World J. Surg. 14, 45-47, 1990
World Journal of Surgery 9 1990 by the Soci6t6 lnternationale de Chirurgie
Surgery for Chronic Pancreatitis in Zaria, Nigeria Oluatope A. Mabogunje, M.D., and James H. Lawrie, M.D. Department of Surgery, Ahmadu Bello University Hospital, Zaria. Nigeria Fifteen children and 23 adults with complications of chronic pancreatitis were managed in Zaria, Nigeria from 1971 to 1987. They comprised 26 patients with chronic pseudocysts, 9 with chronic abdominal pain, and 3 with obstructive jaundice. Internal drainage was performed for 22 (85%) of the pseudocysts, with resection and external drainage, respectively, in 2 each. A longitudinal pancreaticojejunostomy was performed in a child with juvenile tropical pancreatitis syndrome and biliary bypass was performed in the jaundiced patients. The cause of chronic pancreatitis was known only in 8 (31%) of the patients.
weeks to 3 years with a median of 3 months. A tender abdominal mass was frequently present associated in some with nausea, vomiting, and anorexia. A definite history of abdominal trauma was obtained in 4 (40%) of the children (3 boys, I girl) and in 2 (13%1 of the adults (1 man, 1 woman). A definite history of chronic alcohol use was obtained from 2 (18%) of the 11 men. In the others, the likely cause of the pseudocyst could not be determined.
Chronic pancreatitis is a continuing inflammatory disease of the pancreas, characterized by irreversible morphological changes and typically causing pain and/or permanent loss of function [1]. In the Western World, excessive consumption of alcohol is its most common cause [2]. In Northern Nigeria, where Islam is predominant, flagrant consumption of alcohol is uncommon and chronic pancreatitis in adults is not a common clinical problem. On the other hand, chronic pancreatitis may result from childhood malnutrition as occurs in other tropical zones of Asia and Africa [2, 3]. Surgical complications of chronic pancreatitis include a peptic ulcer-like syndrome of abdominal pain, obstructive jaundice from entrapment of the choledochus by pancreatic fibrosis, and chronic pancreatic pseudocyst [4]. From 1971 to 1987, at the Ahmadu Bello University Hospital, Zaria and its affiliated hospitals, a total of 22 male and 16 female patients were treated for surgical complications of chronic pancreatitis.
Pain
Patients
There were 15 children younger than 16 years of age and 23 adults. The age and sex distribution are shown in Table 1. The complications of the disease leading to operation are listed in Table 2.
Pseudocysts There were 10 children (5 boys and 5 girls) and 16 adults (11 men, 5 womenl. The duration of symptoms ranged from 6
Reprint requests: J.H. Lawrie, M.D.. Director of Surgery, Armed Forces Hospital. P.O. Box 7897. Riyadh 11159. Kingdom of Saudi Arabia.
Five children and 4 adultS presented mainly with chronic abdominal pain which ranged in duration from 2 to 19 years with a median of 3 years. Weight loss was prominent in 4 of the children; 1 had a palpable abdominal mass and another presented with diabetes mellitus. Abdominal radiographs in 4 of the children showed pancreatic calcifications. In 2 of these children, the clinical features fit the diagnosis of juvenile tropical pancreatitis syndrome [5, 6]. In 1 of the women, chronic pancreatitis was due to chronic duodenal ulcer.
Jaundice Two women and 1 man presented with obstructive jaundice which had recently appeared, following several years of chronic abdominal pain or dyspesia. They were afebrile. The total bilirubin ranged from 50 to 340/~ml/L with a high conjugated fraction. One of the women had clay-colored stools. Management
Pseudocysts Laparotomy was performed in all of these patients. The pseudocysts were all fully matured and thick-walled, varying in size from 300 to 5,000 ml with a median of 2,000 ml, and contained fluid variously described as clear or opalescent, serous, xanthochromic, dirty dark brown, murky chocolate, or greenish. Two patients had bilocular cysts. The location of the pseudocyst was retrogastric in 18, retrojejunal in 4, in the tail of the pancreas in 2, and in the anterior abdominal compartment in 2. Therefore. a cystgastrostomy was performed in 18, a cystjejunostomy in 4, and resection of the tail of the pancreas in 2. In
46
World J. Surg. Vol. 14, No. 1, Jan./Feb. 1990
Table 1. Age and sex distribution.
Age (yr)
Male
Female
Total
0-9 10-19 20-29 30-39 40--49 50+ Total
7 1 6 3 3 2 22
5 2 0 5 3 1 16
12 3 6 8 6 3 38
Table 2. Complications of the disease.
Pancreatic pseudocyst Abdominal pain Obstructive jaundice Total
Male
Female
Total
16 5 1 22
10 4 2 16
26 9 3 38
the 2 patients with pseudocysts in the anterior abdominal compartment, the diagnosis was not made preoperatively. In each, the cyst wall was adherent to the anterior abdominal wall and was inadvertently opened during celiotomy. For this reason, the cyst walls were biopsied and rubber catheters were placed through these openings for external drainage. In the 3-year-old girl, the fistula drained for 8 months and required surgical closure. In the 34-year-old, a sinogram obtained postoperatively showed filling of the choledochus, but this healed spontaneously within a month.
Pain Laparotomy was performed for pain in only 1 of the children. The body and tail of the pancreas were indurated and the pancreatic duct, which was dilated and stenosed in parts, contained many small calculi which were removed. A Rouxen-Y longitudinal pancreaticojejunostomy was performed [6]. The second child, who was advised to have a laparotomy, absconded. The 3 others were managed medically by the pediatricians [7]. Exploratory laparotomy was performed in the 4 adults. In each, the pancreas was hard and nodular, especially in the head. A posterior duodenal ulcer was present in 1 of the women and vagotomy with pyloroplasty was performed after pancreatic biopsy. Pancreatic biopsies were obtained in each patient.
Obstructive Jaundice One of the women had complete obstruction of the distal choledochus by hard nodular panpancreatitis; choledochoduodenostomy was performed. The second woman had inflammatory changes in the head of the pancreas only, with a dilated gallbladder containing a few stones. The gallstones were removed and a cholecystoduodenostomy was performed. In the third patient, hard granular panpancreatitis was found with dilation of the gallbladder. Cholecystojejunostomy with jejunojejunostomy was performed. The patient remained deeply jaundiced 1 month postoperatively. Therefore, at a second operation, splenectomy with distal pancreatectomy was performed
with a Roux-en-Y pancreatojejunostomy. Operative pancreatography showed ductal dilations and stenoses.
Pathology Pseudocysts. Specimens from 18 pseudocysts were examined histologically. The wall showed a variable mixture of vascular granulation tissue with or without hemorrhage, nonspecific fibrosis infiltrated by chronic inflammatory cells, and collagenization. In some specimens, nodules of pancreatic parenchyma were embedded in the fibrous tissue and there was an instance of fibrosis with metaplastic bone formation. Pain. Three biopsy specimens showed pancreatic fibrosis and infiltration by chronic inflammatory cells. Jaundice. The 3 specimens showed pancreatic fibrosis with mononuclear cell infiltration. The resected pancreatic tail also showed a number of small cysts. Outcome
In general, follow-up has been most unsatisfactory in our patients, largely because they came from large distances, at great expense, and are unwilling to come again without a compelling need. Nine of the patients with pseudocysts were seen in follow-up from 1 month to 4 years. Most of the others defaulted after discharge from hospitals. Two of those operated on for pain were seen up to 3 y e a r s - - t h e child with juvenile tropical pancreatitis syndrome and a woman who subsequently required hysterectomy for symptomatic fibroids. One of the jaundiced women presented 8 years later with no abdominal symptoms, but complained of varicose veins of the legs. Two patients died: 1. A 35-year-old woman had laparotomy for recurrent pancreatic pseudocyst initially managed at a district hospital. A bilocular cyst was present which required a third laparotomy. Postoperatively, she developed deep venous thrombosis in the left leg and septicemia from which she died 1 month later. Culture of the pseudocyst fluid yielded E. coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Bacteroides, and anaerobic streptococcus. 2. A 37-year-old man with chronic abdominal pain for 19 years had laparotomy and biopsy of the fibrotic pancreas. Subsequently, he developed intractable pancreatic ascites of which he died 2 months later. Discussion
There are few reports on surgery for complications of chronic pancreatitis in Africans. Chronic pseudocysts have been reported in a few children and adults [8-11]. In the Western World, a high percentage of pseudocysts in adults is the result of alcoholic pancreatitis while 60% of pediatric cases are due to blunt abdominal trauma and the others are of obscure etiology [12]. In this series, only 8 (31%) of the 26 patients with pseudocysts gave a definite history of trauma or alcoholism, but the cause in the majority remains obscure. All of our patients
O.A. Mabogunje and J.H. Lawrie: Chronic Pancreatitis in Nigeria presented with chronic pseudocysts defined as established pseudocysts unrelated to an episode of acute pancreatitis and whose origin is, therefore, difficult to date [13]. The walls were all mature and suitable for anastomosis. In its complete form, juvenile tropical pancreatitis syndrome is characterized by exocrine and endocrine pancreatic failure, pancreatic calcification, and abdominal pain, but some of these features may be absent [3, 5]. Most patients are younger than 25 years of age and belong to the lower social classes but are not addicted to alcohol. This syndrome is to be distinguished from chronic alcoholic pancreatitis of the Western World which may also be associated with pancreatic calcification. It is not known whether pseudocysts may also develop in juvenile tropical pancreatitis syndrome. Thus, it is impossible to determine how many of the patients with pancreatic pseudocysts of obscure origin had juvenile tropical pancreatitis syndrome. Elsewhere, the use of abdominal ultrasound and computed tomography scan has revolutionized the management of chronic pancreatic diseases [14, 15]. The presence of pseudocyst is readily confirmed, the wall thickness measured, and the effectiveness of surgical drainage assessed postoperatively. Ductal dilatations in chronic pancreatitis can also be assessed. In the absence of such facilities in Zaria, we have relied on clinical methods supplemented by plain abdominal radiographs, barium meal, and the intravenous urogram which provide indirect evidence for the presence of a pseudocyst. Laparotomy is usually required to confirm the diagnosis and treat the condition. F o r the pseudocyst, internal drainage is preferred to external drainage; however, the anterior abdominal pseudocysts in 2 of our patients were inadvertently opened during celiotomy and the option of internal drainage forfeited. In the child, a chronic fistula required surgical closure after 8 months. Postdrainage pseudocysts may be complicated by infection and hemorrhage [14, 15]. In the woman who died in this series, several gram-negative bacilli were cultured from the cystic fluid when she developed septicemia which led to her demise. The second patient who died illustrates the hazard of pancreatic biopsy. Regrettably, he was managed in his district hospital for intractable ascites and was moribund when finally referred back to Zaria. One of the women with obstructive jaundice had stones in her gallbladder. Both her pain and jaundice were relieved by stone removal and cholecystojejunostomy. It was not determined whether she had a stone impacted at the sphincter of Oddi. R6sum6
Quinze adolescents et 23 adultes avec des complications de pancrdatite chronique ont dt6 traitds ~ Zaria, Nigeria. Vingt-six avaient un pseudokyste, 9 se plaignaient de douleurs abdominales chroniques, et 3 d'ict~re obstructif. Un drainage interne a 6td effectud pour 22/26 (85%) des pseudokystes, une rdsection
47 dans 2 cas et un drainage externe dans 2 cas. Une anastomose pancrdaticojdjunale a 6td rdalisd chez un enfant ayant un syndrome de pancrdatite tropicale juvdnile. Une ddrivation biliaire a 6td effectude en cas d'ict~re. La cause de la pancr6atite chronique dtait connue chez 8 (31%) seulement des patients. Resumen
Quince nifios y 23 adultos con complicaciones de pancreatitis cr6nica fueron tratados en Zaria, Nigeria, durante el periodo 1971-1987. E1 grupo incluy6 26 pacientes con pseudoquiestes cr6nicos, 9 con dolor abdominal cr6nico, y 3 con icetericia obstructiva. Se realiz6 drenaje interno en 22 (85%) de los pseudoquistes, resecci6n en 2 y drenaje externo en 2. Se realiz6 una pancreaticoyeyunostomfa longitudinal en un nifio con el sindrome de pancreatitis juvenil tropical, y derivaci6n biliar en los pacientes ictdricos. La causa de la pancreatitis cr6nica pudo ser establecida s61o en 8 (31%) de los pacientes. Acknowledgment
We thank Drs. A.M. Yakubu and J.T. Momoh, whose patients are included in this series, and Mr. R.S. Olayanju for typing the manuscript. References
1. Sarner, M., Cotton, P.B.: Classification ofpancreatitis. Gut 25:756, 1984 2. Sarles, H., Cros, R.C., Bidant, J.M., International Group for the Study of Pancreatic Disease (Marseille): A multicenter inquiry into the etiology of pancreatic diseases. Digestion 19:110, 1979 3. Nwokolo, C., Oli, J.: Pathogenesis of juvenile tropical pancreatitis syndrome. Lancet 1:456, 1980 4. Binton, M.H., Pellegrini, C.A., Stein, S.F., Way, L.W.: Surgical treatment of chronic pancreatitis. Am. J. Surg. 148:754, 1984 5. Nwokolo, C.: The clinical features of juvenile tropical pancreatitis syndrome. Postgrad. Doctor Afr. 4:334, 1982 6. Yakubu, A.M., Garg, S.K., Umar, B.A., Quartey, G.E.K., Osuide, J.A.: Juvenile tropical pancreatitis syndrome in Northern Nigeria: A case report. Ann. Trop. Paediatr. 4:79, 1984 7. Yakubu, A.M.: Pancreatitis in childhood: A review of six cases in Zaria. Niger. J. Paediatr. (in press) 8. Olurin, E.O.: Pancreatic cysts: A report of 10 cases. Br. J. Surg. 58:502, 1971 9. Carswell, LW., Cotter, J., Master, S.P.: Pancreatic pseudocysts in children: Four cases from Uganda. Br. J. Surg. 62:360, 1975 10. Ajao, O.G.: Pancreatic pseudocyst. Trop. Doctor 12:129, 1982 11. Mabogunje, O.A.: Pseudocyst of the pancreas in children: An African series. Ann. Trop. Paediatr. (in press) 12. Cooney, D.R., Grosfeld, J.L.: Operative management of pancreatic pseudocysts in infants and children: A review of 75 cases. Ann. Surg. 182:590, 1975 13. Crass, R.A., Way, L.W.: Acute and chronic pancreatic pseudocysts are different. Am. J. Surg. 142:660, 1981 14. Belinkie, S.A., Russell, J.C., Deutsch, J., Becker, D.R.: Pancreatic pseudocyst. Am. Surg. 49:586, 1983 15. Kane, M.G., Krejs, G.J.: Pancreatic pseudocyst. Adv. Intern. Med. 29:271, 1984
World Journal of Surgery 9 1990 by the Soci6t6 lnternationale de Chirurgie
Surgery for Chronic Pancreatitis in Zaria, Nigeria Oluatope A. Mabogunje, M.D., and James H. Lawrie, M.D. Department of Surgery, Ahmadu Bello University Hospital, Zaria. Nigeria Fifteen children and 23 adults with complications of chronic pancreatitis were managed in Zaria, Nigeria from 1971 to 1987. They comprised 26 patients with chronic pseudocysts, 9 with chronic abdominal pain, and 3 with obstructive jaundice. Internal drainage was performed for 22 (85%) of the pseudocysts, with resection and external drainage, respectively, in 2 each. A longitudinal pancreaticojejunostomy was performed in a child with juvenile tropical pancreatitis syndrome and biliary bypass was performed in the jaundiced patients. The cause of chronic pancreatitis was known only in 8 (31%) of the patients.
weeks to 3 years with a median of 3 months. A tender abdominal mass was frequently present associated in some with nausea, vomiting, and anorexia. A definite history of abdominal trauma was obtained in 4 (40%) of the children (3 boys, I girl) and in 2 (13%1 of the adults (1 man, 1 woman). A definite history of chronic alcohol use was obtained from 2 (18%) of the 11 men. In the others, the likely cause of the pseudocyst could not be determined.
Chronic pancreatitis is a continuing inflammatory disease of the pancreas, characterized by irreversible morphological changes and typically causing pain and/or permanent loss of function [1]. In the Western World, excessive consumption of alcohol is its most common cause [2]. In Northern Nigeria, where Islam is predominant, flagrant consumption of alcohol is uncommon and chronic pancreatitis in adults is not a common clinical problem. On the other hand, chronic pancreatitis may result from childhood malnutrition as occurs in other tropical zones of Asia and Africa [2, 3]. Surgical complications of chronic pancreatitis include a peptic ulcer-like syndrome of abdominal pain, obstructive jaundice from entrapment of the choledochus by pancreatic fibrosis, and chronic pancreatic pseudocyst [4]. From 1971 to 1987, at the Ahmadu Bello University Hospital, Zaria and its affiliated hospitals, a total of 22 male and 16 female patients were treated for surgical complications of chronic pancreatitis.
Pain
Patients
There were 15 children younger than 16 years of age and 23 adults. The age and sex distribution are shown in Table 1. The complications of the disease leading to operation are listed in Table 2.
Pseudocysts There were 10 children (5 boys and 5 girls) and 16 adults (11 men, 5 womenl. The duration of symptoms ranged from 6
Reprint requests: J.H. Lawrie, M.D.. Director of Surgery, Armed Forces Hospital. P.O. Box 7897. Riyadh 11159. Kingdom of Saudi Arabia.
Five children and 4 adultS presented mainly with chronic abdominal pain which ranged in duration from 2 to 19 years with a median of 3 years. Weight loss was prominent in 4 of the children; 1 had a palpable abdominal mass and another presented with diabetes mellitus. Abdominal radiographs in 4 of the children showed pancreatic calcifications. In 2 of these children, the clinical features fit the diagnosis of juvenile tropical pancreatitis syndrome [5, 6]. In 1 of the women, chronic pancreatitis was due to chronic duodenal ulcer.
Jaundice Two women and 1 man presented with obstructive jaundice which had recently appeared, following several years of chronic abdominal pain or dyspesia. They were afebrile. The total bilirubin ranged from 50 to 340/~ml/L with a high conjugated fraction. One of the women had clay-colored stools. Management
Pseudocysts Laparotomy was performed in all of these patients. The pseudocysts were all fully matured and thick-walled, varying in size from 300 to 5,000 ml with a median of 2,000 ml, and contained fluid variously described as clear or opalescent, serous, xanthochromic, dirty dark brown, murky chocolate, or greenish. Two patients had bilocular cysts. The location of the pseudocyst was retrogastric in 18, retrojejunal in 4, in the tail of the pancreas in 2, and in the anterior abdominal compartment in 2. Therefore. a cystgastrostomy was performed in 18, a cystjejunostomy in 4, and resection of the tail of the pancreas in 2. In
46
World J. Surg. Vol. 14, No. 1, Jan./Feb. 1990
Table 1. Age and sex distribution.
Age (yr)
Male
Female
Total
0-9 10-19 20-29 30-39 40--49 50+ Total
7 1 6 3 3 2 22
5 2 0 5 3 1 16
12 3 6 8 6 3 38
Table 2. Complications of the disease.
Pancreatic pseudocyst Abdominal pain Obstructive jaundice Total
Male
Female
Total
16 5 1 22
10 4 2 16
26 9 3 38
the 2 patients with pseudocysts in the anterior abdominal compartment, the diagnosis was not made preoperatively. In each, the cyst wall was adherent to the anterior abdominal wall and was inadvertently opened during celiotomy. For this reason, the cyst walls were biopsied and rubber catheters were placed through these openings for external drainage. In the 3-year-old girl, the fistula drained for 8 months and required surgical closure. In the 34-year-old, a sinogram obtained postoperatively showed filling of the choledochus, but this healed spontaneously within a month.
Pain Laparotomy was performed for pain in only 1 of the children. The body and tail of the pancreas were indurated and the pancreatic duct, which was dilated and stenosed in parts, contained many small calculi which were removed. A Rouxen-Y longitudinal pancreaticojejunostomy was performed [6]. The second child, who was advised to have a laparotomy, absconded. The 3 others were managed medically by the pediatricians [7]. Exploratory laparotomy was performed in the 4 adults. In each, the pancreas was hard and nodular, especially in the head. A posterior duodenal ulcer was present in 1 of the women and vagotomy with pyloroplasty was performed after pancreatic biopsy. Pancreatic biopsies were obtained in each patient.
Obstructive Jaundice One of the women had complete obstruction of the distal choledochus by hard nodular panpancreatitis; choledochoduodenostomy was performed. The second woman had inflammatory changes in the head of the pancreas only, with a dilated gallbladder containing a few stones. The gallstones were removed and a cholecystoduodenostomy was performed. In the third patient, hard granular panpancreatitis was found with dilation of the gallbladder. Cholecystojejunostomy with jejunojejunostomy was performed. The patient remained deeply jaundiced 1 month postoperatively. Therefore, at a second operation, splenectomy with distal pancreatectomy was performed
with a Roux-en-Y pancreatojejunostomy. Operative pancreatography showed ductal dilations and stenoses.
Pathology Pseudocysts. Specimens from 18 pseudocysts were examined histologically. The wall showed a variable mixture of vascular granulation tissue with or without hemorrhage, nonspecific fibrosis infiltrated by chronic inflammatory cells, and collagenization. In some specimens, nodules of pancreatic parenchyma were embedded in the fibrous tissue and there was an instance of fibrosis with metaplastic bone formation. Pain. Three biopsy specimens showed pancreatic fibrosis and infiltration by chronic inflammatory cells. Jaundice. The 3 specimens showed pancreatic fibrosis with mononuclear cell infiltration. The resected pancreatic tail also showed a number of small cysts. Outcome
In general, follow-up has been most unsatisfactory in our patients, largely because they came from large distances, at great expense, and are unwilling to come again without a compelling need. Nine of the patients with pseudocysts were seen in follow-up from 1 month to 4 years. Most of the others defaulted after discharge from hospitals. Two of those operated on for pain were seen up to 3 y e a r s - - t h e child with juvenile tropical pancreatitis syndrome and a woman who subsequently required hysterectomy for symptomatic fibroids. One of the jaundiced women presented 8 years later with no abdominal symptoms, but complained of varicose veins of the legs. Two patients died: 1. A 35-year-old woman had laparotomy for recurrent pancreatic pseudocyst initially managed at a district hospital. A bilocular cyst was present which required a third laparotomy. Postoperatively, she developed deep venous thrombosis in the left leg and septicemia from which she died 1 month later. Culture of the pseudocyst fluid yielded E. coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Bacteroides, and anaerobic streptococcus. 2. A 37-year-old man with chronic abdominal pain for 19 years had laparotomy and biopsy of the fibrotic pancreas. Subsequently, he developed intractable pancreatic ascites of which he died 2 months later. Discussion
There are few reports on surgery for complications of chronic pancreatitis in Africans. Chronic pseudocysts have been reported in a few children and adults [8-11]. In the Western World, a high percentage of pseudocysts in adults is the result of alcoholic pancreatitis while 60% of pediatric cases are due to blunt abdominal trauma and the others are of obscure etiology [12]. In this series, only 8 (31%) of the 26 patients with pseudocysts gave a definite history of trauma or alcoholism, but the cause in the majority remains obscure. All of our patients
O.A. Mabogunje and J.H. Lawrie: Chronic Pancreatitis in Nigeria presented with chronic pseudocysts defined as established pseudocysts unrelated to an episode of acute pancreatitis and whose origin is, therefore, difficult to date [13]. The walls were all mature and suitable for anastomosis. In its complete form, juvenile tropical pancreatitis syndrome is characterized by exocrine and endocrine pancreatic failure, pancreatic calcification, and abdominal pain, but some of these features may be absent [3, 5]. Most patients are younger than 25 years of age and belong to the lower social classes but are not addicted to alcohol. This syndrome is to be distinguished from chronic alcoholic pancreatitis of the Western World which may also be associated with pancreatic calcification. It is not known whether pseudocysts may also develop in juvenile tropical pancreatitis syndrome. Thus, it is impossible to determine how many of the patients with pancreatic pseudocysts of obscure origin had juvenile tropical pancreatitis syndrome. Elsewhere, the use of abdominal ultrasound and computed tomography scan has revolutionized the management of chronic pancreatic diseases [14, 15]. The presence of pseudocyst is readily confirmed, the wall thickness measured, and the effectiveness of surgical drainage assessed postoperatively. Ductal dilatations in chronic pancreatitis can also be assessed. In the absence of such facilities in Zaria, we have relied on clinical methods supplemented by plain abdominal radiographs, barium meal, and the intravenous urogram which provide indirect evidence for the presence of a pseudocyst. Laparotomy is usually required to confirm the diagnosis and treat the condition. F o r the pseudocyst, internal drainage is preferred to external drainage; however, the anterior abdominal pseudocysts in 2 of our patients were inadvertently opened during celiotomy and the option of internal drainage forfeited. In the child, a chronic fistula required surgical closure after 8 months. Postdrainage pseudocysts may be complicated by infection and hemorrhage [14, 15]. In the woman who died in this series, several gram-negative bacilli were cultured from the cystic fluid when she developed septicemia which led to her demise. The second patient who died illustrates the hazard of pancreatic biopsy. Regrettably, he was managed in his district hospital for intractable ascites and was moribund when finally referred back to Zaria. One of the women with obstructive jaundice had stones in her gallbladder. Both her pain and jaundice were relieved by stone removal and cholecystojejunostomy. It was not determined whether she had a stone impacted at the sphincter of Oddi. R6sum6
Quinze adolescents et 23 adultes avec des complications de pancrdatite chronique ont dt6 traitds ~ Zaria, Nigeria. Vingt-six avaient un pseudokyste, 9 se plaignaient de douleurs abdominales chroniques, et 3 d'ict~re obstructif. Un drainage interne a 6td effectud pour 22/26 (85%) des pseudokystes, une rdsection
47 dans 2 cas et un drainage externe dans 2 cas. Une anastomose pancrdaticojdjunale a 6td rdalisd chez un enfant ayant un syndrome de pancrdatite tropicale juvdnile. Une ddrivation biliaire a 6td effectude en cas d'ict~re. La cause de la pancr6atite chronique dtait connue chez 8 (31%) seulement des patients. Resumen
Quince nifios y 23 adultos con complicaciones de pancreatitis cr6nica fueron tratados en Zaria, Nigeria, durante el periodo 1971-1987. E1 grupo incluy6 26 pacientes con pseudoquiestes cr6nicos, 9 con dolor abdominal cr6nico, y 3 con icetericia obstructiva. Se realiz6 drenaje interno en 22 (85%) de los pseudoquistes, resecci6n en 2 y drenaje externo en 2. Se realiz6 una pancreaticoyeyunostomfa longitudinal en un nifio con el sindrome de pancreatitis juvenil tropical, y derivaci6n biliar en los pacientes ictdricos. La causa de la pancreatitis cr6nica pudo ser establecida s61o en 8 (31%) de los pacientes. Acknowledgment
We thank Drs. A.M. Yakubu and J.T. Momoh, whose patients are included in this series, and Mr. R.S. Olayanju for typing the manuscript. References
1. Sarner, M., Cotton, P.B.: Classification ofpancreatitis. Gut 25:756, 1984 2. Sarles, H., Cros, R.C., Bidant, J.M., International Group for the Study of Pancreatic Disease (Marseille): A multicenter inquiry into the etiology of pancreatic diseases. Digestion 19:110, 1979 3. Nwokolo, C., Oli, J.: Pathogenesis of juvenile tropical pancreatitis syndrome. Lancet 1:456, 1980 4. Binton, M.H., Pellegrini, C.A., Stein, S.F., Way, L.W.: Surgical treatment of chronic pancreatitis. Am. J. Surg. 148:754, 1984 5. Nwokolo, C.: The clinical features of juvenile tropical pancreatitis syndrome. Postgrad. Doctor Afr. 4:334, 1982 6. Yakubu, A.M., Garg, S.K., Umar, B.A., Quartey, G.E.K., Osuide, J.A.: Juvenile tropical pancreatitis syndrome in Northern Nigeria: A case report. Ann. Trop. Paediatr. 4:79, 1984 7. Yakubu, A.M.: Pancreatitis in childhood: A review of six cases in Zaria. Niger. J. Paediatr. (in press) 8. Olurin, E.O.: Pancreatic cysts: A report of 10 cases. Br. J. Surg. 58:502, 1971 9. Carswell, LW., Cotter, J., Master, S.P.: Pancreatic pseudocysts in children: Four cases from Uganda. Br. J. Surg. 62:360, 1975 10. Ajao, O.G.: Pancreatic pseudocyst. Trop. Doctor 12:129, 1982 11. Mabogunje, O.A.: Pseudocyst of the pancreas in children: An African series. Ann. Trop. Paediatr. (in press) 12. Cooney, D.R., Grosfeld, J.L.: Operative management of pancreatic pseudocysts in infants and children: A review of 75 cases. Ann. Surg. 182:590, 1975 13. Crass, R.A., Way, L.W.: Acute and chronic pancreatic pseudocysts are different. Am. J. Surg. 142:660, 1981 14. Belinkie, S.A., Russell, J.C., Deutsch, J., Becker, D.R.: Pancreatic pseudocyst. Am. Surg. 49:586, 1983 15. Kane, M.G., Krejs, G.J.: Pancreatic pseudocyst. Adv. Intern. Med. 29:271, 1984
