1
|
Khazaaleh S, Babar S, Alomari M, Imam Z, Chadalavada P, Gonzalez AJ, Kurdi BE. Outcomes of total pancreatectomy with islet autotransplantation: A systematic review and meta-analysis. World J Transplant 2023; 13:10-24. [PMID: 36687559 PMCID: PMC9850868 DOI: 10.5500/wjt.v13.i1.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/24/2022] [Accepted: 12/23/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite the increased use of total pancreatectomy with islet autotransplantation (TPIAT), systematic evidence of its outcomes remains limited.
AIM To evaluate the outcomes of TPIAT.
METHODS We searched PubMed, EMBASE, and Cochrane databases from inception through March 2019 for studies on TPIAT outcomes. Data were extracted and analyzed using comprehensive meta-analysis software. The random-effects model was used for all variables. Heterogeneity was assessed using the I2 measure and Cochrane Q-statistic. Publication bias was assessed using Egger’s test.
RESULTS Twenty-one studies published between 1980 and 2017 examining 1011 patients were included. Eighteen studies were of adults, while three studied pediatric populations. Narcotic independence was achieved in 53.5% [95% Confidence Interval (CI): 45-62, P < 0.05, I2 = 81%] of adults compared to 51.9% (95%CI: 17-85, P < 0.05, I2 = 84%) of children. Insulin-independence post-procedure was achieved in 31.8% (95%CI: 26-38, P < 0.05, I2 = 64%) of adults with considerable heterogeneity compared to 47.7% (95%CI: 20-77, P < 0.05, I2 = 82%) in children. Glycated hemoglobin (HbA1C) 12 mo post-surgery was reported in four studies with a pooled value of 6.76% (P = 0.27). Neither stratification by age of the studied population nor meta-regression analysis considering both the study publication date and the islet-cell-equivalent/kg weight explained the marked heterogeneity between studies.
CONCLUSION These results indicate acceptable success for TPIAT. Future studies should evaluate the discussed measures before and after surgery for comparison.
Collapse
Affiliation(s)
- Shrouq Khazaaleh
- Department of Internal Medicine, Cleveland Clinic Fairview Hospital, Cleveland, OH 44126, United States
| | - Sumbal Babar
- Department of Internal Medicine-Infectious Diseases Division, University of Texas Health Science Center at San Antonio, San Antonio, TX 78249, United States
| | - Mohammad Alomari
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, FI 33324, United States
| | - Zaid Imam
- Department of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
| | - Pravallika Chadalavada
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, FI 33331, United States
| | - Adalberto Jose Gonzalez
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, FI 33331, United States
| | - Bara El Kurdi
- Department of Gastroenterology and Hepatology, University of Texas Health Science Center at San Antonio, San Antonio, TX 78249, United States
| |
Collapse
|
2
|
Abu-El-Haija M, Anazawa T, Beilman GJ, Besselink MG, Del Chiaro M, Demir IE, Dennison AR, Dudeja V, Freeman ML, Friess H, Hackert T, Kleeff J, Laukkarinen J, Levy MF, Nathan JD, Werner J, Windsor JA, Neoptolemos JP, Sheel ARG, Shimosegawa T, Whitcomb DC, Bellin MD. The role of total pancreatectomy with islet autotransplantation in the treatment of chronic pancreatitis: A report from the International Consensus Guidelines in chronic pancreatitis. Pancreatology 2020; 20:762-771. [PMID: 32327370 DOI: 10.1016/j.pan.2020.04.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 03/18/2020] [Accepted: 04/06/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Advances in our understanding of total pancreatectomy with islet autotransplantation (TPIAT) have been made. We aimed to define indications and outcomes of TPIAT. METHODS Expert physician-scientists from North America, Asia, and Europe reviewed the literature to address six questions selected by the writing group as high priority topics. A consensus was reached by voting on statements generated from the review. RESULTS Consensus statements were voted upon with strong agreement reached that (Q1) TPIAT may improve quality of life, reduce pain and opioid use, and potentially reduce medical utilization; that (Q3) TPIAT offers glycemic benefit over TP alone; that (Q4) the main indication for TPIAT is disabling pain, in the absence of certain medical and psychological contraindications; and that (Q6) islet mass transplanted and other disease features may impact diabetes mellitus outcomes. Conditional agreement was reached that (Q2) the role of TPIAT for all forms of CP is not yet identified and that head-to-head comparative studies are lacking, and that (Q5) early surgery is likely to improve outcomes as compared to late surgery. CONCLUSIONS Agreement on TPIAT indications and outcomes has been reached through this working group. Further studies are needed to answer the long-term outcomes and maximize efforts to optimize patient selection.
Collapse
Affiliation(s)
- Maisam Abu-El-Haija
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Takayuki Anazawa
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - Gregory J Beilman
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marco Del Chiaro
- Department of Surgery, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Ashley R Dennison
- Department of Hepatobiliary and Pancreatic Surgery, University of Leicester, UK
| | - Vikas Dudeja
- Department of Surgery, University of Miami, Miami, FL, USA
| | - Martin L Freeman
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Helmut Friess
- Department of Surgery, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany
| | - Jorg Kleeff
- Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Faculty of Medicine and Health Technology, Tampere University, Finland
| | - Marlon F Levy
- Division of Transplant Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Jaimie D Nathan
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, University of Munich, LMU, Germany
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - John P Neoptolemos
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Andrea R G Sheel
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - David C Whitcomb
- Department of Medicine, Cell Biology & Physiology, and Human Genetics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melena D Bellin
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, USA; Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA.
| |
Collapse
|
3
|
Kobayashi T, Miura K, Ishikawa H, Soma D, Zhang Z, Yuza K, Hirose Y, Takizawa K, Nagahashi M, Sakata J, Kameyama H, Kosugi SI, Tada T, Hirukawa H, Wakai T. Six-Year Graft Survival After Partial Pancreas Heterotopic Auto-Transplantation: A Case Report. Transplant Proc 2016; 48:988-90. [PMID: 27234786 DOI: 10.1016/j.transproceed.2016.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 01/14/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Long-term graft survival of partial pancreas auto-transplantation after total pancreatectomy has not been clarified. The clinical implications of repeat completion pancreatectomy for locally recurrent pancreatic carcinoma in the remnant pancreas after initial pancreatectomy also have not been clarified. METHODS We have previously reported a 61-year-old woman presenting with re-sectable carcinoma of the remnant pancreas at 3 years after undergoing a pylorus-preserving pancreaticoduodenectomy for invasive ductal carcinoma of the pancreas head. We also performed distal pancreas auto-transplantation with the use of a part of the resected pancreas to preserve endocrine function. RESULTS The patient was discharged at 20 days after surgery without any complications. She had been followed regularly in our outpatient clinic. She had been treated with S-1 as adjuvant chemotherapy; 72 months after the completion total pancreatectomy with distal partial pancreas auto-transplantation, the patient was alive without any evidence of the pancreatic carcinoma recurrence. The pancreas graft was still functioning with a blood glucose level of 112 mg/dL, HbA1C of 6.7%, and serum C-peptide of 1.2 ng/mL; and urinary C-peptide was 11.6 μg/d. CONCLUSIONS Our patient demonstrated that repeated pancreatectomies can provide a chance for survival after a locally recurrent pancreatic carcinoma if the disease is limited to the remnant pancreas. An additional partial pancreas auto-transplantation was successfully performed to preserve endocrine function. However, the indications for pancreas auto-transplantation should be decided carefully in the context of pancreatic carcinoma recurrence.
Collapse
Affiliation(s)
- T Kobayashi
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.
| | - K Miura
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - H Ishikawa
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - D Soma
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Z Zhang
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - K Yuza
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Y Hirose
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - K Takizawa
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - M Nagahashi
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - J Sakata
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - H Kameyama
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - S-I Kosugi
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - T Tada
- Department of Surgery, Tachikawa General Hospital, Nagaoka, Japan
| | - H Hirukawa
- Department of Surgery, Tachikawa General Hospital, Nagaoka, Japan
| | - T Wakai
- Division of Digestive and General Surgery, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| |
Collapse
|
4
|
Merani S, Toso C, Emamaullee J, Shapiro AMJ. Optimal implantation site for pancreatic islet transplantation. Br J Surg 2008; 95:1449-61. [PMID: 18991254 DOI: 10.1002/bjs.6391] [Citation(s) in RCA: 181] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Since the first report of successful pancreatic islet transplantation to reverse hyperglycaemia in diabetic rodents, there has been great interest in determining the optimal site for implantation. Although the portal vein remains the most frequently used site clinically, it is not ideal. About half of the islets introduced into the liver die during or shortly after transplantation. Although many patients achieve insulin independence after portal vein infusion of islets, in the long term most resume insulin injections. METHODS This review considers possible sites and techniques of islet transplantation in small and large animal models, and in humans. Metabolic, immunological and technical aspects are discussed. RESULTS AND CONCLUSION Many groups have sought an alternative site that might offer improved engraftment and long-term survival, together with reduced procedure-related complications. The spleen, pancreas, kidney capsule, peritoneum and omental pouch have been explored. The advantages and disadvantages of various sites are discussed in order to define the most suitable for clinical use and to direct future research.
Collapse
Affiliation(s)
- S Merani
- Surgical Medical Research Institute, University of Alberta, Edmonton, Canada
| | | | | | | |
Collapse
|
5
|
Blondet JJ, Carlson AM, Kobayashi T, Jie T, Bellin M, Hering BJ, Freeman ML, Beilman GJ, Sutherland DER. The role of total pancreatectomy and islet autotransplantation for chronic pancreatitis. Surg Clin North Am 2008; 87:1477-501, x. [PMID: 18053843 DOI: 10.1016/j.suc.2007.08.014] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Total pancreatectomy and islet autotransplantation are done for chronic pancreatitis with intractable pain when other treatment measures have failed, allowing insulin secretory capacity to be preserved, minimizing or preventing diabetes, while at the same time removing the root cause of the pain. Since the first case in 1977, several series have been published. Pain relief is obtained in most patients, and insulin independence preserved long term in about a third, with another third having sufficient beta cell function so that the surgical diabetes is mild. Islet autotransplantation has been done with partial or total pancreatectomy for benign and premalignant conditions. Islet autotransplantation should be used more widely to preserve beta cell mass in major pancreatic resections.
Collapse
Affiliation(s)
- Juan J Blondet
- Division of Surgical Critical Care/Trauma, Department of Surgery, University of Minnesota, MMC 11, 420 Delaware Street Southeast, Minneapolis, MN 55455, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Sakorafas GH, Tsiotou AG, Peros G. Mechanisms and natural history of pain in chronic pancreatitis: a surgical perspective. J Clin Gastroenterol 2007; 41:689-99. [PMID: 17667054 DOI: 10.1097/mcg.0b013e3180301baf] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pain is a major clinical manifestation of chronic pancreatitis (CP) and a common indication for surgery in these patients. Pathogenesis of pain in CP is multifactorial and the mechanisms of pain may differ from patient to patient. This can explain why one therapeutic method of treatment of pain does not work in all patients and in different stages of the disease. Two main complimentary pathogenetic theories have been proposed to explain the mechanisms of pain in CP, the neurogenic theory and the theory of increased intraductal/intraparenchymal pressures. According to the neurogenic theory, in CP there are alterations of pancreatic/peripancreatic nerves, exposing them to noxious substances and/or activated immune cells, thereby generating pain ("neuroimmune interaction"). The other theory of intraductal/intraparenchymal hypertension suggests that pain in CP is generated as a result of increased pressures within the pancreatic ductal system and/or pancreatic parenchyma, like the pain in the classic compartment syndrome. The theory of intraductal/intraparenchymal hypertension is strongly supported by the good results of drainage procedures in the surgical management of CP. Pancreatic ischemia, oxygen-free radicals, centrally sensitized pain state, acute exacerbations of CP, development of complications from the pancreas (most commonly, pseudocysts) or adjacent organs (usually, duodenal and/or common bile duct stenosis), etc. are other possible contributing factors. Different patterns of pain have been described in idiopathic (early vs. late onset) and in alcoholic CP. Interestingly, pain is automatically relieved during the natural course of the disease in some patients (the "burn-out" phenomenon), after a relatively long time (from a few years to up to 3 decades). However, this is an unpredictable evolution for the individual patient. Therefore, surgery should be offered when pain is intense and after failure of conservative treatment. Surgical management should be individualized, depending on the particular findings of each patient. The knowledge of the pathophysiologic basis and of natural course of pain in CP is of paramount importance for the surgeon to select appropriate therapy for the individual patient with CP.
Collapse
Affiliation(s)
- George H Sakorafas
- Fourth Department of Surgery, Athens University, Medical School, ATTIKON University Hospital, Athens, Greece.
| | | | | |
Collapse
|
7
|
Islet autotransplantation to prevent or minimize diabetes after pancreatectomy. Curr Opin Organ Transplant 2007; 12:82-88. [DOI: 10.1097/mot.0b013e328012dd9e] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
8
|
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.
Collapse
Affiliation(s)
- Nazir A Wani
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Soura, Srinagar, Kashmir 190011, India
| | | | | |
Collapse
|
9
|
Abstract
The apancreatic state secondary to resective surgery for chronic pancreatitis is associated with a high rate of late morbidity and mortality that is due, in part, to endocrine insufficiency. Resective procedures should, therefore, be used very selectively. Over the last 2 decades we have seen a shift from extensive distal resections to limited proximal resections. This is because of the lowering of the operative mortality of pancreatic head resection and its better results in pain relief, while preserving in situ the body and tail of the gland with its metabolic functions. Islet autotransplantation and segmental pancreatic autotransplantation were introduced in 1977 and 1978, respectively. Over 150 and 25 cases of these operations have been reported, respectively. Both techniques are evolving with a goal to improve results. Procedures placing the graft in the iliac fossa and anastomosing the pancreatic duct to the jejunum are now favored over groin placement and duct occlusion. Islet autotransplants achieve a higher yield of islet cells and decrease the exocrine impurity of the preparation. Both methods can prevent or delay the onset of diabetes mellitus, and when diabetes mellitus does occur, it is frequently easier to manage. The long-term function of the grafts appears to be dependent on the beta-cell mass available in the diseased pancreas, the loss of cells related to the transplant procedure, and the characteristics of gradual loss of function from the type of transplant used. Although extensive pancreatic resections are occasionally required, the possibility of autotransplantation should be considered in those patients.
Collapse
Affiliation(s)
- J Guillermo Watkins
- Department of Surgery, Universidad Católica de Chile, Santiago 764-0543, Chile
| | | | | |
Collapse
|
10
|
Wong GY, Sakorafas GH, Tsiotos GG, Sarr MG. Palliation of pain in chronic pancreatitis. Use of neural blocks and neurotomy. Surg Clin North Am 1999; 79:873-93. [PMID: 10470333 DOI: 10.1016/s0039-6109(05)70049-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Effective management of the pain of chronic pancreatitis may require a multidisciplinary approach involving gastroenterologists, anesthesiologists, psychologists or counselors for chemical addiction (alcohol, narcotics), and surgeons. Viable approaches use pharmacologic analgesics with selected psychotropic medications, celiac plexus blocks, and possibly thoracoscopic splanchnic nerve transections. If these management techniques that preserve pancreatic parenchyma and function, fail, resective surgical therapy may be indicated. For most of these patients, all attempts at nonresective therapy should be exhausted before operative intervention.
Collapse
Affiliation(s)
- G Y Wong
- Department of Anesthesiology, Mayo Clinic and Foundation, Rochester, Minnesota, USA
| | | | | | | |
Collapse
|
11
|
Yamaguchi T, Miyata M, Kamiike W, Kobayashi Y, Matsuda H. Histometric analysis of the distal pancreas in pancreatic head cancer. Surg Today 1997; 27:420-8. [PMID: 9130344 DOI: 10.1007/bf02385705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
To clarify the histological status of the pancreas tail after pancreatoduodenectomy (PD), fibrosis, islets of Langerhans, and A, B, and D cells were examined histometrically in surgical cases of pancreatic cancer. The same investigations were also performed during an autopsy examination of the pancreas tail of survivors of surgery who had received either PD or total pancreatectomy with segmental autotransplantation (SAT). In the surgical cases, fibrosis and the islet percentage compared with nonpancreatic cancer cases were significantly higher while the B cell ratio was significantly lower. In addition, in pancreatic cancer patients, the fibrosis and islet ratio in the group with a blocked pancreatic duct were higher while the B cell ratio was lower than in the group with an open pancreatic duct. A direct relationship between the islet ratio and the degree of fibrosis, and an inverse relationship between the B cell ratio and the degree of fibrosis, were thus found. From the autopsy cases, the fibrosis progressed and the islet ratio increased following PD, but after SAT only the islet ratio increased compared to the time of surgery. The progression of fibrosis after PD thus suggests the presence of some problems in both the surgical method and postoperative management.
Collapse
Affiliation(s)
- T Yamaguchi
- First Department of Surgery, Osaka University Medical School, Japan
| | | | | | | | | |
Collapse
|
12
|
Abstract
The medical records of patients subjected to distal pancreatectomy for chronic pancreatitis from 1982 to 1992 were reviewed to ascertain if pain relief could be predicted based on computed axial tomography (CAT) and endoscopic retrograde cholangiopancreatography (ERCP) findings. Of 10 patients who had severe pain preoperatively and disease limited to the body or tail of the pancreas, 9 had no pain or only mild pain postoperatively. Of 7 patients with severe pain preoperatively and diffuse disease or disease localized to the head of the pancreas, 6 required further hospitalization and resection or drainage procedures for severe, recurrent pain. We believe 50% to 60% of distal pancreatectomy procedures meet most criteria for the best operation for a select group of patients with chronic pancreatitis: those patients with severe pain, small ducts (< 5 mm), and whose disease is limited to the body or tail of the gland.
Collapse
Affiliation(s)
- R Sawyer
- Department of Surgery, University of California, Davis Medical Center, Sacramento, California 95817
| | | |
Collapse
|
13
|
Tamura K, Yano S, Kin S, Nagami H, Itakura M, Nakagawa M, Nakase A, Tsuchiya R. Heterotopic autotransplantation of a pancreas segment with enteric drainage after total or subtotal pancreatectomy for chronic pancreatitis. INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1993; 13:119-27. [PMID: 8501353 DOI: 10.1007/bf02786080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Four patients with chronic alcoholic pancreatitis and one patient with idiopathic chronic pancreatitis, who had total or subtotal distal pancreatectomies for persistent pain, underwent simultaneous autotransplantation of a pancreas segment to preserve the pancreatic function. The segment was autotransplanted heterotopically to the iliac fossa with anastomosis of the splenic vessels to the iliac vessels to prevent reinnervation, and the pancreatic duct was anastomosed to the intestine to preserve exocrine function. Postoperatively, the patency of the graft vessels was confirmed by angiography in every patient. Complete pain relief has been obtained in all patients with a followup duration of 4-89 mo. Except for one patient who had been treated preoperatively with insulin injections for diabetes, the patients remained normoglycemic without exogenous insulin administration and demonstrated satisfactory insulin secretion during a 75-g oral glucose tolerance test. An exocrine pancreatic diagnostant test using p-aminobenzoic acid yielded nearly similar levels to the preoperative value for all patients. Heterotopic autotransplantation of the pancreas segment appears to be effective for preserving pancreatic function, as well as providing permanent pain relief for patients with chronic pancreatitis who require extensive resection of the pancreas.
Collapse
Affiliation(s)
- K Tamura
- First Department of Surgery, Shimane Medical University, Izumo, Japan
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Rossi RL, Soeldner JS, Braasch JW, Heiss FW, Shea JA, Watkins E, Silverman ML. Long-term results of pancreatic resection and segmental pancreatic autotransplantation for chronic pancreatitis. Am J Surg 1990; 159:51-7; discussion 57-8. [PMID: 2403763 DOI: 10.1016/s0002-9610(05)80606-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Thirteen patients who underwent extensive pancreatic resection and segmental autotransplantation and who have a median follow-up of 62 months are presented. Eleven patients had technically successful grafts. Three of six patients who underwent total pancreatectomy and three of five patients who underwent near-total resection remain insulin-independent. Those patients who require insulin require small doses and have stable diabetes. Pain has recurred in 7 of the 11 patients who underwent distal subtotal resection; 5 of them required pancreatoduodenectomy and completion pancreatectomy for pain relief. Because of the high rate of recurrence of pain after distal resection, we favor pancreatoduodenectomy as the initial procedure of choice. When distal near-total or total pancreatectomy is required, the addition of segmental autotransplantation offers definitive, although at times transient, benefits in glucose homeostasis compared with no transplantation.
Collapse
Affiliation(s)
- R L Rossi
- Department of General Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts 01805
| | | | | | | | | | | | | |
Collapse
|
15
|
Cuilleret J, Guillemin G. Surgical management of chronic pancreatitis on the continent of Europe. World J Surg 1990; 14:11-8. [PMID: 2407033 DOI: 10.1007/bf01670539] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Surgical management of chronic pancreatitis remains a difficult problem. On the continent of Europe, the main etiology of the disease is alcoholism; thus, alcohol withdrawal is mandatory before surgical treatment. Left splanchnicectomy is no longer used. Total and left subtotal pancreatectomy are abandoned due to their high mortality rates and their severe metabolic sequelae. Distal pancreatectomy is presently reserved for the cases in which the head of the pancreas is least involved. The choice between pancreaticojejunostomy and pancreaticoduodenectomy remains debated. The former has a low postoperative mortality rate while reoperation is less frequent after the latter. Current trends in Europe are to perform more anastomoses and less resections than some years ago. Pancreaticoduodenectomy, however, retains an important role in cases with biliary or duodenal involvement. Whatever the choice of the procedure, the surgical treatment of chronic pancreatitis remains palliative and does not alter the natural course of the disease. The quality and duration of the results depend mainly on alcohol withdrawal.
Collapse
Affiliation(s)
- J Cuilleret
- Chirurgien des Hopitaux, Service de Chirurgie Digestive C.H.U. de Saint-Etienne, France
| | | |
Collapse
|
16
|
Di Carlo V, Chiesa R, Pontiroli AE, Carlucci M, Staudacher C, Zerbi A, Cristallo M, Braga M, Pozza G. Pancreatoduodenectomy with occlusion of the residual stump by Neoprene injection. World J Surg 1989; 13:105-10; discussion 110-1. [PMID: 2543144 DOI: 10.1007/bf01671167] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Pancreatojejunal anastomosis disruption still represents the main postoperative complication after pancreatoduodenectomy. In this study, a technique of occlusion of the residual pancreatic stump instead of pancreatojejunal anastomosis is proposed. Between March, 1981 and August, 1987, we performed 51 pancreatoduodenectomies, using Neoprene injection in the Wirsung duct, for carcinoma of the pancreatic head (28 cases), ampullary carcinoma (12 cases), islet cell carcinoma (5 cases), and chronic pancreatitis (6 cases). We observed a 33.3% overall morbidity, with a 5.8% operative mortality. The complications observed seemed not to be related to the technique of pancreatic stump occlusion, except for 2 pancreatic fistulas which spontaneously resolved. Abdominal ultrasound and computed tomography scan performed during the follow-up did not show any significant morphological alteration of the residual stump. Pancreatic endocrine function was assessed in 10 patients by evaluating blood glucose, plasma insulin and plasma glucagon levels both fasting and after oral glucose, and intravenous arginine infusion. These tests were performed before surgery and 15 days, 6 months, 1, 2, and 3 years after surgery. The results showed that 60% of the patients had impaired glucose tolerance before surgery and the percentage did not significantly change up to 3 years later (75%). No patient developed diabetes mellitus, and only 1 patient progressed from a normal to an impaired glucose tolerance. In conclusion, intraductal injection of Neoprene after pancreatoduodenectomy seems to be a safer procedure compared to pancreatojejunal anastomosis and does not induce a post-surgical diabetes.
Collapse
|
17
|
Hardy JD. Transplantation of tissues and organs. Review of the first 100 years of the Southern Surgical Association. Ann Surg 1988; 207:776-87. [PMID: 3291798 PMCID: PMC1493542 DOI: 10.1097/00000658-198806000-00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- J D Hardy
- University of Mississippi Medical Center, Jackson
| |
Collapse
|
18
|
Mitsuno M, Miyata M, Okuda A, Nakashima N, Sasako Y, Yamaguchi T, Takako T. Segmental autotransplantation of the pancreas after total pancreatectomy for advanced periampullary carcinoma--a case report. THE JAPANESE JOURNAL OF SURGERY 1988; 18:363-8. [PMID: 3043072 DOI: 10.1007/bf02471457] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A case is reported here in which segmental autotransplantation of the pancreas was performed after total pancreatectomy for advanced periampullary carcinoma in an attempt to preserve pancreatic endocrine function. The postoperative course was uneventful. The requirement of insulin decreased after the operation and the daily profile examination, done 5 months following surgery, showed a permissive fluctuation of blood sugar levels without insulin injection. Thus, segmental autotransplantation of the pancreas offers a method of preserving pancreatic endocrine function after total pancreatectomy for periampullary carcinoma in selected patients.
Collapse
Affiliation(s)
- M Mitsuno
- Department of Surgery, Kinan General Hospital, Wakayama, Japan
| | | | | | | | | | | | | |
Collapse
|
19
|
Abstract
Pancreatitis is not one disease but several and perhaps many. Diagnosis is imperfect in all forms and the usual lack of histologic material has hampered attempts to understand the pathogenesis and possible interrelationships of the different forms of pancreatic inflammation. Acute pancreatitis does not as a rule evolve into chronic pancreatitis, even after multiple recurrences. Recurrent acute attacks can be ended by identifying and treating the factor causing the disease, including recently recognized entities such as accessory papilla stenosis associated with pancreas divisum. Attempts to improve the treatment of severe acute pancreatitis are focussing upon preventing injury to pancreatic cell structures, enhancing endogenous mechanisms for capture and disposal of activated enzymes, and upon early detection and debridement of damaged pancreatic and peripancreatic tissues. Pancreatic duct stricture or obstruction as a consequence of scarring from necrotizing pancreatitis may produce recurrent symptoms, now designated as obstructive pancreatitis. Obstructive pancreatitis has its own unique histologic characteristics and is appropriately treated by resection of the blocked segment of pancreas when the point of obstruction is distal to the papilla. Chronic pancreatitis differs from acute or obstructive pancreatitis in that it is difficult or impossible to halt its progression. The role of intraductal protein precipitates, whether of enzymes or perhaps of other unique pancreatic secretory proteins, in the pathogenesis of the disease is being evaluated. The goal of surgical treatment is not to cure, but to reduce pain, overcome associated obstruction of the bile duct or duodenum, and to treat pancreatic duct disruptions including pseudocysts and internal pancreatic fistulas. Because continuing deterioration of pancreatic function is to be expected in chronic pancreatitis, maximum conservation of pancreatic tissue by avoiding resectional procedures is advisable.
Collapse
|