Tohoku
J. exp.
Med.,
Exocrine Surgery
1975,
115, 307-317
Pancreatic
YASUO
SUDA,*
Function
MITSUYASU
SHIRASO•õ
after
and
Upper
Tosnio
Abdominal
SATO
First Department of Surgery, Tohoku University School of Medicine, Sendai
SUDA, Y., SHZRASO,M. and SATO, T. Exocrine Pancreatic Function after Upper Abdominal Surgery. Tohoku J. exp. Med., 1975, 115 (4), 307-317 Daily pancreatic flow and daily outputs of bicarbonate and amylase in pure pancreatic juice were observed in 15 postoperative patients who underwent upper abdominal surgery. Exocrine pancreatic secretion under the stimulation by endogenous or exogenous hormones was well correlated with the extent of pancreatic fibrosis estimated by the histometrical treatment. Exocrine pancreatic secretion in Billroth II type of gastrectomy was depressed to 60-70% of the patients' with Billroth I type of gastrectomy. In distal pancreatectomy the depression in the exocrine pancreatic secretion almost corresponded with the resected volume of pancreas. Exocrine pancreatic secretion in pancreatodoudenectomy was highly depressed beyond the expected value from the resected volume and fibrosis of the pancreas. This was interpreted as partly due to the elimination of hormonal mechanism by duodenectomy and partly due to the denervation of the secretory fibers by surgical manipulation. exocrine pancreatic secretion; pancreatic fibrosis; pancreatoduodenectomy; distal pancreatectomy; gastrectomy
Although many studies have been performed on the physiology or pathophysio logy of exocrine function of pancreas, most of them were animal experiments or carried out on patients with morbid pancreatic fistulae encountered during the postoperative period. The present study deals with the comparison of the exocrine functions in patients who underwent upper abdominal surgery of several types with the external pancreatic duct drainage. The effects of pancreatic or gastric resection and pancreatic fibrosis on the exocrine pancreatic function were investigated by the histometrical treatment of the tissue and the quantitative measurement of pure pancreatic juice. MATERIALS AND METHODS The control cases were tabulated in Table 1. Pancreatic and hepatic functions in these cases were proved to be within normal limits by pancreozymin-secretin test and routine liver function tests performed preoperatively. The other cases studied were tabulated in Tables 2 and 3. The effect of pancreatic fibrosis on the exocrine secretion was investigated in Case 5. The influence of duodenal passage of gastric content upon the exocrine secreReceived * Sendai
Present
for
publication, address:
December Dept
.
of
5, Surg.,
1974. National
Sendai
Kyodo
Hospital,
Hospital,
2-8-8,
Miyagino,
983. •õ
Present
address:
Surgical
Clinic,
Mito
307
3-2-7,
Miyamachi,
Mito
310.
308
Y. Suda TABLE 1.
TABLE 2.
et al.
Control
cases
Cases of pancreatic .fibrosis and gastrectomies
TABLE 3.
Cases of panereatoduodeneetomy
tion was studied in Cases 6, 7, 8 and 9. The effect of distal pancreatic resection on the exocrine pancreatic secretion was examined in Case 10 using Case 9 as control, and that of proximal pancreatic resection was examined in Cases 11 to 15, taking into consideration the fibrotic change of the remnant pancreata. After transduodenal minor sphincterotomy, pancreatic duct drainage was exteriorized through the jejunal loop with a polyethylene tube of 2 mm in caliber. Pancreatic juice was collected every 6 hr into a bottle in an ice bucket. Checking its volume at the bedside, bicarbonate and amylase concentrations were measured for an aliquot according to the methods of Van Slyke et al . (1919) and Caraway (1959) and expressed as total dialy output, i.e. the sum of 4 six-hr outputs . The average daily output on the 7th to 14th postoperative day was used for the purpose of comparison, since the patients recovered so as to have ordinary meals on the 7th to 10th postoperative day. For the purpose of exogenous stimulation , secretin of 0.02 unit/min/kg was infused and pancreozymin of 1 unit/kg was administered by a single injection after the pancreatic
Postoperative
Pancreatic
Function
309
Fig. 1. Point counting method. Intra-acinar and interacinar connective tissue overlapping with the crossings of micrometer was counted. The parenchymal ratio was expressed as a quotient of the parenchymal points by the total crossings. Photo shows the histology of Case 10 with the parenchymal ratio 94.24%.
flow
of
of
a few
consecutive
exocrine
amylase
output
The
In
the
are
of the
head
of
was
applied
glass
disc
overlapping 21 •~
21 •~
expressed
as
In
15
cephalic
separating
The
average
portion
nodes
is
38.09
were
the
approximate would
38.54•}10.22
g ratio
be
preserved
at
of
in
in
cadaver
the
stem
Thus, distal
of
total
tail
the
as
the was
splenic
proximal artery
in usual
to
cadaver
dissect
portion
and
24.45•}7.48
g
in
total
is
resected
the
organ
50
a
views,
was
then
calculated
his
pancreas
with
of
the
pancreata caudal
superior
middle
age
were
pancreatoduodenec 35.00•}10.15 ratio
of
approximately
of
of
a
gastrectomy
weights
pancreatectomy.
1, micro-
tissue. side
weight
mean
40%
its
left
were
Thus,
or
was
in
the
pancreata
portion.
with
cephalic
this
and
of
non-parenchymal
that
histology
pancreatoduodenectomy
The
3:2.
on
normal
1966)
Fig.
ratio
postulated 90%
resected
body
21
caudal
combined
artery.
the
in lens
randomized
ratio
was over
is with
in
g in
ordinary
resected
approximately
shown
al.
crossings.
parenchymal
of
from
et
Parenchymal total
It
resection
ocular
in
and
trichrome
(Weibel
tissue,
slide.
the
wedge
the
counted
over
77•}1.31%.
from
both
10.88
often
splenic
portion of
f
under
usually the
line
60%
weights
and
pancreas
along
head
and
cut-surface
Masson's
As
under connective
92.
pancreata
of
tissue.
was
points
pancreas
cadaver
comparison output
the
and
method
the
histology
pancreata
parenchyma
the
pancreatectomy
pancreas
its
the
from
specimen
equipped
micrometer
on
being
the
intra-acinar of
normal
the
bicarbonate
specimen
counting in
was
parenchymal
value
The
by
caudal
distal
the
for
rate,
stain
point ratio
lattice
and
whole,
the
operated,
parenchymal
pancreatoduodenectomy, vessels.
tomy.
of
in
The
crossings a
obtained had
usual
weighed
as
not
of
parameters
hematoxylin-eosin
was
vessels
the
quotient
the
mesenteric
to
small
points,
histology In
the
the flow
performed by
crossings
microscopically
tometrically, normal
21
As
description.
instead.
the
21 •~
with
a
was
used
investigate
50
following
pancreas
was
plateau.
above-mentioned
pancreas
whose
incising Including
the
examination
case
portion
the
in
resected
pancreas
scope.
i.e.
used
the
to
reached
function,
histological
mid-portion stain.
collections
pancreatic
portion, the
In
cancer,
regional
transected
and
in
1:1. for
the
g cephalic
the lymph at
this
showing remaining
310
Y. Snda
et al.
RESULTS
Daily secretion in normal and fibrotic pancreata Daily flow of pancreatic juice in controls with normal histology ranged from 833.9 to 958.5 ml, the average value being 891.6 ml (Table 4). Daily bicarbonate output ranged from 79.45 to 93.63 mEq with the average of 85.79 mEq. Daily amylase output was 25323 units on the average . Pancreatic parenchyma in 4 controls occupied from 90.47 to 93.96% (mean; 92.58%) of the total tissue . In contrast, daily flow of pancreatic juice and daily outputs of bicarbonate and amylase in Case 5 were 587.7 ml, 59.75 mEq and 15682 units , respectively. The histology of Case 5 was shown in Fig. 2. The histometrical ratio of this tissue was 70.95% of parenchyma. Since the mean control parenchymal ratio in this series was 92.58%, the parenchymal reduction in Case 5 was corrected to 70.95/92.58 or 76.63%. Comparing the parameters of secretory function in Case 5 with control , the extents of reduction in daily flow and daily outputs of bicarbonate and amylase were 65.9%, 69.6% and 61.9% , respectively. Although these values did not TABLE 4.
Fig. 2.
Exocrine pancreatic secretion in controls and pancreatic fibrosis
Histology of Case 5 .
Parenchymal
ratio was estimated
at 70 .95%.
Postoperative exactly
coincide
three
parameters
Daily
pancreatic The
were
was
depressed
at
a
rate.
after
gastric
pancreatic 5. gastric
the
Case
in
decreased case
at
remained
pectively.
Case
7
similar
puts.
By
the
difference
gastrectomy secretion
the
i.e.,
and
three
of
in
and Billroth ‡U, depressed to
TABLE 5.
flow,
these
two
exocrine
60
that to
is, 70%
Exocrine
76.6%,
the
flow the
of
the
66%
above
bicarbonate it
was
pancreatic between in the
Gross
duodenal latter.
secretion
finding
6,
daily
in and suggested function
duodenum. the
gross
operation. in
output
97.7%
gastroje
but
of
Case of
In 6
7
68% that between
passage
and
in
91.2%,
gastrectomy) Case
was
amylase
and
6 (Billroth ‡T
in
of
Case time
of
with
portion
the
resection
gastroduodenos
same
bicarbonate
parameters
cases,
2nd in
and
gastric
with the
at
rates
Case
of
of
all
pancreatic
for histology.
at
daily at
cases
performed
output
parameters
postoperative
* No specimen
but range
the
resection
consistency
gastrectomy), 65%
of
underwent
not
daily
88.9%
control
comparison in
was
of
the
7
folding was
values,
a rate
in
gastric Case
mucosal
(Billroth ‡U
rates,
and
appearance
in
parenchyma
function
underwent
pancreas
control
Comparing of
6
311
resection
cancer
of
the
similar
exocrine
membranous
with
slightly
the
in
I)
normal
comparison
those
reduction
Table for
Function
of
investigation
finding
a
of
for
Histological
degree
secretion
in
junostomy
at
were
(Billroth
this
the
parameters
shown
tomy
with
Pancreatic
were in
res with
depressed
enzyme
there
might
outbe
Billroth ‡T diversion;
the
in gastrectomies
was normal.
Similar comparison was made between Cases 8 and 9 in total gastrectomy. The alimentary tract after total gastrectomy was reconstructed by jejunal substitution for stomach in Case 8 and by esophagojejunostomycombined with Roux en Y jejunojejunostomy in Case 9. Namely, the duodenal passage was preserved in Case 8 but diverted in Case 9. The value of daily pancreatic flowunder total gastrectomy with jejunal interposition was similar to control, showing98.23% of the control value. The bicarbonate and enzyme outputs, however, showeda con siderable depression to 55.9% and 57.2% of controls, respectively. As compared with Case 8, Case 9 showed a depresseddaily flowto 66.3%. This seemedto be due to the diversionof duodenal passage in Case 9. The declines in bicarbonate and enzyme outputs were 68.7% and 52.8%, respectively. The decreaseof 66% and 69% in flow and bicarbonate output under total gastrectomy was almost the same as under subtotal gastrectomy, but the enzyme output was less than the latter.
312
Y. Suda
et al.
Daily pancreatic secretionafter pancreatectomy On the assumption that 60% of pancreas was preserved in distal pancrea tectomy at the stem of the lienal artery, comparison was made between the cases of total gastrectomy with and without distal pancreatectomy (Table 5). In Cases 9 and 10, the alimentary tracts were reconstructed by esophagojejunostomyand Roux en Y jejunojejunostomy. The former was combined with distal pancreatec-t omy, but the latter was not. The parenchymal ratios in both cases were within normal range histometrically. The exocrine parameters of Case 10 showed the decrease of 64.76% in pancreatic flow, 55.72% in bicarbonate output and 64.66% in enzyme output against the respective values of Case 9. These corresponded approximately with the ratio of preserved remnant parenchymata. In ordinary pancreatoduodenectomyas prescribed before, 50% of pancreas parenchyma was preserved. The histology of the pancreatic cut-surface in pancreatoduodenectomy varied with the fibrotic changes for the lesion of the pancreatic head, and the parenchymal ratio ranged from 91.53% to only 2.07%. The parameters of pancreatic exocrine function in 5 pancreatoduodenectomized cases were shown in Table 6 in an ascending order of fibrosis. Case 11 had localizedcephalic pancreatitis which was misjudged as carcinoma. The histology of the resected surface was normal and its parenchymal ratio was estimated at 91.53%. TABLE 6.
Exocrine
pancreatic
secretion
in pancreatoduodenectomy
Comparisonof the exocrineparameters was made between the pancreatoduo denectomized Case 11 with normal histology and the unresected controls. The values of the former were 31.66% of the controls in flow, 19.08% in bicarbonate output and 11.26% in enzyme output. Applied Case 11 as the pancreatoduodenectomizedcontrol, each exocrinepara meter in Case 12 with parenchymal ratio of 82.84% (corrected ratio to Case 11; 90.52%) was depressed in an almost parallel fashion, that is, to 82.8% in flow, 72.6% in bicarbonate output and 81.1% in enzyme output. The data of Case 13 were not exactly comparable with others', since the averages during the 5th to the 10th postoperative day were adopted because of the spontaneous removal of pancreatic duct drainage on the 12th postoperative day. The same comparison was attempted between Case 13 with 85.8% of the corrected parenchymal ratio and Case 11 with the normal histology. The declined ratios were 97.6% in flow,
Postoperative 65.5%
in
bicarbonate
correspond The
with
depression
were
In
in
Case
were
markedly
these
values
case
27.8%
to
mean
concentrations
96.22 2521
to
bonate
and
amylase
of
76.63%
Billroth ‡T control
and
So
far
as
mean in
by
presence the
was
or
degree
absence
performed,
remnant
no in
50.95
the
the
stomach,
or
this
to
110.8
units/100
93
In
98%.
but
ordinary
of
of
the
gastrectomy
was
con
58
or
46%.
concerned,
it
was
concentrations
so
intake
output,
with
92%
bicarbonate
were
not
or
total
concentration
these
surgical
90
mean
amylase
bicar
parencymal
gastrectomy was
or
controls
Mean
corrected
subtotal
daily
mEq/liter,
the
ml.
the
In
estimated Mean
in
concentrations
amylase
Cases
distinguished
mEq/liter.
control,
lower
between
much
were
affected
diet.
therefore,
The seemed
manipulation
no
Decrease the
parenchymal
10
values
clear-cut in
on
was ranged
These
but
9 and
difference
pancreatoduodenectomy
pancreata. and
of
daily
of
were
days.
concentration
resection,
under
the
case
89.9
gastrectomy,
gastric
passage
comparison
concentration
the
of
each
anastomosis,
amylase
total
2.26%
output
such
as
by
the
difference
in
to
to
be
due
denervation
fibers.
the
averaging
or
Y and
output of
ratio.
with
range.
en
control
enzyme
concentration
5
was
and
subtotal
from
control
Roux
ratio
2840.1
bicarbonate
the
bicarbonate
the
secretory
against
or of
parenchymal
from
amylase
concentration
58%
duodenal
From
6%,
or
concentration
the of
56
that
mechanical
the
respective
bicarbonate
in
Case
ratio
outputs,
and
the
not
output.
amylase
ranged
in
did
enzyme
parenchymal
postoperative
averaging
mean
amylase
the
influenced
mean
within
interposition was
assumed
nil,
the
parenchymal
and
daily
concentrations
mean
hand,
the
controls
units/100
anastomosis,
jejunal
centration
to
other
concentrations
Mean
were
or ‡U
the
the
enzyme flow
the
bicarbonate
4
of
in
with
above-mentioned in
3005
On
amylase
mEq/liter.
ranged
54.8%
These
for
39.46%
replacement,
degree
the
output.
except
with
compared
of
concentration
averaging
as
similar
on
14 and
4 times.
and
values
bicarbonate
with
a
bicarbonate
the
ratio
as
Case
313
enzyme ratio
fibrotic
but
big
in
bicarbonate
complete
decreased,
Mean
in
in
almost
as
84.1%
Function
parenchymal
parameters
depressed
Estimated
from
of
were
was
of
flow,
15
and
histological
rates
32.9%
ly.
output
the
Pancreatic
which observed.
from
ratio,
amylase the
to
for with
40 the
concentration less
the
pancreatectomy Mean
38.95
accounted correlation
mean
distal
amylase
bicarbonate
58.12 to
mEq/liter,
60%
decrease
fibrotic ranged
change from
concentration
of 35
to
was.
Secretoryresponsesto exogenoussecretinand pancreozymin The above-described data were on the secretory responses to so-called endogenous stimulation of diet. Responses to the exogenousstimulants were as shown in Table 7. Bicarbonate concentration under the secretin infusion was increased up to 115 to 200%, as compared with the unstimulated values. Flow of pancreatic juice in the fibrotic pancreas under secretin infusion was lower than control. Similar results on bicarbonate concentrationwere obtained in the fibrotic
314
Y. Suda TABLE 7.
* No specimen
Exocrine
pancreatic
for histology .
et al.
secretion
Gross
finding
under
exogenous
of pancreas
stimulation
was normal.
pancreas remnant under pancreatoduodenectomy. In Case 5 with 76.6% of the corrected parenchymal ratio, however, the change in bicarbonate concentration was minimal. The ratio of percent increase in amylase concentration under pancreozymin stimulation was 110 to 160% in the present series. On the other hand, the ratios in flow of juice and bicarbonate concentration were around 110%. Compared with each amylase concentration in the cases studied under pancreozymin stimulation, the percent increase after stimulation was correlated with fibrotic replacement. It was concluded, therefore, that the changes in water and enzyme secretion seemed to be correlated with the pancreatic fibrosis, even under these corresponding hormonal stimulations. DISCUSSION Early surgery
postoperative was
White
1972).
from
700
and
histology
with
the
the
present
observed and the
7th
value
the
gastrectomy,
to
early
10th
and
of
gastric
secretion.
is
diverted Clinically,
As
reported
after
Therefore,
to
liberate
better
was
nutritional
by
the
one
after
two
weeks
.
Duodenal
stimulants
after
absorption
flow
values to
study
to
of was
pancreatic
constant for
one
secretion
endogenous
60
comparable
previously pancreatic
values
and ranging
ductography
which
But
types showed
Tournut
literature,
comparative
anastomotic
duodenum
the
showed the
present
considered different
in
surgery.
enzyme
abdominal
1964;
pancreatic
study,
increase
and
the
normal
upper
al. in
present
gradual
period
et
constant
with
the
(1972). a
for
of of
in
White
day.
content
is not
controls
bicarbonate
available
comparison cases
the a day
after
(Elmslie
juice
1973),
postoperative
function
co-workers
convalescent
were
In
in
ml
(Shiraso
concentrations
of
flow
958
Tournut
authors
pancreatic and
of pancreatic
The
830
of
White
flow
ml.
was
to
pancreas.
pancreatic
4000
surgery
passage
by
Daily
in
the
after
to
exocrine
studied
subtotal 70%
to or
total
depression in
Billroth ‡T
in
Postoperative
gastrectomy study
than (MacLean
reported
from
clear
not
al.
(1963)
by
Vater,
be
1965).
results
Billroth ‡T
the
loop,
to
i.e.
be
taken
ordinary
Assuming
pancreatic
the
of
the
control,
of
would
without 11.3%
corresponded
to were
and
depressed The
secretory
almost
the The
has
produced
the
secretin. extent
of
et
al.
parenchyma
upper (Janowitz
contribute
distal
to
pancreatectomy
of histological the
in
been
White
rabbits
to
under that changes.
was
by
examine
the
pancreatic
As
for
the
cells few
quantitatively
many
literatures
in
of
pancreato for
the
two
cases
decreases
in
et
subsequent
of were
was
function, secretion have
estimated
correspond
experimentally (Wang
al.
et
(1950)
been and
changes
pancreozymin
and
deteriorated the
to
same
(Ragins
the
correlation et
reported its
al.
ligated
histological of
function
acid
the in
investigators Wang
stimulation
gastric and
lack
1962)
Their
function
1962). the
maximal
for
examined
changes
exocrine
Magee
the
parietal
However,
studied and
and
the
40%.
and
has
flow
depression.
anastomosis.
reduction
bicarbonate
as
Dreiling
were
reconstructive
present
pancreatic
bicarbonate
such
secretory
the
pancreatic
diversion
and the
and
1962;
factors
in
in
change
the
19.1%
jejunal
accepted
between 1960).
of
function
concluded
histological
outputs
the Several
between
function
reported
the
but
total
decrease
In in
flow,
parenchymal
al.
control.
Namely,
generally
duct
They
also
pancreatic
the
the
in
the
fibrotic
control.
same
lesion et
pancreatic
in the
pancreatic
pancreatic
Marks
as
been
Feldman
and
was
same correlation
gland
1950;
with
70%
pancreatic
would
changes
gastrectomy
to
in
mechanism
flow
60
depressions
values.
lack
duodenal
of
without
of
the
contents.
pancreas
50%
the
duodenectomy,
exchange
as
35%
to
gastric
eliminated
31.7%
expected
for
pancreatic
to
al.
response
resected as
pancreas
secretory
estimation,
the
the of
against
expected than
stimulation
jejunostomy
total
output
the
lower
endogenous
were
enzyme
30
it et
pancreatoduodenectomy,
and
diversion
remnant
of
noticed that
due
of
estimated
duodenal
secrete
likely
volume
roughly
the
fibrosis
in
The
the
pancreatoduodenectomy,
remnant
enzyme
the
after
papilla
was
secretory
diversion
pancreas
Billroth ‡U
the
(Lenninger
in
more
the
function
consideration.
effect of
by
et was
therefore, loop
difference
considered
resected
was
pancreatoduodenectomy
series
ing
of
suggested,
the
was
exocrine
volume into
the
secretion
study,
in
at
aspirate
duodenal
a
change White
60% tube
duodenal
the
caused
pancreatoduodenectomy
organ.
and
present
stimulation
the
in
that
exocrine
stimulants
about
suction
They
enzyme
gastrectomies
investigate
factors,
should
the
duodenal
order
major
of
and ‡U
endogenous In
in
the
in
gastrectomies.
gastrectomy,
exogenous
by
a
(1952)
acidification.
the
and
balance
Hallenbeck
the
duodenal
Placing
difference
postoperative
and and ‡U
to
patients
of
the
though
or
normal.
absorption
in
Billroth ‡T
response
Billroth ‡T
315
Annis
stimulation,
stimulation
considerable
the
reported
of
dietary
the
and ‡U
to
From
in
Function
1971).
duodenal
with no
due
between
two
the
Billroth ‡T
might
in
secretin
that 30%
however,
between
by
after
compared
also
Kaneko
experiments
noticed
about
as
was
1954;
animal
showed
patients
al.
was
observed
depressed
Billroth ‡U
their
difference
was
in et
Pancreatic
correlation
al. in
1957; which with
316
Y. Suda
et al.
exocrine function was studied. Only the report of Hansky et al. (1963) on the relationship between the canine pancreatic weight and function was comparable with the present study. Since it was confirmed in the present study that the pancreas parenchyma without microscopicallesion occupied90.47to 93.97% of the total organ, pancreas with over 90% parenchyma might be considered as functionally normal. The fibrotic pancreas with 70.95% of parenchymal ratio showed the corresponding decrease in the flow of juice, outputs of bicarbonate and amylase. As for the residual parenchyma and its secretory function after pancreatoduodenectomy, a similar correlation was found when compared with the histologically normal remnant. Namely, the cases with 90.52, 85.77 and 39.46% of the corrected parenchymal ratios against Case 11 with normal histology showed considerably parallel depressionsof their exocrineparameters. In the case with parenchyma of 2.26%, exocrine secretion was extremely low and any numerical correspondence was not obtained. Since the residual parenchymal cells would be still scattered even in an extraordinarily fibrotic pancreas, measurement of parenchyma should be made in the overall organ as possible. As mentioned above, however, under the conditionsof diffuselesion it would be postulated that a quantitatively parallel correlation exists between pancreatic parenchyma and exocrine function in the endogenous stimulation of diet. Since the so-called endogenous stimulation of diet in the present study was not uniform as the stimulant to each patient, the exogenous stimulation with secretin or pancreozymin,though in small numbers, was attempted to confirm the relationship between secretory activity and parenchyma. Under secretin infus ion, a decreasein bicarbonate output was coincidentwith the parenchymal ratio in fibrotic pancreas. The parameters of exocrine function also tended to decrease in a parallel fashion within + 10% divergency, and the more parenchymal reduction resulted in the less secretory outputs. Under pancreozymin stimulation the same tendency was observed. Although there might be arguments for and against that the dose of secretin or pancreozyminused in this study was not appropriate for submaximalstimulation comparablewith each individual, it was suggested that the secretory output was affected by the histological changes and the volume of pancreas remnant even under the exogenous stimulation of secretin and/or pancreozymin. The percent increase in enzyme secretionunder pancreozymin stimulation was much higher in the non-resected pancreas than in the pancreatoduodenectomized. Interaction of neurologicalor endogenousfactors during the exogenousinfusion of stimulants should be taken into consideration. Further studies are required for this matter. Although some questions on the sequel of fibrotic pancreas or pancreatic remnant after pancreatoduodenectomy are still remained, the present study will show a clue for the rational treatment or substitution of enzymes after upper abdominal surgery.
Postoperative
Pancreatic
Function
317
References 1)
Annis,
P.
&
pancreatic 2)
Caraway, and
3)
W.T.
other
Elmslie,
M.,
6)
J.,
between
maximal
7)
Med. &
In:
Y.
&
9)
(1964)
of
Observation 160,
A.,
on
canine
amylase
in
serum
of
pancreatic
fistula
937-949.
Schaffner,
F.
of
&
the
Janowitz,
dog
H.D.
pancreas.
(1962)
Amer.
J.
L.D.,
of
T.T.
J.F.,
I.N.,
Komarow,
H.D.
the
The
(1963)
pancreas
Relationship
in
balance
68,
the
dog.
Proc.
pp.
study
D.F.
of
fluid
Pancreas,
and
edited
by
115-137. following
(1965)
gastrectomy.
Kelly,
secretion
Exocrine
various
types
of
940-949.
Magee,
W.D.,
following
the
London,
chemical
&
pancreatic
on
Churchill,
Gastroenterol.,
Perry,
of
(1962)
Cameron,
Billroth ‡U
Nutrition
Janowitz,
Symposium
after
(1954)
&
weight
654-656. D.A.
White,
loop
D.A. and
Foundation
J.
S.G.,
proximal
O.W.
gastrectomy
determination
Surg.,
secretion
Dreiling,
Results
Jap.
MacLean
D.F.
electrolyte
114,
M.P.
(1971)
Lenninger, the
partial
97-99.
Paulino-Netto,
Dreiling,
Ciba
Reuck
Kaneko
the
32,
Ann.
output
(N.Y.),
H.D.
gastrectomy. 8)
O.M., secretory
Biol.
de
for Path.,
Magee,
on
Tiscoria,
electrolyte. A.V.S.
clin.
literature.
D.A.,
of
878-884.
Hansky,
Janowitz,
Effects
512-527. substrate
J. &
the
Dreiling,
205,
exp.
of
D-L-ethionine
Physiol.,
Soc.
stable
T.T.
review
of
(1952) 31,
Amer.
White,
a
Feldman,
A
fluid.
R.G.,
Effect
5)
G.A. Surgery,
(1959)
body
including 4)
Hallenbeck,
secretion.
Studies
Surg. Mosser,
subtotal
of
Gynec.
D.G.,
pancreatic
Obstet.,
Mannick,
gastrectomy
of
A.
four
juice
120,
in
507-510.
&
Wangensteen,
types.
Surgery,
35,
705-718. 10)
Marks, histamin
and
its
H.,
Evans,
S.A.
&
to
parietal
relation
Shay,
H. cell
(1960) mass
Maximal in
the
acid
dog.
Amer.
secretory J.
response
Physiol.,
to
199,
579-
588. 11)
Ragins, (1957) gastric
12)
13)
juice.
Shiraso, duct
Arch.
M.
Tournut,
A Jap.
&
135,
17-21.
Van
Slyke,
method
exocrine
S.P.
resection
& on
Dragstedt, the
L.R.
secretion
of
electrolyte
early
&
based
and
postoperative
Cullen,
bicarbonate
function
on
the
pancreatic
658-672.
Water,
the
E.
the
Rigler,
gastric
pancreatic 68,
(1972) in
Stillman,
titrating
of
266-272.
of
T.T.
pancreas
D.D.,
for
L.R., ‡U., effect
Gastroenterol.,
White,
exocrine
the
74,
study J.
Dragstedt, on
Surg.,
(1973)
R.
Jr.,
studies
drainage.
human
14)
S.O.,
Quantitative
G.E.
content
(1919) of
protein
period.
the
Studies plasma.
secretion
Surg.
of J.
of
Gynec.
acidosis.
biol.
the
Obstet.,
XIII,
Chem.,
33,
A 167-
178. 15)
Wang, duct
C.C.,
Wang,
upon
the
histological 16)
17)
study.
Weibel,
E.R.,
metric
cytology.
White, of
J.
Amer. T.T.
duct
obstruction.
&
J.
&
R.G.
30, &
J.
Surg., D.F. Surg.
106, (1962)
Effect
of in
ligation rabbits
of
the
pancreatic
with
a
correlated
115-121.
W.F.
(1966)
D.F.
(1963)
Practical
methods
for
morpho
23-38.
Magee,
in
Gynec.
(1950) pancreozymin
160,
Scherle,
Biol.,
enzymes
Magee,
M.I. and
Physiol.,
G.S. Cell
Elmslie,
White,
Grossman, secretin
Amer.
pancreatic
resections. 18)
& of
Kistler,
T.T.,
study
K.J.
action
normal
patients
and
The
disappearing
after
Billroth ‡T
enzymes; and ‡U
A gastric
307-316. Recovery Obstet.,
114,
of
pancreatic
463-466.
function
after
controlled
J. exp.
Med.,
Exocrine Surgery
1975,
115, 307-317
Pancreatic
YASUO
SUDA,*
Function
MITSUYASU
SHIRASO•õ
after
and
Upper
Tosnio
Abdominal
SATO
First Department of Surgery, Tohoku University School of Medicine, Sendai
SUDA, Y., SHZRASO,M. and SATO, T. Exocrine Pancreatic Function after Upper Abdominal Surgery. Tohoku J. exp. Med., 1975, 115 (4), 307-317 Daily pancreatic flow and daily outputs of bicarbonate and amylase in pure pancreatic juice were observed in 15 postoperative patients who underwent upper abdominal surgery. Exocrine pancreatic secretion under the stimulation by endogenous or exogenous hormones was well correlated with the extent of pancreatic fibrosis estimated by the histometrical treatment. Exocrine pancreatic secretion in Billroth II type of gastrectomy was depressed to 60-70% of the patients' with Billroth I type of gastrectomy. In distal pancreatectomy the depression in the exocrine pancreatic secretion almost corresponded with the resected volume of pancreas. Exocrine pancreatic secretion in pancreatodoudenectomy was highly depressed beyond the expected value from the resected volume and fibrosis of the pancreas. This was interpreted as partly due to the elimination of hormonal mechanism by duodenectomy and partly due to the denervation of the secretory fibers by surgical manipulation. exocrine pancreatic secretion; pancreatic fibrosis; pancreatoduodenectomy; distal pancreatectomy; gastrectomy
Although many studies have been performed on the physiology or pathophysio logy of exocrine function of pancreas, most of them were animal experiments or carried out on patients with morbid pancreatic fistulae encountered during the postoperative period. The present study deals with the comparison of the exocrine functions in patients who underwent upper abdominal surgery of several types with the external pancreatic duct drainage. The effects of pancreatic or gastric resection and pancreatic fibrosis on the exocrine pancreatic function were investigated by the histometrical treatment of the tissue and the quantitative measurement of pure pancreatic juice. MATERIALS AND METHODS The control cases were tabulated in Table 1. Pancreatic and hepatic functions in these cases were proved to be within normal limits by pancreozymin-secretin test and routine liver function tests performed preoperatively. The other cases studied were tabulated in Tables 2 and 3. The effect of pancreatic fibrosis on the exocrine secretion was investigated in Case 5. The influence of duodenal passage of gastric content upon the exocrine secreReceived * Sendai
Present
for
publication, address:
December Dept
.
of
5, Surg.,
1974. National
Sendai
Kyodo
Hospital,
Hospital,
2-8-8,
Miyagino,
983. •õ
Present
address:
Surgical
Clinic,
Mito
307
3-2-7,
Miyamachi,
Mito
310.
308
Y. Suda TABLE 1.
TABLE 2.
et al.
Control
cases
Cases of pancreatic .fibrosis and gastrectomies
TABLE 3.
Cases of panereatoduodeneetomy
tion was studied in Cases 6, 7, 8 and 9. The effect of distal pancreatic resection on the exocrine pancreatic secretion was examined in Case 10 using Case 9 as control, and that of proximal pancreatic resection was examined in Cases 11 to 15, taking into consideration the fibrotic change of the remnant pancreata. After transduodenal minor sphincterotomy, pancreatic duct drainage was exteriorized through the jejunal loop with a polyethylene tube of 2 mm in caliber. Pancreatic juice was collected every 6 hr into a bottle in an ice bucket. Checking its volume at the bedside, bicarbonate and amylase concentrations were measured for an aliquot according to the methods of Van Slyke et al . (1919) and Caraway (1959) and expressed as total dialy output, i.e. the sum of 4 six-hr outputs . The average daily output on the 7th to 14th postoperative day was used for the purpose of comparison, since the patients recovered so as to have ordinary meals on the 7th to 10th postoperative day. For the purpose of exogenous stimulation , secretin of 0.02 unit/min/kg was infused and pancreozymin of 1 unit/kg was administered by a single injection after the pancreatic
Postoperative
Pancreatic
Function
309
Fig. 1. Point counting method. Intra-acinar and interacinar connective tissue overlapping with the crossings of micrometer was counted. The parenchymal ratio was expressed as a quotient of the parenchymal points by the total crossings. Photo shows the histology of Case 10 with the parenchymal ratio 94.24%.
flow
of
of
a few
consecutive
exocrine
amylase
output
The
In
the
are
of the
head
of
was
applied
glass
disc
overlapping 21 •~
21 •~
expressed
as
In
15
cephalic
separating
The
average
portion
nodes
is
38.09
were
the
approximate would
38.54•}10.22
g ratio
be
preserved
at
of
in
in
cadaver
the
stem
Thus, distal
of
total
tail
the
as
the was
splenic
proximal artery
in usual
to
cadaver
dissect
portion
and
24.45•}7.48
g
in
total
is
resected
the
organ
50
a
views,
was
then
calculated
his
pancreas
with
of
the
pancreata caudal
superior
middle
age
were
pancreatoduodenec 35.00•}10.15 ratio
of
approximately
of
of
a
gastrectomy
weights
pancreatectomy.
1, micro-
tissue. side
weight
mean
40%
its
left
were
Thus,
or
was
in
the
pancreata
portion.
with
cephalic
this
and
of
non-parenchymal
that
histology
pancreatoduodenectomy
The
3:2.
on
normal
1966)
Fig.
ratio
postulated 90%
resected
body
21
caudal
combined
artery.
the
in lens
randomized
ratio
was over
is with
in
g in
ordinary
resected
approximately
shown
al.
crossings.
parenchymal
of
from
et
Parenchymal total
It
resection
ocular
in
and
trichrome
(Weibel
tissue,
slide.
the
wedge
the
counted
over
77•}1.31%.
from
both
10.88
often
splenic
portion of
f
under
usually the
line
60%
weights
and
pancreas
along
head
and
cut-surface
Masson's
As
under connective
92.
pancreata
of
tissue.
was
points
pancreas
cadaver
comparison output
the
and
method
the
histology
pancreata
parenchyma
the
pancreatectomy
pancreas
its
the
from
specimen
equipped
micrometer
on
being
the
intra-acinar of
normal
the
bicarbonate
specimen
counting in
was
parenchymal
value
The
by
caudal
distal
the
for
rate,
stain
point ratio
lattice
and
whole,
the
operated,
parenchymal
pancreatoduodenectomy, vessels.
tomy.
of
in
The
crossings a
obtained had
usual
weighed
as
not
of
parameters
hematoxylin-eosin
was
vessels
the
quotient
the
mesenteric
to
small
points,
histology In
the
the flow
performed by
crossings
microscopically
tometrically, normal
21
As
description.
instead.
the
21 •~
with
a
was
used
investigate
50
following
pancreas
was
plateau.
above-mentioned
pancreas
whose
incising Including
the
examination
case
portion
the
in
resected
pancreas
scope.
i.e.
used
the
to
reached
function,
histological
mid-portion stain.
collections
pancreatic
portion, the
In
cancer,
regional
transected
and
in
1:1. for
the
g cephalic
the lymph at
this
showing remaining
310
Y. Snda
et al.
RESULTS
Daily secretion in normal and fibrotic pancreata Daily flow of pancreatic juice in controls with normal histology ranged from 833.9 to 958.5 ml, the average value being 891.6 ml (Table 4). Daily bicarbonate output ranged from 79.45 to 93.63 mEq with the average of 85.79 mEq. Daily amylase output was 25323 units on the average . Pancreatic parenchyma in 4 controls occupied from 90.47 to 93.96% (mean; 92.58%) of the total tissue . In contrast, daily flow of pancreatic juice and daily outputs of bicarbonate and amylase in Case 5 were 587.7 ml, 59.75 mEq and 15682 units , respectively. The histology of Case 5 was shown in Fig. 2. The histometrical ratio of this tissue was 70.95% of parenchyma. Since the mean control parenchymal ratio in this series was 92.58%, the parenchymal reduction in Case 5 was corrected to 70.95/92.58 or 76.63%. Comparing the parameters of secretory function in Case 5 with control , the extents of reduction in daily flow and daily outputs of bicarbonate and amylase were 65.9%, 69.6% and 61.9% , respectively. Although these values did not TABLE 4.
Fig. 2.
Exocrine pancreatic secretion in controls and pancreatic fibrosis
Histology of Case 5 .
Parenchymal
ratio was estimated
at 70 .95%.
Postoperative exactly
coincide
three
parameters
Daily
pancreatic The
were
was
depressed
at
a
rate.
after
gastric
pancreatic 5. gastric
the
Case
in
decreased case
at
remained
pectively.
Case
7
similar
puts.
By
the
difference
gastrectomy secretion
the
i.e.,
and
three
of
in
and Billroth ‡U, depressed to
TABLE 5.
flow,
these
two
exocrine
60
that to
is, 70%
Exocrine
76.6%,
the
flow the
of
the
66%
above
bicarbonate it
was
pancreatic between in the
Gross
duodenal latter.
secretion
finding
6,
daily
in and suggested function
duodenum. the
gross
operation. in
output
97.7%
gastroje
but
of
Case of
In 6
7
68% that between
passage
and
in
91.2%,
gastrectomy) Case
was
amylase
and
6 (Billroth ‡T
in
of
Case time
of
with
portion
the
resection
gastroduodenos
same
bicarbonate
parameters
cases,
2nd in
and
gastric
with the
at
rates
Case
of
of
all
pancreatic
for histology.
at
daily at
cases
performed
output
parameters
postoperative
* No specimen
but range
the
resection
consistency
gastrectomy), 65%
of
underwent
not
daily
88.9%
control
comparison in
was
of
the
7
folding was
values,
a rate
in
gastric Case
mucosal
(Billroth ‡U
rates,
and
appearance
in
parenchyma
function
underwent
pancreas
control
Comparing of
6
311
resection
cancer
of
the
similar
exocrine
membranous
with
slightly
the
in
I)
normal
comparison
those
reduction
Table for
Function
of
investigation
finding
a
of
for
Histological
degree
secretion
in
junostomy
at
were
(Billroth
this
the
parameters
shown
tomy
with
Pancreatic
were in
res with
depressed
enzyme
there
might
outbe
Billroth ‡T diversion;
the
in gastrectomies
was normal.
Similar comparison was made between Cases 8 and 9 in total gastrectomy. The alimentary tract after total gastrectomy was reconstructed by jejunal substitution for stomach in Case 8 and by esophagojejunostomycombined with Roux en Y jejunojejunostomy in Case 9. Namely, the duodenal passage was preserved in Case 8 but diverted in Case 9. The value of daily pancreatic flowunder total gastrectomy with jejunal interposition was similar to control, showing98.23% of the control value. The bicarbonate and enzyme outputs, however, showeda con siderable depression to 55.9% and 57.2% of controls, respectively. As compared with Case 8, Case 9 showed a depresseddaily flowto 66.3%. This seemedto be due to the diversionof duodenal passage in Case 9. The declines in bicarbonate and enzyme outputs were 68.7% and 52.8%, respectively. The decreaseof 66% and 69% in flow and bicarbonate output under total gastrectomy was almost the same as under subtotal gastrectomy, but the enzyme output was less than the latter.
312
Y. Suda
et al.
Daily pancreatic secretionafter pancreatectomy On the assumption that 60% of pancreas was preserved in distal pancrea tectomy at the stem of the lienal artery, comparison was made between the cases of total gastrectomy with and without distal pancreatectomy (Table 5). In Cases 9 and 10, the alimentary tracts were reconstructed by esophagojejunostomyand Roux en Y jejunojejunostomy. The former was combined with distal pancreatec-t omy, but the latter was not. The parenchymal ratios in both cases were within normal range histometrically. The exocrine parameters of Case 10 showed the decrease of 64.76% in pancreatic flow, 55.72% in bicarbonate output and 64.66% in enzyme output against the respective values of Case 9. These corresponded approximately with the ratio of preserved remnant parenchymata. In ordinary pancreatoduodenectomyas prescribed before, 50% of pancreas parenchyma was preserved. The histology of the pancreatic cut-surface in pancreatoduodenectomy varied with the fibrotic changes for the lesion of the pancreatic head, and the parenchymal ratio ranged from 91.53% to only 2.07%. The parameters of pancreatic exocrine function in 5 pancreatoduodenectomized cases were shown in Table 6 in an ascending order of fibrosis. Case 11 had localizedcephalic pancreatitis which was misjudged as carcinoma. The histology of the resected surface was normal and its parenchymal ratio was estimated at 91.53%. TABLE 6.
Exocrine
pancreatic
secretion
in pancreatoduodenectomy
Comparisonof the exocrineparameters was made between the pancreatoduo denectomized Case 11 with normal histology and the unresected controls. The values of the former were 31.66% of the controls in flow, 19.08% in bicarbonate output and 11.26% in enzyme output. Applied Case 11 as the pancreatoduodenectomizedcontrol, each exocrinepara meter in Case 12 with parenchymal ratio of 82.84% (corrected ratio to Case 11; 90.52%) was depressed in an almost parallel fashion, that is, to 82.8% in flow, 72.6% in bicarbonate output and 81.1% in enzyme output. The data of Case 13 were not exactly comparable with others', since the averages during the 5th to the 10th postoperative day were adopted because of the spontaneous removal of pancreatic duct drainage on the 12th postoperative day. The same comparison was attempted between Case 13 with 85.8% of the corrected parenchymal ratio and Case 11 with the normal histology. The declined ratios were 97.6% in flow,
Postoperative 65.5%
in
bicarbonate
correspond The
with
depression
were
In
in
Case
were
markedly
these
values
case
27.8%
to
mean
concentrations
96.22 2521
to
bonate
and
amylase
of
76.63%
Billroth ‡T control
and
So
far
as
mean in
by
presence the
was
or
degree
absence
performed,
remnant
no in
50.95
the
the
stomach,
or
this
to
110.8
units/100
93
In
98%.
but
ordinary
of
of
the
gastrectomy
was
con
58
or
46%.
concerned,
it
was
concentrations
so
intake
output,
with
92%
bicarbonate
were
not
or
total
concentration
these
surgical
90
mean
amylase
bicar
parencymal
gastrectomy was
or
controls
Mean
corrected
subtotal
daily
mEq/liter,
the
ml.
the
In
estimated Mean
in
concentrations
amylase
Cases
distinguished
mEq/liter.
control,
lower
between
much
were
affected
diet.
therefore,
The seemed
manipulation
no
Decrease the
parenchymal
10
values
clear-cut in
on
was ranged
These
but
9 and
difference
pancreatoduodenectomy
pancreata. and
of
daily
of
were
days.
concentration
resection,
under
the
case
89.9
gastrectomy,
gastric
passage
comparison
concentration
the
of
each
anastomosis,
amylase
total
2.26%
output
such
as
by
the
difference
in
to
to
be
due
denervation
fibers.
the
averaging
or
Y and
output of
ratio.
with
range.
en
control
enzyme
concentration
5
was
and
subtotal
from
control
Roux
ratio
2840.1
bicarbonate
the
bicarbonate
the
secretory
against
or of
parenchymal
from
amylase
concentration
58%
duodenal
From
6%,
or
concentration
the of
56
that
mechanical
the
respective
bicarbonate
in
Case
ratio
outputs,
and
the
not
output.
amylase
ranged
in
did
enzyme
parenchymal
postoperative
averaging
mean
amylase
the
influenced
mean
within
interposition was
assumed
nil,
the
parenchymal
and
daily
concentrations
mean
hand,
the
controls
units/100
anastomosis,
jejunal
centration
to
other
concentrations
Mean
were
or ‡U
the
the
enzyme flow
the
bicarbonate
4
of
in
with
above-mentioned in
3005
On
amylase
mEq/liter.
ranged
54.8%
These
for
39.46%
replacement,
degree
the
output.
except
with
compared
of
concentration
averaging
as
similar
on
14 and
4 times.
and
values
bicarbonate
with
a
bicarbonate
the
ratio
as
Case
313
enzyme ratio
fibrotic
but
big
in
bicarbonate
complete
decreased,
Mean
in
in
almost
as
84.1%
Function
parenchymal
parameters
depressed
Estimated
from
of
were
was
of
flow,
15
and
histological
rates
32.9%
ly.
output
the
Pancreatic
which observed.
from
ratio,
amylase the
to
for with
40 the
concentration less
the
pancreatectomy Mean
38.95
accounted correlation
mean
distal
amylase
bicarbonate
58.12 to
mEq/liter,
60%
decrease
fibrotic ranged
change from
concentration
of 35
to
was.
Secretoryresponsesto exogenoussecretinand pancreozymin The above-described data were on the secretory responses to so-called endogenous stimulation of diet. Responses to the exogenousstimulants were as shown in Table 7. Bicarbonate concentration under the secretin infusion was increased up to 115 to 200%, as compared with the unstimulated values. Flow of pancreatic juice in the fibrotic pancreas under secretin infusion was lower than control. Similar results on bicarbonate concentrationwere obtained in the fibrotic
314
Y. Suda TABLE 7.
* No specimen
Exocrine
pancreatic
for histology .
et al.
secretion
Gross
finding
under
exogenous
of pancreas
stimulation
was normal.
pancreas remnant under pancreatoduodenectomy. In Case 5 with 76.6% of the corrected parenchymal ratio, however, the change in bicarbonate concentration was minimal. The ratio of percent increase in amylase concentration under pancreozymin stimulation was 110 to 160% in the present series. On the other hand, the ratios in flow of juice and bicarbonate concentration were around 110%. Compared with each amylase concentration in the cases studied under pancreozymin stimulation, the percent increase after stimulation was correlated with fibrotic replacement. It was concluded, therefore, that the changes in water and enzyme secretion seemed to be correlated with the pancreatic fibrosis, even under these corresponding hormonal stimulations. DISCUSSION Early surgery
postoperative was
White
1972).
from
700
and
histology
with
the
the
present
observed and the
7th
value
the
gastrectomy,
to
early
10th
and
of
gastric
secretion.
is
diverted Clinically,
As
reported
after
Therefore,
to
liberate
better
was
nutritional
by
the
one
after
two
weeks
.
Duodenal
stimulants
after
absorption
flow
values to
study
to
of was
pancreatic
constant for
one
secretion
endogenous
60
comparable
previously pancreatic
values
and ranging
ductography
which
But
types showed
Tournut
literature,
comparative
anastomotic
duodenum
the
showed the
present
considered different
in
surgery.
enzyme
abdominal
1964;
pancreatic
study,
increase
and
the
normal
upper
al. in
present
gradual
period
et
constant
with
the
(1972). a
for
of of
in
White
day.
content
is not
controls
bicarbonate
available
comparison cases
the a day
after
(Elmslie
juice
1973),
postoperative
function
co-workers
convalescent
were
In
in
ml
(Shiraso
concentrations
of
flow
958
Tournut
authors
pancreatic and
of pancreatic
The
830
of
White
flow
ml.
was
to
pancreas.
pancreatic
4000
surgery
passage
by
Daily
in
the
after
to
exocrine
studied
subtotal 70%
to or
total
depression in
Billroth ‡T
in
Postoperative
gastrectomy study
than (MacLean
reported
from
clear
not
al.
(1963)
by
Vater,
be
1965).
results
Billroth ‡T
the
loop,
to
i.e.
be
taken
ordinary
Assuming
pancreatic
the
of
the
control,
of
would
without 11.3%
corresponded
to were
and
depressed The
secretory
almost
the The
has
produced
the
secretin. extent
of
et
al.
parenchyma
upper (Janowitz
contribute
distal
to
pancreatectomy
of histological the
in
been
White
rabbits
to
under that changes.
was
by
examine
the
pancreatic
As
for
the
cells few
quantitatively
many
literatures
in
of
pancreato for
the
two
cases
decreases
in
et
subsequent
of were
was
function, secretion have
estimated
correspond
experimentally (Wang
al.
et
(1950)
been and
changes
pancreozymin
and
deteriorated the
to
same
(Ragins
the
correlation et
reported its
al.
ligated
histological of
function
acid
the in
investigators Wang
stimulation
gastric and
lack
1962)
Their
function
1962). the
maximal
for
examined
changes
exocrine
Magee
the
parietal
However,
studied and
and
the
40%.
and
has
flow
depression.
anastomosis.
reduction
bicarbonate
as
Dreiling
were
reconstructive
present
pancreatic
bicarbonate
such
secretory
the
pancreatic
diversion
and the
and
1962;
factors
in
in
change
the
19.1%
jejunal
accepted
between 1960).
of
function
concluded
histological
outputs
the Several
between
function
reported
the
but
total
decrease
In in
flow,
parenchymal
al.
control.
Namely,
generally
duct
They
also
pancreatic
the
the
in
the
fibrotic
control.
same
lesion et
pancreatic
in the
pancreatic
pancreatic
Marks
as
been
Feldman
and
was
same correlation
gland
1950;
with
70%
pancreatic
would
changes
gastrectomy
to
in
mechanism
flow
60
depressions
values.
lack
duodenal
of
without
of
the
contents.
pancreas
50%
the
duodenectomy,
exchange
as
35%
to
gastric
eliminated
31.7%
expected
for
pancreatic
to
al.
response
resected as
pancreas
secretory
estimation,
the
the of
against
expected than
stimulation
jejunostomy
total
output
the
lower
endogenous
were
enzyme
30
it et
pancreatoduodenectomy,
and
diversion
remnant
of
noticed that
due
of
estimated
duodenal
secrete
likely
volume
roughly
the
fibrosis
in
The
the
pancreatoduodenectomy,
remnant
enzyme
the
after
papilla
was
secretory
diversion
pancreas
Billroth ‡U
the
(Lenninger
in
more
the
function
consideration.
effect of
by
et was
therefore, loop
difference
considered
resected
was
pancreatoduodenectomy
series
ing
of
suggested,
the
was
exocrine
volume into
the
secretion
study,
in
at
aspirate
duodenal
a
change White
60% tube
duodenal
the
caused
pancreatoduodenectomy
organ.
and
present
stimulation
the
in
that
exocrine
stimulants
about
suction
They
enzyme
gastrectomies
investigate
factors,
should
the
duodenal
order
major
of
and ‡U
endogenous In
in
the
in
gastrectomies.
gastrectomy,
exogenous
by
a
(1952)
acidification.
the
and
balance
Hallenbeck
the
duodenal
Placing
difference
postoperative
and and ‡U
to
patients
of
the
though
or
normal.
absorption
in
Billroth ‡T
response
Billroth ‡T
315
Annis
stimulation,
stimulation
considerable
the
reported
of
dietary
the
and ‡U
to
From
in
Function
1971).
duodenal
with no
due
between
two
the
Billroth ‡T
might
in
secretin
that 30%
however,
between
by
after
compared
also
Kaneko
experiments
noticed
about
as
was
1954;
animal
showed
patients
al.
was
observed
depressed
Billroth ‡U
their
difference
was
in et
Pancreatic
correlation
al. in
1957; which with
316
Y. Suda
et al.
exocrine function was studied. Only the report of Hansky et al. (1963) on the relationship between the canine pancreatic weight and function was comparable with the present study. Since it was confirmed in the present study that the pancreas parenchyma without microscopicallesion occupied90.47to 93.97% of the total organ, pancreas with over 90% parenchyma might be considered as functionally normal. The fibrotic pancreas with 70.95% of parenchymal ratio showed the corresponding decrease in the flow of juice, outputs of bicarbonate and amylase. As for the residual parenchyma and its secretory function after pancreatoduodenectomy, a similar correlation was found when compared with the histologically normal remnant. Namely, the cases with 90.52, 85.77 and 39.46% of the corrected parenchymal ratios against Case 11 with normal histology showed considerably parallel depressionsof their exocrineparameters. In the case with parenchyma of 2.26%, exocrine secretion was extremely low and any numerical correspondence was not obtained. Since the residual parenchymal cells would be still scattered even in an extraordinarily fibrotic pancreas, measurement of parenchyma should be made in the overall organ as possible. As mentioned above, however, under the conditionsof diffuselesion it would be postulated that a quantitatively parallel correlation exists between pancreatic parenchyma and exocrine function in the endogenous stimulation of diet. Since the so-called endogenous stimulation of diet in the present study was not uniform as the stimulant to each patient, the exogenous stimulation with secretin or pancreozymin,though in small numbers, was attempted to confirm the relationship between secretory activity and parenchyma. Under secretin infus ion, a decreasein bicarbonate output was coincidentwith the parenchymal ratio in fibrotic pancreas. The parameters of exocrine function also tended to decrease in a parallel fashion within + 10% divergency, and the more parenchymal reduction resulted in the less secretory outputs. Under pancreozymin stimulation the same tendency was observed. Although there might be arguments for and against that the dose of secretin or pancreozyminused in this study was not appropriate for submaximalstimulation comparablewith each individual, it was suggested that the secretory output was affected by the histological changes and the volume of pancreas remnant even under the exogenous stimulation of secretin and/or pancreozymin. The percent increase in enzyme secretionunder pancreozymin stimulation was much higher in the non-resected pancreas than in the pancreatoduodenectomized. Interaction of neurologicalor endogenousfactors during the exogenousinfusion of stimulants should be taken into consideration. Further studies are required for this matter. Although some questions on the sequel of fibrotic pancreas or pancreatic remnant after pancreatoduodenectomy are still remained, the present study will show a clue for the rational treatment or substitution of enzymes after upper abdominal surgery.
Postoperative
Pancreatic
Function
317
References 1)
Annis,
P.
&
pancreatic 2)
Caraway, and
3)
W.T.
other
Elmslie,
M.,
6)
J.,
between
maximal
7)
Med. &
In:
Y.
&
9)
(1964)
of
Observation 160,
A.,
on
canine
amylase
in
serum
of
pancreatic
fistula
937-949.
Schaffner,
F.
of
&
the
Janowitz,
dog
H.D.
pancreas.
(1962)
Amer.
J.
L.D.,
of
T.T.
J.F.,
I.N.,
Komarow,
H.D.
the
The
(1963)
pancreas
Relationship
in
balance
68,
the
dog.
Proc.
pp.
study
D.F.
of
fluid
Pancreas,
and
edited
by
115-137. following
(1965)
gastrectomy.
Kelly,
secretion
Exocrine
various
types
of
940-949.
Magee,
W.D.,
following
the
London,
chemical
&
pancreatic
on
Churchill,
Gastroenterol.,
Perry,
of
(1962)
Cameron,
Billroth ‡U
Nutrition
Janowitz,
Symposium
after
(1954)
&
weight
654-656. D.A.
White,
loop
D.A. and
Foundation
J.
S.G.,
proximal
O.W.
gastrectomy
determination
Surg.,
secretion
Dreiling,
Results
Jap.
MacLean
D.F.
electrolyte
114,
M.P.
(1971)
Lenninger, the
partial
97-99.
Paulino-Netto,
Dreiling,
Ciba
Reuck
Kaneko
the
32,
Ann.
output
(N.Y.),
H.D.
gastrectomy. 8)
O.M., secretory
Biol.
de
for Path.,
Magee,
on
Tiscoria,
electrolyte. A.V.S.
clin.
literature.
D.A.,
of
878-884.
Hansky,
Janowitz,
Effects
512-527. substrate
J. &
the
Dreiling,
205,
exp.
of
D-L-ethionine
Physiol.,
Soc.
stable
T.T.
review
of
(1952) 31,
Amer.
White,
a
Feldman,
A
fluid.
R.G.,
Effect
5)
G.A. Surgery,
(1959)
body
including 4)
Hallenbeck,
secretion.
Studies
Surg. Mosser,
subtotal
of
Gynec.
D.G.,
pancreatic
Obstet.,
Mannick,
gastrectomy
of
A.
four
juice
120,
in
507-510.
&
Wangensteen,
types.
Surgery,
35,
705-718. 10)
Marks, histamin
and
its
H.,
Evans,
S.A.
&
to
parietal
relation
Shay,
H. cell
(1960) mass
Maximal in
the
acid
dog.
Amer.
secretory J.
response
Physiol.,
to
199,
579-
588. 11)
Ragins, (1957) gastric
12)
13)
juice.
Shiraso, duct
Arch.
M.
Tournut,
A Jap.
&
135,
17-21.
Van
Slyke,
method
exocrine
S.P.
resection
& on
Dragstedt, the
L.R.
secretion
of
electrolyte
early
&
based
and
postoperative
Cullen,
bicarbonate
function
on
the
pancreatic
658-672.
Water,
the
E.
the
Rigler,
gastric
pancreatic 68,
(1972) in
Stillman,
titrating
of
266-272.
of
T.T.
pancreas
D.D.,
for
L.R., ‡U., effect
Gastroenterol.,
White,
exocrine
the
74,
study J.
Dragstedt, on
Surg.,
(1973)
R.
Jr.,
studies
drainage.
human
14)
S.O.,
Quantitative
G.E.
content
(1919) of
protein
period.
the
Studies plasma.
secretion
Surg.
of J.
of
Gynec.
acidosis.
biol.
the
Obstet.,
XIII,
Chem.,
33,
A 167-
178. 15)
Wang, duct
C.C.,
Wang,
upon
the
histological 16)
17)
study.
Weibel,
E.R.,
metric
cytology.
White, of
J.
Amer. T.T.
duct
obstruction.
&
J.
&
R.G.
30, &
J.
Surg., D.F. Surg.
106, (1962)
Effect
of in
ligation rabbits
of
the
pancreatic
with
a
correlated
115-121.
W.F.
(1966)
D.F.
(1963)
Practical
methods
for
morpho
23-38.
Magee,
in
Gynec.
(1950) pancreozymin
160,
Scherle,
Biol.,
enzymes
Magee,
M.I. and
Physiol.,
G.S. Cell
Elmslie,
White,
Grossman, secretin
Amer.
pancreatic
resections. 18)
& of
Kistler,
T.T.,
study
K.J.
action
normal
patients
and
The
disappearing
after
Billroth ‡T
enzymes; and ‡U
A gastric
307-316. Recovery Obstet.,
114,
of
pancreatic
463-466.
function
after
controlled
