POST-OPERATIVE PANCREATITIS - Postgraduate...

248

POST-OPERATIVE PANCREATITISBy ARCHIBALD E. CARTER, F.R.C.S.

Fromn\the Department of Surgery, Harvard Medical School, and the Peter B3nt Brigham Hospital, Boston, Massachusetts

IntroductionPost-operative pancreatitis has been the subject

of several recent reports which, together with acommentary on our own experience, are reviewedin this presentation.The first reference to the condition was by

Schneider and Sebening (I928)1 in a general dis-cussion on pancreatitis. In 1949, Millbourn2 madethe first survey of pancreatitis following gastricresection, noting that 90% of all cases showed arise in the serum amylase post-operatively, the risebeing the highest when extensive duodenal mobili-zation had occurred and lowest when adherentulcers were left behind. He came to the conclusionthat the occurrence of post-operative pancreatitisdepended upon the following conditions.

(I) Mechanical injury direct to the pancreas andespecially to the pancreatic ducts.

(2) Vascular conditions.(3) Spasm of the sphincter of Oddi.(4) Stagnation of duodenal contents.In this same year Metheney and Lundmark3,

noting a case in which pancreatitis developed fivedays after a Polya type gastrectomy with retrocolicanastomosis quoted Horsley4 and Brunsgaard5 whoreported the difficulties in recognizing the compli-cation. Warren (I9516 and I9547) reviewed theliterature on the incidence of the condition aftergastrectomy and recorded seven cases, six fatal,after 892 operations. He also quoted the aetio-logical factors stated by Millbourn, especiallyemphasizing the vascular effects.Dunphy, Brooks and Ackroyd (i953)8 showed

the condition could follow extensive mobilizationof the head of the pancreas (5 cases), appendicitis(i case) and that in 2 cases the major lesion wasthrombosis of vessels to the head of the pancreasassociated with surgery elsewhere. Howard,Frewley and Artz (I955)9 state that serum amylaselevels are usually lowered by surgery other than inthe pancreatic area. Cope's (I93810 and i93911)observations that adrenalectomy is followed by arise in serum amylase and cortisone and Desoxy-corticosterone acetate administration by a fall,provides experimental evidence for these obser-vations in the light of current knowledge of adrenal

and pituitary activity in trauma: similarly, Gray(I94i)12 showed that anesthesia produces a fall inserum amylase values.During the course of this study, Perryman and

Hoerr (i955)13 reported their findings based uponserum amylase determination. Excluding a mis-cellaneous group and their patients who had directintervention on the pancreas, they showed that I6of 32 gastrectomies (type not stated) and 8 of 23common bile duct explorations, showed a rise inserum amylase postoperatively: none of their 6simple cholecystectomies showed elevation inserum amylase after surgery though 2 of 8 vago-tomies and gastrojejunostomies did. At this sametime, Mahaffey and Howard (I955)14 reported 20gastrectomies (type not stated) of which 7 showeda rise of over ioo% in serum amylase postopera-tively, 5 a slight rise and 8 a fall; of 28 operationson the biliary tract, 4 showed a rise above the high-est normal level. They quote 50 other cases withvarying. changes though in some, for exampleresection and grafting for aortic aneurysm, directtrauma to the pancreas is not definitely excluded.While there is no doubt that pancreatitis may

follow many varieties of surgery even far away fromthe pancreas, pancreatitis following surgery in thepancreatic area, when the pancreas and its ductshave not been interfered with, is the conditionmost likely to be confused with other postoperativecomplications in the area. The present observa-tions were made to determine any precipitatingfactors in surgery in the pancreatic area and at thesame time, an attempt has been made to extendthe usefulness of other serum pancreatic enzymedeterminations.

The Present StudyThis paper will be divided into two parts, firstly

the results obtained by study of serum amylase andlipase levels, and secondly, by determination ofserum trypsin inhibition.

Part i. Observation on SerumAmylase ChangesMaterials and Methods

Forty-four patients were studied, being selected

copyright. on 22 M

ay 2018 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.32.367.248 on 1 M

ay 1956. Dow

nloaded from

http://pmj.bmj.com/

May 1956 CARTER: Post-Operative Pancreatitis 49

POST OPERATIVE PANCREATITIS

GROUP I.SUB-GROUP A: 15 CASES SUB-GROUP B: 16 CASES.

33 - 5 .

2 50

I

LrJ

0 0P + * 2

L,

0

20 20

POINTSNN INTERLS OF 24 HOURS

FIG. i.-Group I: 31 cases, showing in Subgtoup A the usual ranges of elevation of serum amylaseand in Subgroup B the ranges of fall or minimal elevation when there was no suspicion ofpancreatitis.

irrespective of sex or age, from those undergoingsimple cholecystectomy and simple gastrectomy toascertain the changes in serum amylase levels inthe first 24-72 hours after operation near to butnot involving the pancreas directly. In this groupare included, as comparison, patients who hadcommon bile duct exploration or removal of pepticulcers adherent to the pancreas. No patient hadany part of the pancreas removed or mobilized.Two patients were studied during the course of anattack of acute pancreatitis, one before and oneafter surgery. .Blood samples were collected 24hours before surgery, 24 and 48 hours after sur-gery, and at 24 hour intervals until a normal levelwas reached. Normal levels were defined on 76patients without pancreatic disease.Serum amylase determination was by the method

of Free and Myers (I944)15 reproducible to within. 4%. Normal levels lay between 0.78 and 20

glucose units per ml. serum with a wide variabilityin individuals. In order to arrive at a level abovewhich the presence of pancreatitis could beassumed, two standard deviations above the high-

est normal level obtained were used, providing afigure of 50 glucose units per ml. serum. Threepatients known to have acute pancreatitis showedserum amylase levels between 70 and 286 units.Serum lipase was also determined by Gold-

stein's (I948)16 method but although a satisfactorymethod, did not provide a wide enough range ofchange in result to be of aid in the problem and isnot reported further.

ResultsSerum amylase levels are presented as outlined

above in the following groups.Group x. (Fig. i)

Illustrating the two types of change that may beexpected in those patients whose serum amylasevalues never entered levels suspicious of theirhaving pancreatitis.

Subgroup Ia. Fifteen cases, 12 of whom devel-oped serum amylase levels above the highest nor-mal (zo units) 24 or 48 hours after surgery. Sixsimple cholecystectomies, 2 common duct explora-

copyright. on 22 M


http://pmj.bm

j.com/

Postgrad M


ay 1956. Dow

nloaded from

http://pmj.bmj.com/

S POSTGRADUATE MEDICAL JOURNAL May 1956

POST OPERATIVE PANCREATITISGROUP 2

SUB-GOUP A: 4 CASES . SUB-GOU 8 : 3 CAES.

240 240

t22 220

00 I 2100210

S0 ISO10 CM

hi O \\ .

FIG. 2.-Group 2: 7 cases showing the falls from and rises into ' pancreatitis 'levels in two subgroups when there was no suspicion of pancreatitis.

70

SC.

POINTS INTERVALS OF 24 HOURSFIG. z.--Group 2: 7 cases showing the falls from and rises into 'pancreatitis'

levels in two subgroups when there was no suspicion of pancreatitis.

tions, 6 simple gastrectomies and i gastrectomy foradherent ulcer make up this group.

Subgroup ib. Sixteen cases, who demonstratethe patterns of minimal change or fall in serumamylase after surgery. 6 cases had simple chole-cystectomy, 2 common duct exploration, 7 simplegastrectomy, and i removal of an adherent gastriculcer.

Group 2Demonstrates in two subgroups those cases who

although without clinical evidence of acute pan-creatitis, had levels of serum amylase higher thanthe level (50 units) above which acute pancreatitiscould be assumed present.

Subgroup A. Four cases, whose amylase levelswere over 50 before operation: 2 simple chole-cystectomies preceded by' biliary colic', presum-ably from a stone impacted temporarily at theampulla of Vater, i common duct exploration,similarly preceded by ' biliary colic' who had astone removed from the ampulla, and i case whohad a simple gastrectomy for nonadherent, simplegastric ulcer: this latter man had received 3,500 c.cof blood 24 hours before his serum amylase wasfirst estimated and it is thought that he may havehad a mild pancreatic oedema as an allergic(Arthus) phenomenon. It is to be noted that theirsurgery in no way prevented the fall in serum amy-lase levels to be expected on relief of their disease.

copyright. on 22 M


http://pmj.bm

j.com/

Postgrad M


ay 1956. Dow

nloaded from

http://pmj.bmj.com/



SUB GROUP A SIMPLE CHOLECYSTECTOMY SUB GROUP B COMMON' BILE DUCT EXPLORATION15 CASES 7 CASES

250 2O223

60 60

40 40

$.30 30

O _

00

I OP OP 2 3 4

POINTS IN INTERVALS OF 24 HOURS

FIG. 3.-Group 3: 22 cases whose amylase levels before and after surgery for (a) simple cholecystectomyand (b) common bile duct exploration are shown.

Subgroup B. Demonstrates 3 cases whose serumamylase levels reached over 50 units in the immed-iate postoperative phase. One of these whosehighest level was reached at 48 hours, had a simplecholecystectomy for acute cholecystitis: at the timeof surgery he was found to have an aortic aneurysmwhose upper end was at the level of the coeliacartery and from which he died 6 weeks later. It isthought that he may have suffered a mild vascularinterference to the pancreas associated with hisaneurysm. The other cases represent levels reach-ed after the exploration of the common duct andafter excision of an adherent gastric ulcer. Noneof these three cases had clinical evidence of acutepancreatitis, each recovering uneventfully.Group 3

This group, in all 39 cases, compared the simpleprocedure of cholecystectomy with the addedtrauma of exploration of the common bile ductsand simple gastrectomy with the effects of excisionof an ulcer adherent to the pancreas. (Figs. 3and 4.)

Subgroup A. Fifteen cases of simple chole-

cystectomy. There is a relatively clear-cut dis-tinction between those cases (six) whose serumamylase rose considerably (i.e., more than xo units)after surgery and those (six) whose amylase fell orrose only very little: two cases demonstrate thehigh preoperative amylase associated with' biliarycolic ' and one the high level as 48 hours associatedwith an aortic aneurysm.l

Subgroup B. Seven cases whose common bileducts were explored illustrate that only one casejust reached a level over 50 units, an incidence of

:7 or 14.3%.Subgroup C. Thirteen cases subjected to sim-

ple gastrectomy: only 5 developed a postoperativelevel above the highest normal and even in the casewith a very high preoperative level, it appears thatthere is little effect upon the pancreas, as estimatedby serum amylase levels, as a result of performinga simple gastrectomy.

Subgroup D. Four cases whose peptic ulcerswere 'shaved' off the pancreas are illustrated.One developed a level within the pancreatitis rangethough his clinical condition did not suggest hishaving pancreatitis; his ulcer was in the first part

copyright. on 22 M


http://pmj.bm

j.com/

Postgrad M


ay 1956. Dow

nloaded from

http://pmj.bmj.com/

252 POSTGRADUATE MEDICAL JOURNAL May I956


SUSB-O OUP C : SIMPLE GASTRECTOMY. WSU-SROUP : ASTRECMTOY FOR13 CASES 4 CASES ADHERENT ULER

ISO

I 0

- OP *1 +2 *3 -I OP -*I .2 +3

POIN1T IN INTERVALS OF 24 NOURS

FIG. 4.-Group 3: I7 cases showing the alterations in pre- and post-operative serum amylase after (c)simple gastrectomy and (d) removal of adherent peptic ulcers.

of the duodenum and he may well have had sometemporary pancreatic duct obstruction.

Group 4. (Fig. 5)These two cases are of special interest, being the

only ones in this study who had clinical pan-creatitis.

Case i. Demonstrates the levels of serumamylase reached during a severe attack of acutepancreatitis, starting 16 days before operation:after her recovery she underwent a simple chole-cystectomy for chronic calculous cholecystitisfollowing which her recovery was uneventful. Shedemonstrated only a small rise of serum amylaseabove the highest normal, falling into Groups IAand 3A.

Case 5. Following a cholecystectomy and ex-ploration of the common bile ducts for stone, theoperation passing without difficulty, she developeda moderately severe acute pancreatitis on thesecond day after operation. Her serum amylaselevels are illustrated and it is to be noted that her

amylase was higher on the second than on the firstday.CommentOver the whole group, 4 cases (9.75) developed

postoperative serum amylase levels above the ar-bitrary limit for the diagnosis of pancreatitis,though only one had clinical pancreatitis. Noneof the simple gastrectomies had a postoperativeamylase level that was suspicious and only one ofthe simplec holecystectomies (6.25%): commonduct exploration increased the incidence of high(over 50) levels to 25% in biliary tract operationand, in the case of the gastrectomies, the removalof adherent ulcers produced a 25% incidence ofsuspiciously high levels.

Part 2. The Use of Serum Trypsin InhibitionIntroduction

Storer and Kazdan (1953)17 showed parallelchanges occur between serum amylase and serumtrypsin activity in acute pancreatitis. In an

copyright. on 22 M


http://pmj.bm

j.com/

Postgrad M


ay 1956. Dow

nloaded from

http://pmj.bmj.com/


POST OPERATIVE PANCREATITISGROUP 4: 2 CASES

30C

20A CASE I.

20

80

on , \

w

10

- 15 -14 -13 -12 -I O. +1 +2 *3 +4POINTS IN ITERVALS OF 24 HOURS

FIG. 5.-Group 4: 2 cases-cases demonstrating serum amylase levels inacute pancreatitis followed by cholecystectomy. Case 5-serumamylase levels in acute pancreatitis following common bile ductexploration.

attempt to find another laboratory procedure ofsimplicity which could help distinguish betweenthose cases whose serum amylase levels rose towithin the ' pancreatitis' range without clinicalevidence of acute pancreatitis, and those whoselevels similarly rose but developed clinical acutepancreatitis, an indirect procedure for measuringserum tryptic activity was adopted, using the capa-city of serum to inhibit a standard quantity oftrypsin.Materials and Methods

Thirty-seven patients were selected from thegroup described in Part i. Their selection was

based solely upon whether this trypsin inhibitionhad been studied or not. As serum on storage,even in the cold tends to increase its proteolyticand decreases its inhibitory action spontaneously,the samples were processed as soon as possible aftercollection.

Preparation of Serum Trypsin InhibitorsChristensen's (1946)18 method of removal of the

proteolytic components of serum was used, andthe residual inhibitors then assayed againsta standard of o. mg. trypsin by the method ofFree and Myers (I943)15. The result may beexpressed in many ways but for simplicity in this

copyright. on 22 M


http://pmj.bm

j.com/

Postgrad M


ay 1956. Dow

nloaded from

http://pmj.bmj.com/


POST OPERATIVE PANCREATTISGROUP 5

CAS A cir 5 Cas 9C CAf i e lC3m

A

11\, //

r/

I

2= 0

POINTS ININTERWALS OF H HOURS

FIG. 6.-Group 5: Comparison of serum amylase and serum trypsin inhibition levels in acutepancreatitis (Cases i and 5) with others showing serum amylase levels in the ' pancreatitis'range but without clinical pancreatitis (9 cases in the group).

study it has been recorded as the percentageinhibition of o. i mg. trypsin: occasionally there hasbeen complete inhibition in which case the test isrepeated, using 0.2 mg. trypsin and the resultexpressed as a percentage over Ioo%. It is feltthat, although this method is indirect, the amountof inhibitor present in serum reflects inversely theamount of trypsin therein and might be an indica-tor of pancreatic activity in a fashion similar toserum amylase determination.

ResultsThe results will be presented in three groups

corresponding to the three possible levels to whichthe serum amylase may rise or fall post-operatively.No distinction will be drawn between any surgicalprocedures.Group 5. (Fig. 6) (Table I)Serum Amylase Levels above 50 glucose units per

ml. serum (i.e., within 'pancreatitis' range).In Fig. 6, cases I and 5 both developed clinical

pancreatitis and the inverse change in trypsininhibition and serum amylase is clear. Similarlyin Case 9, (simple cholecystectomy with incidentalaortic aneurysm) there is a marked inverse change.Cases 8 and 32 in Fig. 6 and the remainder of the

group of nine patients demonstrated no such relationship.

TABLE I (GROUP 5)SERUM TRYPSIN INHIBITION COMPARED WITH SERUM

AMYLASE LEVELS OVER 50 UNITS

Serum amylase Serum trypsin(glucose units inhibition

Case No. per ml. serum) (% o.I mg. trypsin)I 206.5 84.25

242.0 50.55286.o 94.256s.o 89.755.0 78.75

23.1 72.523.8 70.513.3 79.754.62 66.75

5 1 .45 82.124.1 0

71.5 54.2552.5 83.7510.4 82.1

8 I9.35 68.583.5 8i.84.67 88.7

9 6. 9I.o44.4 99.2563.75 73.02.87 85.5

copyright. on 22 M


http://pmj.bm

j.com/

Postgrad M


ay 1956. Dow

nloaded from

http://pmj.bmj.com/



11O110

CASE 25 CASE 27 CASE 2 CASE 41

100 .100

90

u0 s l s 50

40 40

1

20- 20

"I,

10 / 10

w 0


FIG. 7.-Group 6: z cases (25 and 27) showing the sharp fall in trypsininhibition and 2 cases (z and 41) not showing this fall in association with

serum amylase levels in the range 20-50 units (12 cases in the group).

TABLE i.-Continued

Serum amylase Serum trypsin(glucose units inhibition

Case No. per ml. serum) (% o.I mg. trypsin)12 223.0 76.0

41.6 83.45.3 71.25

14 126.25 11.12

12.65 64.750.5 79.2

31 54.5 67.04.6 79.44.6 69.9

35 I29.0 79.2530.4 78.75i8.6 78.257.45 84.2

40 27.8 6i.o51.5 65.2526.25 71.08.7 79.2

Group 6. (Fig. 7) (Table 2)Serum Amylase Levels above the highest normal

(20 units) but below 'pancreatitis levels' (50 units).In Fig. 6, four of the twelve patients in this

group are illustrated. Cases 25 and 27 are seen to

demonstrate the inverse change seen in Fig. 5.Case 25 had an attack of 'biliary colic' 7 daysbefore cholecystectomy and common duct explora-tion. Case 27 had an adherent gastric ulcerdissected from the pancreas. In the remainder ofthe figure and in Table 2, the usual absence ofany regular correlative change in either estimationis seen.

Group 7. (Table 3) (Fig. 8)Serum Amylase Levels Remaining within the

Normal RangeThe remaining i6 patients, 4 of whom are

illustrated in Fig. 8, comprise the group in whichthere can be seen to be no correlation betweenserum amylase and serum trypsin inhibition levels.

CommentWhile single estimations of serum trypsin inhibi-

tion, unless widely abnormal, are without value,a series taken at the same time as serum amylasevalues are assayed may be of value in determiningwhich rises in serum amylase that would otherwisebe only suspicious are, in fact, definite evidence of

copyright. on 22 M


http://pmj.bm

j.com/

Postgrad M


ay 1956. Dow

nloaded from

http://pmj.bmj.com/


TABLE 2 (GROUP 6)SERUM TRYPSIN INHIBITION COMPARED WITH SERUM

AMYLASE LEVELS IN RANGE 20-50 UNITS

Case No. Serum amylase Trypsin inhibition

2 5.o6 81.o35.6 83.05.2 80.94.32 72.5

7 I8.2 28.6538.2 49.4io.6 48.1

i6 9.25 Ioo.o18.45 o00.0

9.25 35.7532.3 88.755-4 70.o

18 4.2 54-7527.3 78.30.5 87.5

19 2.19 82.08. 88.02.6 85.5

21 8.03 97.758.35 34.0

23.1 93.08.o 9o.o

25 27.8 81.2543.8 17.02.78 94.0

26 3.64 88.oi6.8 99.o2.96 94.25

27 3.48 94.023.6 19.18.48 42.75

34 11.25 102.7531-55 Io8.752.14 90.6

41 1.67 66.5I4.5 83.622. I 76.66.19 84.75

46 3-I9 4.2525.0 79.04.68 77.25

the presence of pancreatitis when an inverse ratiois found.

DiscussionIt is certain that, should there be much direct

trauma to the pancreas or its ducts in such a wayas to interfere with blood supply or drainage, thestage is set for the development of acute pancreati-tis. Nevertheless, the complication is known tooccur following the simplest and least traumatic

TABLE 3 (GROUP 7)SERUM TRYPSIN INHIBITION COMPARED WITH SERUMAMYLASE LEVELS WITHIN NORMAL RANGE (0.5-20 UNITS)

Case No. Serum amylase Trypsin inhibition

13 I9.7 87.211.55 82.2510.4 71.29.9 82.0

15 2.6 87.53.4 75.23.2 58.7

17 7.53 82.84.37 79.258.o8 91.44.85 70.0

20 7.7 71.85.0 70.06.4 95.0

24 1.25 77.25I.68 76.71.25 I39.o

29 16.9 92.5I6.9 95.015.3 71.5

30 3.25 82.44.0 84.92.28 73.7

32 1.49 I00.0

5.93 86.252.97 69.5

36 0.77 50.01.7 49.03.93 88.o

39 26.0 47.020.8 6 .o

13.6 67.5

42 4.325 70.5o.86 88.754.0 88.0

43 2.6 80.81.72 75.88.o 92.0

44 8.4 77.752.98 75.253.43 77.25

45 10.3 73-757.28 82.56.55 120.0

47 4.32 80.o1.54 1I0.O3-54 86.5

48 6.85 II5.510.3 92.55-9 8o.5

copyright. on 22 M


http://pmj.bm

j.com/

Postgrad M


ay 1956. Dow

nloaded from

http://pmj.bmj.com/



CASE 30 CASE 42 CASE 43 CASE 44

loe 100

0 o

F o

I /

; ;

n-

I0 I0


FIG. 8.-Group 7: 4 cases demonstrating no correlation between trypsin inhibition andserum amylase in the normal range (15 cases in the group.)

procedures in the pancreatic area and even, asreported by other authors, in areas well away fromthe pancreas. In these latter cases, acute pan-creatitis presents as a complication fairly distinctfrom those that might be expected, and, providedit is kept in mind, should present little difficultyin recognition. There are, however, the trouble-some few whose epigastric surgery, usuallycarried out without incident, is followed by acutepancreatitis at an early time in the post-operativeperiod when it can be confused with other com-plications. Other investigators recently13' 14 haverecorded their experience in these circumstanceswith evidence that the addition of common bileduct exploration to biliary tract surgery results ina higher proportion of elevated serum amylaselevels and that between one third and one half ofgastrectomies will show such elevation.

This study was directed to two aspects of theproblem firstly to discover any factors in sur-gery upon the biliary tract or stomach likely toencourage the development of pancreatitis, andsecondly, any other tests or observations that couldfacilitate the diagnosis. Two patterns of response

to biliary tract and gastric surgery in which thepancreas is not involved are clearly seen: theremay be relatively little change in either the level ofserum amylase or trypsin inhibition, or there maybe a rise in amylase beyond the upper limit ofnormal but not to 'pancreatitis' levels without anycorresponding change in trypsin inhibition. Evenso, there is the occasional case whose amylasereaches 'pancreatitis' levels (in this series one casewhich probably could be included in the 'vascularconditions' group of Millbourne) after simplecholecystectomy (i in 15 - 6.75%). None of thesimple gastrectomies reached suspicious levels, butremoval of adherent ulcers showed a 25% inci-dence of suspicious levels (i in 17 - 5.9% of allgastrectomies) and the passage of instrumentsalong the common bile duct similarly increased theincidence to I in 7 (I4.3%) of the group or 2 in 22(9. %) of all the biliary tract operations (Table 4).There has often been little clinical suspicion ofthe presence of pancreatitis until a serum amylaseestimation was done and the observations on theuse of serum trypsin inhibition have been of valuein these cases. As demonstrated in the two cases

copyright. on 22 M


http://pmj.bm

j.com/

Postgrad M


ay 1956. Dow

nloaded from

http://pmj.bmj.com/

258 POSTGRADUATE MEDICAL JOURNAL May 1956TABLE 4

PERCENTAGE OF CASES DEVELOPING SERUM AMYLASELEVELS POST-OPERATIVELY INTO THE ' PANCREATITIS'

RANGE, OVER 50 UNITSPer cent. of cases

Operative procedures with serum amylaselevels over 50 units

Simple cholecystectomy .... 6.75Common duct exploration .. 14.3All biliary tract operations .. 9.1Simple gastrectomy .. .. oExcision of adherent peptic ulcers 25.0All gastric operations .. .. 5.9

with undoubted pancreatitis, at the time when theserum amylase is rising, though not necessarily atits highest, there is a sharp fall in the inhibitorycapacity -due, it is believed, to the taking up ofinhibitors by trypsin. The figures show that,assuming the concept to be valid, there is evidencethat amylase levels do not have to rise even into'pancreatitis' levels for the inhibition levels toshow inverse ratios. In every case in which thisinverse change occurred, there was either certainacute pancreatitis or the stage was set by possiblevascular interference (Fig. 6, Groups 5 and 9),exploration of the common bile duct (Fig. 7,Group 6, Case 25), or the removal of an adherentpeptic ulcer (Fig. 7, Group 6, Case 27). Case 8(Fig. 4, Group 3D and Fig. 6, Group 5) is ofinterest in this regard: an adherent peptic(gastric) ulcer was shaved off the pancreas andthe patient showed a high level (= 83.5 units)of serum amylase without a correspondingfall in trypsin inhibition post-operatively. It isbelieved, therefore, that he did not have pancreati-tis but his high level amylase was due to absorptionof pancreatic amylase 'leaking' into the peritonealcavity from the raw ulcer bed.As a fall in trypsin inhibition is thought to be a

reflection of a rise in blood trypsin level and asimple test to perform, it appears to be a usefuladditional laboratory procedure to distinguishbetween true pancreatitis, or its mild form, pan-creatic oedema, from high serum amylase levelsnot indicative of pancreatitis. It is possible thatthe observation of a sharp fall in inhibition at atime that serum amylase level is even relatively lowwill indicate a predictable further rise in amylase

and the development of pancreatitis; nevertheless,single estimations of trypsin inhibition, not unlikesingle estimations of serum amylase, are not alwaysof significance and it is believed that, wheneverthere is a suspicion of the possible development ofpancreatitis, a series of tests should be performed.Summary

Observations on 41 patients undergoing biliarytract and gastric surgery are presented. It isdemonstrated that serum trypsin inhibition is ofvalue in distinguishing between high serum amy-lase levels not due to pancreatitis and those due tothe development of this condition after surgery.The experience of the use of serum amylase levelsalone on the assessment of precipitating factors inthe development of post-operative pancreatitis ispresented.Acknowledgments

I wish to express my thanks to Dr. Francis D.Moore, at whose suggestion these observationswere made, for his continuous advice and en-couragement, and to him and the members of thesurgical staff of the Peter Bent Brigham Hospitalfor allowing their patients to be studied.

BIBLIOGRAPHYi. SCHNEIDER, V., and SEBENING, W. (1928), Surg. Gynec.

and Obst., 46, 735.2. MILLBOURN, E. (1949), Act. Chir. Scand., 98, I.3. METHENEY, D., and LUNDMARK, V. (1949), Northwest

Med., 48, 765.4. HORSLEY, J. SHELTON (1939), Ann. Surg., 3Io, 6I6.5. BRUNSGAARD, C. (1946), Act. Clin. Scand. Suppl., 117, Io8.6. WARREN, K. (I95I), Surgery, 29, 643.7. WARREN, K. (x954), J.A.M.A., 154, 803.8. DUNPHY, J. E., BROOKS, J., and ACKROYD, F. (I953),

New Eng. J. Med., 248, 455.9. HOWARD, J. M., FREWLEY, J. P., and ARTZ, C. P. (1955)s

Ann. Surg., 141, 337.io. COPE, O. (1938), Am. J. Physiol., 122, 428.I . COPE, O. (i939), Endocrinol., 25, 236 and 248.12. GRAY, S. H., PROBSTEIN, J. G., and HEIFETZ, C. J.

(194I), Arch. Int. Med., 67, 805.I3. PERRYMAN, R. G., and HOERR, S. O. (1955), Anm. J. Surg.,

88, 417.14. MAHAFFEY, J. H., and HOWARD, J. M. (1945), Arch. Surg.,

70, 348.15. FREE, A. H., and MYERS, V. C. (1943), J. Lab. and Clin.

Med., 28, 1,387.i6. GOLDSTEIN, J. (1948), Ibid., 33, 1,047.I7. STORER, J., and KAZDAN, P. (1953), Surg., 33, 683.18. CHRISTENSON, L. R. (1946-47), J. Gen. Physiol., 30, I49.

copyright. on 22 M


http://pmj.bm

j.com/

Postgrad M


ay 1956. Dow

nloaded from

http://pmj.bmj.com/

POST-OPERATIVE PANCREATITIS - Postgraduate...

Documents

Transcript of POST-OPERATIVE PANCREATITIS - Postgraduate...