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Partial Pancreatectomy: Excision of the Tail and Body of the Pancreas
PARTIAL PANCREATECTOMY: EXCISION OF THE TAIL AND BODY OF THE PANCREAS RICHARD
B.
CATTELL
Considerable progress has been made in recent years in the surgical treatment of diseases of the pancreas. With increased interest and study of this problem, more conditions have been successfully treated by partial or total removal of this gland. Unfortunately, there are serious obstacles to the establishment of a correct diagnosis both before operation and at the time of abdominal exploration. With an increasing experience in the management of these lesions it is probable that means will be discovered which will permit more accurate diagnoses. It is only by keeping in mind the possibility of the presence of the lesions of the pancreas in obscure upper abdominal conditions that the presence of the pancreatic lesions may be suspected or proved. Unfortunately, there are few diagnostic aids, such as the roentgenographic visualization of organs adjacent to the pancreas, when distortion or displacement of these organs occurs. Determinations are made of the amylase or lipase concentration in the blood and incomplete digestion of carbohydrates and protein may be found by special studies of the stools. At times lesions of the pancreas attain sufficient size to produce localizing signs in this region. For the most part, however, it is necessary to make a presumptive diagnosis of a pancreatic lesion based on the history in the absence of other demonstrable findings. There has been sufficient experience in the surgical treatment of pancreatic lesions to demonstrate that this organ is amenable to surgical attack. When the lesion involving the pancreas is sufficiently serious to justify a major procedure it must be appreciated that it carries consider.able risk both as to morbidity and mortality. In the Surgical Clinics of North America for June 1948, I presented the technic employed in this clinic for removal of malignant lesions involving the lower end of the common bile duct, ampulla of Vater, duodenum and head of the pancreas. This procedure of radical pancreatoduodenal resection has been carried out for 63 malignant le~ions and 5 benign lesions in this area, with mortality of approximately 13 per cent. We have encountered fewer lesions that are confined to the tail or body which are amenable to surgical removal. In the past three years, partial pancreatectomy with removal of the tail and body of the pancreas has been carried out a number of times without mortality. The technic of this operation will be presented. 779
780
RICHARD B. CATTELL
INDICATIONS FOR OPERATION
1. Cysts of the Pancreas ~. Recurrent Relapsing Pancreatitis 3. Pancreatolithiasis 4. Pancreatic Fistulas 5. Islet Adenoma 6. Carcinoma of the Body of the Pancreas
The single cysts encountered in the body of the pancreas that do not communicate with the ducts can usually be excised without removal of portions of the pancreas. When they are of large size and associated with chronic inflammation, operation may be conducted in two stages with marsupialization and drainage of the cyst at the first stage, followed by removal of the tail and body in three months, during which time the cavity shrinks to a small size, permitting more accurate identification of the surrounding structures. Most of the single cysts that communicate with the ducts are best treated either in one or two stages by partial pancreatectomy. The multilocular cysts which usually follow recurrent inflammation of the gland may be treated in a similar manner, but all require resection of the body to accomplish complete relief of symptoms. We have not encountered multiple or multilocular cysts that appear to be of congenital type. Increasing numbers of patients are being seen with chronic relapsing pancreatitis. If the process is chiefly confined to the body, partial pancreatectomy offers the best chance of relief of the disabling pain and digest~ve symptoms. This lesion is likely to be extensive and in some cases, after exploration, partial pancreatectomy has been deemed unwise and an attempt made to relieve the symptoms by left thoracolumbar sympathectomy. Pancreatolithiasis is infrequently encountered. We have observed cases with the stones confined to the head, and ~ cases with pancreatolithiasis and diffuse calcinosis limited to the body and tail. The severe symptoms present in these cases justify partial pancreatectomy when technically feasible. It has been carried out in ~ patients. Pancreatic fistula may be the result of trauma or penetrating wounds or may follow acute pancreatitis when drainage has been instituted. Pancreatic fistula, however, most frequently occurs as a result of drainage of cysts of the pancreas. At times, these fistulas may be transplanted into the jejunum or stomach. Excision of the fistula with closure of the communications to the pancreatic ducts is rarely successful. Partial pancreatectomy may be the most effective means of curing this condition. Failure to discover hyperfunctioning pancreatic adenomas of the islet cells may necessitate partial pancreatectomy, as suggested by
PARTIAL PANCREATECTOMY
781
Waugh, when the adenoma cannot be discovered. In the few patients treated at the clinic the adenoma has been found and removed locally but in 1 case in which the adenoma showed malignant degeneration, partial pancreatectomy was carried out by Marshall. We have had no experience with partial pancreatectomy for carcinoma of the body of the pancreas. A successful case was reported by GordonTaylor in 1934; the patient was living at that time, seven years after partial pancreatectomy. Unfortunately, most of the malignant lesions of the body of the pancreas already have extended beyond the gland, making resection impossible. ANATOMY
The most satisfactory approach for exposure of the body and tail of the pancreas is through the gastrocolic omentum on the left side. The tail of the pancreas is usually in close relationship to the lower portion of the hilum of the spleen and injury to the latter structure may be unavoidable, particularly if chronic inflammation of the pancreas is present. The upper portion of the transverse mesocolon may likewise be densely adherent to the inferior border of the pancreas, making a line of dissection difficult to obtain. The stomach is usually adherent to the anterior surface of the pancreas, but can usually be disengaged without difficulty. The protection of the vascular structures in the region of the pancreas is the most difficult technical part of the operation. These structures are by no means constant in their course and relationship and must be individually identified as the procedure is carried out. The splenic artery passes along the superior aspect of the body, giving off branches to both the body and tail. There are large longitudinal arteries from the gastroduodenal artery that pass into the pancreas on its superior aspect. Similarly, the inferior pancreatoduodenal artery gives large branches to the body on the inferior surface. Both the middle colic arteries and the inferior mesenteric artery must be carefully identified and displaced downward to a void injury. The large venous channels in this area are even more difficult to identify and protect than the arteries. The splenic vein lies on the superior aspect of the body and, as it passes to the left, comes to rest behind the body and tail. When inflammation is present it may appear to be an integral part of the pancreas. The junction of the splenic and superior mesenteric veins forms the portal vein and must be identified previous to division of the neck of the pancreas. In partial pancreatectomy only the duct of Wirsung is encountered. The accessory duct rarely passes beyond the neck of the pancreas. If some degree of obstruction to the duct is present it can usually be identified by palpation on the anterior surface or by aspiration.
782
RICHARD B. CATTELL
PHYSIOLOGY
The greater concentration of the islet tissue is found in the tail of the pancreas. There is sufficient islet tissue in the head to maintain normal carbohydrate metabolism after removal of the body and tail in most cases. Diabetes mellitus has been present preoperatively in a number of our cases of partial pancreatectomy but has not been made more severe by the procedure. In no patients following partial pancreatectomy has diabetes mellitus resulted. Similarly, there is sufficient tissue for the production of adequate amounts of pancreatic ferment from the head of
Fig. 29!i!.-Exposure of the body of the pancreas by division of the gastrocolic omentum. Wide exposure of this region is readily ohtained.
the pancreas when the body has been removed. Some steatorrhea has been observed following partial pancreatectomy, however, as evidenced by incomplete fat digestion as well as by abnormal digestive symptoms. TECHNIC OF PARTIAL PANCREATECTOMY
The abdomen is opened and explored through a left rectus incision, usually paramedian in position, deflecting the rectus muscle outward to the left. The anterior two layers of the gastrocolic omentum are divided, preserving the gastroepiploic arteries along the greater curvature of the stomach. The gastrohepatic omentum is opened widely (Fig. 292) extending from the right margin of the lesser sac to the spleen. The splenocolic ligament is divided, displacing the splenic flexure of the
PARTIAL PANCREATECTOMY
783
colon downward. Elevation of the stomach and depression of the posterior layers of the transverse mesocolon permit wide exposure and access to the body and tail of the pancreas (Fig. 292). Most of the lesions involving the body and tail for which partial pancreatectomy is necessary lead to such gross changes in the pancreas and adjacent structures that the limits of the pancreas are hard to determine. For this reason, removal of the spleen, leaving it attached to the
Fig. 293.-The splenic artery has been ligated and divided, as well as the vasa brevia. The spleen has been delivered from the wound and the tail of the pancreas is elevated.
pancreas, is necessary. The splenic artery is first identified as it comes down from the celiac axis (Fig. 292). It is ligated and divided at the point where it passes to the left at a considerable distance from the spleen (Fig. 293). After division of the vasa brevia vessels to the upper portion of the spleen, the latter is delivered from the wound with elevation of the tail of the pancreas (Fig. 293). Dissection is then carried out from in back, elevating the spleen and tail of the pancreas from the kidney and identifying the structures of the hilum of the kidney. Great care must be directed to protect the inferior mesenteric artery and vein, which are in contact with the inferior margin 6
784
RICHARD B. CATTELL
of the body of the pancreas, separated only by the one posterior layer of the peritoneum of the transverse mesocolon. With further elevation of the body of the pancreas, the splenic vein is isolated and separated from the superior aspect of the pancreas. Displacement of this structure backward permits its accurate ligation and division. The proximal side of the splenic vein is then followed to its junction with the superior mesenteric
Fig. ~94.-Diagrammatic representation of the major structures encountered at the junction of the body and head of the pancreas. The splenic vein has been ligated (as have the hranches from the gastroduodenal and superior mesenteric arteriesr The neck of the pancreas has been divided showing the duct of Wirsung. Inset, Closure of the cut end of the pancreas.
vein. At times this dissection must be discontinued because of technical difficulties, and the neck of the pancreas is elevated after identification of the superior mesenteric vein and portal vein. The longitudinal superior pancreatic arteries, both anterior and posterior, as they leave the gastroduodenal artery are now secured and ligated. Following this, the short arterial branches of the superior mesenteric artery at the inferior border of the pancreas are dealt with. If the neck of the pancreas has not already been divided, it is divided at this time, with removal of the operative specimen (Fig. 294). As the neck of the pancreas is sectioned, the duct
PARTIAL PANCREATECTOMY
785
of Wirsung is identified and carefully closed by nonabsorbable suture ligatures. The neck of the pancreas is then carefully closed by interrupted nonabsorbable sutures, as shown in Figure 294, inset. This results in good hemostasis of the cut end of the pancreas, as well as effective closure of the tiny duct radicals. Gelfoam is quite useful in the control of ooze from the bed of the pancreas. A small incision is then made through the gastrohepatic omentum for the introduction of a cigaret gauze drain to the bed of the pancreas. The gastrocolic omentum is then closed. SUMMARY
An increasing number of lesions of the pancreas are being encountered which involve the body and tail. Indications for partial pancreatectomy with excision of the tail and body of the pancreas are: cysts, recurrent cysts, chronic relapsing pancreatitis, pancreatolithiasis, pancreatic fistulas, islet adenoma and carcinoma. Inflammatory lesions are the most common. A technic for partial pancreatectomy is presented.
B.
CATTELL
Considerable progress has been made in recent years in the surgical treatment of diseases of the pancreas. With increased interest and study of this problem, more conditions have been successfully treated by partial or total removal of this gland. Unfortunately, there are serious obstacles to the establishment of a correct diagnosis both before operation and at the time of abdominal exploration. With an increasing experience in the management of these lesions it is probable that means will be discovered which will permit more accurate diagnoses. It is only by keeping in mind the possibility of the presence of the lesions of the pancreas in obscure upper abdominal conditions that the presence of the pancreatic lesions may be suspected or proved. Unfortunately, there are few diagnostic aids, such as the roentgenographic visualization of organs adjacent to the pancreas, when distortion or displacement of these organs occurs. Determinations are made of the amylase or lipase concentration in the blood and incomplete digestion of carbohydrates and protein may be found by special studies of the stools. At times lesions of the pancreas attain sufficient size to produce localizing signs in this region. For the most part, however, it is necessary to make a presumptive diagnosis of a pancreatic lesion based on the history in the absence of other demonstrable findings. There has been sufficient experience in the surgical treatment of pancreatic lesions to demonstrate that this organ is amenable to surgical attack. When the lesion involving the pancreas is sufficiently serious to justify a major procedure it must be appreciated that it carries consider.able risk both as to morbidity and mortality. In the Surgical Clinics of North America for June 1948, I presented the technic employed in this clinic for removal of malignant lesions involving the lower end of the common bile duct, ampulla of Vater, duodenum and head of the pancreas. This procedure of radical pancreatoduodenal resection has been carried out for 63 malignant le~ions and 5 benign lesions in this area, with mortality of approximately 13 per cent. We have encountered fewer lesions that are confined to the tail or body which are amenable to surgical removal. In the past three years, partial pancreatectomy with removal of the tail and body of the pancreas has been carried out a number of times without mortality. The technic of this operation will be presented. 779
780
RICHARD B. CATTELL
INDICATIONS FOR OPERATION
1. Cysts of the Pancreas ~. Recurrent Relapsing Pancreatitis 3. Pancreatolithiasis 4. Pancreatic Fistulas 5. Islet Adenoma 6. Carcinoma of the Body of the Pancreas
The single cysts encountered in the body of the pancreas that do not communicate with the ducts can usually be excised without removal of portions of the pancreas. When they are of large size and associated with chronic inflammation, operation may be conducted in two stages with marsupialization and drainage of the cyst at the first stage, followed by removal of the tail and body in three months, during which time the cavity shrinks to a small size, permitting more accurate identification of the surrounding structures. Most of the single cysts that communicate with the ducts are best treated either in one or two stages by partial pancreatectomy. The multilocular cysts which usually follow recurrent inflammation of the gland may be treated in a similar manner, but all require resection of the body to accomplish complete relief of symptoms. We have not encountered multiple or multilocular cysts that appear to be of congenital type. Increasing numbers of patients are being seen with chronic relapsing pancreatitis. If the process is chiefly confined to the body, partial pancreatectomy offers the best chance of relief of the disabling pain and digest~ve symptoms. This lesion is likely to be extensive and in some cases, after exploration, partial pancreatectomy has been deemed unwise and an attempt made to relieve the symptoms by left thoracolumbar sympathectomy. Pancreatolithiasis is infrequently encountered. We have observed cases with the stones confined to the head, and ~ cases with pancreatolithiasis and diffuse calcinosis limited to the body and tail. The severe symptoms present in these cases justify partial pancreatectomy when technically feasible. It has been carried out in ~ patients. Pancreatic fistula may be the result of trauma or penetrating wounds or may follow acute pancreatitis when drainage has been instituted. Pancreatic fistula, however, most frequently occurs as a result of drainage of cysts of the pancreas. At times, these fistulas may be transplanted into the jejunum or stomach. Excision of the fistula with closure of the communications to the pancreatic ducts is rarely successful. Partial pancreatectomy may be the most effective means of curing this condition. Failure to discover hyperfunctioning pancreatic adenomas of the islet cells may necessitate partial pancreatectomy, as suggested by
PARTIAL PANCREATECTOMY
781
Waugh, when the adenoma cannot be discovered. In the few patients treated at the clinic the adenoma has been found and removed locally but in 1 case in which the adenoma showed malignant degeneration, partial pancreatectomy was carried out by Marshall. We have had no experience with partial pancreatectomy for carcinoma of the body of the pancreas. A successful case was reported by GordonTaylor in 1934; the patient was living at that time, seven years after partial pancreatectomy. Unfortunately, most of the malignant lesions of the body of the pancreas already have extended beyond the gland, making resection impossible. ANATOMY
The most satisfactory approach for exposure of the body and tail of the pancreas is through the gastrocolic omentum on the left side. The tail of the pancreas is usually in close relationship to the lower portion of the hilum of the spleen and injury to the latter structure may be unavoidable, particularly if chronic inflammation of the pancreas is present. The upper portion of the transverse mesocolon may likewise be densely adherent to the inferior border of the pancreas, making a line of dissection difficult to obtain. The stomach is usually adherent to the anterior surface of the pancreas, but can usually be disengaged without difficulty. The protection of the vascular structures in the region of the pancreas is the most difficult technical part of the operation. These structures are by no means constant in their course and relationship and must be individually identified as the procedure is carried out. The splenic artery passes along the superior aspect of the body, giving off branches to both the body and tail. There are large longitudinal arteries from the gastroduodenal artery that pass into the pancreas on its superior aspect. Similarly, the inferior pancreatoduodenal artery gives large branches to the body on the inferior surface. Both the middle colic arteries and the inferior mesenteric artery must be carefully identified and displaced downward to a void injury. The large venous channels in this area are even more difficult to identify and protect than the arteries. The splenic vein lies on the superior aspect of the body and, as it passes to the left, comes to rest behind the body and tail. When inflammation is present it may appear to be an integral part of the pancreas. The junction of the splenic and superior mesenteric veins forms the portal vein and must be identified previous to division of the neck of the pancreas. In partial pancreatectomy only the duct of Wirsung is encountered. The accessory duct rarely passes beyond the neck of the pancreas. If some degree of obstruction to the duct is present it can usually be identified by palpation on the anterior surface or by aspiration.
782
RICHARD B. CATTELL
PHYSIOLOGY
The greater concentration of the islet tissue is found in the tail of the pancreas. There is sufficient islet tissue in the head to maintain normal carbohydrate metabolism after removal of the body and tail in most cases. Diabetes mellitus has been present preoperatively in a number of our cases of partial pancreatectomy but has not been made more severe by the procedure. In no patients following partial pancreatectomy has diabetes mellitus resulted. Similarly, there is sufficient tissue for the production of adequate amounts of pancreatic ferment from the head of
Fig. 29!i!.-Exposure of the body of the pancreas by division of the gastrocolic omentum. Wide exposure of this region is readily ohtained.
the pancreas when the body has been removed. Some steatorrhea has been observed following partial pancreatectomy, however, as evidenced by incomplete fat digestion as well as by abnormal digestive symptoms. TECHNIC OF PARTIAL PANCREATECTOMY
The abdomen is opened and explored through a left rectus incision, usually paramedian in position, deflecting the rectus muscle outward to the left. The anterior two layers of the gastrocolic omentum are divided, preserving the gastroepiploic arteries along the greater curvature of the stomach. The gastrohepatic omentum is opened widely (Fig. 292) extending from the right margin of the lesser sac to the spleen. The splenocolic ligament is divided, displacing the splenic flexure of the
PARTIAL PANCREATECTOMY
783
colon downward. Elevation of the stomach and depression of the posterior layers of the transverse mesocolon permit wide exposure and access to the body and tail of the pancreas (Fig. 292). Most of the lesions involving the body and tail for which partial pancreatectomy is necessary lead to such gross changes in the pancreas and adjacent structures that the limits of the pancreas are hard to determine. For this reason, removal of the spleen, leaving it attached to the
Fig. 293.-The splenic artery has been ligated and divided, as well as the vasa brevia. The spleen has been delivered from the wound and the tail of the pancreas is elevated.
pancreas, is necessary. The splenic artery is first identified as it comes down from the celiac axis (Fig. 292). It is ligated and divided at the point where it passes to the left at a considerable distance from the spleen (Fig. 293). After division of the vasa brevia vessels to the upper portion of the spleen, the latter is delivered from the wound with elevation of the tail of the pancreas (Fig. 293). Dissection is then carried out from in back, elevating the spleen and tail of the pancreas from the kidney and identifying the structures of the hilum of the kidney. Great care must be directed to protect the inferior mesenteric artery and vein, which are in contact with the inferior margin 6
784
RICHARD B. CATTELL
of the body of the pancreas, separated only by the one posterior layer of the peritoneum of the transverse mesocolon. With further elevation of the body of the pancreas, the splenic vein is isolated and separated from the superior aspect of the pancreas. Displacement of this structure backward permits its accurate ligation and division. The proximal side of the splenic vein is then followed to its junction with the superior mesenteric
Fig. ~94.-Diagrammatic representation of the major structures encountered at the junction of the body and head of the pancreas. The splenic vein has been ligated (as have the hranches from the gastroduodenal and superior mesenteric arteriesr The neck of the pancreas has been divided showing the duct of Wirsung. Inset, Closure of the cut end of the pancreas.
vein. At times this dissection must be discontinued because of technical difficulties, and the neck of the pancreas is elevated after identification of the superior mesenteric vein and portal vein. The longitudinal superior pancreatic arteries, both anterior and posterior, as they leave the gastroduodenal artery are now secured and ligated. Following this, the short arterial branches of the superior mesenteric artery at the inferior border of the pancreas are dealt with. If the neck of the pancreas has not already been divided, it is divided at this time, with removal of the operative specimen (Fig. 294). As the neck of the pancreas is sectioned, the duct
PARTIAL PANCREATECTOMY
785
of Wirsung is identified and carefully closed by nonabsorbable suture ligatures. The neck of the pancreas is then carefully closed by interrupted nonabsorbable sutures, as shown in Figure 294, inset. This results in good hemostasis of the cut end of the pancreas, as well as effective closure of the tiny duct radicals. Gelfoam is quite useful in the control of ooze from the bed of the pancreas. A small incision is then made through the gastrohepatic omentum for the introduction of a cigaret gauze drain to the bed of the pancreas. The gastrocolic omentum is then closed. SUMMARY
An increasing number of lesions of the pancreas are being encountered which involve the body and tail. Indications for partial pancreatectomy with excision of the tail and body of the pancreas are: cysts, recurrent cysts, chronic relapsing pancreatitis, pancreatolithiasis, pancreatic fistulas, islet adenoma and carcinoma. Inflammatory lesions are the most common. A technic for partial pancreatectomy is presented.