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Anastomosis of the Duct of Wirsung: Its Use in Palliative Operations for Cancer of the Head of the Pancreas
ANASTOMOSIS OF THE DUCT OF WIRSUNG Its Use in Palliative Operations for Cancer of the Head of the Pancreas RICHARD
B.
CATTELL
AN increasing experience with the surgical treatment of cancer of the pancreas has uncovered new problems. Approximately SO per cent of malignancies of the head of the pancreas can be resected with some prospect of cure. This leaves a large proportion of patients in whom only means of palliative benefit are available. In a recent review of 56 patients with carcinoma of the head of the pancreas who were operated on previous to 1935 when Whipple's first radical resection was presented, we were surprised to find that the duration of life following the anastomosis of the biliary tract to the intestinal tract was short. Of the patients surviving the relatively simple proced~re of cholecyst jejunostomy, 75 per cent were dead within six months of operation or nine months after the onset of their obstructive jaundice. The most conspicuous symptoms associated with carcinoma of the head of the pancreas are those which are the result of the obstruction of the biliary tract. The intense and persisting pruritus that shows little response to medical measures of relief, quickly responds to the short-circuiting operation of joining the gallbladder to the intestinal tract. If the gallbladder is not available because of previous disease or operation, similar relief follows anastomosis of the common duct to the jejunum. The establishment of an external biliary fistula either by drainage of the gallbladder or common duct likewise will relieve the jaundice but has the disadvantage of diverting all bile which is so necessary for normal digestion. Replacement therapy with bile salts or whole bile oHers a somewhat difficult therapeutic problem in these cases. A patient with obstructive jaundice due to carcinoma of the head of the pancreas who has had cholecyst jejunostomy is very appreciative of the immediate relief of his pruritus. Even though the surgeon recognizes that such a palliative procedure may oHer a reasonable survival period of relative comfort, he may be less aware of the
digestive disturbances which continue unabated by the relief of the obstructive iaundice. Insufficient attention has been called to the associated condition present in most of these patients, that of obstruction of the pancreatic duct. It is the purpose of this paper to emphasize the symptoms related to the obstruction of the pancreatic ducts and to call attention 686
ANASTOMOSIS OF THE DUGI' OF WIRSUNG
637
to the physical signs by which it can be recognized at operation, as well as to present a method for its relief. The symptoms presented by patients with obstructive jaundice due to carcinoma are well recognized and need not be enumerated. The earliest symptoms associated with obstruction to the pancreatic ducts are the direct result of a diminished amount of external pancreatic secretion in the intestinal tract. A change in bowel function is frequently the first symptom. An unusual amount of intestinal gas may be present with occasional watery stools or intermittent diarrhea. The stool may become foamy and of increased bulk. General abdominal discomfort and indigestion are frequent complaints. The patient may complain of a sensation of pressure low in the epigastrium. Back pain may be the only localizing symptom. This may be more prominent while lying down, and interfere with sleep. The most comfortable position for the relief of this symptom is found by sitting up and leaning forward. This pain is usually more pronounced on the right side, although usually it passes across the median line. When the malignancy is primary in the duct of Wirsung or in the head of the pancreas, the process may extend considerably before causing obstructive jaundice. These patients may develop anorexia, weight loss, anemia and weakness. When the carcinoma is in the body of the pancreas the malignancy may be quite extensive before there are sufficient localizing symptoms to suspect the pancreas as the site of origin. Since physical examination may be negative, and laboratory and roentgenologic findings inconclusive, exploration is too often delayed until no surgical relief is possible. In our earlier experience, no attempt was made to differentiate clinically between carcinoma of the body of the pancreas, carcinoma of the head of the pancreas or carcinoma of the ampulla of Vater. Any patient who presented progressive painless jaundice and who had enlargement of the liver and a palpable gallbladder had a diagnosis of carcinoma of the pancreas. Following a review of over 100 histories of patients with this condition and with the recognition of the symptoms that follow exclusion of the pancreatic juice from the gastrointestinal tract, we have been able to make a much more accura~ diagnosis of the location of the carcinoma causing the obstructive jaundice. It i!\ possible to differentiate carcinoma of the amphlla from carcinoma of the head of the pancreas by reviewing the order of onset of symptoms. Carcinoma that begins in the head of the pancreas will usually cause obstruction of the ducts of Wirsung and Santorini before obstruction of the common bile duct. Thus, the symptoms of indigestion, gas, bloating, diarrhea and bulky foamy stools will be initial symptoms. On the contrary, carcinoma of the ampulla of Vater causes early obstruction of the common bile duct so that pruritus and jaundice are the first symptoms and only later as the pancreatic ducts' are encroached upon are the other symptoms produced.
638
RICHARD B. CATrELL
Obstruction of the duct of Wirsung is easy to recognize at operation. Palpation of the body of the pancreas enables one to determine whether the body is diffusely enlarged and firm, with blunting of the tail. It also permits digital palpation of the duct itself. This is possible without any dissection and the area of the duct can be felt through either the gastrohepatic or gastrocolic omentum without opening these structures. The duct is most readily felt in the body in its mid portion before it joins the neck. The duct runs a longitudinal course nearer the anterior surface of the pancreas and usually is at the junction of the middle and upper third of the body. The normal duct cannot be palpated but when dilatation is present as the result of obstruction, one can pass the pulp of the index finger deeply into the fluctuant course of the duct. If further evidence is needed to prove its· dilatation, a needle can be passed into the duct and clear pancreatic juice evacuated. A normal duct cannot be identified by this means. As experience increases in palpation of the pancreas, one can readily detect changes of the duct system. In carcinoma of the head of the pancreas, the duct of Wirsung is usually dilated and can be palpated without difficulty. The duct may vary in size, depending on the duration and completeness of the obstruction, from a few millimeters in diameter to 2 cm. in diameter. The largest duct system that we have explored held over 800 cc. of clear pancreatic fluid. At times the acinar cells of the pancreas have been little in evidence and the duct system will make up most of the pancreatic mass that can be felt. With these findings recognized, it will at once be evident that relief of the obstruction can readily be accomplished by anastomosis of the duct to the intestinal tract in a manner similar to that for the relief of the biliary obstruction. We have now had considerable experience in the identification of the duct of Wirsung in these cases. It has been anastomosed to the jejunum forty times in 41 radical pancreatoduodenal resections when it was feasible to resect the carcinoma. In only one resection, our first one performed in August 1940, have we failed to anastomose the duct in one of these resections. It is our firm opinion that this is the most important factor in reducing serious complications following resection of the head and has been a material factor in keeping the operative mortality down to approximately 17 per cent. In only 1 patient in whom the duct was anastomosed following resection did the anastomosis fail to be maintained. Failure to anastomose the duct may result in an external pancreatic fistula which may lead to postoperative hemorrhage or retroperitoneal sepsis. Furthermore, failure to anastomose the duct, even. though serious complications are avoided, usually leads to sufficient physiologic disturbances in digestion that pancreatic replacement therapy is necessary and even with it nutrition still is impaired and few patients regain their normal weight.
_J
ANASTOMOSIS OF THE DUcr OF WmSUNG
689
In patients in whom resection is not feasible because of distant spread or local invasion, it may still be possible to return the pancreatic juice to the intestinal tract as well as relieve the obstructive jaundice. In 14 patients in whom we thought resection was not feasible we have anastomosed the duct of Wirsung as well as the gallbladder to the jejunum, thus relieving both the pancreatic and biliary obstructions. There has been no postoperative death in these 14 cases even though these patients represent poor surgical risks. The exposure of the pancreas.,for this anastomosis is best accomplished by dividing the gastrocolic omentum. The lesser peritoneal
Fig. 244.-Exposure of the pancreas is best obtained by division of the gastrocolic omentum.
sac is entered at the right margin, following which the stomach and first part of the duodenum are elevated and the right transverse colon displaced downward, with the middle colic vessels intact (Fig. 244). The proximal jejunum is then brought up in an antecolic position and the anastomosis to the pancreatic duct done 12 inches (80 cm.) from the ligament of Treitz. The duct of Wirsung must be anastomosed to the jejunum in continuity, in other words, a side-to-side anastomosis must be made since division of the pancreas would leave the distal duct obstructed. We have accomplished this anastomosis by two technical procedures. 1. If only moderate distention of the duct is present, the jejunum is
640
RICHARD B. CA'ITELL
sutured to the mid portion of the body of the pancreas, following which the seromuscular coat of the jejunum is divided, exposing the mucosa. The anterior surface of the pancreas is incised over the duct
Fig. 245.-a, Anastomosis of the duct of Wirsung to the jejunum by the necrosing suture technic. The seromuscular coat of jejunum is incised. The pancreas is entered over the duct and a silk suture is passed into the duct and jejunal mucosa. b, When the duct of Wirsung is markedly dilated, an open anastomosis is preferable. The mucosa of the duct is sutured to the mucosa of the jejunum over aT-tube.
but is not entered (Fig. 245, a). A braided silk suture is then passed through the anterior wall of the duct and through 1 cm. of the exposed jejunal mucosa and is tied tightly. The opposite side of the
ANAsrOMOSIS OF THE DUCT OF WIRSUNG
641
Jejunum is then sutured to the upper side of the pancreatic body above the duct. 2. If the duct of Wirsung is large, it is opened for a distance of 2 cm., a T --tube inserted into it and an open anastomosis performed to the jejunum, ,suturing the mucosa of the duct to the mucosa of the jejunum with a no~absorbable suture line outside (Fig. 245, b). When this anastomosis has been completed either by the necrosing suture technic or by open anastomosis, the efferent loop of the jejunum is then brought over to the gallbladder anq a cholecyst jejunostomy done 3 or 4 inches. (7.5 to 10 cm.) distal to the pancreatic anastomosis. The operation is completed by doing an entero-enterostomy 4 inches (10 cm.) proximal to each of the two previous anastomoses, thus
Fig. 246.-The usual cholecystjejunostomy is shown distal to the pancreatojejunai anastomosis. A jejunojejunostomy short circuits the two anastomoses.
short-circuiting them to avoid regurgitation into the two duct systems (Fig. 246). The relief that may be accomplished by anastomosis of the duct of Wirsung in an inoperable carcinoma of the head of the pancreas ~s well illustrated by the following case report. REPORT OF CASE This patient was first seen July 9, 1945. He had been well until January, 1944, eighteen months previously, when he first consulted his physician because of indigestion' and watery stools. A complete gastrointestinal roentgenologic study was done,.which was negative. No abnormality of the stomach or duode~um was Ilote~ and the. colon appeared normal. In spite of the negative findings, he was treated for peptic ulcer. In October, 1944, he had a six-day illness with epigas-
642
RICHARD B. CATTELL
tric discomfort, back pain and fever, but no jaundice. His highest temperature was 101 0 • A cholecystogram was made which showed filling of the gallbladder but delay in emptying. He was then well for three months, when attacks developed of epigastric pain, chills, fever, nausea and vomiting, and in January, 1945, jaundice was Rrst noted. During this time he had lost over 50 pounds, from a normal weight of 200 to 146 pounds. In February, 1945, he was operated on at another hospital, at which time a large dilated gallbladder was found, the common duct was dilated with edema of the gastrohepatic omentum, and there was a hard symmetrical tumor in the head of the pancreas. Cholecystostomy was performed and he made a good recovery from operation and was reasonably comfortable as long as the gallbladder sinus remained open. However, his bowel symptoms and epigastric discomfort continued. At our initial examination in July, 1945, his weight was 150 pounds. There was a small sinus in the right upper quadrant incision which drained mucus and bile. His blood studies showed no secondary anemia. The prothrombin was 90 per cent of normal, the blood bilirubin 1.9 mg. per cent. The patient was operated on July 13, 1945. A large symmetrical tumor, 8 cm. in diameter, was found Rlling'the head of the pancreas. It obstructed the common bile duct which Was 3 cm. in diameter. The gallbladder was dilated in spite of the persisting sinus which communicated with it. After dissection of the gastrohepatic and gastrocolic ligaments, with division of the right gastric and gastroduodenal arteries, the tumor was found to be invading the portal vein and adherent to the superior mesenteric vessels. The tumor extended posteriorly to involve the jejunum in the region of the ligament of Treitz. The duct of Wirsung was 1.5 cm. in diameter and could be readily palpated. Regional lymph nodes were removed for study 'but did not show metastases. The tumor .was considered to be inoperable because of invasion of tne portal vein and superior mesenteric vessels. A side-to-side anastomosis between the duct of Wirsung and the jejunum was performed, utilizing a necrosing silk suture technic to establish the anastomosis. The gallbladder was detached from the abdominal wall and a cholecyst jejunostomy performed. A jejunojejunostomy was then done 3 inches (7.5 cm.) proximal to these two anastomoses. The patient made a good recovery from operation and was discharged from the hospital July 31, eighteen days after operation. He was reexamined September 13, 1945, October 29, 1945, and January 4, 1946. At the visit on January 4 he weighed 169 pounds and was actively working and felt greatly improved. His epigastric pressure and discomfort were relieved. He had been taking vitamin Bl and panteric capsules. Recurrent headaches had developed but roentgenograms of the cervical spine and skull were negative for metastases. He had one formed stool daily of normal color but of somewhat increased bulk. There was no jaundice, and blood bilirubin was normal. In December, 1946, he weighed 180 pounds but had had occasional digestive upsets and abdominal discomfort, the latter relieved by lying down. On several occasions he had had epigastric pain lasting from one to three days, with loss of appetite and occasional headache. The attacks would clear within ten days to two weeks. He was continuing to be active in his business. COMMENT
In spite of the usual course of carcinoma of the pancreas which leads to death in 75 per cent of cases within nine months of the onset
ANASTOMOSIS OF THE DUcr OF WmSUNG
643
of obstructive jaundice, some patients live for a considerable period. This patient has been under observation for two years from the onset of his symptoms, and eighteen months after relief of his biliary and pancreatic obstruction. The conspicuous feature of his course was the relative degree of comfort that followed the palliative procedure, especially his proven ability to regain and maintain an essentially normal weight. His digestive and bowel functions were markedly improved and to a much greater degree than we have observed following cholecyystjejunostomy alone. Except for occasional attacks of abdominal discomfort, epigastric pain and indigestion, he has been relatively free of symptoms during this period of observation. From a clinical viewpoint he has had no return of obstructive jaundice and his pancreatic duct anastomosis has remained open. This case presents an unusually favorable response to duct anastomosis and is one of the most favorable results that we have observed in the 14 patients in whom this procedure has been carried out. The back pain, epigastric discomfort and pain have usually been considered to be due to extension of the malignancy. In a number of patients we have seen pain relieved following relief of obstruction of the pancreatic ducts, and believe that such obstruction may be responsible for pain and discomfort in these cases. From our observation of patients who have had relief of obstructive jaundice by cholecystjejunostomy, we conclude that gain in weight cannot be anticipated. This has been equally true of patients who have had pancreatoduodenectomy performed without anastomosis of the pancreas to the jejunum. For this reason we recommend anastomosis of the duct of Wirsung in all cases in which pancreatoduodenal resection is done and in suitable cases of inoperable cancer of the head of the pancreas for the palliative benefit which may occur. SUMMARY
Obstruction of the duct of Wirsung is a common finding'in cancer of the head of the pancreas. It leads to marked disturbance of nutrition and causes digestive and bowel symptoms. A new method of anastomosis of the duct of Wirsung to the jejunum in cases of inoperable carcinoma of the head of the pancreas is presented. This may be done as an open anastomosis over a T-tube or as a closed anastomosis with a necrosing suture technic. Anastomosis of the duct of Wirsung in inoperable cases restores the pancreatic juice to the intestinal tract and may be followed by temporary dramatic relief of digestive symptoms and by satisfactory gain in weight. A case is reported to illustrate what may be accomplished by this procedure. Anastomosis of the duct of Wirsung as well as anastomosis of the biliary tract to the jejunum should be done whenever feasible to offer the greatest possible palliative benefit.
B.
CATTELL
AN increasing experience with the surgical treatment of cancer of the pancreas has uncovered new problems. Approximately SO per cent of malignancies of the head of the pancreas can be resected with some prospect of cure. This leaves a large proportion of patients in whom only means of palliative benefit are available. In a recent review of 56 patients with carcinoma of the head of the pancreas who were operated on previous to 1935 when Whipple's first radical resection was presented, we were surprised to find that the duration of life following the anastomosis of the biliary tract to the intestinal tract was short. Of the patients surviving the relatively simple proced~re of cholecyst jejunostomy, 75 per cent were dead within six months of operation or nine months after the onset of their obstructive jaundice. The most conspicuous symptoms associated with carcinoma of the head of the pancreas are those which are the result of the obstruction of the biliary tract. The intense and persisting pruritus that shows little response to medical measures of relief, quickly responds to the short-circuiting operation of joining the gallbladder to the intestinal tract. If the gallbladder is not available because of previous disease or operation, similar relief follows anastomosis of the common duct to the jejunum. The establishment of an external biliary fistula either by drainage of the gallbladder or common duct likewise will relieve the jaundice but has the disadvantage of diverting all bile which is so necessary for normal digestion. Replacement therapy with bile salts or whole bile oHers a somewhat difficult therapeutic problem in these cases. A patient with obstructive jaundice due to carcinoma of the head of the pancreas who has had cholecyst jejunostomy is very appreciative of the immediate relief of his pruritus. Even though the surgeon recognizes that such a palliative procedure may oHer a reasonable survival period of relative comfort, he may be less aware of the
digestive disturbances which continue unabated by the relief of the obstructive iaundice. Insufficient attention has been called to the associated condition present in most of these patients, that of obstruction of the pancreatic duct. It is the purpose of this paper to emphasize the symptoms related to the obstruction of the pancreatic ducts and to call attention 686
ANASTOMOSIS OF THE DUGI' OF WIRSUNG
637
to the physical signs by which it can be recognized at operation, as well as to present a method for its relief. The symptoms presented by patients with obstructive jaundice due to carcinoma are well recognized and need not be enumerated. The earliest symptoms associated with obstruction to the pancreatic ducts are the direct result of a diminished amount of external pancreatic secretion in the intestinal tract. A change in bowel function is frequently the first symptom. An unusual amount of intestinal gas may be present with occasional watery stools or intermittent diarrhea. The stool may become foamy and of increased bulk. General abdominal discomfort and indigestion are frequent complaints. The patient may complain of a sensation of pressure low in the epigastrium. Back pain may be the only localizing symptom. This may be more prominent while lying down, and interfere with sleep. The most comfortable position for the relief of this symptom is found by sitting up and leaning forward. This pain is usually more pronounced on the right side, although usually it passes across the median line. When the malignancy is primary in the duct of Wirsung or in the head of the pancreas, the process may extend considerably before causing obstructive jaundice. These patients may develop anorexia, weight loss, anemia and weakness. When the carcinoma is in the body of the pancreas the malignancy may be quite extensive before there are sufficient localizing symptoms to suspect the pancreas as the site of origin. Since physical examination may be negative, and laboratory and roentgenologic findings inconclusive, exploration is too often delayed until no surgical relief is possible. In our earlier experience, no attempt was made to differentiate clinically between carcinoma of the body of the pancreas, carcinoma of the head of the pancreas or carcinoma of the ampulla of Vater. Any patient who presented progressive painless jaundice and who had enlargement of the liver and a palpable gallbladder had a diagnosis of carcinoma of the pancreas. Following a review of over 100 histories of patients with this condition and with the recognition of the symptoms that follow exclusion of the pancreatic juice from the gastrointestinal tract, we have been able to make a much more accura~ diagnosis of the location of the carcinoma causing the obstructive jaundice. It i!\ possible to differentiate carcinoma of the amphlla from carcinoma of the head of the pancreas by reviewing the order of onset of symptoms. Carcinoma that begins in the head of the pancreas will usually cause obstruction of the ducts of Wirsung and Santorini before obstruction of the common bile duct. Thus, the symptoms of indigestion, gas, bloating, diarrhea and bulky foamy stools will be initial symptoms. On the contrary, carcinoma of the ampulla of Vater causes early obstruction of the common bile duct so that pruritus and jaundice are the first symptoms and only later as the pancreatic ducts' are encroached upon are the other symptoms produced.
638
RICHARD B. CATrELL
Obstruction of the duct of Wirsung is easy to recognize at operation. Palpation of the body of the pancreas enables one to determine whether the body is diffusely enlarged and firm, with blunting of the tail. It also permits digital palpation of the duct itself. This is possible without any dissection and the area of the duct can be felt through either the gastrohepatic or gastrocolic omentum without opening these structures. The duct is most readily felt in the body in its mid portion before it joins the neck. The duct runs a longitudinal course nearer the anterior surface of the pancreas and usually is at the junction of the middle and upper third of the body. The normal duct cannot be palpated but when dilatation is present as the result of obstruction, one can pass the pulp of the index finger deeply into the fluctuant course of the duct. If further evidence is needed to prove its· dilatation, a needle can be passed into the duct and clear pancreatic juice evacuated. A normal duct cannot be identified by this means. As experience increases in palpation of the pancreas, one can readily detect changes of the duct system. In carcinoma of the head of the pancreas, the duct of Wirsung is usually dilated and can be palpated without difficulty. The duct may vary in size, depending on the duration and completeness of the obstruction, from a few millimeters in diameter to 2 cm. in diameter. The largest duct system that we have explored held over 800 cc. of clear pancreatic fluid. At times the acinar cells of the pancreas have been little in evidence and the duct system will make up most of the pancreatic mass that can be felt. With these findings recognized, it will at once be evident that relief of the obstruction can readily be accomplished by anastomosis of the duct to the intestinal tract in a manner similar to that for the relief of the biliary obstruction. We have now had considerable experience in the identification of the duct of Wirsung in these cases. It has been anastomosed to the jejunum forty times in 41 radical pancreatoduodenal resections when it was feasible to resect the carcinoma. In only one resection, our first one performed in August 1940, have we failed to anastomose the duct in one of these resections. It is our firm opinion that this is the most important factor in reducing serious complications following resection of the head and has been a material factor in keeping the operative mortality down to approximately 17 per cent. In only 1 patient in whom the duct was anastomosed following resection did the anastomosis fail to be maintained. Failure to anastomose the duct may result in an external pancreatic fistula which may lead to postoperative hemorrhage or retroperitoneal sepsis. Furthermore, failure to anastomose the duct, even. though serious complications are avoided, usually leads to sufficient physiologic disturbances in digestion that pancreatic replacement therapy is necessary and even with it nutrition still is impaired and few patients regain their normal weight.
_J
ANASTOMOSIS OF THE DUcr OF WmSUNG
689
In patients in whom resection is not feasible because of distant spread or local invasion, it may still be possible to return the pancreatic juice to the intestinal tract as well as relieve the obstructive jaundice. In 14 patients in whom we thought resection was not feasible we have anastomosed the duct of Wirsung as well as the gallbladder to the jejunum, thus relieving both the pancreatic and biliary obstructions. There has been no postoperative death in these 14 cases even though these patients represent poor surgical risks. The exposure of the pancreas.,for this anastomosis is best accomplished by dividing the gastrocolic omentum. The lesser peritoneal
Fig. 244.-Exposure of the pancreas is best obtained by division of the gastrocolic omentum.
sac is entered at the right margin, following which the stomach and first part of the duodenum are elevated and the right transverse colon displaced downward, with the middle colic vessels intact (Fig. 244). The proximal jejunum is then brought up in an antecolic position and the anastomosis to the pancreatic duct done 12 inches (80 cm.) from the ligament of Treitz. The duct of Wirsung must be anastomosed to the jejunum in continuity, in other words, a side-to-side anastomosis must be made since division of the pancreas would leave the distal duct obstructed. We have accomplished this anastomosis by two technical procedures. 1. If only moderate distention of the duct is present, the jejunum is
640
RICHARD B. CA'ITELL
sutured to the mid portion of the body of the pancreas, following which the seromuscular coat of the jejunum is divided, exposing the mucosa. The anterior surface of the pancreas is incised over the duct
Fig. 245.-a, Anastomosis of the duct of Wirsung to the jejunum by the necrosing suture technic. The seromuscular coat of jejunum is incised. The pancreas is entered over the duct and a silk suture is passed into the duct and jejunal mucosa. b, When the duct of Wirsung is markedly dilated, an open anastomosis is preferable. The mucosa of the duct is sutured to the mucosa of the jejunum over aT-tube.
but is not entered (Fig. 245, a). A braided silk suture is then passed through the anterior wall of the duct and through 1 cm. of the exposed jejunal mucosa and is tied tightly. The opposite side of the
ANAsrOMOSIS OF THE DUCT OF WIRSUNG
641
Jejunum is then sutured to the upper side of the pancreatic body above the duct. 2. If the duct of Wirsung is large, it is opened for a distance of 2 cm., a T --tube inserted into it and an open anastomosis performed to the jejunum, ,suturing the mucosa of the duct to the mucosa of the jejunum with a no~absorbable suture line outside (Fig. 245, b). When this anastomosis has been completed either by the necrosing suture technic or by open anastomosis, the efferent loop of the jejunum is then brought over to the gallbladder anq a cholecyst jejunostomy done 3 or 4 inches. (7.5 to 10 cm.) distal to the pancreatic anastomosis. The operation is completed by doing an entero-enterostomy 4 inches (10 cm.) proximal to each of the two previous anastomoses, thus
Fig. 246.-The usual cholecystjejunostomy is shown distal to the pancreatojejunai anastomosis. A jejunojejunostomy short circuits the two anastomoses.
short-circuiting them to avoid regurgitation into the two duct systems (Fig. 246). The relief that may be accomplished by anastomosis of the duct of Wirsung in an inoperable carcinoma of the head of the pancreas ~s well illustrated by the following case report. REPORT OF CASE This patient was first seen July 9, 1945. He had been well until January, 1944, eighteen months previously, when he first consulted his physician because of indigestion' and watery stools. A complete gastrointestinal roentgenologic study was done,.which was negative. No abnormality of the stomach or duode~um was Ilote~ and the. colon appeared normal. In spite of the negative findings, he was treated for peptic ulcer. In October, 1944, he had a six-day illness with epigas-
642
RICHARD B. CATTELL
tric discomfort, back pain and fever, but no jaundice. His highest temperature was 101 0 • A cholecystogram was made which showed filling of the gallbladder but delay in emptying. He was then well for three months, when attacks developed of epigastric pain, chills, fever, nausea and vomiting, and in January, 1945, jaundice was Rrst noted. During this time he had lost over 50 pounds, from a normal weight of 200 to 146 pounds. In February, 1945, he was operated on at another hospital, at which time a large dilated gallbladder was found, the common duct was dilated with edema of the gastrohepatic omentum, and there was a hard symmetrical tumor in the head of the pancreas. Cholecystostomy was performed and he made a good recovery from operation and was reasonably comfortable as long as the gallbladder sinus remained open. However, his bowel symptoms and epigastric discomfort continued. At our initial examination in July, 1945, his weight was 150 pounds. There was a small sinus in the right upper quadrant incision which drained mucus and bile. His blood studies showed no secondary anemia. The prothrombin was 90 per cent of normal, the blood bilirubin 1.9 mg. per cent. The patient was operated on July 13, 1945. A large symmetrical tumor, 8 cm. in diameter, was found Rlling'the head of the pancreas. It obstructed the common bile duct which Was 3 cm. in diameter. The gallbladder was dilated in spite of the persisting sinus which communicated with it. After dissection of the gastrohepatic and gastrocolic ligaments, with division of the right gastric and gastroduodenal arteries, the tumor was found to be invading the portal vein and adherent to the superior mesenteric vessels. The tumor extended posteriorly to involve the jejunum in the region of the ligament of Treitz. The duct of Wirsung was 1.5 cm. in diameter and could be readily palpated. Regional lymph nodes were removed for study 'but did not show metastases. The tumor .was considered to be inoperable because of invasion of tne portal vein and superior mesenteric vessels. A side-to-side anastomosis between the duct of Wirsung and the jejunum was performed, utilizing a necrosing silk suture technic to establish the anastomosis. The gallbladder was detached from the abdominal wall and a cholecyst jejunostomy performed. A jejunojejunostomy was then done 3 inches (7.5 cm.) proximal to these two anastomoses. The patient made a good recovery from operation and was discharged from the hospital July 31, eighteen days after operation. He was reexamined September 13, 1945, October 29, 1945, and January 4, 1946. At the visit on January 4 he weighed 169 pounds and was actively working and felt greatly improved. His epigastric pressure and discomfort were relieved. He had been taking vitamin Bl and panteric capsules. Recurrent headaches had developed but roentgenograms of the cervical spine and skull were negative for metastases. He had one formed stool daily of normal color but of somewhat increased bulk. There was no jaundice, and blood bilirubin was normal. In December, 1946, he weighed 180 pounds but had had occasional digestive upsets and abdominal discomfort, the latter relieved by lying down. On several occasions he had had epigastric pain lasting from one to three days, with loss of appetite and occasional headache. The attacks would clear within ten days to two weeks. He was continuing to be active in his business. COMMENT
In spite of the usual course of carcinoma of the pancreas which leads to death in 75 per cent of cases within nine months of the onset
ANASTOMOSIS OF THE DUcr OF WmSUNG
643
of obstructive jaundice, some patients live for a considerable period. This patient has been under observation for two years from the onset of his symptoms, and eighteen months after relief of his biliary and pancreatic obstruction. The conspicuous feature of his course was the relative degree of comfort that followed the palliative procedure, especially his proven ability to regain and maintain an essentially normal weight. His digestive and bowel functions were markedly improved and to a much greater degree than we have observed following cholecyystjejunostomy alone. Except for occasional attacks of abdominal discomfort, epigastric pain and indigestion, he has been relatively free of symptoms during this period of observation. From a clinical viewpoint he has had no return of obstructive jaundice and his pancreatic duct anastomosis has remained open. This case presents an unusually favorable response to duct anastomosis and is one of the most favorable results that we have observed in the 14 patients in whom this procedure has been carried out. The back pain, epigastric discomfort and pain have usually been considered to be due to extension of the malignancy. In a number of patients we have seen pain relieved following relief of obstruction of the pancreatic ducts, and believe that such obstruction may be responsible for pain and discomfort in these cases. From our observation of patients who have had relief of obstructive jaundice by cholecystjejunostomy, we conclude that gain in weight cannot be anticipated. This has been equally true of patients who have had pancreatoduodenectomy performed without anastomosis of the pancreas to the jejunum. For this reason we recommend anastomosis of the duct of Wirsung in all cases in which pancreatoduodenal resection is done and in suitable cases of inoperable cancer of the head of the pancreas for the palliative benefit which may occur. SUMMARY
Obstruction of the duct of Wirsung is a common finding'in cancer of the head of the pancreas. It leads to marked disturbance of nutrition and causes digestive and bowel symptoms. A new method of anastomosis of the duct of Wirsung to the jejunum in cases of inoperable carcinoma of the head of the pancreas is presented. This may be done as an open anastomosis over a T-tube or as a closed anastomosis with a necrosing suture technic. Anastomosis of the duct of Wirsung in inoperable cases restores the pancreatic juice to the intestinal tract and may be followed by temporary dramatic relief of digestive symptoms and by satisfactory gain in weight. A case is reported to illustrate what may be accomplished by this procedure. Anastomosis of the duct of Wirsung as well as anastomosis of the biliary tract to the jejunum should be done whenever feasible to offer the greatest possible palliative benefit.