Colonic complications are rare in acute pancreatitis. Over the last 9 years at St. Mary's Hospital, London, UK, we have managed severe acute pancreatitis by intensive supportive therapy followed by sub-total pancreatic resection and/or debridement in those who fail to improve. Of the 22 patients who have undergone this form of surgery, nine were found to have colonic involvement in the form of either necrosis or perforation. In addition, one patient presenting at West Middlesex University Hospital, Isleworth, UK, had severe acute pancreatitis and almost total colonic necrosis as an unexpected finding at emergency laparotomy. These ten patients comprised seven men and three women of median age 59 years and with a median of four Ranson criteria. In seven patients, colonic involvement was discovered at the time of pancreatic surgery or laparotomy for pancreatitis and in the remainder it presented between 1 and 3 weeks later as either a faecal fistula (n = 2) or persistent abdominal sepsis (n = 1). The ascending colon was involved in one patient, the splenic flexure and descending colon in one, the transverse colon in three, the splenic flexure alone in four, and one patient had almost total colonic involvement. All patients underwent resection of the involved colon and exteriorization with either a proximal colostomy (n = 7) or ileostomy (n = 3) and a distal mucous fistula. Pathological examination of the resected colons revealed a spectrum of changes from pericolitis through to ischaemic necrosis suggesting at least two possible mechanisms. Six patients died from overwhelming sepsis between 1 day and 4 weeks (median 11 days) after colonic resection. Severe acute pancreatitis must be recognized as a cause of colonic ischaemia and necrosis; this complication is associated with a very poor prognosis despite surgical intervention.
Splenectomy is performed routinely during distal pancreatectomy, yet the spleen has an important role in host defence and can often be preserved. A personal series of 100 distal pancreatectomies undertaken for pancreatic disease between 1978 and 1990 included 23 patients undergoing total pancreatic resection. The remaining 77 patients, who form the basis of the present report, underwent primary distal pancreatectomy and comprised 34 women and 43 men with a median age of 41 years (range 17-78 years). Conventional distal pancreatectomy including splenectomy was performed in 42 patients (55 per cent) for chronic pancreatitis (34 patients), pancreatic neoplasia (six patients), suspected pancreatitis (one patient) or pancreatitic trauma (one patient). Conservative resection with splenic preservation was performed in 35 patients (45 per cent) for chronic pancreatitis (12 patients), suspected pancreatitis (13 patients, including eight patients with pancreas divisum), pancreatic neoplasia (six patients), recurrent acute pancreatitis (two patients) and pancreatic trauma (two patients). There were no postoperative deaths in either group. Early complications followed conventional resection in 10 patients (24 per cent) and conservative resection in seven patients (20 per cent). In five patients the splenic vessels were ligated away from the splenic hilum and the spleen was left in situ, but subsequent isotope scans and haematological indices showed no hyposplenism. The spleen can safely be preserved in many distal pancreatic resections, including those for inflammatory disease, and we now prefer a retrograde technique for dissecting the pancreas off the splenic vessels.
To demonstrate any difference in outcome between patients with carcinoma at various sites within the large bowel, analysis of a large number of patients is necessary. From the Large Bowel Cancer Project, 4292 patients have been evaluated to compare mode of presentation, surgical management, pathological findings and outcome. Carcinoma at the splenic flexure was associated with the highest risk of obstruction (49 per cent); postoperative cardiopulmonary complications (36 per cent); in-hospital mortality (18 per cent); and the lowest age-adjusted 5-year survival (28 per cent), even after curative resection (38 per cent). This survival disadvantage was seen even in those without obstruction. Further, it was not accounted for by differences in age, sex, Dukes' stage or tumour differentiation between the various sites as stratification by these variables failed to alter significance (log rank chi 2 = 11.1; d.f. = 4; P less than 0.05). Compared with carcinoma of the left colon and rectum, tumours in the right colon were more likely to be poorly differentiated and locally advanced (in terms of fixation and penetration of the bowel wall) but were not associated with a higher risk of either distant spread at presentation or local recurrence. Age-adjusted 5-year survival following curative surgery was higher for the right colon (65 per cent) than the left (59 per cent).
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