How much of the pancreatic head should we resect in Frey's procedure?

Surgical Treatment for Chronic Pancreatitis With a Normal-Sized Pancreatic Head and a Dilated Duct: Frey or Extended Partington Procedure?

BACKGROUND

Surgical drainage for chronic pancreatitis patients with a normal-sized pancreatic head remains controversial. Both Frey and extended Partington procedures could be used, but the level of evidence is weak.

METHOD

The object of this prospective cohort study was to assess the mid-term results concerning pain, quality of life, and pancreatic function of surgical drainage (Frey or extended Partington procedure) in patients with painful chronic pancreatitis and a normal-sized pancreatic head.

RESULTS

Fifty-nine patients (Frey procedure: 14 cases; extended Partington procedure: 45 cases) were enrolled in the study with a median length of follow-up of 16 months. The effective and complete pain relief rate was 85% and 58%, respectively. The Izbicki score decreased from 53.4 preoperatively to 8.8 postoperatively. The general 12-Item Short Form Health Survey (SF-12) score increased from 45.2 to 75.4. The pancreatic insufficiency did not change significantly postoperatively. At three months after surgery, the complete pain relief and Izbicki score were more favorable in the Frey group than in the extended Partington group.

CONCLUSION

Both Frey and extended Partington procedures resulted in excellent pain relief and quality of life improvement and did not worsen pancreatic function. The Frey procedure could yield a more favorable result in the early postoperative period.

Changing trends in the minimally invasive surgery for chronic pancreatitis

Chronic pancreatitis is a debilitating pancreatic inflammatory disease characterized by intractable pain resulting in poor quality of life. Conventional management of pancreatic pain consists of a step-up approach with medications and lifestyle modifications followed by endoscopic intervention. Traditionally surgery is reserved for patients who do not improve with other interventions. However, recent studies suggest that early surgical intervention is more beneficial as it can mitigate the progression of the pathological process and prevent loss of pancreatic function. Despite the widespread adoption of minimally invasive approaches in various gastrointestinal surgical disorders, minimally invasive surgery for chronic pancreatitis is slow to evolve. Technical difficulty due to severe inflammatory changes has been the major impediment to the widespread usage of minimally invasive surgery in chronic pancreatitis. With this background, the present review aimed to critically analyze the available evidence on the minimally invasive treatment of chronic pancreatitis. A Pub Med search of all relevant articles was performed using the appropriate keywords, parentheses, and Boolean operators. Most initial laparoscopic series have reported the feasibility of lateral pancreaticojejunostomy, considered an adequate procedure only in a small proportion of patients. The pancreatic head is the pacemaker of pain, so adequate decompression is critical for long-term pain relief. Recent studies have documented the feasibility of minimally invasive duodenum-preserving pancreatic head resection. With improvements in laparoscopic instrumentation and technological advances, minimally invasive surgery for chronic pancreatitis is gaining momentum. However, more high-quality evidence is required to document the superiority of minimally invasive surgery for chronic pancreatitis.

Reporting of longitudinal pancreatojejunostomy with partial pancreatic head resection (the Frey procedure) for chronic pancreatitis: A systematic review

BACKGROUND

Longitudinal pancreatojejunostomy with partial pancreatic head resection (the Frey procedure) is accepted for surgical treatment of painful chronic pancreatitis. However, conduct and reporting are not standardized and thus, making comparisons difficult. This study assesses the reporting standards of this procedure.

DATA SOURCES

A systematic literature review was performed between January 1987 and January 2020. The keyword and Medical Subject Heading "chronic pancreatitis" was used together with the individual operation term "Frey pancreatojejunostomy". Reports were included if they provided original information on conduct and outcome. Thirty-three papers providing information on 1205 patients constituted the study population. Risk of bias in included reports was assessed.

RESULTS

Etiology of chronic pancreatitis (alcohol) was reported in 26 of 28 (93%) studies, duration of symptoms prior to surgery in 19 (58%) studies and pre-operative opiate use in 12 (36%) studies. In terms of morphology, pancreatic duct diameter was reported in 17 (52%) studies and diameter of the pancreatic head in 13 (39%) studies. In terms of technique, three (9%) studies reported weight of excised parenchyma. There were 9 (0.7%) procedure-related deaths. Post-operative follow-up ranged from 6 to 82.5 months. No studies reported post-operative portal hypertension.

CONCLUSIONS

There is substantial heterogeneity between studies in reporting of clinical baseline, morphology of the diseased pancreas, operative detail and outcome after longitudinal pancreatojejunostomy with partial pancreatic head resection. This critically compromises the comparison between centers and between surgeons. Structured reporting is necessary for clinicians to assess choice of procedure and for patients to make informed choices when seeking treatment for painful chronic pancreatitis.

[Long-term outcomes of pancreatic head resection in chronic pancreatitis]

OBJECTIVE

To analyze the effect of timing of surgery, quality of resection and removal of MPD-stones on long-term results of duodenum-preserving pancreatic head resection (DPPHR).

MATERIAL AND METHODS

The study included 110 patients with chronic pancreatitis (CP) who underwent DPPHR in 2014-2019. Evaluation of long-term outcomes included pain syndrome severity, exocrine and endocrine insufficiency and quality of life (QoL). Patients were stratified depending on duration of disease (within 36 months, >36 months after manifestation), volume of resected pancreatic head tissue according to CT data, removal of MPD-stones.

RESULTS

Surgical treatment within 36 months after clinical manifestation was followed by less pain syndrome (VAS score 1.16±1.76 vs. 2.03±1.87, p=0.02), exocrine insufficiency (69.8% vs. 98.5%, p<0.001). Resection of more than 50% of the pancreatic head and removal of MPD-stones were accompanied by pain relief, improved pancreatic secretory function and quality of life.

CONCLUSION

Pancreatic head resection in patients with chronic pancreatitis should be performed within 3 years after clinical manifestation. Resection of more than 50% of the pancreatic head with extraction of MPD-stones ensures pain relief, better endocrine and exocrine function, as well as higher QoL in long-term follow-up period.

Bile duct preserving pancreatic head resection (BDPPHR): Can we conclusively define the extent of head resection in surgery for chronic pancreatitis?

The role of surgical management for chronic pancreatitis in providing pain relief and improving quality of life is significant. Surgical techniques involving pancreatic head resection scored more over the drainage procedures. Among the resection procedures, Frey’s procedure received widespread acceptance. However, the exact extent of pancreatic head resection to be performed and the limits of the resection are still debatable. The present report of bile duct preserving pancreatic head resection (BDPPHR) describes an innovative approach to the pancreatic head and conclusively defines the extent of head resection. The simplicity, feasibility and easy reproducibility of the BDPPHR is also reiterated.

International consensus guidelines for surgery and the timing of intervention in chronic pancreatitis

BACKGROUND/OBJECTIVES

Chronic pancreatitis (CP) is a complex inflammatory disease with pain as the predominant symptom. Pain relief can be achieved using invasive interventions such as endoscopy and surgery. This paper is part of the international consensus guidelines on CP and presents the consensus guideline for surgery and timing of intervention in CP.

METHODS

An international working group with 15 experts on CP surgery from the major pancreas societies (IAP, APA, JPS, and EPC) evaluated 20 statements generated from evidence on 5 questions deemed to be the most clinically relevant in CP. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the level of evidence available for each statement. To determine the level of agreement, the working group voted on the 20 statements for strength of agreement, using a nine-point Likert scale in order to calculate Cronbach's alpha reliability coefficient.

RESULTS

Strong consensus was obtained for the following statements: Surgery in CP is indicated as treatment of intractable pain and local complications of adjacent organs, and in case of suspicion of malignant (cystic) lesion; Early surgery is favored over surgery in a more advanced stage of disease to achieve optimal long-term pain relief; In patients with an enlarged pancreatic head, a combined drainage and resection procedure, such as the Frey, Beger, and Berne procedure, may be the treatment of choice; Pancreaticoduodenectomy is the most suitable surgical option for patients with groove pancreatitis; The risk of pancreatic carcinoma in patients with CP is too low (2% in 10 year) to recommend active screening or prophylactic surgery; Patients with hereditary CP have such a high risk of pancreatic cancer that prophylactic resection can be considered (lifetime risk of 40-55%). Weak agreement for procedure choice in patients with dilated duct and normal size pancreatic head: both the extended lateral pancreaticojejunostomy and Frey procedure seems to provide equivalent pain control in patients.

CONCLUSIONS

This international expert consensus guideline provides evidenced-based statements concerning key aspects in surgery and timing of intervention in CP. It is meant to guide clinical practitioners and surgeons in the treatment of patients with CP.

Laparoscopic longitudinal pancreatojejunostomy and modified Frey's operation for chronic calcific pancreatitis

Background

Chronic pancreatitis is a debilitating disease presenting with pain, diabetes and steatorrhoea. Surgery offers better long-term pain relief than other interventions, but there is still uncertainty about the optimal surgical procedure and approach and a lack of long-term follow-up data in patients with chronic calcific pancreatitis selected for laparoscopic surgical treatment.

Methods

This was an observational cohort study of patients who underwent laparoscopic surgery for chronic calcific pancreatitis between January 2006 and April 2017, and had completed a minimum follow-up of 1 year at a tertiary-care teaching institute. Eligibility for the laparoscopic approach was main duct diameter greater than 7 mm, absence of extensive head calcification, size of head less than 3·5 cm, absence of local complications, and ASA grade I or II status. The primary outcome variable was a reduction in pain score by 1 year. Secondary outcomes were hospital stay, complications, pain score at 3 and 5 years, and the development or progression of exocrine and endocrine insufficiency.

Results

Some 57 patients were scheduled to undergo laparoscopic surgery for chronic pancreatitis: longitudinal pancreatojejunostomy (39), modified Frey's procedure (15) and pancreatoduodenectomy for suspicion of malignancy (3). The latter three patients were excluded from the analysis. Conversion to open surgery was needed in ten of the 57 patients (18 per cent). The mean(s.d.) age of the analysed cohort was 34·2(3·7) years and there was a predominance of men (34, 63 per cent). Adequate pain relief was achieved in 91, 89 and 88 per cent of patients at 1, 3 and 5 years of follow-up respectively.

Conclusion

Laparoscopic surgical management of chronic calcific pancreatitis with longitudinal pancreatojejunostomy or modified Frey's procedure is feasible, safe and effective in selected patients for the relief of pain.

Role of original and modified Frey's procedures in chronic pancreatitis

AIM

To retrospectively review patients with chronic pancreatitis (CP) treated with Frey’s procedures between January 2009 and January 2014.

METHODS

A retrospective review was performed of patients with CP treated with Frey’s procedures between January 2009 and January 2014 in the Department of Pancreatic Surgery. A cross-sectional study of postoperative pain relief, quality of life (QoL), and alcohol and nicotine abuse was performed by clinical interview, letters and telephone interview in January 2016. QoL of patients was evaluated with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) version 3.0. The patients were requested to fill in the questionnaires by themselves via correspondence or clinical interview.

RESULTS

A total of 80 patients were enrolled for analysis, including 44 who underwent the original Frey’s procedure and 36 who underwent a modified Frey’s procedure. The mean age was 46 years in the original group and 48 years in the modified group. Thirty-five male patients (80%) were in the original group and 33 (92%) in the modified group. There were no differences in the operating time, blood loss, and postoperative morbidity and mortality between the two groups. The mean follow-up was 50.3 mo in the original group and 48.7 mo in the modified group. There were no differences in endocrine and exocrine function preservation between the two groups. The original Frey’s procedure resulted in significantly better pain relief, as shown by 5-year follow-up (P = 0.032), better emotional status (P = 0.047) and fewer fatigue symptoms (P = 0.028). When stratifying these patients by the M-ANNHEIM severity index, no impact was found on pain relief after the two types of surgery.

CONCLUSION

The original Frey’s procedure is as safe as the modified procedure, but the former yields better pain relief. The severity of CP does not affect postoperative pain relief.

Short and long-term post-operative outcomes of duodenum preserving pancreatic head resection for chronic pancreatitis affecting the head of pancreas: a systematic review and meta-analysis

BACKGROUND

To evaluate the short and long term outcomes of duodenum preserving pancreatic head resection (DPPHR) procedures in the treatment of painful chronic pancreatitis.

METHODS

A systematic literature search was performed to identify all comparative studies evaluating long and short term postoperative outcomes (pain relief, morbidity and mortality, pancreatic exocrine and endocrine function).

RESULTS

Five published studies fulfilled the inclusion criteria including 1 randomized controlled trial comparing the Beger and Frey procedure. In total, 323 patients underwent surgical procedures for chronic pancreatitis, including Beger (n = 138) and Frey (n = 99), minimal Frey (n = 32), modified Frey (n = 25) and Berne's modification (n = 29). Two studies comparing the Beger and Frey procedure were entered into a meta-analysis and showed no difference in post-operative pain (RD = -0.06; CI -0.21 to 0.09), mortality (RD = 0.01; CI -0.03 to 0.05), morbidity (RD = 0.12; CI -0.00 to 0.24), exocrine insufficiency (RD = 0.04; CI -0.10 to 0.18) and endocrine insufficiency (RD = -0.14 CI -0.28 to 0.01).

CONCLUSION

All procedures are equally effective for the management of pain for chronic pancreatitis. The choice of procedure should be determined by other factors including the presence of secondary complications of pancreatitis and intra-operative findings. Registration number CRD42015019275. Centre for Reviews and Dissemination, University of York, 2009.

Single center experience in selecting the laparoscopic Frey procedure for chronic pancreatitis

AIM: To share our experience regarding the laparoscopic Frey procedure for chronic pancreatitis (CP) and patient selection.

METHODS: All consecutive patients undergoing duodenum-preserving pancreatic head resection from July 2013 to July 2014 were reviewed and those undergoing the Frey procedure for CP were included in this study. Data on age, gender, body mass index (BMI), American Society of Anesthesiologists score, imaging findings, inflammatory index (white blood cells, interleukin (IL)-6, and C-reaction protein), visual analogue score score during hospitalization and outpatient visit, history of CP, operative time, estimated blood loss, and postoperative data (postoperative mortality and morbidity, postoperative length of hospital stay) were obtained for patients undergoing laparoscopic surgery. The open surgery cases in this study were analyzed for risk factors related to extensive bleeding, which was the major reason for conversion during the laparoscopic procedure. Age, gender, etiology, imaging findings, amylase level, complications due to pancreatitis, functional insufficiency, and history of CP were assessed in these patients.

RESULTS: Nine laparoscopic and 37 open Frey procedures were analyzed. Of the 46 patients, 39 were male (85%) and seven were female (16%). The etiology of CP was alcohol in 32 patients (70%) and idiopathic in 14 patients (30%). Stones were found in 38 patients (83%). An inflammatory mass was found in five patients (11%). The time from diagnosis of CP to the Frey procedure was 39 ± 19 (9-85) mo. The BMI of patients in the laparoscopic group was 20.4 ± 1.7 (17.8-22.4) kg/m² and was 20.6 ± 2.9 (15.4-27.7) kg/m² in the open group. All patients required analgesic medication for abdominal pain. Frequent acute pancreatitis or severe abdominal pain due to acute exacerbation occurred in 20 patients (43%). Pre-operative complications due to pancreatitis were observed in 18 patients (39%). Pancreatic functional insufficiency was observed in 14 patients (30%). Two laparoscopic patients (2/9) were converted. In seven successful laparoscopic cases, the mean operative time was 323 ± 29 (290-370) min. Estimated intra-operative blood loss was 57 ± 14 (40-80) mL. One patient had a postoperative complication, and no mortality was observed. Postoperative hospital stay was 7 ± 2 (5-11) d. Multiple linear regression analysis of 37 open Frey procedures showed that an inflammatory mass (P < 0.001) and acute exacerbation (P < 0.001) were risk factors for intra-operative blood loss.

CONCLUSION: The laparoscopic Frey procedure for CP is feasible but only suitable in carefully selected patients.

Short- and long-term results of the Frey procedure for chronic pancreatitis

BACKGROUND

The aim of this study was to determine the short- and long-term results of the Frey procedure for chronic pancreatitis.

METHODS

From November 1998 to December 2013, 41 patients underwent the Frey procedure for painful chronic pancreatitis at Kyushu University Hospital. The short- and long-term results of the Frey procedure including mortality, morbidity, pain relief, weight gain and pancreatic endocrine function were analyzed. The long-term results were analyzed in 29 patients who had been followed-up for more than 12 months. The long-term follow-up rate was 85%.

RESULTS

There was no mortality. Early postoperative complications occurred in seven patients (17%), including pancreatic fistula in four (10%, International Study Group of Pancreatic Fistula ISGPF grade B) and hemorrhage in three (7%). Long-term relief of abdominal pain was achieved in 90% (26/29) of cases. One patient developed relapse of inflammation of the head of pancreas during the follow-up period, necessitating pylorus-resecting pancreatoduodenectomy. Only two patients (7%) developed new-onset diabetes mellitus after the Frey procedure during the follow-up period.

CONCLUSIONS

The Frey procedure for painful chronic pancreatitis may be safe and pancreatic endocrine function is preserved. Complete decompression of the pancreatic ducts in the head of pancreas and full length drainage of the main pancreatic duct from the head of pancreas to the tail may be important in the Frey procedure to prevent recurrence of acute inflammation.

Tratamento cirúrgico da pancreatite crônica com a técnica de F rey: panorama atual

INTRODUÇÃO: A pancreatite crônica é desordem inflamatória progressiva caracterizada pela destruição irreversível do parênquima pancreático, podendo estar associada à dor crônica incapacitante e perda permanente da função endócrina e exócrina. A principal indicação cirúrgica é a dor abdominal intratável e a escolha da melhor técnica a ser empregada permanece um desafio. A técnica descrita por Frey conseguiu combinar a eficácia no controle da dor das operações de ressecção com as baixas taxas de mortalidade e morbidade das derivativas. OBJETIVO: Comparar e discutir os resultados do tratamento cirúrgico da pancreatite crônica com a técnica de Frey. MÉTODOS: Revisão bibliográfica de 276 artigos científicos disponíveis no Medline/Pubmed e no banco de dados de teses nacionais com os descritores pancreatite crônica, tratamento cirúrgico e cirurgia de Frey. Foram selecionados os 30 artigos de maior importância e que relataram maior experiência com esta opção cirúrgica. CONCLUSÕES: A técnica de Frey demonstra ser opção de alta efetividade no controle da dor abdominal secundária à pancreatite crônica no longo prazo naqueles pacientes com dor abdominal incapacitante e aumento volumétrico da cabeça pancreática, com menores taxas de morbidade e mortalidade. Os estudos demonstraram pequena interferência da técnica na deterioração das funções endócrina e exócrina.

Implication of pancreatic image findings in total pancreatectomy with islet autotransplantation for chronic pancreatitis

OBJECTIVE

To clarify the implication of pancreatic findings on transabdominal ultrasound and/or abdominal computed tomographic scan on outcomes of islet isolation and endocrine function after total pancreatectomy (TP) with islet autotransplantation (IAT).

METHODS

Retrospective review of islet isolations and graft functions in a cohort of patients with chronic pancreatitis who received TP with IAT from December 2007 to September 2009. Patients were categorized into the following 2 groups on the basis of their transabdominal ultrasound or computed tomographic findings before IAT: early group (normal or equivocal of Cambridge classification) and advanced group (mild to marked).

RESULTS

A total of 12 patients (early group, n=6; advanced group, n=6) were included. Total islet yield per pancreas weight and per patient body weight in the early group was significantly higher compared with that in the advanced group (6989±659 vs 3567±615 islet equivalents per gram, P<0.01; 8556±953 vs 3847±739 islet equivalents per kilogram, P<0.01, respectively). Four patients (67%) in the early group became insulin-free, whereas 2 patients (33%) in the advanced group obtained insulin independence. However, both groups maintained islet graft function and similar glycated hemoglobin levels after transplantation.

CONCLUSIONS

Excellent glycemic control was observed in both groups of patients who received TP with IAT, although the early group showed a significantly better outcome of islet isolation.

Has the Partington procedure for chronic pancreatitis become a thing of the past? A review of the evidence

INTRODUCTION

For the surgical management of chronic pancreatitis with an inflammatory pancreatic head mass, extended drainage operations such as Beger and Frey procedures were established in the 1980s as an alternative to resectional procedures like pancreaticoduodenectomy and as opposed to simple drainage operations such as lateral pancreaticojejunostomy, that is, the Partington procedure. With the relatively rapid adoption of the two procedures, it seems that the Partington procedure has become a thing of the past.

MATERIALS AND METHODS

The Partington procedure was re-evaluated with regard to the historical aspects and its present status by a literature review.

RESULTS

The results show that this procedure relieves chronic abdominal pain in 66-91% of patients with a mean follow-up of 3.5-9.1 years. It is important to note that this procedure is generally used for inflammatory disease left of the gastroduodenal artery and is specifically not used as the procedure of choice for inflammatory disease of the pancreatic head.

CONCLUSION

For patients with a dilated main pancreatic duct but without an inflammatory pancreatic head mass, the Partington procedure is still the procedure of choice, since it is technically simple to perform with a minimum of morbidity and mortality, preserving pancreatic endocrine and exocrine function. Because it is a relatively simple technique, the laparoscopic approach will be justified as a treatment of appropriate patients in the near future.