[Duodenum preserving resection of the head of the pancreas: a standard procedure in chronic pancreatitis]

Chronic fibrous-degenerative pancreatitis with involvement of adjacent organs and their dysfunction: contemporary approaches to surgical treatment

BACKGROUND

Presently, there is no single opinion concerning the method preferable for surgical treatment of chronic pancreatitis (CP) with dysfunction of adjacent organs.

METHODS

Surgical treatment was applied to 144 patients with CP. In 54 (37.5%) patients, CP was complicated by dysfunction of adjacent organs. Particularly these were biliary hypertension (BH) in 36 (25%) patients and chronic duodenal obstruction (CDO) in 8 (5.5%) patients. In 5 (3.5%) patients, BH was combined with CDO, and another 5 (3.5%) patients had a combination of BH, CDO and venous hypertension (VH) of the portomesenteric area. In 24 patients with BH, we applied intraoperative monitoring of biliary pressure (IOM BP) in the process of performing duodenum-preserving pancreas resections. Frey's procedure was applied in 26 (48.1%) cases, where CP was complicated by the development of CDO, BH or CDO + BH. To correct BH, Frey's procedure was supplemented by application of hepatico-entero anastomosis (HEA) in 10 patients, pancreas lingual was excised; internal biliopancreatic anastomosis was applied in two patients. Beger's procedure was used in 2 (3.7%) patients, in which CP was complicated by BH + CDO + VH. Pancreaticoduodenal resection (PDR) according to Whipple was used in 5 (9.2%) cases. Longitudinal pancreatic-enteric anastomosis (LPEA) supplemented by HEA due to BH was applied to 8 (14.8%) patients.

RESULTS

The results of chronic treatment were traced in 23 (42.5%) patients throughout the period of 6 to 36 months. Life quality indicators appeared to be the best among the patients who underwent resection surgeries on the pancreas.

CONCLUSIONS

The method selected to treat surgically the patients with CP that involves adjacent organs and causes their dysfunction is duodenum-preserving resection surgeries on pancreas head, which in some cases should be supplemented by application of biliodigestive anastomosis or biliopancreatic diversion in the area of pancreas resection to eliminate the BH.

Customized Surgical Strategy in Chronic Pancreatitis

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.

RESECTION OPERATIONS IN SURGICAL TREATMENT OF PATIENTS WITH CHRONIC PANCREATITIS COMPLICATED BY BILIARY HYPERTENSION

Surgical treatment was applied in 145 patients with complicated forms of chronic pancreatitis (CP) at the department of surgery of the Ivano-Frankivsk Regional Clinical Hospital in 2009–2016. Fourty-nine (33.7 %) patients had symptoms of biliary hypertension (BH); in five (3.4 %) of them BH was combined with chronic duodenal obstruction (CDO), the other 5 (3.4 %) patients had a combination of BH+CDP and local venous hypertension of pancreaticobiliary area vessels. Resection-type surgeries were applied in 28 (57.1 %) patients with CP complicated by BH. Intraoperative monitoring of biliary pressure was used in 17 patients in the process of duodenum-preserving resections of the pancreas. Frey’s procedure was applied to 20 (71.4 %) patients, in whom BH persisted after the resection stage of the surgery; Frey’s procedure was supplemented by interventions on bile ducts: hepaticoenteroanastomosis was applied in 12 patients, excision of pancreas lingula was applied in one patient, internal biliopancreatic anastomosis was applied in one patient. Berne modification was used in 2 (7.2 %) patients, and pancreaticoduodenal resection (PDR) according to Whipple – in 6 (21.4 %) patients. Remote results were studied in 19 (67.8 %) patients. Patients after duodenum-preserving resections had the best quality of life indicators, for BH signs were absent.

Duodenum-preserving pancreatic head resection--a randomized controlled trial comparing the original Beger procedure with the Berne modification (ISRCTN No. 50638764)

OBJECTIVE

A prospective, randomized study was performed to evaluate two variations of the duodenum-preserving pancreatic head resection (DPPHR), either with (Beger procedure) or without (Berne modification) the division of the pancreas anterior to the portal vein, in patients with chronic pancreatitis.

METHODS

Randomized, controlled, patient-blinded trial of patients with inflammatory pancreatic head tumors. The primary endpoint was the duration of surgery. Other a priori-ordered endpoints were length of ICU stay, postoperative complication, length of hospital stay, and quality of life after 24 months.

RESULTS

Sixty-five patients were randomized to the Berne or Beger procedures. The Berne modification could be performed faster (46 minutes difference, P < .05). The median length of stay on the ICU was one day in both groups (P = .97) but the median hospital stay was shorter in the Berne group (11 (8-39) versus 15 (8-47); P = .015). The quality of life two years after surgery did not differ significantly between the two groups (EORTC-QLQ-C30, Beger 65.6% vs. Berne 71.3%, P = .371). Three patients who had received the Berne procedure were reoperated on during the follow-up period due to ongoing pancreatitis and bile duct obstruction (P = .22).

CONCLUSION

The Berne technique is technically simpler compared with the original Beger procedure, reflected in its significantly shorter operation times and hospital stays. The quality of life is similar after both procedures. The Berne modification of DPPHR adds to our panel of surgical procedures that can be applied with effective early and late outcomes.

Duodenum preserving pancreatectomy in chronic pancreatitis: design of a randomized controlled trial comparing two surgical techniques [ISRCTN50638764]

Background

Chronic pancreatitis is an inflammatory disease which is characterized by an irreversible conversion of pancreatic parenchyma to fibrous tissue. Beside obstructive jaundice and pseudocyst formation, about half of the patients need surgical intervention due to untreatable chronic pain during the course of the disease. In most of the patients with chronic pancreatitis, the head of the pancreas is the trigger of the chronic inflammatory process. Therefore, resection of pancreatic head tissue must be the central part of any surgical intervention. However, it is unclear to which extent the surgical procedure must be radical in order to obtain a favourable outcome for the patients.

Design

A single centre randomized controlled, superiority trial to compare two techniques of duodenum preserving pancreatic head resection. Sample size: 65 patients will be included and randomized intraoperatively. Eligibility criteria: All patients with chronic pancreatitis and indication for surgical resection and signed informed consent. Cumulative primary endpoint (hierarchical model): duration of surgical procedure, quality of life after one year, duration of intensive care unit stay, duration of hospital stay. Reference treatment: Resection of the pancreatic head with dissection of the pancreas from the portal vein and transsection of the gland (Beger procedure). Intervention: Partial Resection of the pancreatic head without transsection of the organ and visualization of the portal vein (Berne procedure).

Duration: September 2003-October 2007.

Organisation/responsibility

The trial is conducted in compliance with the protocol and in accordance with the moral, ethical, regulatory and scientific principles governing clinical research as set out in the Declaration of Helsinki (1989) and the Good Clinical Practice guideline (GCP). The Center for Clinical Studies of the Department of Surgery Heidelberg is responsible for planning, conducting and final analysis of the trial.

[Duodenum-preserving pancreas head resection-an operative technique for retaining the organ in the treatment of chronic pancreatitis]

Chronic pancreatitis is an inflammatory disease characterized by the progressive conversion of pancreatic parenchyma to fibrous tissue. The most frequent causes are alcohol overconsumption and anatomic variants such as pancreas divisum, cholelithiasis, and individual genetic predisposition. The process of fibrosis with consecutive loss of pancreatic parenchyma leads to exocrine insufficiency and maldigestion and, in advanced stages of the disease, to diabetes mellitus. Beside exocrine and endocrine malfunction, mechanical complications occur such as the formation of pancreatic pseudocysts and duodenal and common bile duct obstruction. About 50% of patients with chronic pancreatitis need surgical intervention due to untreatable chronic pain. As recent investigations suggest that the head of the pancreas triggers the chronic inflammatory process, resection of this inflammatory mass must be regarded as pivotal in any surgical intervention. Radical techniques such as the Whipple procedure are undoubtedly successful regarding pain reduction but, even in its pylorus-preserving variant, associated with high postoperative morbidity due to a large loss of pancreatic parenchyma and the absence of duodenal passage. Thirty years ago, H.G. Beger described for the first time the technique of duodenum-preserving pancreatectomy, which better combines resection of the pancreatic head with low morbidity. Over the years, different variations of the original Beger technique (Frey, Izbicky, Berne modification) have been developed, and the excellent results obtained with these methods underline that organ-sparing techniques should be preferred in the surgical treatment of chronic pancreatitis.

Size of the pancreatic head as a prognostic factor for the outcome of Beger's procedure for painful chronic pancreatitis

BACKGROUND

Duodenum-preserving resection of the head of the pancreas (DPRHP) according to Beger has been developed as an alternative to pylorus-preserving resection of the pancreatic head for painful chronic pancreatitis.

METHODS

Between 1988 and 2000, 36 consecutive DPRHPs were performed. The group was divided into patients with (group 1; n = 23) and without (group 2; n = 13) significant enlargement of the pancreatic head. Pain was the indication for surgery in all patients.

RESULTS

Complications occurred in 12 patients, necessitating reoperation in 11. Initial overall results were favourable; significant improvement or complete relief of pain was reported in 27 of 35 patients. Long-term results were obtained in 27 of 30 patients; the overall success rate was 16 of 27, 13 of 16 patients with distinct enlargement of the pancreatic head and 3 of the 11 with minimal or no enlargement (P = 0.018).

CONCLUSION

DPRHP can be performed with good early results. This effect is sustained in patients with distinct localized disease of the pancreatic head. In those without, the long-term results are disappointing.

Surgical treatment and long-term follow-up in chronic pancreatitis

In the past two decades our knowledge of the pathophysiology and surgical treatment options in chronic pancreatitis have improved substantially. Surgical treatment in chronic pancreatitis has evolved from radical to organ-preserving procedures. The classic Whipple resection is no longer indicated in chronic pancreatitis, and operations like the duodenum-preserving pancreatic head resection and the pylorus-preserving Whipple have replaced it as surgical standards. These procedures allow the preservation of exocrine and endocrine pancreatic function, provide pain relief in up to 90% of patients, and contribute to an improvement in the quality of life.

Extended drainage versus resection in surgery for chronic pancreatitis: a prospective randomized trial comparing the longitudinal pancreaticojejunostomy combined with local pancreatic head excision with the pylorus-preserving pancreatoduodenectomy

OBJECTIVE

To analyze the efficacy of extended drainage--that is, longitudinal pancreaticojejunostomy combined with local pancreatic head excision (LPJ-LPHE)-and pylorus-preserving pancreatoduodenectomy (PPPD) in terms of pain relief, control of complications arising from adjacent organs, and quality of life.

SUMMARY BACKGROUND DATA

Based on the hypotheses of pain origin (ductal hypertension and perineural inflammatory infiltration), drainage and resection constitute the main principles of surgery for chronic pancreatitis.

METHODS

Sixty-one patients were randomly allocated to either LPJ-LPHE (n = 31) or PPPD (n = 30). The interval between symptoms and surgery ranged from 12 months to 10 years (mean 5.1 years). In addition to routine pancreatic diagnostic workup, a multidimensional psychometric quality-of-life questionnaire and a pain score were used. Endocrine and exocrine functions were assessed in terms of oral glucose tolerance and serum concentrations of insulin, C-peptide, and HbA1c, as well as fecal chymotrypsin and pancreolauryl testing. During a median follow-up of 24 months (range 12 to 36), patients were reassessed in the outpatient clinic.

RESULTS

One patient died of cardiovascular failure in the LPJ-LPHE group (3.2%); there were no deaths in the PPPD group. Overall, the rate of in-hospital complications was 19.4% in the LPJ-LPHE group and 53.3% in the PPPD group, including delayed gastric emptying in 9 of 30 patients (30%; p < 0.05). Complications of adjacent organs were definitively resolved in 93.5% in the LPJ-LPHE group and in 100% in the PPPD group. The pain score decreased by 94% after LPJ-LPHE and by 95% after PPPD. Global quality of life improved by 71% in the LPJ-LPHE group and by 43% in the PPPD group (p < 0.01).

CONCLUSIONS

Both procedures are equally effective in terms of pain relief and definitive control of complications affecting adjacent organs, but extended drainage by LPJ-LPHE provides a better quality of life.