as it identified cancer in only 3 of 8 patients in whom it was employed. False negative FNA may delay the diagnosis and treatment of pancreatic malignancies. Patients in whom there is a high index of suspicion of pancreatic or peripancreatic malignancy based on clinical presentation, CT scan, or ERCP assessment do not require preoperative, histologic proof of malignancy prior to pancreaticoduodenectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Ninety-one pancreatic injuries, 47 from blunt trauma, were reviewed with respect to management principles stressed in qi previous reviews. The pancreatic complication rate was 25%. Blunt injury was suspected preoperatively in only 30%. Even short-term observation led to morbidity. Operations done more than 6 hours after admission had a higher complication rate (45%) than those done less than 6 hours after admission (18%). Penrose drainage without a sump was not associated with increased complications. Distal pancreatectomy was done 32 times; splenectomy was done in only 18 patients. Individual duct ligation was rarely done and did not result in a high fistula rate. Pancreatic stump oversew with nonabsorbable suture was associated with a higher rate of pancreatic complications than absorbable suture (58% vs 30%). Only 56% of patients receiving distal pancreatectomy required hyperalimentation. Postoperative serum amylase values were not useful, and amylase values from drainage fluid predicted complications only when they were above 100,000 U/L. Details of pancreatic trauma management are less important than early operation in minimizing morbidity.

The experience with 131 patients with 157 pseudocysts is reported. One hundred and twenty patients with 146 pseudocysts underwent 165 operations. There were ten operative deaths (8.3%) three of which were not attributable to the pseudocyst or its operative management. Sixteen patients died six months to 14 years after operation. Deaths in six of the 16 patients were in part attributable to pancreatitis or complications of pseudocyst management. The operative mortality was highest in patients undergoing incision and drainage and cystoduodenostomy. Other factors influencing mortality unfavorably included postoperative gastrointestinal hemorrhage from a pseudocyst; rupture or fistulization of the cyst into the gastrointestinal tract if associated with hemorrhage, and evidence of common duct obstruction, or the location of cysts in the head or uncinate process of the pancreas. Visceral angiography should be performed on all patients with pseudocysts. The risk of massive gastrointestinal or intra-abdominal hemorrhage is highest in the 10% of patients having pseudoaneurysms associated with their pseudocysts. Incision and drainage of pseudocysts is associated with a high rate of recurrence of the cyst and continued pain. Incision and drainage should only be used if the cyst is infected, or the cyst wall is not mature enough to hold sutures. Cystogastrostomy and cystojejunostomy are the procedures of choice for mature cysts. The presence of a pseudoaneurysm visualized on preoperative visceral angiography is an indication for an excisional operation as are the presence of multiple cysts, compression of the common duct or duodenum by the cyst, evidence of left sided portal hypertension, recurrent cysts or evidence of chronic pancreatitis.

A collaborative Veterans Administration and University of California, Davis Medical Center group of 586 patients with histologically proved pancreatic carcinoma was reviewed. During laparotomy, 159 patients underwent 251 frozen-section pancreatic biopsies with subsequent permanent section examination of the same tissue block. All 112 positive frozen-section diagnoses were corroborated on permanent sectioning. The 47 patients with false-negative biopsy specimens were equally divided between sampling and interpretation error. We conclude that in this group of 159 pancreatic cancer patients, 30% failed to be correctly diagnosed by intraoperative frozen-section biopsy. This failure was due to patient sampling and interpretation error in equal proportion. Interpretation error rates were not influenced by the type or number of biopsies. Patient sampling error is apparently reduced by repeated biopsy, and specimen sampling error occurred less frequently with wedge biopsy.

Patients with chronic pancreatitis needing operative management include those with severe pain, those with complications of pancreatitis, or those in whom it is not possible to distinguish cancer of the pancreas from chronic pancreatitis. The use of endoscopic retrograde cholangiopancreatography, CT, and angiography to define the structural abnormalities has increased the surgeon's ability to select an operation matched to the patient's needs. A longitudinal pancreaticojejunostomy should be performed in patients whose ducts are dilated. When the head of the pancreas is enlarged and thickened, pancreaticoduodenectomy has been the traditional operation of choice. However, local resection with pyloric and duodenal preservation should now be considered an alternative that has a lower mortality rate and less likelihood of creating diabetes or exocrine insufficiency. Patients whose ducts are of insufficient caliber to permit longitudinal pancreaticojejunostomy are candidates for resection of the proximal or distal pancreas, depending on the site of disease or, alternatively, for the Beger or Warren procedure. Pain relief is achieved with surgery in about 80 per cent of patients with chronic pancreatitis. Many of the late deaths following operation for chronic pancreatitis are attributable, not to the operation, but to the effects of alcoholism. There is a need for surgeons to improve their observations and assessment of operative results.