Abstract: Gas-producing bacteria are known to selectively colonize a variety of abdominal viscera, but gas-producing infection limited to the spleen until now has not been reported. A gas-producing (emphysematous) infection of the spleen was diagnosed in a super-super-obese diabetic patient with abdominal pain and signs of sepsis. The patient presented a serious diagnostic challenge because massive abdominal obesity did not enable her to pass through the aperture of a standard computerized tomography unit. Therapeutic options were limited because computerized tomography-guided drainage or splenectomy were technically not feasible or were considered too risky.
Abstract: The presence of a hiatal hernia is generally considered a contraindication to gastric banding in the morbidly obese, despite recent reports indicating favorable outcomes following simultaneous repair of sliding hernias and laparoscopic adjustable gastric banding (LAGB). A 66-year-old woman weighing 120 kg (BMI 45) with arterial hypertension and gastroesophageal reflux-related chronic obstructive pulmonary disease underwent repair of a large paraesophageal hernia and LAGB. At 40 months followup, the patient had lost 44% excess body weight (BMI 36) and had no complaints of heartburn, regurgitation or dysphagia. She was no longer hypertensive and her pulmonary condition had improved significantly. Barium swallow at 30 months showed normal anatomy and positioning of the band. Because other minimally traumatic surgical options are lacking, the author believes morbidly obese patients with hiatal hernia should not be denied the advantages of LAGB. Adequate weight reduction, resolution of gastroesophageal reflux and other co-morbidities can be expected if an appropriate surgical technique is used.
Abstract: Although laparoscopic adjustable gastric banding has become a widely used surgical modality for the treatment of morbid obesity, the technique and its complications remain fairly unknown to the medical community in general. Late complications occur in 10% to 20% of patients and usually manifest as upper gastrointestinal symptoms such as total food intolerance. However, seemingly unrelated symptoms such as chest pain may be the primary complaint. A rare but important complication to recognize and treat is gastric necrosis due to herniation of the stomach through the band. From the lessons learned with 2 patients and review of the literature, the diagnostic pitfalls and means for achieving a prompt diagnosis are discussed and a management protocol intended for emergency department staff is provided.
Abstract: BACKGROUND: Boerhaave's syndrome requires urgent thoracotomy, laparotomy, or both for esophageal repair and pleuromediastinal debridement. Minimally invasive techniques may be suitable alternatives. MATERIALS AND METHODS: Over a period of 12 months, three patients with spontaneous esophageal perforations after forceful vomiting were treated by a combination of minimally invasive techniques including laparoscopy, thoracoscopy, mediastinoscopy, and endoscopic stenting. RESULTS: Esophageal repair was performed transhiatally via laparoscopy using primary suture, primary suture reinforced by a fundic patch, and fundic patch alone in one patient each. One patient had a second perforation of the proximal esophagus, which was sutured through a cervical incision. This patient successfully underwent secondary endoscopic stenting for a persistent esophageal fistula. Mediastinal debridement was performed transhiatally and also by means of a mediastinoscope introduced via the cervical incision in one patient. One patient required secondary thoracoscopic debridement of a pleural empyema but died of sepsis after 1 month. The two other patients recovered and were discharged from the hospital after 2 and 8 weeks, respectively. CONCLUSIONS: Boerhaave's syndrome is amenable to minimally invasive techniques. Avoidance of a formal thoracotomy with its resulting morbidity could be of considerable benefit to these critically ill patients.
Abstract: BACKGROUND: Despite the well documented morbidity associated with its reversal, Hartmann's procedure remains the favoured option in patients with complicated diverticular disease in the presence of diffuse peritonitis. A prospective study was conducted to determine whether primary anastomosis with diverting colostomy constitutes a valid alternative to the Hartmann procedure. METHODS: Between 1994 and 1998, all patients with diffuse peritonitis due to perforated diverticulitis of sigmoid origin underwent resection and primary anastomosis with diverting colostomy. Restoration of colonic continuity was programmed six weeks later, after verification of the anastomose by gastrografin enema. The group included 5 men and 15 women with a mean age of 72 years (32-97 years). The ASA classification of the patients was as follows: ASA II (n = 2), ASA III (n = 12), ASA IV (n = 3), ASA V (n = 3). The mean delay between onset of symptoms and surgery was 74 hours (8-215 hours). RESULTS: Operative mortality and morbidity was 15% (n = 3) and 50% respectively. No patients showed signs of suture disruption and this was confirmed by routine radiological controls of the anastomoses. Mean length of hospitalization was 20 +/- 10 days (SD; median: 18 days). Closure of the colostomy using a small peristomal incision was performed in all surviving patients after a mean delay of 45 +/- 9 days (range 28-67 days). Mean length of hospitalization for colostomy closure was 7 +/- 3 days (range 3-18 days) without mortality. CONCLUSIONS: Applied systematically to all patients with diffuse peritonitis due to perforated diverticular disease, primary anastomosis was found to be as safe as the Hartmann procedure but appears to be superior in terms of total length of hospital stay, interval to stoma closure and rates of stoma closure. Primary anastomosis with diverting colostomy could constitute a valid alternative to the Hartmann procedure in selected patients with complicated diverticular disease, even in the presence of diffuse peritonitis.
Abstract: A patient with obstructive Brunner's gland hyperplasia presenting as an annular duodenal stricture is reported. Surgical biopsy was required to obtain a tissue specific diagnosis and obstruction was relieved by performing a Roux-en-Y duodenojejunostomy. Brunner's gland hyperplasia poses a diagnostic challenge. Conservative management is usually adequate after a histological diagnosis has been firmly established.
Abstract: Mass lesions of the mesentery may be fortuitously encountered on computerized tomographic (CT) scans, posing a diagnostic challenge. Despite CT, magnetic resonance (MR) imaging and a surgical biopsy, a patient with mesenteric lipodystrophy was misdiagnosed as having a low-grade mesenteric liposarcoma. Spontaneous regression of the mass on control CT scan and review of the pathological material prompted us to reconsider the diagnosis of malignancy. Because a wide variety of tumors and pseudotumors produce alterations in the density and volume of mesenteric fat on CT scan, a surgical biopsy is usually necessary to obtain a tissue-specific diagnosis, but even then pathological findings may be equivocal. As final resort the natural evolution assessed by radiological follow-up can be of help in determining the nature of the disease.
Abstract: BACKGROUND AND METHODS: Fourteen patients with caustic necrosis of the digestive tract extending beyond the pylorus were included in a multicenter retrospective study to define a surgical strategy. Twelve patients underwent esophagogastrectomy. Two patients had total gastrectomy without esophagectomy. In addition, all patients underwent duodenal stripping (n = 7) or pancreaticoduodenectomy (n = 7). Immediate biliopancreatic reconnection was performed in ten patients. Four patients had biliary diversion and/or pancreatic duct ligation. RESULTS: Seven in-hospital deaths occurred after a mean delay of 27 days (range 16-45 days). There were two late deaths occurring 6 and 12 months postoperatively. Morbidity was noted in 86% of survivors. Acute or chronic airway tract injuries were incurred by 57% of patients. Among the five long-term survivors two were able to feed orally and had preserved voice function. One long-term survivor could resume oral feeding only, another was considered psychologically unfit for digestive reconstruction but had normal voice function and the last patient was deprived of oral feeding and phonation. CONCLUSIONS: Early radical debridement is capable of saving patients with gastrointestinal necrosis extending beyond the pylorus. Necrosis of the duodenum can be managed by pancreaticoduodenectomy or by duodenal stripping, with similar results. Immediate reconnection of the bile and pancreatic ducts to a small bowel Roux-en-Y loop appears preferable to biliary diversion and pancreatic duct ligation. Normal oral feeding and the preservation of voice function can sometimes be achieved but depends on late scarring of the airway-alimentary tract junction. Quality of life is often compromised by prolonged hospital stays, staged surgical procedures and the handicap of a feeding jejunostomy and tracheal tube.
Abstract: OBJECTIVE: To review and update the authors' experience with resectional surgery for proximal bile duct carcinoma (Klatskin tumor) and assess the role of liver resection over the past 25 years. BACKGROUND: Until recently, resection of proximal bile duct carcinoma was uncommon, with most patients undergoing palliative procedures. The authors adopted a radical surgical approach aimed at definitive cure in 1974. Recent reports suggest that resection improves outcome. METHODS: The records of 40 of 94 patients (23 men, 17 women, age range 34-81 years) diagnosed with proximal bile duct carcinoma who underwent resection between 1968 and 1993 were reviewed. According to the Bismuth classification, there were five type I, four type II, 25 type III, and six type IV lesions; 11 patients underwent tumor resection alone, and 25 patients had combined tumor and liver resection (seven of these also underwent an associated regional vascular resection). In 3 patients, venous allografts were harvested from cadaveric donors and used to reconstruct the portal vein. Four patients underwent liver transplantation; in two, organ cluster-type resections including the liver with porta hepatitis and pancreas were performed. RESULTS: The resectability rate in the more recent period of the study was 49.4%. Most type I, three (of four) type II, T in situ, T1a, T1b, and all stage 0 tumors were resected without hepatectomy. In the other subgroups of tumors, the main surgical procedure was hepatectomy. Thirty-day mortality was 12.5%. After tumor resection alone, survival at 1, 3, and 5 years was 81.8%, 45.5%, and 27.3%, respectively. After tumor resection and hepatectomy without vascular resection, 1-, 3-, and 5-year survival was 66.7%, 16.7%, and 6%, respectively. With vascular resection, survival rates were similar: 64%, 20%, and 4%, respectively. CONCLUSION: The type of surgery required to achieve cure is closely related to tumor location, TNM classification, and staging. Increasing resectability through the use of hepatectomy improves survival and offers a chance of cure in patients with more advanced disease.
Abstract: Management of the pancreatic remnant following pancreaticojejunostomy remains a technical challenge particularly when the pancreas is soft. A simple technique that consolidates the pancreas in preparation for pancreaticojejunostomy is described. Application of this technique in patients for whom a difficult anastomosis was anticipated has yielded good results.
Abstract: Esophageal perforation is a life-threatening situation and represents a major therapeutic challenge. Results have improved in recent years particularly as a result of progress in antibiotic therapy and the use of total parenteral nutrition. Surgical management retains a predominant role, involving early primary closure and thoracic drainage. We have made an addition to the surgical management by applying an absorbable mesh and fibrin glue to the repaired site. Seven patients (ages 38-79 years) were treated as described. The mean interval from leak to surgery was 28 hours. Six patients had an uneventful postoperative course with a mean hospital stay of 34 days (range 26-45 days). In one case the technique failed and the patient required an exclusion-diversion procedure. All 7 patients recovered without mortality. We believe that this technique provides a real improvement for this precarious esophageal repair.
Abstract: From 1970 to 1992 a total of 63 patients underwent operation for ampullary tumor: 40 pancreatoduodenectomies (PDs), 3 total PDs, 8 ampullectomies, and 12 bypass or exploratory laparotomies. The resectability rate was 68%. There were 9 benign tumors, 1 anaplastic tumor, and 53 adenocarcinomas. According to Martin's classification, there were 7 stage I, 11 stage II, 14 stage III, and 21 stage IV tumors. All patients with stage I, II, and III tumors underwent resection. Patients with stage IV tumors had either resection (n = 11) or bypass (n = 10). The mean duration of hospital stay was 20.6 days. Operative mortality was 12.7% for the whole series and 7.5% after PD (2.5% for the last 10 years). Overall survival was 40% at 5 years (85% for stage I, 65% for stage II, 44% for stage III, and 8% for stage IV). Survival was better for stages I, II, and III after PD than after ampullectomy. For stage IV patients survival was 70% after PD versus 20% after bypass at 1 year and 25% versus 0% after 2 years. In our opinion, PD should be proposed even for benign lesions because two of our patients had to undergo repeat operation (PD) 4 and 22 years later, respectively, for stage IV disease. PD is our choice for all tumors of the ampulla.
Abstract: BACKGROUND: Controversy persists regarding digestive reconnection following subtotal gastrectomy for carcinoma. A randomized prospective trial comparing Billroth I and Billroth II procedures for mortality, digestive comfort, survival, and patterns of recurrence was conducted. STUDY DESIGN: Thirty patients underwent Billroth I and 32 patients underwent Billroth II procedures. Stages I, II, III, and IV of the tumor-node-metastasis (TNM) staging system accounted for 27, 16, 47, and 10 percent of tumors, respectively. Billroth I and II groups were well-matched for clinicopathologic variables. RESULTS: Duration of surgery, volume of blood transfused, and abdominal drainage were similar in the two groups. The duration and volume of gastric drainage were greater in patients following Billroth I procedures. Four fistulas were noted in the Billroth I group and one fistula developed in a patient following Billroth II gastrectomy. Billroth I gastrectomy and low preoperative serum albumin were independent risk factors for fistula development. Fistula development accounted for an increase in the duration of hospital stay following Billroth I procedures. Hospital mortality was similar in the two groups. Five-year actuarial survival rate was 42 and 40 percent for patients undergoing Billroth I and Billroth II procedures, respectively. Long-term survival was similar for patients having each procedure, and this was verified for all TNM stages. There were seven recurrences at the hepatic pedicle in the Billroth I group and one recurrence of this type in the Billroth II group, requiring four reinterventions. CONCLUSIONS: Digestive comfort and long-term survival are similar after Billroth I and Billroth II gastrectomy for carcinoma. Billroth I gastrectomy is associated with an increased risk of fistula development and of recurrence of carcinoma at the hepatic pedicle.
Abstract: Creation of an intrahepatic shunt using a metallic prosthesis introduced via a transjugular approach constitutes an alternative to surgery in the treatment of portal hypertension. Although rare, the specific complications of this technique justify close collaboration between radiologists and surgeons. The authors report two serious complications after failure of intrahepatic shunt, requiring emergency laparotomy.
Abstract: The creation of an intrahepatic portosystemic shunt using an expandable stent introduced by a transjugular route constitutes an alternative to surgical shunts for the management of portal hypertension. A 61-year-old woman with Child C cryptogenic cirrhosis and acute variceal bleeding presented a massive haemoperitoneum due to a tear at the portal vein confluence during a failed attempt at TIPS. Surgical salvage consisting in an end-to-side portocaval shunt was performed under adverse conditions because of massive haemorrhagic infiltration of the hepatic pedicle. The patient died shortly after surgery of irreversible shock. A 61-year-old male with Child C alcoholic liver disease underwent an urgent TIPS procedure for recurrent variceal bleeding. However, the stent was placed too distally, at the splenomesenteric junction, causing splenic and portal vein thrombosis. After surgical removal of the impacted stent and thrombectomy, an end-to-side portocaval shunt was performed. The patient died 1 month later of infected ascites. Although serious procedural complications are uncommon in expert hands, transjugular intrahepatic portosystemic shunting is an invasive technique that is associated with potentially fatal complications.
Abstract: Over a 16 month period seven patients underwent surgery using venous allografts either to reconstruct the portal vein, or to construct a mesocaval 'H' graft or a shunt between the coronary vein and the subhepatic inferior vena cava. The allografts were harvested during multiorgan procurement from the bifurcation of the inferior vena cava, the common iliac vein and the external iliac vein and kept in a preservation solution at 4 degrees C for a mean time of 6 days (range 1-29) before use. Subsequent thrombosis was clinically evident in only two patients. The use of venous allografts appears to be a useful alternative to other venous replacements.
Abstract: Hemangiopericytoma is an uncommon vascular tumor with variable malignant potential. The origin, structure and function of pericytes remains controversial. Intra-abdominal hemangiopericytomas are highly aggressive soft tissue tumors with a great propensity for malignant transformation. We report on a case of hemangiopericytoma of the pancreas in a 53-year-old female presenting with abdominal pain. Ultrasonography and CT scan revealed a cystic tumor of the head of the pancreas. The patient underwent successful pancreaticoduodenal resection and is alive with no signs of recurrence 25 months following surgery. Ultrastructural studies are necessary to differentiate hemangiopericytomas from other sarcomas. Malignancy may be ascertained only in the presence of metastases or local recurrence. Routine surveillance is advocated.
Abstract: From 1983 to 1989, 96 oesophagectomies (30% of all oesophagectomies performed during this period) were performed without thoracotomy and then analyzed retrospectively. Most were performed due to contraindications including age (17%), respiratory disease (47%), heart disease (37%) or for superficial oesophageal lesions (35% were stage T1). Operative mortality was 3.1%. Fistulization of the anastomosis occurred in 7.5% of the cases. Actuarial survival rate at 5 years was 29% and was independent of age but dependent on localization, the size of the tumour, presence of parietal invasion and TNM classification. However, patient selection introduced bias and a prospective randomized study comparing oesophagectomy without thoracotomy and oesophagectomy via right thoracotomy and midline incision demonstrated that mortality and complications were similar with the two techniques. Long term survival was not dependent on access route, but on the stage of the disease.
Abstract: A modified technique of orthotopic hepatic transplantation with inferior vena caval preservation and piggy-back procedure is described. This procedure, used in 14 patients, avoided the need for temporary vena cava clamping in nine cases and reduced the need for venous bypass during orthotopic liver transplantation. The indications, results and advantages of this procedure are described.
Abstract: Between 1980 and 1990, 25 patients were treated for large incisional hernias using the skin lacing technique. Twenty-four hernias were midline and one was at the site of a McBurney incision. Hernia defects were greater than 10 cm in diameter for 24 patients. A 1 cm-wide uninterrupted segment of skin was harvested from excess skin overlying the hernia and was then alternatively passed through the left and right fascial margins of the hernia. The operative mortality was nil. Two wound abscesses were drained locally and did not mandate removal of the skin lace. After a mean follow-up of 4.9 years, 3 recurrences were observed. Among 22 patients who had a successful repair of their incisional hernia, 20 returned to their previous occupations and two others reported improvement in performing their daily tasks. The skin lacing technique is an interesting alternative to other more sophisticated techniques in the management of large incisional hernias.
Abstract: From 1975 to 1989, 51 patients presenting with hepatocellular carcinoma complicating genetic haemochromatosis were managed in our institution. Twenty-one patients underwent a laparotomy. Laparotomy was limited to surgical exploration or palliation in 8 patients in whom the tumour was deemed unresectable. Thirteen patients underwent either a partial hepatectomy (11 patients) or a total hepatectomy and liver transplantation (2 patients). Actuarial survival at 1 and 3 years following partial hepatectomy was 56% and 40% respectively. There was one hospital death in the resection group and in the transplant group. Only 3 patients have remained free of tumour recurrence after a mean follow-up of 18 months. Common clinical and histological features for patients with this condition included masculine gender, age 50 years or above, 10 or more years of history of diagnosed genetic haemochromatosis, high alcohol intake, and grade III or IV hepatic fibrosis.
Abstract: Focal nodular hyperplasia remains a difficult diagnostic and clinical dilemma. Over a 10-year period, 20 patients with this diagnosis underwent surgery in our service. Eight of the patients had focal nodular hyperplasia discovered incidentally as part of investigation or surgery for other unrelated conditions. Seventeen of the patients were female, with 64% receiving oral contraceptives. In the 12 patients without concomitant disease all but one had upper abdominal pain. Despite the use of CT scan, isotope studies, NMR, angiography, ultrasound and biopsy, a firm preoperative diagnosis of focal nodular hyperplasia was made in only one patient. Resective surgery was performed without complication in all cases. During a mean follow-up of 42 months (range 6-128 months) one patient died from lymphoma and two patients had recurrent abdominal pain. This study highlights the difficulty in preoperative diagnosis of focal nodular hyperplasia. Conservative treatment can be considered or resective surgery safely performed for symptomatic or suspect lesions.
Abstract: Using the traditional technique for liver transplantation, there are two supra and subhepatic anastomoses to the vena cava. With the piggy-back method, the donor's inferior vena cava is implanted terminolaterally into the recipient's inferior vena cava. The aim of this work was to evaluate results in two matched groups. PATIENTS AND METHODS. From June 1992 to May 1993, 13 patients underwent piggy-back liver transplantation (group 1) and 14 others underwent traditional liver transplantation (group 2). There were 17 men and 10 women, mean age 48 years (range 25-65 years). There was no significant difference between the groups for age, sex, indications, number of rejections and retransplantations. RESULTS. There were no deaths in group 1 and 2 deaths in group 2 within the first 30 days postoperatively. There was no significant difference between groups 1 and 2 for duration of cold ischaemia (552 +/- 323 vs 463 +/- 345 min respectively), the number of packed cell transfusions (9.8 +/- 11 vs 11.1 +/- 5.5), duration of the operation (474 +/- 151 vs 500 +/- 95 min), duration of anastomosis (56 +/- 17 vs 66 +/- 20 min), creatinine levels at day 30 (140 +/- 79 vs 200 +/- 145 min). But there was a significant difference in the anhepatic phase (56 +/- 17 vs 66 +/- 20 min). CONCLUSION. Unexpectedly, there was no significant difference between the two types of transplantation with the exception of the anhepatic phase.
Abstract: A case of tumor seeding in an abdominal trocar hole after laparoscopic extraction of an incidental gallbladder carcinoma is reported. The high incidence of occult tumors of the gallbladder and appendix warrants caution when dissecting and extracting operative specimens.
Abstract: We report the case of a 31-year-old male patient with a diffuse form of Caroli's disease presenting as recurring bouts of biliary pancreatitis. Following sphincterotomy, the patient remained asymptomatic for 5 years. He then developed acute cholangitis and, at laparotomy, all superficial liver cysts were fenestrated in order to remove intrahepatic bile duct calculi. A right hepatectomy, removing the most severely affected liver parenchyma was not considered feasible because of the small size of the left lobe and the existence of an associated congenital hepatic fibrosis. In diffuse forms of Caroli's disease biliary drainage techniques have often proved ineffective in preventing recurring bouts of cholangitis. Moreover, liver resection is seldom feasible because of associated congenital hepatic fibrosis. In this setting, liver transplantation may represent the only effective and durable form of treatment.
Abstract: The authors describe a musculocutaneous flap which can be used in trochanteric pressure sores in paraplegics. Described by Little and Lyons (1983), this reconstructive unit combines the proximal muscular segment of the tensor fasciae latae (TFL) and gluteus medius muscles in a round shaped flap pedicled on the lateral circumflex femoral artery. The anatomical basis of this muscle combination is found in the anastomotic network between the superior gluteal artery which supplies gluteus medius muscle and lateral circumflex femoral artery, the principal vascular pedicle of the TFL muscle. Cutaneous defects of the trochanter and associated osteitis are frequent complications in paraplegic patients which often require ostectomy and coverage of the bony prominence by well vascularised, padded skin. Musculocutaneous flaps are well suited for this purpose and we review various reconstructive units that may be brought into trochanteric defects. Among these, the gluteus medius-TFL flap appears to be an interesting option for, in case of recurrent ulcers, other donor areas are left intact, and the flap itself could give rise to a subsequent "traditional" TFL flap.
Abstract: Mucoceles of the appendix and associated pseudomyxoma peritonei are a heterogeneous group comprising various histopathologic lesions with differing prognoses. Between 1983 and 1990, we treated eight patients with appendiceal mucocele, three cystadenomas and five cystadenocarcinomas, three of which had accompanying pseudomyxoma peritonei. All patients were more than 50 years of age. Women outnumbered men by seven to one. Preoperative diagnosis was acute appendicitis or appendiceal abscess in all instances of mucocele unaccompanied by pseudomyxoma peritonei. Ultrasound of the abdomen, together with paracentesis, diagnosed pseudomyxoma peritonei in two of three patients. Elevated carcinoembryonic antigen levels were found in six of the eight patients and monitoring of this parameter was useful in the early detection of the two recurrences observed. The three patients with cystadenomas remain free of disease after appendectomy. Of the five patients treated for cystadenocarcinoma by right colectomy, two underwent reoperation after recurrence of disease. One patient died 41 months later of intestinal obstruction caused by pseudomyxoma peritonei. Pseudomyxoma peritonei significantly decreases survival of patients with appendiceal mucocele. In these patients, aggressive initial surgical management, repeated if need be, is indicated.
Abstract: We report the case of a patient who, at 28-week amenorrhea, presented with spontaneous hemoperitoneum in a pre-eclamptic syndrome. When caesarean section was performed, abdominal exploration revealed a liver hematoma which caused the rupture of Glisson's capsule. The related literature is reviewed.
Abstract: Reference in the surgical literature to the use of pseudocysto-duodenostomy whether laterolateral by Ombredanne [6] or transduodenal by Kerschner [4], is uncommon. The author with the aid of specially designed three-jaw prong, now, prefer to use pseudocysto-duodenostomy. From 1970, 411 patients underwent surgery for complicated chronic pancreatitis. 67 of the 93 patients requiring an internal cysto-intestinal procedure were treated by pseudocysto-duodenostomy; 11 additional patients were treated by derivation in the first retroperitoneal transposed jejunal loop. Postoperative mortality for the first month was 0%. The actuarial survival rate at 5 years was 86.9%. These satisfactory results have encouraged us to compare this new operative method with cystojejunostomy. It allows pancreatic secretions to drain into their natural anatomical site. Compared with external drainage it avoids the often prolonged and costly complications.
