Adson, Martin A.

Abstract The management of pancreatic pain is a controversial subject and the treatment recommended varies from one extreme to the other. Some authorities advise simply waiting for chronic pancreatitis to ‘burn out’, while others practise removal of the entire gland. In this paper we present 141 patients who underwent surgery for chronic pancreatitis at the Mayo Clinic. The main indication for operation was pancreatic pain and the choice of operation was based on anatomical abnormalities in the gland. The long-term results of the policy are reviewed (mean follow-up 8·5 years). Length of history, aetiology of disease, pancreatic dysfunction and pathology, time after operation and continued alcohol abuse were computer analysed for a statistically significant influence on pain relief, ability to work, pancreatic function and survival. There was one operative death (mortality rate 0·7 per cent). Continued drinking was not shown to affect postoperative pain relief but 10-year survival was significantly less in alcoholics than in those with non-alcoholic pancreatitis (P < 0·02). Dilated ducts and duct calculi were associated with good results for pain relief although this association did not achieve statistical significance. Parenchymal calcification and time after operation did not influence the results of surgery. When the operation failed to relieve pain, spontaneous remission occurred in a few cases only. Seventy-seven per cent of patients had lasting relief of pain and operations selected on the basis of gross pathology were equally effective in relieving pain. Longitudinal pancreaticojejunostomy in those with dilated ducts and a Whipple operation for disease of the pancreatic head gave good results. However quality of life and pancreatic function were severely impaired by 80–95 per cent distal resections and by total pancreatectomy. An extended proximal resection is suggested for patients with diffuse disease and non-dilated ducts.

AbstractMost of what has been learned about resection of hepatic metastases comes from the study of colorectal cancer because such lesions are so common. One‐fourth or more of patients who have liver metastases from such lesions have hepatic tumors that can be removed, but only about 25% of these patients will live 5 years or more after such tumors have been removed. When resection so often fails to improve survival, there is a need to know when metastatic lesions should be removed. Study of determinants of prognosis, patterns of failure, and the natural history of the disease have shown that surgical failure is determined by the presence of extrahepatic metastases (even when removed) and limited resective margins. The patient's gender and the locoregional stage of the primary resected lesions influence survival, but not so much as to withhold resective treatment from these less favored groups. Studies of size, site, and number of hepatic metastases removed show therapeutic limitations associated with extremes, but these determinants of prognosis after resection must be studied in better ways. Although, at times, palliation is a reasonable goal, this aspect of resective treatment has not been studied well. When there are no good therapeutic alternatives to resection of hepatic metastases and when risk is low, such palliative operations may be justified. Only with further study will absolute contraindications to surgical therapy be well defined. There is an obvious need for biologic control of cancer.