Preface Considerable progress has been made in recent years in the relatively new field of pancreatic surgery. In a previous review, the authors were struck by the divergence of opinion relative to surgical diseases of the pancreas. Many different operative procedures had been tried and advocated with varying results in the management of various pancreatic lesions. This method of trial and error is, of course, necessary for advancement in any field. Since any individual's experience with pancreatic surgery is limited, it is difficult to assess the numerous therapeutic measures being advocated on the basis of personal experience. There is need, therefore, for a summary of our present knowledge referable to surgery of the pancreas and a place for a large clinical experience. There is opportunity in a private clinic to acquire this experience, since the management of patients with such disorders can be made the responsibility of a few members of the Staff during the developmental stages, and methods of therapy may be evaluated, following which they may be generally applied if they have proved valid. This book is based on experiences with over 1000 patients with surgical diseases of the pancreas treated at the Lahey Clinic. No detailed analysis of all cases is attempted since it was felt it would complicate the problem to present them from a statistical point of view. Rather, a selective review of case groups is utilized, particularly emphasizing problems with conflicting viewpoints. Specific problems, although presented in historical perspective, are analyzed in terms of our personal experience with a series of such cases treated by different operative methods, and important features of these methods are documented by illustrative case reports. Thus, the individual surgeon may refer to a particular case in point and discern at least one satisfactory method of answering his problem. There has been in recent years a conspicuous evolution in the treatment of pancreatic disease, so that even today one's idea of the proper therapy of a particular lesion may soon change. For that reason, the subject is presented as a monograph, with particular emphasis on the clinical aspects—including diagnosis, surgical treatment, and the results of such treatment. No attempt has been made to cover all phases of the subject. The safety of the operative procedures advocated in many of these complicated conditions has been held paramount, as is reflected by the low operative mortality in all benign conditions. Frequent reference has been made to the surgical literature, sometimes with editorial comment, and important contributions of others have been duly recognized. The discussion of the various pancreatic lesions represents our current concepts, and some of these concepts must be considered tentative. For this reason, experiences are summarized but no final conclusions are drawn. Further testing of the proposed procedures here and elsewhere will be necessary to permit established conclusions. The ever-changing concepts in surgical therapy are well illustrated by the discussions on carcinoma of the pancreas, and the more radical attacks on pancreatic cysts and chronic relapsing pancreatitis. The clinical management of these patients with surgical diseases of the pancreas has been carried out by the various members of the general surgical department of the Lahey Clinic and it is a pleasure to acknowledge also the essential help provided by other departments, particularly that of Gastro-enterology, Medicine, Neurosurgery and Anesthesia. This work has had the constant support and encouragement of our Chief, Dr. Frank H. Lahey, to whom we are indebted for the opportunity of pursuing this interest and presenting it. All surgeons interested in surgery of the pancreas have had the stimulus of the important contributions of Dr. Allen O. Whipple, and we are appreciative of this opportunity to acknowledge his influence on the development of this field of surgery. Acknowledgment for the use of drawings and other material from the literature accompanies the plates or is contained in the bibliography. It is a pleasure to acknowledge the indispensable help of Miss Charlotte R. Thompson of the Editorial Department in the preparation and revision of the manuscript. We are indebted to Mr. P. D. Malone for the excellent drawings and to Mr. George L. Buchanan for the photographs. If this book proves of value to the surgeon who is interested, or wishes to become interested, in the problems of pancreatic surgery, the authors will feel that the effort has been worth while. RICHARD B. CATTELL, M.D. KENNETH W. WARREN, M.D. May, 1953

Richard B. Cattell Kenneth W. Warren

Surgery of the pancreas