Acta chirurgica Scandinavica最新文献

Published reports have been reviewed and the results compared in an attempt to differentiate between pancreatic pain and abdominal pain from other causes, and between the pain of acute pancreatitis and that of chronic pancreatitis and pancreatic carcinoma. The role of pain as a diagnostic sign has been assessed, as have the patterns of pain in chronic pancreatitis.

Seventy patients were treated either surgically, by percutaneous puncture, or conservatively for pancreatic pseudocysts at this hospital; 61 (87%) had pain, which in most cases was moderate. Before admission 14 patients had been taking opioid drugs regularly and 18 had used opioids occasionally. Nine patients used non-opioid analgesic drugs less than once a day. Pain relief after treatment was less effective in patients for whom pain was the main symptom. The patients in whom pseudocysts were a complication of chronic alcoholic pancreatitis had more severe pain than those whose pseudocysts followed trauma or attacks of acute pancreatitis. There was a positive correlation between the degree of pain and the size of the pseudocyst in patients with acute pancreatitis, but there was no correlation between the degree of pain and the presence of bacteria in the cyst fluid (n = 8). Pseudocysts in the tail of the pancreas caused less pain than those in the head.

Pain from pancreatic cancer is, in most cases, both severe and debilitating. Large doses of morphine are sometimes not tolerated or accepted by the patient, and are often ineffective. It has been claimed that "coeliac plexus block is the simplest, most effective and least hazardous" means of palliation (49, 59); we think that this is true, and that coeliac plexus block should be considered more often than it is today, and at an earlier stage. Only in rare cases should pain from pancreatitis be treated with a nerve block.

Ultrasonography of the liver was performed on 27 patients during laparotomy for liver lesions--11 primary and 13 metastatic mainly colon/rectum malignancies, and three benign conditions. Supplementary information on the liver parenchyma was provided in 11 cases (41%) in which the surgical strategy was decided simply by inspection and palpation of the liver. Ultrasound was most valuable for visualizing the vascular anatomy of the liver, giving clarification in 18 cases (66%), especially the relationship of tumor to portal and hepatic veins. This was decisive for the surgical strategy in four cases, enabling resection in two and modifying planned procedure in two. In a case of polycystic liver, ultrasonography imaged deep-lying cysts and aided the fenestration procedure. Liver resection was performed in 16 cases without operative mortality. Hepatic ultrasonography is useful for determining tumor spread, but of even greater value for the determination of strategy by clarifying tumor/vascular anatomic relationships.

The association between histopathological changes and the incidence of abdominal pain in patients with chronic pancreatitis was reviewed from published reports, and compared with that in our own series (n = 65). Recurrent tissue necrosis caused by autodigestion, and the formation of pseudocysts, are the likely causes of the intermittent pain that marks the early stages of chronic pancreatitis. In contrast, the persistent pain of advanced chronic pancreatitis is associated with incomplete duct obstruction in a pancreas that is still able to secrete. The cause of persistent pain may therefore be segmental distension of the walls of the duct as a result of focally increased pressure. Perineural scarring has been seen in both painful and painless chronic pancreatitis.

The effects of number of operations, experience of the surgeon, and type of hospital on operative mortality have been studied in 444 patients treated for abdominal aortic aneurysms. In the elective group (n = 279) there was a significant difference in mortality between hospitals in which more than 10 such operations were done compared with those in which less than 10 were done during the study period (p = 0.05; odds ratio (OR) 2.7). In the ruptured group there was no statistically significant difference (p = 0.14; OR 1.9). In the elective group, units with vascular surgical experience had an operative mortality of 4.8% compared with 11.3% for other units (p = 0.05; OR 2.6). In the ruptured group the figures were 52.5% and 73.3% respectively (p = 0.03; OR 2.5). There was no difference in operative mortality between university, county and local hospitals. Outcome of treatment after operations for abdominal aortic aneurysm was related to number of operations carried out and experience, whereas the type of hospital seemed less important.