PANCREAS, Diseases of.
Cystic disease of the pancreas is comparatively rare. It is usually a false cyst and is due to traumatism often of a severe character. The fluid is therefore blood-stained and the swelling follows the outlines of the lesser sac of peritoneum. Excision is therefore not possible, but opening the sac and drainage is generally followed by rapid and complete cure. The operation is little if at all more dangerous than the average abdominal section. The writer has seen several cases which were diagnosed before hand, operated on, and cured completely thereby.
In one case where a large tumour closely simulating an aneurism formed after a severe localised injury to the abdomen, the writer the tumour, the contents of which were found by Professor Matthew Hay to consist of pure pancreatic juice. Gallons of this fluid were removed from time to time, but the patient did not suffer from any of the symptoms supposed to always follow the arrest of the secretion of the gland, though the enormous quantities of fluid possessing in a very active form all the physiological qualities of undiluted pancreatic juice continued to be removed by the aspirator for many weeks. The tumour, after one of the tappings, rapidly filled up with a bloody liquid. Symptoms of peritonitis supervened, but the patient made a rapid and complete recovery, and remains perfectly well, now 35 years since the tappings.
Acute pancreatitis, whether of the IN.emorrhagic, fat-necrotic, parenchy matous, gangrenous or suppurative types, must he met by opening the abdominal cavity as soon as the stage of shock has passed away. Any free fluid in the abdomen must be removed and the exudation and blood cleared out from the smaller peritoneal sac and surrounding areolar tissue, and free drainage provided. The pancreas is reached through an anterior incision in the abdominal wall after freely incising the gastro-colic omen tom. When the stomach is retracted upwards and the colon pulled downwards the peritoneum forming the small sac lying on the anterior surface of the gland is to be divided. The important point is the provision of the freest possible drainage, and the route to he selected for this purpose will depend upon the conditions found present. A large tube as well as a gauze drain should be passed down to the gland, and in some cases it may he necessary to incise the capsule in order to lodge this in the pancreatic tissue. The drains may be brought out through the wound in the abdom
inal wall, or a counter-opening should be made in the loin communicating directly with the lesser sac of the peritoneum. When a gangrenous condition of the organ is found, the dead portion may be removed by curetting and the cavity packed with sterile gauze, but the outlook is usually hopeless.
Chronic pancreatitis being nearly always associated with blocking of the common duct by gall-stones or of the pancreatic duct by calculi, the indications for treatment are usually clear, and this will consist in the removal of the obstruction and the establishment of free drainage of the bile-ducts. Where the surgeon finds no such obstruction present, or if any irremovable constriction or tumour is found, the proper course to pursue will be to establish free drainage of the bile-ducts by performing a cholecyst-enterostomv. Operation should not he delayed till the inflam matory action has invaded the islands of Langerhans; when such has already occurred, the only resource left will be the administration of pancreatic extract in a Keratin-coated pill or tabloid to supply the absent or diminished internal secretion of the cirrhosed organ in order to prevent, if possible, the advent of glycosuria.
Some cases of chronic pancreatitis are of syphilitic origin, and rapid relief of symptoms follows the exhibition of anti-syphilitic remedies. One such case demonstrated at operation in a young congenital syphilitic reacted at once to mercury and Iodide of Potash, and regained good health almost at once.
Cancer of the Pancreas.—The last-mentioned operations afford the only practicable method of dealing with malignant disease of the gland. Since removal of the neoplasm is as a rule impossible, the surgeon must content himself with relieving the jaundice by draining the bile-ducts.
Coffey suggests that the operation of pancreato-enterostomy should be performed when the duct of Wirsung is found occluded, as gastro-enteros tomy is employed in pyloric obstruction. He advises that the cut end of the pancreas should be implanted into a loop of intestine, as it was found impracticable to implant the stripped pancreatic duct directly into the intestine.