Growing Role of Early Surgery in Chronic Pancreatitis: A Practical Clinical Approach

Vol. 61, No.3 Printed in U.S.A.

GASTROENTEROLOGY

Copyright© 1971 by The Williams & Wilkins Co.

CURRENT CLINICAL CONCEPTS Thomas R . Hendrix, M .D . Current Clinical Concepts Editor The Johns Hopkins University School of Medicine Baltimore, Maryland

GROWING ROLE OF EARLY SURGERY IN CHRONIC PANCREATITIS: A PRACTICAL CLINICAL APPROACH JOHN

A.

DIXON, M.D ., AND EDWIN ENGLERT , JR., M.D.

Departments of Medicine and Surgery, University of Utah College of Medicine, and Veterans Administration Hospital, Salt Lake City, Utah

Many patients with chronic pancreatitis of the alcoholic, idiopathic, and familial varieties pursue a progressive if variable course over a period of years characterized by pain and ultimately by some of the complications of weight loss, debility, narcotic addiction, diabetes, pancreatic calcification, pseudocyst formation, and steatorrhea. With the exception of the complete elimination of alcoholic intake, medical measures are generally unrewarding. Procedures designed to provide drainage of the duct of Wirsung or excision of diseased pancreas can be applied with good results and an acceptable mortality when carefully selected for each individual patient on the basis of gross operative findings and operative pancreatography. Consequently, the use of surgery in the well established but early phases of the disease should be carefully considered in an attempt to prevent or modify the end stages of the disease process. Management of the patient with chronic inflammatory disease of the pancreas is most challenging for the gastroenterologist and surgeon. It is not at all certain that chronic pancreatitis is merely the result of acute pancreatitis, but Dreiling and Janowitz 1 list 66 possible etiological factors in the pathogenesis of acute and/or chronic pancreatitis, many of which can be alleviated by various forms of specific therapy. 2 The patient with alcoholic pancreatitis, 3 familial pancreatitis•·a or the rather nondescript "idiopathic" pancreatitis seems less amenable to treatment. 7 Moreover, treatment of every sort is usually unduly Received March 30, 1971. Address requests for reprints to: Dr. Edwin Englert, Jr., Veterans Administration Hospital, Salt Lake City, Utah 84113.

withheld because of delayed diagnosis. Fitzgerald et al. 3 noted a mean duration of symptoms of 3 Vz years for males and 5 years for females before diagnosis. Gambill et al. 8 described the average prediagnosis interval as 7 1/z years. Severe pain is the prominent symptom in 80 to 98%9 • 10 of cases. After variable periods an average weight loss of 20% of body weight occurs in advanced cases. 8 Pancreatic calcification occurs in 31% 10 and glucose intolerance in 64% of these patients. 9 Once a progressive trait is established, the disease appears to move inexorably but at a variable pace in its course with resulting debility, narcotic addiction, and psychiatric problems. 1 0 • 11 The medical therapy of chronic pancreatitis leaves much to be desired. 1• 9 • 12 The intake of alcohol in any form is proscribed. 9 • 13 Despite medical therapy, how-

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ever, pain, diarrhea, inanition, incapacitation with alcohol, and narcotic addiction are all too frequently prominent and intractable. 14 The lack of response to medical therapy and desire to assist these unfortunate persons have resulted in the application of a wide variety of surgical procedures directed at known or presumed etiological factors in this protean disease. 15 Cholecystectomy, exploration of common duct, sphincterotomy, vagotomy and pyloroplasty, subtotal gastrectomy, sympathectomy, 16 and celiac ganglionectomy, 17 as well as a number of types of resective and drainage procedures on the pancreas, have been applied with varying degrees of success. 1 5 The proper application of the direct procedures of ductal drainage or pancreatic excision (based upon an attack on the effects, rather than any presumed etiology, of the disease) has brought the best results. 18 Recent additional improvement in the surgical management of these patients has been attributed to the individualized application of a direct procedure for each patient based upon the gross findings of the pancreas at surgery 1 9 • 20 and upon operative pancreatography, 21 - 24 performed by choledochotomy, 14 transpancreatic injection of the duct of Wirsung, 2 5 caudal injection after excision of the tail of the pancreas, or transduodenal injection via the ampulla of Vater. 26 The findings of this radiographic technique indicate the type and probability of success of ductal drainage procedures. 2 7 This information, coupled with the gross observation of the pancreas, is sufficient to provide considerable precision in the selection of an operation. 2 0 • 2 8 Rationale of Early Surgery In light of these four observations, viz delayed diagnosis indicating an advanced process by the time diagnosis is made, high incidence of serious sequelae, the emergence of criteria to tailor the surgical maneuver to the pathology, and success attending the use of such individualized surgical intervention, it appears that the time has arrived to give serious thought to

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surgical exploration earlier in the course of chronic pancreatitis than heretofore. Proper timing for early surgery requires two major considerations: accurate diagnosis and clear cut demonstration that the natural history of the specific patient in question has entered the phase of progressive (recurrent or continuous) chronic pancreatitis. Diagnosis is difficult because the classic pentad of pain, calcification, pseudocyst, diabetes mellitus, and steatorrhea is late and rarely complete, and any one or two of these can be due to an entirely separate process. Enzyme studies are not often helpful as they may be in acute pancreatitis. Many of these patients present only with classic or atypical pain patterns and are considered as neurotic or functional patients by the unsuspecting clinician. A high index of suspicion is required, and, although not sensitive enough to detect every case, careful secretin tests and search for the aforementioned sequelae should be carried out in all patients with constant or recurrent abdominal pain, especially when the pain has a component of boring into the back or into the mid-, right, or left epigastrium. Once diagnosed, progression of the disease is easier to defme. A history of recurrent or continuing pain and appearance of any complication or sequelae is documentary. At exploration, the criteria for, and surgical techniques indicated by, the findings in the individual patients are outlined below. Biliary Tract Procedures Despite careful screening and previous operations, a few cases with residual biliary tract disease appear in the chronic pancreatitis category. 2 These may or may not be associated with alcoholic pancreatitis. 29 Gross inspection at the time of operation usually reveals a pathological gallbladder or dilated common duct. The pancreas may be diffusely indurated. Pancreatography reveals a normal duct of Wirsung. Operative cholangiography may demonstrate common duct stones, common duct strictures, impacted ampullary stones, or fi-

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brosis of the ampulla of Vater. Appropriate correction of these problems can usually be accomplished with low mortality and without serious sequelae. This should modify the process, thereby preventing or reducing the sequelae and complications. Good results, as measured by long term relief of pain, are obtained in 93 % of cases. 30 If alcoholic pancreatitis coexists with biliary tract disease, postoperative results are less favorable and tend to resemble those in alcoholic pancreatitis. 1 5 Drainage of Cysts Pseudocysts of the pancreas may be found grossly at the time of operation. Pancreatography may demonstrate a major ductal connection or ductal obstruction in association with a pancreatic cyst. 14 Large cysts are managed by anastomosis to the stomach, duodenum, or jejunum. 31 Results are adequate in 90 ~r ofcases without recurrence of the cyst. 15 • 32 Such drainage procedures must be regarded as directed to only one manifestation of pancreatitis and rarely effect the progression of the underlying disease process.

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the ampulla of Vater with replacement of sphincteric muscle fibers by thick collagen bundles. Jones et al. 37 report an over-all mortality of 1.24% for the operation. The elimination of sphincteric function and duodenal reflux which has been demonstrated by barium examination has not been complicated by recurrent postoperative cholangitis. Good results have been reported in 72 to 90% 18 • 38 of patients so treated. As would be anticipated, results have been better in those patients who do not continue to use alcohol, but even in the alcoholic group, significant improvement in the reduction of pain has been reported in 76% of patients. The efficacy of sphincterotomy, in which the sphincter is merely divided, has been questioned because of evidence of early return of sphincteric function and restoration of normal intraductal pressures. 39 In contrast, sphincteroplasty, in which a significant segment of the musculature of the sphincter is excised, has been demonstrated by postoperative T-tube pressure studies, postoperative cineradiography, postoperative upper gastrointestinal series, and clinical results to be quite different physiologically. It definitively alters ductal dynamics over a prolonged period. 37 It should be emphasized that this procedure should not be performed when pancreatography demonstrates intrapancreatic ductal obstruction. 38

Sphincteroplasty and Retrograde Ductal Dilation In this procedure the duodenum is opened and a pancreatogram obtained by inserting a catheter through the ampulla of Vater into the duct of Wirsung. 33 If ampullary fibrosis, 34 or stenosis of the ductal Distal Pancreatectomy orifice or immediately adjacent duct of In 4 to 6% of cases only the distal or left Wirsung is present, sphincteroplasty and unroofing or retrograde dilation of the duct pancreas is involved by pancreatitis. This are carried out. 35 The gross indications for may occur rarely in the idiopathic or alcothis procedure are mild to moderate de- holic forms, but is more frequently associgrees of chronic pancreatitis without cyst ated with trauma, where ductal injury has formation and evidence of sphincteric or occurred, producing fibrotic obstruction and accessible ductal stenosis. 36 The pancrea- resultant pancreatitis. 18 Gross findings in tographic indications are either a normal this situation are usually limited in the panduct or a duct with stenosis or obstruction creas to the region left of the superior mesof the first millimeters adjacent to the am- enteric vessels with fibrosis, occasionally pulla with diffuse ductal dilation. 37 The calcification, and pseudocyst formation. 2 finding of multiple strictures or stones con- Pancreatography is particularly useful in traindicates this operative procedure. this circumstance as it accurately delineates Acosta and Nardi 36 found histological the site and character of the obstruction evidence in 76% of patients of fibrosis of and suggests the area of the gland to be

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excised. 33 The operative mortality is low, and, when pathology is confined to resected segment of the gland, the results are excellent. 40 Longitudinal Pancreaticojejunostomy In this procedure the pancreatic duct is opened longitudinally through its entire length. 4 1 Following removal of calculi, the pancreas is sutured to the jejunum as suggested by Cox and Gillesby 42 and Puestow and Gillesby 43 • 44 using the Roux-en-Y procedure, to a jejunal loop, 4 5 or to the adjacent stomach according to the technique of Nardi and Cebalous. 26 The indications for this operation are extensive gross findings, palpable dilation of the duct, multiple strictures, multiple areas of calcification, and pancreatitis involving the entire gland. 20 Pancreatography in these patients demonstrates dilation of the entire ductal system with multiple strictures. 22 It is important to note, however, that an occasional patient will be found to have a normal or even a very small duct in association with advanced pancreatic changes. 42 These patients are not suitable for drainage procedures. 38 • 46 Duval 45 earlier described a limited resection of the distal pancreas with anastomosis of a loop of jejunum to provide drainage. This is satisfactory if a single mid-ductal obstruction is present. Subsequent experience has indicated a greater degree of success with the more extensive drainage procedure of opening the entire duct. 47 Utilizing this procedure, a success rate of approximately 70% with concomitant rehabilitation has been achieved with a mortality rate of less than 1%. 48 As might be expected when performing an operation directed to the effects, i.e., ductal obstruction, rather than the cause of a disease, the disease itself apparently continues to progress without pain and some other symptoms. In one series of 20 patients, all remained completely free of pain following an operation to decompress the pancreatic duct. Diabetes appeared in 4 (who were not diabetic at the time that they were operated upon), 3 developed tuberculosis, 1 developed a peptic ulcer, and 2 developed intermittent

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obstructive jaundice. Five ultimately died of causes commonly found in patients who have a chronic debilitating illness. 48 While it has been suggested that there may be some return of endocrine and exocrine pancreatic function following this procedure, Lempke et al. 46 believe that no conclusion concerning the possible beneficial effect of lateral pancreaticojejunostomy upon the endocrine and exocrine functions of the pancreas can be made on the basis of data collected to date. While these procedures leave diseased pancreas in situ, they have the virtue of lower operative morbidity and mortality and a lessened instance of postoperative diabetes than the major pancreatic excisions. Although diabetes may still occur as a consequence of the progression of the disease, it has been reported to be much easier to control than diabetes following near total or total pancreatectomy. 42 Ductal drainage is indicated particularly in the patient who is an alcoholic and in whom the management of brittle diabetes might be almost impossible. "Near-Total" or 95 % Distal Pancreatectomy "Near-total" pancreatectomy as described by Child et al. 14 and Fry and Child 49 involves removal of most of the pancreatic ductal system, leaving a narrow rim of gland remaining in the duodenal curve to provide endocrine and some exocrine function. The gross operative findings which indicate the choice of this procedure are extensive involvement of the entire gland with fibrosis, calcification; multiple areas of ductal obstruction, and intrapancreatic cyst formation. Pancreatography, while showing dilated ducts and obstruction, is of lesser importance when resectional therapy is employed. The rationale for this procedure is simply that the excision of almost the entire pancreas should actually eliminate the disease process, not just drain a diseased gland. Pancreatectomy, however, entails the risks of greater operative morbidity, exocrine complications of pancreatic ablation, unstable diabetes, and more surgical

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technical difficulties than drainage procedures. In the largest series of patients (57) subjected to this operation, as reported by Child et al., 14 no postoperative surgical deaths were noted. This enviable situation will undoubtedly be altered as more procedures are performed. The surgical morbidity, however, has been considerable. The average hospital stay was 27 days with the longest being 62 days. In 42 patients, follow-up studies indicate that 30, or about 70%, were completely rehabilitated. A substantially higher percentage of patients, close to 90%, may be classified as cured if those temporarily rehabilitated with some remaining disability are added to those determined to have been completely rehabilitated. 14 The return to extensive use of alcohol and nacrotics precludes a good result and satisfactory rehabilitation in some patients. Despite the residual pancreas, diabetes develops in many patients after this operation. However, the 5% remainder of the gland apparently secretes sufficient insulin to prevent the brittle type of diabetes so commonly encountered after total pancreatectomy. 49 Exocrine insufficiency and difficulty in management of diabetes may still be a problem in some irresponsible alcoholic patients. Total Pancreatectomy Excision of the entire pancreas by pancreaticoduodenectomy is usually reserved for those patients with disabling symptoms from advanced chronic pancreatitis, who have operative gross findings of marked destruction of the pancreas associated with calcification and innumberable points of intraductal obstruction. 50 • 51 In one series, only 8 of 530 patients treated surgically for chronic relapsing pancreatitis were subjected to pancreaticoduodenectomy. 18 Operative pancreatography may be academically interesting, .but rarely provides information which is essential to the selection of the surgical procedure. In Warren et al. 's series, 52 there was no operative mortality although hospital stay was prolonged in 2 patients. Long term follow-up showed good to excellent results in 5 of 6 patients. Diabetes and steatorrhea were present af-

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ter operation in all patients. 52 • 53 Postoperative jejunal ulceration due to gastric hypersecretion has been largely controlled by making an extensive gastrectomy and adding vagotomy. 52 It is of interest that abdominal pain has been reported in chronic pancreatitis in patients following total pancreatectomy who continue the ingestion of alcohol. The Case for Early Surgery Newton 54 wrote in 1929: "It would appear that the danger of extensive operations on the pancreas has been exaggerated and it is unnecessary to perform operations on this organ in a spirit of desperation." With surgical therapy guided by gross operative findings of the gland and pancreatography, and with careful postoperative management involving the use of pancreatic enzymes and insulin and the avoidance of alcohol, it appears that Newton's prophecy has come to pass and the good results can be obtained in 70 to 80% of patients with the progressive chronic pancreatitis of the familial, idiopathic, and alcoholic varieties. Reluctance to apply surgical measures in the past centered around: (1) poor results incident to operations directed at supposed etiological factors in the disease, (2) difficulties in diagnosis, (3) morbidity and mortality of an extensive surgical procedure, and (4) lack of predictability of results. 1 As discussed, many of these reasons no longer seem applicable. An unstated but real reason for surgical reluctance revolves around the fact that these patients are usually demanding and difficult to deal with; if the surgeon operates, it is the surgeon rather than the internist or gastroenterologist who is called in the middle of the night, a situation which has a certain dampening effect on surgical fervor. While no surgeon is enthusiastic about the indiscriminate application of procedures of the magnitude described, there is, nevertheless, a trend to consider early surgery in patients with progressive pancreatitis before addiction, calcification, and steatorrhea occur. Several authors suggest surgical exploration after two or more major attacks of proven pancreatitis of the alcoholic,

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familial, or idiopathic varieties. 55 • 5 6 A slightly more conservative course is suggested by others who would intervene when evidence of "chronicity" is noted with persistent pain, beginning weight loss, and debility, but before narcotic addiction, steatorrhea, and pancreatic calcification and diabetes are present. 28 In advanced chronic pancreatitis, the indications for laparotomy are well established. It is the intermediate and mild forms of the disease that must now be singled out for careful evaluation of the applicability of "early" surgery. Our current indications involve: (1) proof of diagnosis; and either (2) clear cut progression, intractability, or continuation of pain and symptoms; or (3) appearance of any one of the major complications of chronic pancreatitis.

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REFERENCES 1. Dreiling DA, Janowitz HD, Perrier CV: Pancrea-

tic Inflammatory Disease. New York, Hoeber, 1864, p 73 2. Frey CF: The operative treatment of pancreatitis. Arch Surg (Chicago) 98:406-417, 1969 3. Fitzgerald 0 , Fitzgerald P, Finley J, eta!: A clinical study of chronic pancreatitis. Gut 4:193:215, 1963 4. Comfort MW, Steinberg AG: Pedigree of a family with hereditary chronic relapsing pancreatitis. Gastroenterology 21:54-63, 1952 5. Gross JB, Gambill EE, Ulrich JA: Hereditary pancreatitis. Amer J Med 33:358-364, 1962 6. Hendren WH, Grup JM, Patton AS: Pancreatitis of childhood: experience with fifteen cases. Arch Dis Child 40:132-145, 1965 7. Sarles H, et a!: Observations on two hundred five cases of acute pancreatitis, recurring pancreatitis, and chronic pancreatitis. Gut 6:545-560, 1965. 8. Gambill EE, Comfort MW, Baggenstoss AH : Chronic relapsing pancreatitis: analysis of twentyseven cases associated with disease of the biliary tract. Gastroenterology 11 :1-33, 1948 9. Strum WB, Spiro HM: Chronic pancreatitis. Ann Intern Med 74:264-277, 1971 10. Warren KW, Veidenheimer MC : Surgery of chronic relapsing pancreatitis. Postgrad Med 57: 465-478, 1966 11. Burke JE, eta!: Chronic pancreatitis. Med Clin N Amer 54 :479-492, 1970 12. Howat HT: The management of chronic pancreatitis, Modern Trends in Gastroenterology. London, Butterworth, 1968, p 766-802 13. Rehabilitation of the Alcoholic : A Report from

19.

20.

21.

22.

23.

24. 25.

26.

27.

28.

29.

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the Study Group on Rehabilitation of the Alcoholic and Public Offender, Rehabilitation Services Series No. 69-11, Washington DC, US Department of Health, Education and Welfare, Social and Rehabilitation Service, Rehabilitation Service Administration, 1968 Child CG III, Frey CF, Fry WJ: A reappraisal of removal of 95 S~ of the distal portion of the pancreas. Surg Gynec Obstet 129: 49-56, 1969 Howard JM, Jordan SL: Surgical Diseases of the Pancreas. Philadelphia, JB Lippincott and Co, 1960, p 199-200 Ogle WS, French LA: Relief of pain in chronic relapsing pancreatitis with sympathetic denervation. Ann Surg 143:504, 1956 Connelly JE, Richards V: Bilateral splanchnicectomy and lumbodorsal sympathectomy for chronic relapsing pancreatitis. Ann Surg 131:5865, 1950 Warren KW, McDonald WN, Veidenheimer WC : Trends in pancreatic surgery. Surg Clin N Amer 44:743-761,1964 Warren KW: Pathologic considerations as a guide to surgical procedures in the management of chronic relapsing pancreatitis. Gastroenterology 36:224-236, 1959 Warren KW, Veidenheimer M: Pathologic considerations in the choice of operation for chronic relapsing pancreatitis. New Eng J Med 266:253, 1962 Leger L: Surgical contrast visualization of the pancreatic duct. J Int Coli Surg 16:285-293, 1951 Jacquemet P, Liotta D, Mallet-Guy P : The Early Radiological Diagnosis of Diseases of the Pancreas and Ampulla of Vater. Springfield, lll, Charles C Thomas Publisher, 1965 Kenny N, Nardi GL: Pancreatography, a safe and effective technique. Amer J Surg 110:863868, 1965 Doubilet H, Poppe! MH, Mulholland JH : Pancreatography. Radiology 3:325-339, 1955 Remine WH. Gambill EE, Priestley JT, et a!: Chronic pancreatitis. Postgrad Med 34:721-732, 1966 Nardi GL, Cebalous AJ : The diagnosis and management of recurrent pancreatitis. Amer Surg 821-823, 1966 Acosta JM , Nardi GL: Papillitis, inflammatory diseases of the ampulla of Vater. Arch Surg (Chicago) 92:354-358, 1966 Acosta JM , Nardi GL, Civantos F: Distal pancreatic duct inflammation. Ann Surg 172:256263, 1970 Sarles H: Pancreatitis Symposium, Marseille, April 25 and 26, 1963. Vaasa, Switzerland, and New York, S Karger, 1965

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30. Dixon JA, Hillam J: The treatment of biliary tract disease associated · with acute pancreatitis. ArnerJ Surg 120:371-375, 1970 31. Warren KW, Baker AL Jr: The choice of surgical procedures in the treatment of pancreatic cysts. Surg Clin N Amer 38:815-823, 1958 32. Waugh JM, Linn TE: Clinical and surgical aspects of pancreatic pseudocysts: An analysis of 58 cases. Arch Surg (Chicago) 77:47, 1958 33. Nardi GL: Technique of sphincteroplasty in recurrent pancreatitis. Surg Gynec Obstet 110:639646, 1960 34. McPherdem NT, Ainslie JD, McCray WH, et al: Fibrosis of the ampulla of Vater. Arch Surg (Chicago) 83:146-158, 1961 35. Nardi GL, Acosta JM: Papillitis as a cause of pancreatitis and abdominal pain. Ann Surg 164: 611-617, 1966 36. Acosta JM, Nardi GL: Papillitis. Arch Surg (Chicago) 92:354- 361, 1966 37. Jones SA, Smith LL, Gregory G: Sphincteroplasty for recurrent pancreatitis, a second report. Ann Surg 147:180-186, 1958 38. Jones SA, Steadman RA, Keller TB, eta!: Transduodenal sphincteroplasty (not sphincterotomy) for biliary and pancreatic disease. Indications, contraindications and results. Amer J Surg 118:292308, 1969 39. Eisemen B, Brown WH, Virabutr S, eta!: Sphincterotomy-evaluation of · physiological rational. Arch Surg (Chicago) 79:294- 298, 1959 40. Mallet-Guy P: Surgical treatment of chronic pancreatitis. Arch Surg (Chicago) 70:609-618, 1955 41. Partington PF, Roshell REL: Modified Puestow procedure for retrograde drainage of the pancreatic duct. Ann Surg 152:1037- 1048, 1960 42. Cox WD, Gillesby WJ: Longitudinal pancreaticojejunostomy in alcoholic pancreatitis. Arch Surg (Chicago) 20:355-364, 1954 43. Puestow CB, Gillesby WJ: Management of pan-

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creatic cysts and pancreatic lithiasis. Amer Surg 20:355-364, 1954 44. Gillesby WJ, Puestow CB: Surgery for chronic recurrent pancreatitis. Surg Clin N Amer 41:8393, 1961 45. Duval MK Jr: Pancreaticojejunostomy for chronic pancreatitis. Surgery 41:1019-1024, 1957 46. Lempke RE, King RD, Kaiser GC: Lateral pancreaticojejunostomy. Arch Surg (Chicago) 87: 90-100, 1963 47. Puestow CB, Gillesby WJ: Pancreaticojejunostomy for chronic relapsing pancreatitis: an evaluation. Surgery 50:859-862, 1961 48. Duval MK: Pancreatitis-the role of surgery in treatment. Rocky Mountain Med J 66:46- 49, 1969. 49. Fry WJ, Child CG III: 95% distal pancreatectomy for chronic pancreatitis. Ann Surg 162: 543-549, 1965 50. Waugh JM, Dixon CF, Claggett DT, et al: Total pancreatectomy: symposium presenting four successful cases and a report of metabolic observations. Proc Mayo Clin 21:25-34, 1946 51. Longmire WP Jr, Jordan PH Jr, Briggs JB: Experience with resection of the pancreas in the treatment of chronic relapsing pancreatitis. Ann Surg 144:681-692, 1956 52. Warren KW, Poulantzas JK, Kune GA: Life after total pancreatectomy for chronic pancreatitis. Ann Surg 164:830-834, 1964 53. McCullagh EP, Cook JR, Shires EK: Diabetes following total pancreatectomy. Clinical observations of ten cases of diabetes. Diabetes 7:298308, 1958 54. Newton A: Disorders of the pancreas. Surg Gynec Obstet 48:808-810, 1929 55. Egdahl RH: Chronic alcoholic pancreatitis: a surgical disease? Surgery 55:604- 607, 1967 56. Sun DC: Diagnosis and management of chronic pancreatitis. Arizona Med 27:83-87, Apri\1970