review of literature on clinical pancreatology - The Pancreapedia

performed. In 1880, Carl Thiersch <strong>of</strong> Leipzig, Germany, reported the first possible survivor <strong>of</strong>pancreatic surgery. A 38 year old male after initial operation for a presumed abdominal wallabscess by an unnamed physician, underwent delayed operative drainage <strong>of</strong> 3 liter <strong>of</strong> dark,chocolate-colored fluid. A persistent fistula with drainage <strong>of</strong> clear fluid followed thereafter.Thiersch’s probing and dilatation <strong>of</strong> the fistula demonstrated a tract heading toward theregion <strong>of</strong> the pancreatic tail.The first case <strong>of</strong> chemical diagnosis <strong>of</strong> pancreatic fistula in humans was published byDiedrich Kulenkampff <strong>of</strong> Bremen, Germany. He performed a trocar drainage <strong>of</strong> a presumedecchinococcal cysta <strong>of</strong> the liver in 1881. The resultant persistent fistula caused maceration <strong>of</strong>the skin. Chemical analysis revealed alkaline character with an albumin precipitate onheating. The fluid was able to breakdown starch, protein and fat and in the absence <strong>of</strong> thebile led to the relatively confident diagnosis <strong>of</strong> pancreatic juice.Pancreatic cystsThe resection <strong>of</strong> pancreatic cysts was apparently not considered feasible until Karl vonRokitansky, a gynecologic surgeon in Vienna, attempted a cystectomy in 1881. Duringpartival resection <strong>of</strong> a pancreatic cyst in the lesser sac there was intraoperative disruption <strong>of</strong>transverse colon, spillage <strong>of</strong> fluid into the peritoneal cavity and major hemorrhage. The cystawas eventually removed, but the patient died <strong>of</strong> sepsis ten days later. The autopsy showedthat the cyst originated from the head <strong>of</strong> pancreas.On December 2, 1881, Nathan Bozeman operated on a 41 year old femal admitted toWomen’s Hospital in New York with the presumed diagnosis <strong>of</strong> a large ovarian cyst. Fiveliters <strong>of</strong> light brownish fluid was drained intraoperatively from the cyst. The cyst was found tobe mobile within the abdominal cavity with a pedicle connecting to the tail <strong>of</strong> pancreas. Thepedicle was ligated and the cyst excised. Postoperative pain was controlled with rectaladministration <strong>of</strong> tinctures <strong>of</strong> quinine, beer-juice, opium and brandy. The early postoperativecourse was unremarkable but the long term outcome after discharge is unknown.The world’s first planned pancreatic surgery was performed by Karl Gussenbauer <strong>of</strong> Pragueon December 22, 1882. The patient was a 40 year old male who developed epigastric painand a large palpable mass after extensive consumption <strong>of</strong> alcohol. Air inflation <strong>of</strong> thestomach and colon showed that the tumor was located behind both organs. This observationled Gussenbauer to the assumption that the tumor was likely caused by a pancreatic cysta.Due to the detoriorating condition <strong>of</strong> the patient, Gussenbauer performed marsupialization <strong>of</strong>the cyst wall to the abdominal wall with placement <strong>of</strong> a large drain and packning into thecavity. The pancreatic healed gradually and the patient remained well for at least 8 yearsafter surgery. During his career, Gussenbauer operated on at least three smilar patients withpancreatic cysts.After Gussenbauer’s publication, the number <strong>of</strong> operations for pancreatic cysts increasedrapidly. Kuster was able to collect 13 published cases reported within 5 years afterGussenbauer’s initial presentation. By 1900, there were 149 reported cases which includenot only pseudocysts, but also retention and proliferative cysts. At that time mortality for cystexcision was close to 19 percent and for external marsupialization was 3 percent.Procedures such as cystoduodenostomy by Louis Ombredanne in 1911, cystogastrostomyby Rudolf Jedlicka 1921, cystjejunostomy by Adolf Henle in 1923 (but first reported by OttoHahn in 1927) introduced new standards in pancreatic surgery.First pancreatic resectionsThe first true pancreatic resection in humans was not performed until 1882. Prior to that, only