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Siegel JB, Mukherjee R, Lancaster WP, Morgan KA. Distal Pancreatectomy for Pancreatitis in the Modern Era. J Surg Res 2022; 275:29-34. [PMID: 35219248 DOI: 10.1016/j.jss.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 10/20/2021] [Accepted: 01/24/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Distal pancreatectomy has not been well examined in the modern era to guide management for pancreatitis. We evaluated this heterogeneous group and the preoperative factors associated with clinically relevant postoperative pancreatic fistula (CR-POPF). METHODS Patients undergoing distal pancreatectomy at a single academic institution from August 2012 to January 2020 were evaluated. Univariate and multivariate logistic regressions were conducted between preoperative factors and CR-POPF. RESULTS One hundred and thirty patients underwent distal pancreatectomy. Indication for operative management included chronic pancreatitis and/or pseudotumor in 24.6% (n = 32), disconnected left pancreatic remnant in 31.5% (n = 41), chronic distal pseudocyst in 20.8% (n = 27), and distal necrosis in 13.8% (n = 18). Significant complications (Clavien-Dindo grade ≥ III) were seen in 34% of patients. After surgery, 34.2% developed diabetes, 40% had persistent opioid use, and 22.3% had CR-POPF. In multivariate analysis, male sex was significantly associated with CR-POPF (odds ratio 3.1, P = 0.037), and having a preoperative, therapeutic endoscopic retrograde cholangiopancreatography was protective (odds ratio 0.28, P = 0.020). CONCLUSIONS Distal pancreatectomy is undertaken in pancreatitis with high morbidity. Female sex and preoperative, therapeutic endoscopic retrograde cholangiopancreatography were significant protective factors for CR-POPF. The natural history of this approach is relevant for those with distal pancreatitis failing medical management.
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Affiliation(s)
- Julie B Siegel
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina.
| | - Rupak Mukherjee
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - William P Lancaster
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Katherine A Morgan
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
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Jiang L, Ning D, Cheng Q, Chen XP. Endoscopic versus surgical drainage treatment of calcific chronic pancreatitis. Int J Surg 2018; 54:242-247. [DOI: 10.1016/j.ijsu.2018.04.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 03/22/2018] [Accepted: 04/13/2018] [Indexed: 01/10/2023]
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Dhar VK, Levinsky NC, Xia BT, Abbott DE, Wilson GC, Sussman JJ, Smith MT, Poreddy S, Choe K, Hanseman DJ, Edwards MJ, Ahmad SA. The natural history of chronic pancreatitis after operative intervention: The need for revisional operation. Surgery 2016; 160:977-986. [PMID: 27450713 DOI: 10.1016/j.surg.2016.05.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 05/09/2016] [Accepted: 05/24/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND For patients with chronic pancreatitis, duodenum-sparing head resections and pancreaticoduodenectomy are effective operations to relieve abdominal pain. For patients who develop recurrent symptoms after their index operation, the long-term management remains controversial. METHODS Between 2002 and 2014, patients undergoing operative intervention for chronic pancreatitis were identified retrospectively. Patients requiring reoperation after their index operation were reviewed. RESULTS A total of 121 patients with chronic pancreatitis underwent an index operation. At a median time of 33 months, 85 patients underwent no further operative intervention, while 36 patients underwent reoperation. A reoperative procedure was completed with acceptable perioperative morbidity and blood loss. After a revision operation, 25% of patients became narcotic independent. Narcotic requirements decreased from 143 morphine equivalent milligrams per day (MEQ/d) to 80 MEQ/d, and 58% of patients required less than 50 MEQ/d. Insulin requirements were not increased from preoperative levels. Multivariate analysis demonstrated only narcotic requirement and exocrine insufficiency after the index operation to be predictive for the need for a revision operation. CONCLUSION Our data demonstrate the following: (1) A significant number of patients undergoing duodenum-sparing head resections (26%) or pancreaticoduodenectomy (29%) required reoperation for recurrent abdominal pain; and (2) a revisional operation can be effective in relieving recurrent abdominal symptoms. Patients with recurrent symptoms should be considered for additional operative intervention.
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Affiliation(s)
- Vikrom K Dhar
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Nick C Levinsky
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Brent T Xia
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Daniel E Abbott
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Gregory C Wilson
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Jeffrey J Sussman
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Milton T Smith
- Department of Gastroenterology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Sampath Poreddy
- Department of Gastroenterology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Kyuran Choe
- Department of Radiology, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Dennis J Hanseman
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Michael J Edwards
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH
| | - Syed A Ahmad
- Department of Surgery, University of Cincinnati Pancreatic Disease Center, University of Cincinnati Medical Center, Cincinnati, OH.
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Cooper MA, Makary MA, Ng J, Cui Y, Singh VK, Matsukuma K, Andersen DK. Extent of pancreatic fibrosis as a determinant of symptom resolution after the Frey procedure: a clinico-pathologic analysis. J Gastrointest Surg 2013; 17:682-7. [PMID: 23345052 DOI: 10.1007/s11605-012-2110-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 11/21/2012] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the association of histopathologic features of chronic pancreatitis and pain relief after the Frey procedure. DESIGN We retrospectively analyzed 35 patients who underwent the Frey procedure for chronic pancreatitis over a 5-year period (November 2005 to February 2011). SETTING Thirty-five patients with varied etiologies of chronic pancreatitis and persistent symptoms were referred to a multi-disciplinary pancreatitis clinic where a consensus decision to recommend surgery was established. The Frey procedure was then performed. MAIN OUTCOME MEASURES We compared symptomatic outcomes with the degree of pancreatic fibrosis, duct dilatation, and presence of pancreatic duct stones based on a blinded evaluation of resected pancreatic tissue. RESULTS Symptom resolution was associated with severe or extensive (>75 %) fibrosis and absence of symptom resolution was associated with mild or minimal (<25 %) fibrosis (chi-squared, p value < 0.05). Symptom resolution was associated with pancreatic duct >4 mm and absence of symptom resolution was associated with pancreatic duct ≤4 mm (chi-squared, p value < 0.05). There was no difference in outcomes for patients with and without pancreatic duct stones. CONCLUSION Symptom resolution after the Frey procedure is more likely in the setting of severe or extensive fibrosis due to chronic pancreatitis.
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Affiliation(s)
- Michol A Cooper
- Department of Surgery, Johns Hopkins Hospital, Blalock 655, 600 N. Wolfe St., Baltimore, MD 21231, USA.
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Abstract
OBJECTIVE We measured a comprehensive set of outcome measures after different surgical procedures for painful chronic pancreatitis (CP) at long-term follow-up. BACKGROUND Pain caused by CP can be alleviated through operative intervention with type of procedure depending on anatomical abnormalities. Outcome measures include functional (pain relief, quality of life [QoL]), medical (endo- and exocrine function), and clinical (reoperation) results reported by patient. METHODS A cross-sectional cohort of 223 consecutive patients who underwent surgical drainage, head resection, or left-sided pancreas resection, depending on anatomical abnormalities, was analyzed. Participating patients were reassessed during a prospectively scheduled outpatient clinic visit. RESULTS At follow-up, 44 patients had died; 146 of 179 living patients consented to participate in the study. After 63 months (range: 14-268), 68% reported no or little pain, 19% reported intermediate pain, and 12% reported severe pain. Preoperative daily opioid use (OR: 3.04; 95% confidence interval [CI]: 1.09-8.49) and high numbers of preceding endoscopic procedures (OR [odds ratio]: 3.89; 95% CI: 1.01-14.9) were associated with persistent severe pain. Compared with the general population, physical more than mental QoL remained impaired (P < 0.05). At follow-up, endocrine insufficiency was present in 57% of patients and exocrine insufficiency was present in 77%. Independently, a head resection and a reoperation for any cause were moderately associated with new-onset diabetes (P < 0.1). Compared with patients who underwent left-sided resection, the risk of developing exocrine insufficiency after surgery was higher after drainage or head resection. After 20 months (interquartile range: 10-51) after surgery, 26 (12%) of 223 patients underwent 1 or more elective reoperations. CONCLUSIONS Operative intervention for painful CP, tailored to anatomical abnormalities, results in excellent to fair long-term pain relief, but approximately 10% of patients do not respond. QoL scores remained slightly compromised. High preoperative pain levels, suggested through daily opioid use and high numbers of endoscopic procedures, are associated with less favorable outcome.
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Morgan KA, Nishimura M, Uflacker R, Adams DB. Percutaneous transhepatic islet cell autotransplantation after pancreatectomy for chronic pancreatitis: a novel approach. HPB (Oxford) 2011; 13:511-6. [PMID: 21689235 PMCID: PMC3133718 DOI: 10.1111/j.1477-2574.2011.00332.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In selected patients with chronic pancreatitis, extensive pancreatectomy can be effective for the treatment of intractable pain. The resultant morbid diabetes can be ameliorated with islet autotransplantation (IAT). Conventionally, islet infusion occurs intraoperatively after islet processing. A percutaneous transhepatic route in the immediate postoperative period is an alternative approach. METHODS A prospectively collected database of patients undergoing pancreatectomy with percutaneous IAT (P-IAT) was reviewed. Hospital billing data were obtained and median charges determined and compared with estimated charges for an intraoperative infusion method of IAT (I-IAT). RESULTS Thirty-six patients (28 women; median age 48 years) underwent pancreatectomy with P-IAT. Median operative time was 232 min (range: 98-395 min) and median estimated blood loss was 500 cc (range: 75-3000 cc). Median time from pancreatic resection to islet transplantation was 269 min (range: 145-361 min). A median of 208 248 IEq (2298 IEq/kg) were harvested. Median peak portal venous pressure during islet infusion was 13 mmHg (range: 5-37 mmHg). Postoperative complications occurred in 15 patients (42%) and included hepatic artery pseudoaneurysm and portal vein thrombosis; the latter occurred in two patients with portal pressures during infusion > 30 mmHg. At a median follow-up of 10.7 months, eight patients (22%) were insulin-free. Median pertinent charges for P-IAT were US$36,318 and estimated median charges for I-IAT were US$56,440. Surgeon time freed by P-IAT facilitated an additional 66 procedures, charges for which amounted to US$463,375. CONCLUSIONS Percutaneous transhepatic IAT is feasible and safe. Islet infusion in the immediate postoperative period is cost-effective. Further follow-up is needed to assess longterm results.
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Affiliation(s)
- Katherine A Morgan
- Department of Surgery, Medical University of South CarolinaCharleston, SC, USA
| | - Michael Nishimura
- Department of Surgery, Medical University of South CarolinaCharleston, SC, USA
| | - Renan Uflacker
- Department of Radiology, Digestive Disease Center, Medical University of South CarolinaCharleston, SC, USA
| | - David B Adams
- Department of Surgery, Medical University of South CarolinaCharleston, SC, USA
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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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Murage KP, Ball CG, Zyromski NJ, Nakeeb A, Ocampo C, Sandrasegaran K, Howard TJ. Clinical framework to guide operative decision making in disconnected left pancreatic remnant (DLPR) following acute or chronic pancreatitis. Surgery 2010; 148:847-56; discussion 856-7. [PMID: 20797747 DOI: 10.1016/j.surg.2010.07.039] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Accepted: 07/15/2010] [Indexed: 12/17/2022]
Abstract
BACKGROUND Disconnected left pancreatic remnant (DLPR) presents clinically as a pancreatic fistula, pseudocyst, or obstructive pancreatitis. Optimal operative treatment, either distal pancreatectomy (DP) or internal drainage (ID), remains unknown. This paper critically evaluates our operative experience in patients with DLPR. METHODS A retrospective analysis of a consecutive case series from a single, high-volume institution was carried out. A total of 76 patients with radiographic-confirmed DLPR (computed tomography + endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography) who had operations between November 1995 and September 2008 were included. Pancreas preservation (the use of ID) was our default unless anatomic, physiologic, or technical factors precluded it. Follow-up to July 2009 was done (median follow-up, 22 months). Standard statistical methodology was used (P < .05 = statistical significance). RESULTS The mean age of this cohort was 52 years (range, 18-85); 57% of the patients were male. A total of 59 (73%) had acute pancreatitis, whereas 17 (22%) had chronic pancreatitis. Presentation was pseudocyst in 53%, pancreatic fistula in 34%, and obstructive pancreatitis in 13%. Resection (DP) and drainage (ID) options were utilized equally for each clinical presentation as follows: pseudocyst, 60/40; pancreatic fistula, 50/50; or obstructive pancreatitis, 50/50. The strongest driver for DP (92%) was a small pancreatic remnant and splenic vein thrombosis. In contrast, large pancreatic remnants had ID 70% of the time. No differences in short- or long-term outcomes between DP or ID options were identified. CONCLUSION Using anatomic, physiologic, and technical factors to guide operative choice in DLPR, we report a 74% success rate with DP and an 82% success rate with ID at a median follow-up of 22 months. A pancreatic remnant size >6 cm favored ID options over resection.
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Affiliation(s)
- Kariuki P Murage
- Departments of Surgery and Radiology, Indiana University School of Medicine, Indianapolis, IN, USA
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Morgan KA, Fontenot BB, Harvey NR, Adams DB. Revision of anastomotic stenosis after pancreatic head resection for chronic pancreatitis: is it futile? HPB (Oxford) 2010; 12:211-6. [PMID: 20590889 PMCID: PMC2889274 DOI: 10.1111/j.1477-2574.2009.00154.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Because survival after pancreaticoduodenectomy for cancer is limited, it is difficult to assess longterm pancreaticojejunal anastomotic patency. However, in patients with benign disease, pancreaticojejunal anastomotic stenosis may become problematic. What happens when pancreaticojejunal anastomosis revision is undertaken? METHODS Patients undergoing pancreatic anastomotic revision after pancreatic head resection for benign disease between 1997 and 2007 at the Medical University of South Carolina were identified. A retrospective chart review and analysis were undertaken with the approval of the Institutional Review Board for the Evaluation of Human Subjects. Longterm follow-up was obtained by patient survey at a clinic visit or by telephone. RESULTS During the study period, 237 patients underwent pancreatic head resection. Of these, 27 patients (17 women; median age 42 years) underwent revision of pancreaticojejunal anastomosis. Six patients (22%) had a pancreatic leak or abscess at the time of the index pancreatic head resection. The indication for revision of anastomosis was intractable pain. All patients underwent preoperative magnetic resonance cholangiopancreatography (MRCP), which indicated anastomotic stricture in 18 patients (63%). Nine other patients underwent exploration based on clinical suspicion caused by recurrent pancreatitis and stenosis was confirmed at the time of surgery. Six patients (22%) had perioperative complications after revision. The median length of stay was 12 days. There were no perioperative deaths; however, late mortality occurred in four patients (15%). Six of 23 survivors (26%) at the time of follow-up (median 56 months) reported longterm pain relief. CONCLUSIONS Stricture of the pancreaticojejunal anastomosis after pancreatic head resection presents with recurrent pancreatitis and pancreatic pain. MRCP has good specificity in the diagnosis of anastomotic obstruction, but lacks sensitivity. Pancreaticojejunal revision is safe, but rarely effective, as a means of pain relief in patients with the pain syndrome associated with chronic pancreatitis.
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Affiliation(s)
- Katherine A Morgan
- Section of Gastrointestinal Surgery, Digestive Disease Center, Medical University of South Carolina, Charleston, SC 29425, USA.
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