Introduction
Michael G. Sarr
The last two decades have witnessed the escalating evolution of surgical
thought/approach toward pancreatic diseases. New operations, new approaches, new techniques, and maybe even new philosophies of the operative management of pan- creatic disease have been embraced based on a better understanding of etiopathogenesis of pancreatic diseases (e.g., necrotizing pancreatitis), introduction of new technology (laparoscopy, minimal access approaches, interventional radiology/endoscopy), and the vast advances in both diagnosis (computed tomography, endoscopic ultrasonography, magnetic resonance imaging, positron emission tomography) and critical care medi- cine. Indeed, even a new disease has been described (intraductal papillary mucinous neoplasm); though it had always been there, we just never recognized it! With these advances, experience with certain operations has increased markedly (e.g., pancreatico- duodenectomy) as operative morbidity and mortality have decreased, convincing our internal medicine/gastroenterologic colleagues that aggressive resectional approaches to the pancreas (in experienced centers) are associated with operative mortalities of <5%
and are no longer complicated by the mortality rates of 20–25% of the 1960s and 1970s.
New operations have appeared:
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Chronic pancreatitis
– Duodenum-preserving head resection (Beger/Frey procedures) – Thoracoscopic splanchnicectomy
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Necrotizing pancreatitis
– Aggressive necrosectomy with several different techniques of peripancreatic drainage
– Minimal access necrosectomy (not just drainage)
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Recurrent pancreatitis
– Sphincterotomy/septectomy
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Pancreas transplantation
– Islet cell, segmental, whole organ
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New technology
– Laparoscopic approaches to enucleation of pancreatic islet cell neoplasms, distal pancreatectomy, internal (enteric) drainage of pseudocyst, gastro- jejunostomy, even necrosectomy for necrotizing pancreatitis
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