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Milano RV, Morneault-Gill K, Kamal HY, Barkin JA, Chadwick CB. Pancreatitis in cystic fibrosis: Presentation, medical and surgical management, and the impact of modulator therapies. Pediatr Pulmonol 2024; 59 Suppl 1:S53-S60. [PMID: 38501345 DOI: 10.1002/ppul.26958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 01/19/2024] [Accepted: 03/01/2024] [Indexed: 03/20/2024]
Abstract
Patients with Cystic Fibrosis (CF) are at increased risk of acute (AP) and chronic (CP) pancreatitis, and their complications. The extent of remaining healthy pancreatic parenchyma determines the risk of developing future episodes of pancreatitis, as well as pancreatic exocrine or endocrine insufficiency. Pancreatitis may be the presenting symptom of CF, and genetic testing is especially important in pediatrics. AP and recurrent AP are managed with intravenous fluid hydration and pain control, in addition to early refeeding and treatment of complications. With the use of modulator therapy in CF, pancreatic function may be restored to some extent. CP related pain is managed with analgesics and neuromodulators, with surgery if indicated in specific situations including TPIAT as a possible type of surgical intervention. Long-term sequelae of CP in patients with CF include exocrine pancreatic insufficiency treated with pancreatic enzyme replacement therapy, fat-soluble vitamin deficiencies and associated metabolic complications such as bone disease/osteoporosis, pancreatogenic diabetes, and less commonly, pancreatic cancer. We review the presentation and etiologies of pancreatitis in CF patients as well as the management of AP and CP primarily in children.
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Affiliation(s)
- Reza V Milano
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Kayla Morneault-Gill
- Department of Pediatrics, Division of Gastroenterology, University of Florida, College of Medicine, Gainesville, Florida, USA
| | - Hebat Y Kamal
- Department of Pediatrics, Division of Gastroenterology, University of Florida, College of Medicine, Gainesville, Florida, USA
| | - Jodie A Barkin
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Christina Baldwin Chadwick
- Department of Pediatrics, Division of Gastroenterology, University of Florida, College of Medicine, Gainesville, Florida, USA
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Nathan JD, Ellery K, Balakrishnan K, Bhatt H, Ganoza A, Husain SZ, Kumar R, Morinville VD, Quiros JA, Schwarzenberg SJ, Sellers ZM, Uc A, Abu-El-Haija M. The Role of Surgical Management in Chronic Pancreatitis in Children: A Position Paper From the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Pancreas Committee. J Pediatr Gastroenterol Nutr 2022; 74:706-719. [PMID: 35258494 PMCID: PMC10286947 DOI: 10.1097/mpg.0000000000003439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Chronic pancreatitis (CP) is rare in childhood but impactful because of its high disease burden. There is limited literature regarding the management of CP in children, specifically about the various surgical approaches. Herein, we summarize the current pediatric and adult literature and provide recommendations for the surgical management of CP in children. METHODS The literature review was performed to include the scope of the problem, indications for operation, conventional surgical options as well as total pancreatectomy with islet autotransplantation, and outcomes following operations for CP. RESULTS Surgery is indicated for children with debilitating CP who have failed maximal medical and endoscopic interventions. Surgical management must be tailored to the patient's unique needs, considering the anatomy and morphology of their disease. A conventional surgical approach (eg, drainage operation, partial resection, combination drainage-resection) may be considered in the presence of significant and uniform pancreatic duct dilation or an inflammatory head mass. Total pancreatectomy with islet autotransplantation is the best surgical option in patients with small duct disease. The presence of genetic risk factors often portends a suboptimal outcome following a conventional operation. CONCLUSIONS The morphology of disease and the presence of genetic risk factors must be considered while determining the optimal surgical approach for children with CP. Surgical outcomes for CP are variable and depend on the type of intervention. A multidisciplinary team approach is needed to assure that the best possible operation is selected for each patient, their recovery is optimized, and their immediate and long-term postoperative needs are well-met.
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Affiliation(s)
- Jaimie D. Nathan
- Nationwide Children’s Hospital, Department of Abdominal Transplant and Hepatopancreatobiliary Surgery, The Ohio State University College of Medicine, Department of Surgery, Columbus, Ohio, United States
| | - Kate Ellery
- University of Pittsburgh Medical Center, Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh, Pennsylvania, United States
| | - Keshawadhana Balakrishnan
- Texas Children’s Hospital, Section of Pediatric Gastroenterology, Baylor College of Medicine, Department of Pediatrics, Houston, Texas, United States
| | - Heli Bhatt
- University of Minnesota, Masonic Children’s Hospital, Minneapolis, Minnesota, United States
| | - Armando Ganoza
- University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Hillman Center for Pediatric Transplantation, Pittsburgh, Pennsylvania, United States
| | - Sohail Z. Husain
- Lucile Packard Children’s Hospital at Stanford, Pediatric Gastroenterology, Hepatology and Nutrition and Department of Pediatrics, Stanford University, Palo Alto, California, United States
| | - Rakesh Kumar
- Promedica Russell J. Ebeid Children’s Hospital, Toledo, Ohio, United States
| | - Veronique D. Morinville
- McGill University Health Center, Montreal Children’s Hospital, Division of Pediatric Gastroenterology and Nutrition, Montreal, Quebec, Canada
| | - J. Antonio Quiros
- Icahn School of Medicine, Mount Sinai Kravis Children’s Hospital, New York, New York, United States
| | - Sarah J. Schwarzenberg
- University of Minnesota, Masonic Children’s Hospital, Minneapolis, Minnesota, United States
| | - Zachary M. Sellers
- Lucile Packard Children’s Hospital at Stanford, Pediatric Gastroenterology, Hepatology and Nutrition and Department of Pediatrics, Stanford University, Palo Alto, California, United States
| | - Aliye Uc
- University of Iowa, Carver College of Medicine, Stead Family Department of Pediatrics, Iowa City, Iowa, United States
| | - Maisam Abu-El-Haija
- Cincinnati Children’s Hospital Medical Center, Division of Gastroenterology, Hepatology and Nutrition, University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, United States
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Baykal A, Kaynaroglu V, Aran O, Onat D. A Case of Renal Artery Stenosis Secondary to Chronic Pancreatitis. Acta Chir Belg 2020. [DOI: 10.1080/00015458.1999.12098474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- A. Baykal
- Hacettepe University School of Medicine, Department of General Surgery, Ankara, Turkey
| | - V. Kaynaroglu
- Hacettepe University School of Medicine, Department of General Surgery, Ankara, Turkey
| | - O. Aran
- Hacettepe University School of Medicine, Department of General Surgery, Ankara, Turkey
| | - D. Onat
- Hacettepe University School of Medicine, Department of General Surgery, Ankara, Turkey
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Kokhanenko NY, Kashintsev AA, Bobylkov AA, Avanesyan RG, Shepichev EV, Ivanov AL, Solovyova LA, Shiryajev YN. Staged Interventional and Surgical Treatment of Patient with Chronic Pancreatitis Complicated by Pancreaticopleural Fistula with Lung Abscesses. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e922195. [PMID: 32307403 PMCID: PMC7193244 DOI: 10.12659/ajcr.922195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Patient: Male, 37-year-old Final Diagnosis: Chronic alcoholic pancreatitis • pancreaticopleural fistula • left lung abscesses Symptoms: Fever with a body temperature of 39.1°C • left thoracic pain • severe cough with purulent sputum • shortness of breath • upper abdominal pain Medication: — Clinical Procedure: Repeated thoracenteses • chest tube • drainage of lung abscesses • ultrasound-guided drainage of pancreatic pseudocyst • ultrasound-guided transparietal external-internal pancreatic duct stenting • Bern modification of Beger procedure Specialty: Surgery
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Affiliation(s)
- Nikolay Y Kokhanenko
- Department of Faculty Surgery named after Professor A.A. Rusanov, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russian Federation
| | - Alexey A Kashintsev
- Department of Faculty Surgery named after Professor A.A. Rusanov, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russian Federation.,Sixth Department of Surgery, Mariinsky Hospital, Saint Petersburg, Russian Federation
| | - Andrey A Bobylkov
- Department of Surgery, Nikolayevsky Hospital, Saint Petersburg, Russian Federation
| | - Ruben G Avanesyan
- Department of General Surgery with Course of Endoscopy, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russian Federation.,Fifth Department of Surgery, Mariinsky Hospital, Saint Petersburg, Russian Federation
| | - Evgeniy V Shepichev
- Department of Polytrauma Surgery, Mariinsky Hospital, Saint Petersburg, Russian Federation
| | - Artem L Ivanov
- Department of Faculty Surgery named after Professor A.A. Rusanov, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russian Federation.,Department of Surgery, Nikolayevsky Hospital, Saint Petersburg, Russian Federation
| | - Lyudmila A Solovyova
- Department of Faculty Surgery named after Professor A.A. Rusanov, Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russian Federation
| | - Yuri N Shiryajev
- Fourth Department of Surgery, Saint Petersburg City Hospital #15, Saint Petersburg, Russian Federation
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Abstract
Despite major advances in the management of patients with chronic pancreatitis, yet the disease remains an enigmatic process of uncertain pathogenesis, unpredictable clinical course, and unclear treatment. In most of the cases intractable pain is the main indication for surgical intervention. Furthermore complications related to adjacent organs, endoscopically not permanently controlled pancreatic pseudocysts, ductal pathology, conservatively intractable internal pancreatic fistula or suspected malignancy also require surgery. The ideal surgical approach should address all these problems — tailoring the various therapeutic options to meet the individual patient's needs. In our opinion, the ideal procedure for chronic pancreatitis is the duodenum preserving pancreatic head resection in terms of an extended drainage procedure, were the extent of the pancreatic head resection may be tailored to the morphology of the pancreatic gland, thus allowing a tailored concept (to resect and/or drain as much as necessary but as little as possible). Looking at the present data, there is no need to transsect the pancreatic axis above the portal vein. If portal vein thrombosis is present, an extended drainage procedure is mandatory without transsection of the neck of the pancreas.
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Affiliation(s)
- O Mann
- Department of General-, Visceral- Thoracic Surgery, University Medical Center Hospital Eppendorf, Hamburg, Germany.
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6
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Advances in surgical treatment of chronic pancreatitis. World J Surg Oncol 2015; 13:34. [PMID: 25845403 PMCID: PMC4326204 DOI: 10.1186/s12957-014-0430-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Accepted: 12/24/2014] [Indexed: 12/23/2022] Open
Abstract
The incidence of chronic pancreatitis (CP) is between 2 and 200 per 100,000 persons and shows an increasing trend year by year. India has the highest incidence of CP in the world at approximately 114 to 200 per 100,000 persons. The incidence of CP in China is approximately 13 per 100,000 persons. The aim of this review is to assist surgeons in managing patients with CP in surgical treatment. We conducted a PubMed search for “chronic pancreatitis” and “surgical treatment” and reviewed relevant articles. On the basis of our review of the literature, we found that CP cannot be completely cured. The purpose of surgical therapy for CP is to relieve symptoms, especially pain; to improve the patient’s quality of life; and to treat complications. Decompression (drainage), resection, neuroablation and decompression combined with resection are commonly used methods for the surgical treatment of CP. Before developing a surgical regimen, surgeons should comprehensively evaluate the patient’s clinical manifestations, auxiliary examination results and medical history to develop an individualized surgical treatment regimen.
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7
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Cauchy F, Regimbeau JM, Fuks D, Balladur P, Tiret E, Paye F. Influence of bile duct obstruction on the results of Frey's procedure for chronic pancreatitis. Pancreatology 2013; 14:21-6. [PMID: 24555975 DOI: 10.1016/j.pan.2013.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Revised: 10/19/2013] [Accepted: 10/21/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To evaluate the influence of a biliary obstruction (BO) requiring biliary bypass on both short and long-term outcomes of patients undergoing Frey's procedure for chronic pancreatitis (CP). METHODS From 1999 to 2010, 33 consecutive patients underwent Frey's procedure for CP in two centers. Seventeen (54%) patients underwent biliary bypass to treat an associated BO. Characteristics and outcomes of these patients were compared to those of 16 others without BO. RESULTS Patients with BO had more severe disease including lower BMI and larger pancreatic head (4 cm vs. 6 cm, p = 0.021). The operative mortality was nil. Patients with BO experienced more overall postoperative complications (71% vs. 31%, p = 0.024) but similar major complication rates (18% vs. 6%, p = 0.316) compared to those without BO. After a median follow-up of 51 (1-96) months, 91% of the patients experienced either partial or complete relief of their symptoms and 36% exhibited deterioration of their endocrine function. Multivariate analysis revealed preoperative BO to be associated with long-term impairment of endocrine function (OR: 43.249; 95% CI 2.221-84.277; p = 0.013). CONCLUSION In patients undergoing Frey's procedure for CP, associated BO can be safely managed using biliary bypass. However, the severity of CP in these patients is responsible for a higher risk of long-term endocrine insufficiency.
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Affiliation(s)
- F Cauchy
- Department of Digestive Surgery, Hôpital Saint Antoine, 184, rue du faubourg Saint Antoine, 75570 Paris Cedex 12, France
| | - J M Regimbeau
- Department of Digestive Surgery, CHU Amiens-Picardie, Place Victor Pauchet, 80054 Amiens Cedex, France
| | - D Fuks
- Department of Digestive Surgery, CHU Amiens-Picardie, Place Victor Pauchet, 80054 Amiens Cedex, France
| | - P Balladur
- Department of Digestive Surgery, Hôpital Saint Antoine, 184, rue du faubourg Saint Antoine, 75570 Paris Cedex 12, France
| | - E Tiret
- Department of Digestive Surgery, Hôpital Saint Antoine, 184, rue du faubourg Saint Antoine, 75570 Paris Cedex 12, France
| | - F Paye
- Department of Digestive Surgery, Hôpital Saint Antoine, 184, rue du faubourg Saint Antoine, 75570 Paris Cedex 12, France.
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Regimbeau JM, Fuks D, Bartoli E, Fumery M, Hanes A, Yzet T, Delcenserie R. A comparative study of surgery and endoscopy for the treatment of bile duct stricture in patients with chronic pancreatitis. Surg Endosc 2012; 26:2902-8. [PMID: 22580872 DOI: 10.1007/s00464-012-2283-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2011] [Accepted: 03/26/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND This study aimed to compare the outcomes of endoscopic treatment (ET) and surgical treatment (ST) for common bile duct (CBD) stricture in patients with chronic pancreatitis (CP). METHODS From 2004 to 2009, 39 patients (35 men and 4 women; median age, 52 years; range, 38-66 years) were referred for CBD stricture in CP. Of these 39 patients, 33 (85 %) underwent primary ET, and 6 underwent primary ST. Treatment success was defined in both groups as the absence of signs denoting recurrence, with normal serum bilirubin and alkaline phosphatase levels after permanent stent removal in ET group. The follow-up period was longer than 12 months for all the patients. RESULTS For the patients treated with ET, the mean number of biliary procedures was 3 (range, 1-10) per patient including extractible metallic stents in 35 % and multiple plastic stents in 65 % of the patients. The mean duration of stent intubation was 11 months. The surgical procedure associated with biliary drainage (4 choledochoduodenostomies, 1 choledochojejunostomy, and 1 biliary decompression within the pancreatic head) was a Frey procedure for five patients and a pancreaticojejunostomy for one patient. The overall morbidity rate was higher in the ST group. The total hospital length of stay was similar in the two groups (16 vs 24 days, respectively; p = 0.21). In terms of intention to treat, the success rates for ST and ET did not differ significantly (83 % vs 76 %; p = 0.08). Due to failure, 17 patients required ST after ET. Event-free survival was significantly longer in the ST group (16.9 vs 5.8 months; p = 0.01). The actuarial success rates were 74 % at 6 months, 74 % at 12 months, and 65 % at 24 months in the ST group and respectively 75 %, 69 %, and 12 % in the ET group (p = 0.01). After more than three endoscopic procedures, the success rates were 27 % at 6 months and 18 % at 18 months. CONCLUSION For bile duct stricture in CP, surgery is associated with better long-term outcomes than endoscopic therapy. After more than three endoscopic procedures, the success rate is low.
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Affiliation(s)
- Jean-Marc Regimbeau
- Department of Digestive Surgery, Amiens University Hospital and Jules Verne University of Picardy, Place Victor Pauchet, 80054, Amiens Cedex 01, France.
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9
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Perwaiz A, Singh A, Chaudhary A. Surgery for chronic pancreatitis. Indian J Surg 2011; 74:47-54. [PMID: 23372307 DOI: 10.1007/s12262-011-0374-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 11/10/2011] [Indexed: 12/27/2022] Open
Abstract
Chronic pancreatitis (CP) is progressive inflammatory process of the pancreas. Abdominal pain remains the most debilitating symptom affecting quality of life, apart from diabetes mellitus, steatorrhoea and weight loss. The treatment options have evolved over the past decades and are aimed to provide durable relief in pain with possible attempt to support or improve the failing endocrine and exocrine functions. Surgical treatment options have shown the potentials to provide superior long term results compared to the pharmacological and endoscopic modalities and are broadly divided in to drainage, resection and combination hybrid procedures. The choice is based on the morphology of the main pancreatic duct, presence of head mass and associated complication of CP. Knowing the basic nature of the disease, total pancreatectomy seems a curative option but not without significant morbidities. There is recent paradigm shift towards organ sparing surgical procedures with reasonable success. Despite recent advancement in the treatment modalities for CP the overall quality of life remains moderate which need further addressal.
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Affiliation(s)
- Azhar Perwaiz
- Department of GI Surgery, GI Oncology and Bariatric Surgery, Room No-10, 11th floor, OPD block, Medanta, The Medicity, Sector-38, 12001 Gurgaon, Haryana India
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10
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Chronic pancreatitis: modern surgical management. Langenbecks Arch Surg 2010; 396:139-49. [PMID: 21174215 DOI: 10.1007/s00423-010-0732-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Accepted: 12/01/2010] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Chronic pancreatitis (CP) is a disease with enormous social and personal impact. It is most commonly caused by the abuse of alcohol combined with nicotine. CP is usually characterised by an inflammatory mass located in the pancreatic head. Its natural course is characterised by persistent or recurrent painful attacks as well as progressive loss of pancreatic function due to fibrosis of the parenchyma with consecutive endocrine and exocrine insufficiency. CONCLUSIONS The only success parameter of any treatment is the effective long-lasting pain relief and improvement in the quality of life. The surgical armamentarium includes simple drainage procedures, resections of different extents or a combination of both. Duodenum-preserving resection of the pancreas offers the best short-term outcome according to trials conducted so far. It has the benefit of combining the highest safety with the highest efficiency. Additionally, the extent of the operation can be adapted to the morphology of the individual patient.
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11
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Surgical treatment in chronic pancreatitis timing and type of procedure. Best Pract Res Clin Gastroenterol 2010; 24:299-310. [PMID: 20510830 DOI: 10.1016/j.bpg.2010.03.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Revised: 03/01/2010] [Accepted: 03/07/2010] [Indexed: 01/31/2023]
Abstract
Pain relief and improvement in the quality of life are of paramount importance for any intervention in chronic pancreatitis. In several trial good results have been published after different drainage procedures and resections. An optimal surgical intervention should manage mainly the intractable pain, resolve the complications of the adjacent organs and achieve the drainage of the main pancreatic duct. An optimal procedure should guarantee a low relapse rate, preserve a maximum of endocrine and exocrine function, and most importantly, restore quality of life. Thus an ideal operation should representing a one-stop-shopping. According to the trials conducted so far, Duodenum-preserving resection of the pancreatic head offers the best short-term outcome. It combines the highest safety of all surgical procedures with the highest efficacy. By varying the extent of the cephalic resection, it offers the possibility of customizing surgery according to the individual patient's morphology.
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12
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Cocieru A, Saldinger PF. Frey procedure for pancreaticopleural fistula. J Gastrointest Surg 2010; 14:929-30. [PMID: 19862581 DOI: 10.1007/s11605-009-1063-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2009] [Accepted: 09/29/2009] [Indexed: 01/31/2023]
Affiliation(s)
- Andrei Cocieru
- Department of Surgery, Danbury Hospital, 24 Hospital Avenue, Danbury, CT 06810, USA
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13
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Regimbeau JM. [Management of chronic pancreatitis: endoscopy or surgery?]. JOURNAL DE CHIRURGIE 2009; 146:115-128. [PMID: 19541313 DOI: 10.1016/j.jchir.2009.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The indications for interventional treatment (endoscopic or surgical) of chronic pancreatitis can be classified in several major groups of lesions or symptoms: pain, consequences of fibrosis on neighboring organs (biliary, duodenal or even colic stenosis, thrombosis of the splenic vein with segmental portal hypertension), consequences of duct rupture above the obstacle (persistent symptomatic pseudocyst, refractory pancreatic ascites), and suspected cancer. Finally, surgery is indicated for patients for whom endoscopic procedures are impossible (papillae inaccessible) or too close together. Recently, two new criteria have been suggested: the number of procedures necessary for achieving the objective set, and the duration of hospitalization.
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Affiliation(s)
- J-M Regimbeau
- Service de chirurgie viscérale et digestive, CHU d'Amiens Nord, université de Picardie Amiens Nord, place Victor-Pauchet, 80054 Amiens cedex 01, France.
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14
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Cataldegirmen G, Bogoevski D, Mann O, Kaifi JT, Izbicki JR, Yekebas EF. Late morbidity after duodenum-preserving pancreatic head resection with bile duct reinsertion into the resection cavity. Br J Surg 2008; 95:447-52. [PMID: 18161761 DOI: 10.1002/bjs.6006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Reinsertion of the distal common bile duct (CBD) into the pancreatic resection cavity during duodenum-preserving pancreatic head excision (DPPHE) may be an alternative option to Whipple resection or bilioenteric anastomosis when chronic pancreatitis is associated with CBD stenosis. METHODS Outcome in 82 patients with chronic pancreatitis who underwent DPPHE with CBD reinsertion was compared with that in 432 who had DPPHE without reinsertion and 50 who had a Whipple procedure or pylorus-preserving pancreatoduodenectomy (PPPD). RESULTS There were no deaths after DPPHE with CBD reinsertion, compared with four (0.9 per cent) after DPPHE without reinsertion and three (6 per cent) after classical resection. Overall morbidity rates were 30, 28.9 and 36 per cent respectively. Fifteen patients (18 per cent) who had DPPHE with CBD reinsertion developed a stricture at the reinsertion site, compared with a long-term stricture rate of 2.3 per cent (ten patients) after DPPHE without CBD reinsertion and 4 per cent (two patients) after PPPD/Whipple resection. CONCLUSION Although associated with a high incidence of anastomotic stricture, reinsertion of the CBD into the resection cavity as part of DPPHE can be used to preserve duodenal passage and offers an alternative to extended resection for chronic pancreatitis.
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Affiliation(s)
- G Cataldegirmen
- Department of General, Visceral and Thoracic Surgery, University Medical Centre Hamburg-Eppendorf, University of Hamburg, Martinistrasse 52, 20246 Hamburg, Germany
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Regimbeau JM, Dumont F, Yzet T, Chatelain D, Bartoli É, Brazier F, Bréhant O, Dupas JL, Mauvais F, Delcenserie R. Prise en charge chirurgicale de la pancréatite chronique. ACTA ACUST UNITED AC 2007; 31:672-85. [DOI: 10.1016/s0399-8320(07)91917-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Wani NA, Parray FQ, Wani MA. Is any surgical procedure ideal for chronic pancreatitis? Int J Surg 2006; 5:45-56. [PMID: 17386915 DOI: 10.1016/j.ijsu.2006.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2005] [Revised: 01/17/2006] [Accepted: 01/18/2006] [Indexed: 12/16/2022]
Abstract
Chronic pancreatitis continues to be a major therapeutic challenge for all pancreatic surgeons. This article is written with a purpose to review various surgical procedures developed from time to time for the relief of pain in these patients. Since no single procedure can be labeled as "ideal" because of the problems of the inability to address the whole pathology at the initial procedure, failure or recurrence of the pain; most of the pancreatic and practicing surgeons may benefit from knowledge of the various procedures being performed, even though the personal experience of the surgeon most of the time ultimately dictates the final choice of the procedure for the patient.
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Affiliation(s)
- Nazir A Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir 190011, India
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Strate T, Taherpour Z, Bloechle C, Mann O, Bruhn JP, Schneider C, Kuechler T, Yekebas E, Izbicki JR. Long-term follow-up of a randomized trial comparing the beger and frey procedures for patients suffering from chronic pancreatitis. Ann Surg 2005; 241:591-8. [PMID: 15798460 PMCID: PMC1357062 DOI: 10.1097/01.sla.0000157268.78543.03] [Citation(s) in RCA: 158] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To report on the long-term follow-up of a randomized clinical trial comparing pancreatic head resection according to Beger and limited pancreatic head excision combined with longitudinal pancreatico-jejunostomy according to Frey for surgical treatment of chronic pancreatitis. SUMMARY BACKGROUND DATA Resection and drainage are the 2 basic surgical principles in surgical treatment of chronic pancreatitis. They are combined to various degrees by the classic duodenum preserving pancreatic head resection (Beger) and limited pancreatic head excision combined with longitudinal pancreatico-jejunostomy (Frey). These procedures have been evaluated in a randomized controlled trial by our group. Long-term follow up has not been reported so far. METHODS Seventy-four patients suffering from chronic pancreatitis were initially allocated to DPHR (n = 38) or LE (n = 36). This postoperative follow-up included the following parameters: mortality, quality of life (QL), pain (validated pain score), and exocrine and endocrine function. RESULTS Median follow-up was 104 months (72-144). Seven patients were not available for follow-up (Beger = 4; Frey = 3). There was no significant difference in late mortality (31% [8/26] versus 32% [8/25]). No significant differences were found regarding QL (global QL 66.7 [0-100] versus 58.35 [0-100]), pain score (11.25 [0-75] versus 11.25 [0-99.75]), exocrine (88% versus 78%) or endocrine insufficiency (56% versus 60%). CONCLUSIONS After almost 9 years' long-term follow-up, there was no difference regarding mortality, quality of life, pain, or exocrine or endocrine insufficiency within the 2 groups. The decision which procedure to choose should be based on the surgeon's experience.
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Affiliation(s)
- Tim Strate
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany
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Cunha JEM, Penteado S, Jukemura J, Machado MCC, Bacchella T. Surgical and interventional treatment of chronic pancreatitis. Pancreatology 2004; 4:540-50. [PMID: 15486450 DOI: 10.1159/000081560] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The management of patients with chronic pancreatitis (CP) remains a challenging problem. Main indications for surgery are intractable pain, suspicion of malignancy, and involvement of adjacent organs. The main goal of surgical treatment is improvement of patient quality of life. The surgical treatment approach usually involves proximal pancreatic resection, but lateral pancreaticojejunal drainage may be used for large-duct disease. The newer duodenum-preserving head resections of Beger and Frey provide good pain control and preservation of pancreatic function. Thoracoscopic splanchnicectomy and the endoscopic approach await confirmatory trials to confirm their efficiency in the management of CP. Common bile duct obstruction is addressed by distal Roux-en-Y choledochojejunostomy but when combined with dudodenal obstruction must be treated by pancreatic head resection. Pancreatic ascites due to disrupted pancreatic duct should be treated by internal drainage. The approach to CP is multidisciplinary, tailoring the various therapeutic options to meet each individual patient's needs.
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Affiliation(s)
- J E M Cunha
- Department of Gastroenterology, Surgical Division, São Paulo University Medical School, São Paulo, Brazil.
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19
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Abstract
Biliary stricture and duodenal obstruction have been increasingly recognized as complications of chronic pancreatitis. The anatomical relationship of the distal common bile duct and the duodenum with the head of the pancreas is the main factor for their involvement in chronic pancreatitis. In hospitalized patients with pancreatitis, the incidence of biliary stricture and duodenal obstruction is reported to be about 6% and 1.2%, respectively. For patients requiring an operation for chronic pancreatitis the incidence increases to 35% for biliary stricture and 12% for duodenal obstruction. Fibrosis around the distal common bile duct can cause stenosis with obstruction of bile flow. Clinically, the presentation of these patients ranges from being asymptomatic with elevated alkaline phosphatase or bilirubin, or both, to being septic with cholangitis. Jaundice, cholangitis, hyperbilirubinemia, and persistent elevation of serum alkaline phosphatase occur more frequently in patients with pancreatitis with a biliary stricture. A twofold elevation of alkaline phosphatase is a marker of possible common duct stenosis in patients with chronic pancreatitis. The incidence of both biliary cirrhosis and cholangitis in these patients is about 10%. ERCP reveals a characteristic long, smoothly tapered stricture of the intrapancreatic common bile duct. In duodenal obstruction, the factors that convert self-limiting edema to chronic fibrosis and stricture formation are unknown, but ischemia superimposed on inflammation may be the major cause. These patients present with a prolonged history of nausea and vomiting. Barium studies typically show a long constricting lesion of the duodenum, and endoscopy reveals reactive inflammatory changes in a narrowed duodenum. Operation is indicated in patients with common bile duct strictures secondary to chronic pancreatitis when there is evidence of cholangitis, biliary cirrhosis, common duct stones, progression of stricture, elevation of alkaline phophatase and/or bilirubin for over a month, and an inability to rule out cancer. The operation of choice is either choledochoduodenostomy or choledochojejunostomy. A cholecystoenterostomy is less favored because of its higher failure rate (23%). Endoscopic stenting plays a role in patients who are unfit for surgery, but it is not recommended as definitive therapy. For duodenal obstruction, failure to resolve the obstruction with 1-2 weeks of conservative therapy is an indication for bypass. The operation of choice is a gastrojejunostomy. Not uncommonly, combined obstruction of the pancreatic duct, common bile duct, and duodenum will develop. Combined drainage procedures or resection are used to manage these problems.
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Affiliation(s)
- Joseph D Vijungco
- Department of General Surgery, Rush-Presbyterian-St. Luke's Medical Center, 1653 West Congress Parkway, Chicago, Illinois 60612, USA
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20
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Abstract
In the past decade, our understanding of the genetic basis, pathogenesis, and natural history of pancreatitis has grown strikingly. In severe acute pancreatitis, intensive medical support and non-surgical intervention for complications keeps patients alive; surgical drainage (necrosectomy) is reserved for patients with infected necrosis for whom supportive measures have failed. Enteral feeding has largely replaced the parenteral route; controversy remains with respect to use of prophylactic antibiotics. Although gene therapy for chronic pancreatitis is years away, our understanding of the roles of gene mutations in hereditary and sporadic pancreatitis offers tantalising clues about the disorder's pathogenesis. The division between acute and chronic pancreatitis has always been blurred: now, genetics of the disorder suggest a continuous range of disease rather than two separate entities. With recognition of pancreatic intraepithelial neoplasia, we see that chronic pancreatitis is a premalignant disorder in some patients. Magnetic resonance cholangiopancreatography and endoscopic ultrasound are destined to replace endoscopic retrograde cholangiopancreatography for many diagnostic indications in pancreatic disease.
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Affiliation(s)
- R M S Mitchell
- Division of Gastroenterology, Duke University Medical Center, Durham, NC 27710, USA
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21
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Knoefel WT, Eisenberger CF, Strate T, Izbicki JR. Optimizing surgical therapy for chronic pancreatitis. Pancreatology 2003; 2:379-84; discussion 385. [PMID: 12138226 DOI: 10.1159/000065085] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- W T Knoefel
- Department of Surgery, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
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22
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Strate T, Yekebas E, Knoefel WT, Bloechle C, Izbicki JR. Pathogenesis and the natural course of chronic pancreatitis. Eur J Gastroenterol Hepatol 2002; 14:929-34. [PMID: 12352211 DOI: 10.1097/00042737-200209000-00002] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This article gives an overview about current thinking in pathogenesis and natural course /therapy in chronic pancreatitis. Alcohol consumption is still the most relevant factor in the development of chronic pancreatitis, a disease with enormous personal and social impact, shortening life expectancy up to 10-20 yrs. Pathogenesis of chronic pancreatitis has to be considered for different symptoms. Particularly pain, the most bothering symptom, is most likely due to a combination of hypertension in the organ and parenchymal alterations. Pathogenesis of pancreatic head enlargement remains largely elusive. In particular it is not known what triggers growth factors to step into action. Most other symptoms like common bile duct stenosis or portal hypertension are secondary to this enlargement of the head of the pancreas.
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Affiliation(s)
- Tim Strate
- Department of General Surgery, University Hospital Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany
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23
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Izbicki JR, Bloechle C, Knoefel WT, Rogiers X, Kuechler T. Surgical treatment of chronic pancreatitis and quality of life after operation. Surg Clin North Am 1999; 79:913-44. [PMID: 10470335 DOI: 10.1016/s0039-6109(05)70051-7] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
In conclusion, surgical therapy in patients with chronic pancreatitis may be characterized as follows: 1. Independently, several investigators have found intraductal and intraparenchymatous hypertension in patients with chronic pancreatitis. Decompression of the ductal system as the main principle of surgical therapy achieves clinical pain relief in most patients with chronic pancreatitis. The precondition is a consequent drainage of the main pancreatic duct and tributary ducts of second and third order up to the prepapillary region. The presence of an inflammatory tumor in the head of the pancreas or ductal abnormalities in the prepapillary region or a pancreas divisum requires performance of an extended drainage operation (LPJ-LPHE) to achieve pain relief and an improved quality of life. An extended drainage operation effectively manages complications arising from adjacent organs, such as distal common bile duct stenosis, segmental duodenal stenosis, and internal pancreatic fistulas. The extent of decompression has to be tailored to the anatomic and morphologic situation of the patient. 2. In patients with chronic pancreatitis, the main pancreatic duct is usually dilated. A small duct (3-5 mm) is only small for the surgeon. For the sclerosing entity of chronic pancreatitis with a truly small duct, that is, less than 3 mm in diameter ("small duct disease"), a longitudinal V-shaped excision of the ventral pancreas, as opposed to left resection, provides a new perspective for a sufficient drainage. 3. In the presence of segmental portal hypertension, a simple or extended drainage operation does not result in a normalization of the portal venous blood flow; however, how often relevant upper gastrointestinal hemorrhage develops from segmental portal hypertension is unclear. Therefore, the clinical relevance of this special problem needs further evaluation. 4. Postoperative morbidity of LPJ-LPHE is significantly lower in comparison to resectional procedures, such as PD, PPPD, and DPRHP. A lower perioperative mortality rate is not justified anymore as a relevant criterion in favor of drainage procedures because resectional procedures are burdened by a minimal or no mortality in experienced centers; however, PD and PPPD are greatly hampered by a significantly decreased postoperative global quality of life as opposed to the LPJ-LPHE. This is reflected by a significantly lower rate of social and professional rehabilitation. 5. The incidence of exocrine and endocrine organ dysfunction is lower after LPJ-LPHE compared with PD or PPPD, but not compared with DPRHP. Preservation of the gastroduodenal passage and the continuity of the bile duct with its associated feedback mechanisms of exocrine pancreatic secretion and glucose metabolism seem to be responsible for this phenomenon. 6. An early surgical or endoscopic interventional drainage of the hypertensive pancreatic duct system possibly offers the chance to favorably manipulate the natural course of chronic pancreatitis with regard to a delayed onset of exocrine or endocrine insufficiency. 7. Late mortality reflects continued alcohol abuse rather than the effect of an operative procedure.
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Affiliation(s)
- J R Izbicki
- Department of General Surgery, University Hospital Eppendorf, University of Hamburg, Germany
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24
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Abstract
BACKGROUND Nutritional intake after pancreatectomy may be impaired. The extent of the problem and the effect on intake of specific nutrients is unknown. METHODS A 1-week weighed dietary food intake (using digital scales and a food diary) was studied in 15 patients, a median of 4 (range 1-30) months after pancreatectomy. Results were expressed as a percentage of estimated average requirement (EAR), reference nutrient intake (RNI) or lower RNI (LRNI) values. RESULTS The median energy intake was 1914 (range 1154-2804) kcal/day, representing a median of 88 (56-154) per cent of EAR. Fat intake was low (72 (60-123) g/day); protein intake was adequate (139 (99-219) per cent of RNI). Deficiencies were observed in the intake of vitamin D (17 (6-56) per cent of LRNI) and, in some patients, selenium (107 (19-203) per cent of LRNI). CONCLUSION Nutritional intake in the months after pancreatectomy could be improved by increasing fat intake (with enzyme supplements as appropriate). This 7-day study also suggests that these patients may require vitamin D and possibly selenium supplementation.
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Affiliation(s)
- C Maskell
- Department of Nutrition and Dietetics, Royal South Hants Hospital, Southampton, UK
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25
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Eddes EH, Masclee AM, Gooszen HG, Frölich M, Lamers CB. Effect of duodenum-preserving resection of the head of the pancreas on endocrine and exocrine pancreatic function in patients with chronic pancreatitis. Am J Surg 1997; 174:387-92. [PMID: 9337159 DOI: 10.1016/s0002-9610(97)00120-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Chronic pancreatitis leads to progressive destruction of pancreatic parenchyma affecting exocrine and endocrine function. We prospectively evaluated the effect of duodenum-preserving resection of the head of the pancreas on pancreatic function. METHODS Exocrine and endocrine function were measured in a combined test including (1) urinary PABA recovery; (2) plasma glucose, glucagon, and C-peptide responses; and (3) plasma pancreatic polypeptide response. Nineteen patients were included. RESULTS Compared with the preoperative state, plasma glucose levels did not increase postoperatively. Plasma C-peptide levels were reduced postoperatively but the difference was not significant. The percentage of insulin-dependent patients did not increase after operation (32% versus 32%). Glucose tolerance improved in 4 patients and deteriorated in 3 patients. Postoperative basal and-meal stimulated plasma pancreatic polypeptide levels were significantly reduced. Postoperative urinary PABA recovery was not significantly different from preoperative values. CONCLUSIONS Neither exocrine nor endocrine pancreatic function are negatively influenced by duodenum-preserving pancreatic head resection.
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Affiliation(s)
- E H Eddes
- Department of General Surgery, Leiden University Hospital, The Netherlands
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26
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Eddes EH, Masclee AM, Gielkens HA, Gooszen HG, Lamers CB. Gallbladder motility after duodenum-preserving resection of the head of the pancreas. Scand J Gastroenterol 1997; 32:878-83. [PMID: 9299664 DOI: 10.3109/00365529709011195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Duodenum-preserving resection of the head of the pancreas (DPRHP) is performed in patients with chronic pancreatitis (CP) localized in the head of the pancreas. It has been suggested that functional integrity of the upper digestive tract is preserved after DPRHP. We tested this hypothesis with regard to gallbladder motility. METHODS Gallbladder motility and cholecystokinin (CCK) secretion were studied fasting, after cephalic vagal stimulation with sham feeding, and after regular feeding in 9 patients after DPRHP, in 6 unoperated patients with CP, and 9 healthy control subjects. RESULTS Mean fasting gallbladder volume in patients after DPRHP (49 +/- 10 cm3) and patients with CP (53 +/- 10 cm3) was larger than in controls (33 +/- 3 cm3). Sham-feeding gallbladder contraction did not differ between patients after DPRHP, patients with CP, and controls. Both postprandial CCK secretion and gallbladder contraction in patients after DPRHP (78 +/- 16 pM. 120 min; 47% +/- 6%) and patients with CP (72 +/- 18 pM.120 min; 40% +/- 7%) were significantly reduced (P < 0.05) compared with controls (151 +/- 13 pM.120 min; 74% +/- 4%). Fasting gallbladder volume, sham feeding, and regular-feeding-induced gallbladder contraction and postprandial CCK secretion did not differ between operated and unoperated patients with CP. CONCLUSIONS Gallbladder motility and CCK secretion are reduced in patients with pancreatic insufficiency. A DPRHP procedure does not further influence these results. These findings support the concept that gallbladder motor function is preserved after DPRHP.
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Affiliation(s)
- E H Eddes
- Dept. of General Surgery, University Hospital, Utrecht, The Netherlands
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Izbicki JR, Bloechle C, Broering DC, Broelsch CE. Reinsertion of the distal common bile duct into the resection cavity during duodenum-preserving resection of the head of the pancreas for chronic pancreatitis. Br J Surg 1997; 84:791-2. [PMID: 9189088 DOI: 10.1046/j.1365-2168.1997.02661.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- J R Izbicki
- Department of Surgery, University Hospital Eppendorf, University of Hamburg, Germany
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Izbicki JR, Bloechle C, Broering DC, Broelsch CE. Reinsertion of the distal common bile duct into the resection cavity during duodenum-preserving resection of the head of the pancreas for chronic pancreatitis. Br J Surg 1997. [DOI: 10.1002/bjs.1800840615] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
A personal series is reported of 52 patients who underwent proximal pancreatoduodenectomy for severe chronic pancreatitis between 1979 and 1994. There were 13 women and 39 men of median age 42.2 (range 12-70) years. Disease predominantly affected the head of pancreas, with calcification present in 37 patients. Indications for operation were chronic pain (47 patients), obstructive jaundice (19) and duodenal stenosis (six); cancer was suspected in 12. In addition, 14 patients had a pseudocyst, two pancreatic endocrine failure and 20 exocrine failure. Aetiology was chronic alcohol abuse in 34, recurrent acute pancreatitis in five and unknown in 13. Pylorus-preserving proximal pancreatoduodenectomy was performed in 45 patients, while the remaining seven had partial gastrectomy. Drainage of a dilated distal pancreatic duct by side-to-side pancreaticojejunal anastomosis was included in 15 patients. Mean operating time was 6.2 (range 4.5-9.5) h and mean blood loss was 2.7 (range 0.2-13.0) litres. There were no hospital deaths, but three patients required a second operation and five had percutaneous drainage of infected collections. During a median follow-up of 54 months, six patients required completion distal pancreatectomy for renewed pain and four others had persistent pain. Four patients required intervention for stricture at the biliary-enteric anastomosis. Ten patients have died from causes not directly related to chronic pancreatitis. Proximal pancreatoduodenectomy is a relatively safe procedure, effectively palliating pain in 80 per cent of patients with chronic pancreatitis.
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Affiliation(s)
- G N Stapleton
- Department of Surgery, Hammersmith Hospital, London, UK
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30
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Büchler MW, Lübke D, Müller MW, Friess H. Vergleich pyloruserhaltende Whippel-Operation mit duodenumerhaltender Pankreaskopfresektion. Eur Surg 1996. [DOI: 10.1007/bf02626003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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31
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Izbicki JR, Bloechle C, Broelsch CE. Drainage versus Resektion bei chronischer Pankreatitis—Die longitudinale Pankreatojejunostomie verbunden mit der limitierten Pankreaskopfexzision nachFrey im Vergleich zur duodenumerhaltenden Pankreaskopfresektion nachBeger. Eur Surg 1996. [DOI: 10.1007/bf02626002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Izbicki JR, Bloechle C, Knoefel WT, Kuechler T, Binmoeller KF, Broelsch CE. Duodenum-preserving resection of the head of the pancreas in chronic pancreatitis. A prospective, randomized trial. Ann Surg 1995; 221:350-8. [PMID: 7726670 PMCID: PMC1234583 DOI: 10.1097/00000658-199504000-00004] [Citation(s) in RCA: 230] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Two techniques of duodenum-preserving resection of the head of the pancreas were compared in a prospective, randomized trial. The technical feasibility and effects on quality of life were assessed. SUMMARY BACKGROUND DATA Drainage and resection are the principles of surgery in chronic pancreatitis. The techniques of duodenum-preserving resection of the head of the pancreas as described by Berger and Frey combine both to different degrees. The efficacy of both procedures has not been compared thus far. METHODS Forty-two patients were allocated randomly to either Beger's (n = 20) or Frey's (n = 22) group. In addition to routine pancreatic diagnostic work-up, a multidimensional psychometric quality-of-life questionnaire and and a pain score were used. Assessment of endocrine and exocrine function included oral glucose tolerance test, serum concentrations of insulin, C-peptide, and HbA1c, as well as fecal chymotrypsin and pancreolauryl test. The interval between symptoms and surgery ranged from 12 months to 12 years, with a mean of 5.7 years. The mean follow-up was 1.5 years. RESULTS There was no mortality. Overall morbidity was 14% (20% Beger, 9% Frey). Complications from adjacent organs were resolved definitively in 94% (90% Beger, 100% Frey). A decrease of 95% and 94% of the pain score after Beger's and Frey's procedure, respectively, and an increase of 67% of the overall quality-of-life index in both groups were observed. Endocrine and exocrine function did not differ between both groups. CONCLUSIONS Both techniques of duodenum-preserving resection of the head of the pancreas are equally safe and effective with regard to pain relief, improvement of quality of life, and definitive control of complications affecting adjacent organs. Neither procedure leads to further deterioration of endocrine and exocrine pancreatic function.
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Affiliation(s)
- J R Izbicki
- Department of Surgery, University of Hamburg, Germany
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