Founder's lecture. The vicissitudes of pancreatic surgery.

Using Senn's treatise as the benchmark from which to measure the advances of pancreatic surgery during the last century, it may be said that acceptable, if not totally successful, progress has been achieved in a number of areas. Injuries to the head of the pancreas, particularly those combined with duodenal trauma, continue to pose difficult operative and management problems. Persistent pancreatic and intestinal fistulas and infection substantially increase morbidity and prolong the hospital stay of some patients with injuries of the body and tail of the gland. Means to control or eliminate the effects of extravasated activated pancreatic juice are needed. Severe hemorrhagic gangrenous pancreatitis, with its excessive morbidity and mortality, offers numerous opportunities for improvement in management. The role of peritoneal lavage and of early resection have not been completely settled and require further carefully controlled evaluation. Why in one case of acute pancreatitis does the mild edematous variety develop and in the next the devastating gangrenous type? Although the majority of patients with chronic pancreatitis can be successfully treated, surgery often falls short of complete rehabilitation. Careful selection of patients and procedures as well as collaboration with colleagues in the psychologic and rehabilitative fields are essential to achieve optimal results. What are the important events within the pancreas that lead to the pathologic changes of chronic pancreatitis? Cancer of the pancreas remains one of the most discouraging problems of pancreatic surgery, and unfortunately, major surgical therapeutic break-throughs do not appear at hand. Earlier diagnosis or technical improvements may add a few percentage points to the survival rate, but our greatest hope for improvement may lie in adjunctive therapies that will help to control the basic biologic aggressiveness of this tumor. What accounts for the biologic aggressiveness of this tumor and how might this characteristic be modified? Of the endocrine tumors the best surgical results by far have been achieved with insulinomas. Diagnosis, localization, and excision are usually successful although occult and multiple tumors still pose a problem. Malignancy is rare (10 percent) in insulinomas, common in vipomas (35 percent), and frequent (66 percent) in gastrinomas and glucagonomas. Although the incidence of malignancy in the latter three tumors diminishes the efficacy of surgical excision, prolonged palliation and occasional cures are achieved. Operation is once again assuming an important role in the management of gastrinoma.(ABSTRACT TRUNCATED AT 400 WORDS)