We have previously reported our efforts to minimize postgastrectomy symptoms in two patients with benign disease who underwent resection of the head of the pancreas and the duodenum. In these cases the pylorus and first portion of the duodenum were preserved during pancreaticoduodenectomy. Our experience has now been extended to encompass 18 patients, eight of whom were available for comprehensive evaluation an average of six months postoperation. These studies have attempted to differentiate malabsorption of pancreatic insufficiency from possible gastrointestinal dysfunction of the new alimentary connection. Pancreatic insufficiency was evaluated by a 72-hour stool collection and radioactive trioctanoate (RATO) test. Gastrointestinal absorption was evaluated by D-xylose excretion and the Schilling test, as well as serum vitamin. A, vitamin B-12, carotene, folate, iron, and total iron binding capacity. Gastrointestinal secretion and motility were assessed by using pyloric fluoroscopy, gastric barium emptying, the Hunt test, and gastric acid analysis. Finally, a questionnaire regarding clinical symptoms of postgastrectomy syndromes and malabsorption was answered. Although every patient exhibited marked pancreatic insufficiency by laboratory tests, 88% described normal formed bowel movements, and weight loss was claimed by only 25%. Other test findings were generally normal. While the follow-up period has been limited to three years, the current data demonstrate that gastrointestinal function subsequent to preservation of the pylorus has not thus far predisposed to postgastrectomy syndromes or marginal ulcers. All of the patients required intensive pancreatic enzyme replacement.

Despite recent advances in perioperative support care, surgery for obstructive jaundice is still associated with significant morbidity and mortality. For this reason, preoperative percutaneous transhepatic drainage (PTD) has been recommended for these patients. This method of management, however, has only been supported by retrospective and nonrandomized studies. Therefore, a prospective, randomized study was performed to determine the effect of preoperative PTD on operative mortality, morbidity, hospital stay, and hospital cost. Thirty-day mortality was 8.1% among 37 patients undergoing preoperative PTD, compared to 5.3% for 38 patients who went to surgery without preoperative drainage. Overall morbidity was also slightly, but not significantly, higher in patients who underwent preoperative PTD, (57% versus 53%). However, total hospital stay was significantly longer (p less than 0.005) in the PTD group (31.4 days versus 23.1 days). The cost of this excess hospitalization and the PTD procedure at our university medical center was over +8000 per patient. The authors conclude that preoperative PTD does not reduce operative risk but does increase hospital cost and, therefore, should not be performed routinely.

No abstract

A computerized analysis of prognostic variables was performed in 96 proven cases of extrahepatic bile duct carcinoma treated over a 24-year period at UCLA. Forty-nine percent of the lesions were in the upper third of the bile ducts and 47% of these were resected, for an operative mortality rate of 23% and a maximum survival rate of 4.5 years. Palliative procedures in this region were associated with a 16% mortality rate and maximum survival rate of three years. The patients whose lesions were in the middle third suffered no operative mortality rate for resection or palliation and had a 12% five-year survival rate, with the longest survivor lasting 11 years. In the lower third lesions, 67% were resected by Whipple's procedures, for an 8% mortality rate and a five-year survival rate of 28% extending to nine years. Resection of these difficult carcinomas offers the best hope of survival but must be weighed against the high operative mortality risk in those lesions located in the hilar region.

We reviewed the records of 340 patients with a tissue diagnosis of pancreatic cancer treated at UCLA Medical Center between 1973 and 1988. Sixty-one patients underwent pancreatic resection (group I), 173 had some form of surgical palliation (group II), and 106 had neither (group III). The diagnosis was made 1 to 2 months more quickly in the last 8 years of the review than in the first 8 years, but the effect of early diagnosis on curability was negligible. Biliary obstruction was best treated by cholecystojejunostomy or choledochojejunostomy, which were equally effective. Anastomoses to the jejunum were safer and more effective than were those to the duodenum for the relief of biliary obstruction. Gastrojejunostomy should be performed prophylactically as well as therapeutically. It was effective and safe in both settings. Surgical palliation for pancreatic cancer was generally effective and was associated with an operative mortality rate of less than 10%. However morbidity was high, with significant complications occurring in one third of cases.