Correspondence
Bleeding pseudocysts and pseudoaneurysms in chronic pancreatitis Sir We read with interest the article by Hamel et al. ( B r J Surg 1991; 78: 1059-63). This provided an excellent review of an interesting and serious complication of chronic pancreatitis. However, no mention was made of erosion of the aorta by a pseudocyst, a complication of pseudocyst formation we have recently experienced. We believe that in such a case a policy of pancreatic resection, as suggested by the authors, would not be advisable. A 66-year-old woman with a history of chronic pancreatitis and a pancreatic pseudocyst in the head of the pancreas causing jaundice (in whom there was no coagulopathy ) underwent cystgastrostomy. On the seventh day after operation she had two substantial haematemeses. Gastroscopy was attempted but the stomach was full of blood. In view of continued bleeding, the abdomen was reopened. No bleeding point could be found in the stomach but the cyst was distended with clotted blood. The clot was removed to reveal torrential bleeding from the side wall of the aorta. This was controlled by oversewing with interrupted silk sutures. She made an uneventful recovery and was eventually discharged home on the 18th day after operation. Although the aorta is an immediate anatomical relation of a pseudocyst, it is surprising that there have been few reports of erosion of this vessel. We feel that this source should be considered when dealing with a case of upper gastrointestinal haemorrhage in a patient with chronic pancreatitis. While it is suggested that primary pancreatic resection be undertaken in these patients, this would obviously have been inappropriate in this case where the operation had to be swift and unrefined.
N. A. Burgess M. W. %riven M. H. Lewis East Glamorgan General Hospital Church Village Mid Glamorgan UK
pancreaticojejunostomy and choledochojejunostomy. A pyloruspreserving Whipple operation was performed in 20 patients. An abdominal abscess was noted after operation in three patients, but this could be treated without operative drainage. A drain was placed in the abscess by ultrasonically guided puncture in one case. In none of the 22 patients was there a need for relaparotomy to drain an intra-abdominal abscess. Reoperation was performed in one patient because of wound dehiscence. No patient died in the postoperative admission period. Patients were discharged from hospital at a mean of 18.5 (range 8-55) days. In conclusion, postoperative drainage after Whipple's procedure may be omitted without undue complications.
J. Jeekel Department of Surgery University Hospital Dgkzigi Dr. Molenwuterplein 40 3015 GD Rotterdam The Netherlands
Staphylococcal infection of hidradenitis excisions Sir Our wound clinic has previously described a series of 50 axillary skin excisions for suppurative hidradenitis ( B r J Surg 1987; 74: 95-7). Of these, 17 suffered staphylococcal infection attributed to friction by the Silastic" foam (Dow Corning, Reading, U K ) used as a dressing and held in place by adhesive tape. Many patients develop allergy to such tape. To avoid this problem we have in recent years included in the Mastic foam (as it is setting) a length of elastic net (Surgifix no. 3, 2 cm width). The free ends of the net are tied to the brassiere strap for women and taken round the neck for men. An unexpected benefit from this procedure has been the elimination of friction and staphylococcal infection. The elasticity of the net allows the dressing to accommodate to arm movement without undue pressure on the wound in contrast to the non-compliance of the adhesive tape previously used.
No abdominal drainage after Whipple's procedure Sir After Whipple's resection one o r two drains are usually left in the upper abdominal cavity. This practice is based on the concept that postoperative leakage of blood, bile and pancreatic secretion may occur and that the consequences of this leakage may be reduced by leaving a drain. Drains are placed in the area around the pancreaticojejunostomy and choledochojejunostomy, anticipating possible leakage from these anastomoses. Often the drain is left in situ for a few days as leakage may occur 4-7 days after operation. It is questionable whether this drainage procedure is effective. Anastomotic leakage is a well known problem after Whipple's procedure, but one that should affect less than 10 per cent of patients in experienced hands. If leakage occurs, a drain may not be useful as a diagnostic tool or therapeutic method and might even be hazardous as it creates a pathway for contamination. Often the drain is obstructed within a few days or separated from the anastomotic area by omentum or adhesions. From 1989 until September 1991 an intra-abdominal drain was omitted after Whipple's resection in 22 patients. In 14 patients operated on in the same period a drain was positioned after Whipple's resection because of diffuse bleeding or because a different surgeon performed the operation, but these cases are not considered further. Resection of the pancreas was performed for carcinoma of the head of the pancreas ( n = 12), periampullary cancer ( n = 5), villous adenoma of the duodenum or pancreatic duct ( n = 2 ) and chronic pancreatitis ( n = 3). The age of the patients varied from 43 to 79 years. In all cases a single layer anastomosis was performed for
182
The dressing sling shown before artachment
10
the hrassikre strap
J. Marks University of Wales College of Medicine Cardif CF4 4 X N UK
Gynaecomastia Sir I enjoyed reading the review by .nds and Greenall ( B r J Surg 1991; 78: 907-11) on gynaecomastia. However, on a global scale (and especially with the worldwide distribution of The British Journal of
Br. J. Surg.. Vol. 79, No. 2, February 1992
Bleeding pseudocysts and pseudoaneurysms in chronic pancreatitis Sir We read with interest the article by Hamel et al. ( B r J Surg 1991; 78: 1059-63). This provided an excellent review of an interesting and serious complication of chronic pancreatitis. However, no mention was made of erosion of the aorta by a pseudocyst, a complication of pseudocyst formation we have recently experienced. We believe that in such a case a policy of pancreatic resection, as suggested by the authors, would not be advisable. A 66-year-old woman with a history of chronic pancreatitis and a pancreatic pseudocyst in the head of the pancreas causing jaundice (in whom there was no coagulopathy ) underwent cystgastrostomy. On the seventh day after operation she had two substantial haematemeses. Gastroscopy was attempted but the stomach was full of blood. In view of continued bleeding, the abdomen was reopened. No bleeding point could be found in the stomach but the cyst was distended with clotted blood. The clot was removed to reveal torrential bleeding from the side wall of the aorta. This was controlled by oversewing with interrupted silk sutures. She made an uneventful recovery and was eventually discharged home on the 18th day after operation. Although the aorta is an immediate anatomical relation of a pseudocyst, it is surprising that there have been few reports of erosion of this vessel. We feel that this source should be considered when dealing with a case of upper gastrointestinal haemorrhage in a patient with chronic pancreatitis. While it is suggested that primary pancreatic resection be undertaken in these patients, this would obviously have been inappropriate in this case where the operation had to be swift and unrefined.
N. A. Burgess M. W. %riven M. H. Lewis East Glamorgan General Hospital Church Village Mid Glamorgan UK
pancreaticojejunostomy and choledochojejunostomy. A pyloruspreserving Whipple operation was performed in 20 patients. An abdominal abscess was noted after operation in three patients, but this could be treated without operative drainage. A drain was placed in the abscess by ultrasonically guided puncture in one case. In none of the 22 patients was there a need for relaparotomy to drain an intra-abdominal abscess. Reoperation was performed in one patient because of wound dehiscence. No patient died in the postoperative admission period. Patients were discharged from hospital at a mean of 18.5 (range 8-55) days. In conclusion, postoperative drainage after Whipple's procedure may be omitted without undue complications.
J. Jeekel Department of Surgery University Hospital Dgkzigi Dr. Molenwuterplein 40 3015 GD Rotterdam The Netherlands
Staphylococcal infection of hidradenitis excisions Sir Our wound clinic has previously described a series of 50 axillary skin excisions for suppurative hidradenitis ( B r J Surg 1987; 74: 95-7). Of these, 17 suffered staphylococcal infection attributed to friction by the Silastic" foam (Dow Corning, Reading, U K ) used as a dressing and held in place by adhesive tape. Many patients develop allergy to such tape. To avoid this problem we have in recent years included in the Mastic foam (as it is setting) a length of elastic net (Surgifix no. 3, 2 cm width). The free ends of the net are tied to the brassiere strap for women and taken round the neck for men. An unexpected benefit from this procedure has been the elimination of friction and staphylococcal infection. The elasticity of the net allows the dressing to accommodate to arm movement without undue pressure on the wound in contrast to the non-compliance of the adhesive tape previously used.
No abdominal drainage after Whipple's procedure Sir After Whipple's resection one o r two drains are usually left in the upper abdominal cavity. This practice is based on the concept that postoperative leakage of blood, bile and pancreatic secretion may occur and that the consequences of this leakage may be reduced by leaving a drain. Drains are placed in the area around the pancreaticojejunostomy and choledochojejunostomy, anticipating possible leakage from these anastomoses. Often the drain is left in situ for a few days as leakage may occur 4-7 days after operation. It is questionable whether this drainage procedure is effective. Anastomotic leakage is a well known problem after Whipple's procedure, but one that should affect less than 10 per cent of patients in experienced hands. If leakage occurs, a drain may not be useful as a diagnostic tool or therapeutic method and might even be hazardous as it creates a pathway for contamination. Often the drain is obstructed within a few days or separated from the anastomotic area by omentum or adhesions. From 1989 until September 1991 an intra-abdominal drain was omitted after Whipple's resection in 22 patients. In 14 patients operated on in the same period a drain was positioned after Whipple's resection because of diffuse bleeding or because a different surgeon performed the operation, but these cases are not considered further. Resection of the pancreas was performed for carcinoma of the head of the pancreas ( n = 12), periampullary cancer ( n = 5), villous adenoma of the duodenum or pancreatic duct ( n = 2 ) and chronic pancreatitis ( n = 3). The age of the patients varied from 43 to 79 years. In all cases a single layer anastomosis was performed for
182
The dressing sling shown before artachment
10
the hrassikre strap
J. Marks University of Wales College of Medicine Cardif CF4 4 X N UK
Gynaecomastia Sir I enjoyed reading the review by .nds and Greenall ( B r J Surg 1991; 78: 907-11) on gynaecomastia. However, on a global scale (and especially with the worldwide distribution of The British Journal of
Br. J. Surg.. Vol. 79, No. 2, February 1992
