Impact of pancreatic head resection on direct medical costs in patients with chronic pancreatitis

Swedish national guidelines for chronic pancreatitis

Chronic pancreatitis (CP) should be suspected in the case of recurrent upper abdominal pain of unknown origin and/or clinical signs of exocrine pancreatic insufficiency (EPI). Alcohol is the most common etiological factor associated with CP, others being smoking, male gender, and hereditary forms. CP is often associated with recurrent episodes of acute exacerbations.As of today, there is no accepted clinical definition of CP. However, irreversible morphological changes within the pancreas often occur, including dilatation of the main and branch pancreatic ducts, calcifications in ducts and parenchyma, parenchymal atrophy, and development of pseudocysts, though less so in the early phase of CP.

Geographical variance in reporting of elective surgery for chronic pancreatitis

The selection of optimum surgical procedure from the range of reported operations for chronic pancreatitis (CP) can be difficult. The aim of this study is to explore geographical variation in reporting of elective surgery for CP. A systematic search of the literature was performed using the Scopus database for reports of five selected procedures for CP: duodenum-preserving pancreatic head resection, total pancreatectomy with islet autotransplantation (TPIAT), Frey pancreaticojejunostomy, thoracoscopic splanchnotomy and the Izbicki V-shaped resection. The keyword and MESH heading 'chronic pancreatitis' was used. Overall, 144 papers met inclusion criteria and were utilized for data extraction. There were 33 reports of duodenum-preserving pancreatic head resection. Twenty-one (64%) were from Germany. There were 60 reports of TPIAT, 53 (88%) from the USA. There are only two reports of TPIAT from outwith the USA and UK. The 34 reports of the Frey pancreaticojejunostomy originate from 12 countries. There were 20 reports of thoracoscopic splanchnotomy originating from nine countries. All three reports of the Izbicki 'V' procedure are from Germany. There is geographical variation in reporting of surgery for CP. There is a need for greater standardization in the selection and reporting of surgery for patients with painful CP.

Diagnostic and therapeutic recommendations for chronic pancreatitis. Recommendations of the Working Group of the Polish Society of Gastroenterology and the Polish Pancreas Club

This article describes the latest diagnostic and therapeutic recommendations in chronic pancreatitis, developed by the Working Group of the Polish Society of Gastroenterology and the Polish Pancreas Club. The recommendations refer to the diagnosis of chronic pancreatitis, autoimmune pancreatitis, conservative management, treatment of pain, and exocrine and endocrine pancreatic insufficiency, treatment of chronic pancreatitis by endoscopic and surgical methods, and oncological surveillance of chronic pancreatitis. This paper refers to the Polish recommendations published in 2011, which have been updated and supplemented. All recommendations were voted by experts of the Polish Society of Gastroenterology and the Polish Pancreas Club, who evaluated them each time on a five-degree scale, where I meant full acceptance, II – acceptance with some reservation, III – acceptance with serious reservation, IV – rejection with some reservation and V – full rejection. The results of the voting, together with a brief commentary, have been included with each recommendation put to the vote. In addition, the expert group assessed the value of clinical studies on which the statements are based, on a scale where A means high (based on meta-analyses and randomised clinical trials), B means medium (based on clinical trials and observational studies), and C means low (based mainly on expert opinion).

Cost-effectiveness of benign Wirsung duct strictures treatment in chronic pancreatitis

Introduction

Chronic pancreatitis (CP) is an important problem for modern medicine, the healthcare system (Poland – NFZ) and the national insurance system (Poland – ZUS). The chronic nature of the disease, the lack of targeted treatment and the low mortality rate lead to an accumulation of patients who demand expensive treatment, both conservative and invasive. Rising costs in health care are forcing the need for a more cost-effective method of treatment.

Aim

The primary aim of this study was to perform a retrospective calculation of costs in both surgical and endoscopic treatment, hospital stay, healthcare, and public insurance of patients suffering from chronic pancreatitis. Parallel quality of life analysis was performed. It was possible to develop a cost-effective therapeutic algorithm for patients with an uncomplicated stricture of Wirsung’s duct within the Polish health care system.

Results

In Poland, the hospital costs of endoscopic treatment of patients with chronic pancreatitis were higher than those of the surgical treatment group despite both resulting in a similar life quality.

Conclusions

From a cost-effectiveness perspective, it was shown that surgical intervention is a more cost-effective therapy than endotherapy. Furthermore, patients with benign stricture of the main pancreatic duct in chronic pancreatitis should not be treated with endotherapy for longer than 12 months.

The socio-economic impact of chronic pancreatitis: a systematic review

RATIONALE, AIMS AND OBJECTIVES

Chronic pancreatitis (CP) is a progressive inflammatory disorder with pain being the most frequent symptom. It is associated with loss of function, pancreatogenic diabetes and digestive enzyme deficiency. The impact of local complications and loss of pancreatic function results in unknown and unreported costs. This study attempts to identify both the direct and indirect costs associated with CP.

METHODS

A MEDLINE literature review was performed for all relevant articles relating to any aspect of direct and indirect costs as a result of CP.

RESULTS

In the UK, there are 12,000 admissions per annum of patients with CP at an estimated cost of £55.8 million. The costs for loss of pancreatic function are estimated at £45-90 million and $75.1 million for endocrine and exocrine function, respectively. Chronic pain contributes $638 million per year in costs. The protracted course of CP and paucity of monetary data make quantifying direct and indirect costs difficult. An estimate of direct and indirect costs is at £285.3 million per year. This equates to £79,000 per person per year.

CONCLUSIONS

Patients with CP consume a disproportionately high volume of resources.

Management of mucinous cystic neoplasms of the pancreas

The purpose of this study was to investigate the actual management of mucinous cystic neoplasm (MCN) of the pancreas. A systematic review was performed in December 2009 by consulting PubMed MEDLINE for publications and matching the key words “pancreatic mucinous cystic neoplasm”, “pancreatic mucinous cystic tumour”, “pancreatic mucinous cystic mass”, “pancreatic cyst”, and “pancreatic cystic neoplasm” to identify English language articles describing the diagnosis and treatment of the mucinous cystic neoplasm of the pancreas. In total, 16 322 references ranging from January 1969 to December 2009 were analysed and 77 articles were identified. No articles published before 1996 were selected because MCNs were not previously considered to be a completely autonomous disease. Definition, epidemiology, anatomopathological findings, clinical presentation, preoperative evaluation, treatment and prognosis were reviewed. MCNs are pancreatic mucin-producing cysts with a distinctive ovarian-type stroma localized in the body-tail of the gland and occurring in middle-aged females. The majority of MCNs are slow growing and asymptomatic. The prevalence of invasive carcinoma varies between 6% and 55%. Preoperative diagnosis depends on a combination of clinical features, tumor markers, computed tomography (CT), magnetic resonance imaging, endoscopic ultrasound with cyst fluid analysis, and positron emission tomography-CT. Surgery is indicated for all MCNs.

Italian consensus guidelines for chronic pancreatitis

This paper gives practical guidelines for diagnosis and treatment of chronic pancreatitis. Statements have been elaborated by working teams of experts, by searching for and analysing the literature, and submitted to a consensus process by using a Delphi modified procedure. The statements report recommendations on clinical and nutritional approach, assessment of pancreatic function, treatment of exocrine pancreatic failure and of secondary diabetes, treatment of pain and prevention of painful relapses. Moreover, the role of endoscopy in approaching pancreatic pain, pancreatic stones, duct narrowing and dilation, and complications was considered. Recommendations for most appropriate use of various imaging techniques and of ultrasound endoscopy are reported. Finally, a group of recommendations are addressed to the surgical treatment, with definition of right indications, timing, most appropriate procedures and techniques in different clinical conditions and targets, and clinical and functional outcomes following surgery.

The epidemiology and socioeconomic impact of chronic pancreatitis

Epidemiological studies have been published worldwide in recent decades describing the incidence, mortality, aetiology and trends of chronic pancreatitis. Accumulated evidence suggests that chronic pancreatitis is increasing in incidence and hospital admission rates are rising accordingly. Alcoholic chronic pancreatitis was previously more common in the developed world than elsewhere, but is now increasing worldwide due to growing per capita alcohol consumption in each nation. Supporting alcohol and smoking cessation in individual patients is essential to slow disease progression and improve overall health, as most patients will die of cirrhosis, cardiovascular disease or smoking related cancers rather than chronic pancreatitis. The socioeconomic impact of chronic pancreatitis is difficult to quantify as little data exists, however given the rising incidence the costs to health care and society are likely to increase. This chapter will describe the epidemiology and aetiology of chronic pancreatitis worldwide and discusses the factors that influence its socioeconomic impact.

Consensus guidelines in the management of branch duct intraductal papillary mucinous neoplasm: a cost-effectiveness analysis

BACKGROUND AND AIMS

Based on consensus guidelines, surgical resection of branch duct intraductal papillary mucinous neoplasm (BD-IPMN) is indicated in patients with symptoms of cyst size >or=30 mm, intramural nodules, or dilated main pancreatic duct greater than 6 mm. The aim of this study was to determine the cost effectiveness of consensus guideline implementation in the management of BD-IPMN.

METHODS

We developed a decision analytic model to compare the costs and effectiveness of three management strategies for a cohort of 60-year-old patients with branch duct IPMN: (1) surveillance using consensus guidelines for surgical resection (surveillance strategy), (2) surgical resection based on symptoms without surveillance (no surveillance strategy), and (3) immediate surgery (surgery strategy). The primary outcomes were quality-adjusted life years (QALYs), cost, and incremental cost-effectiveness ratio (ICER). Sensitivity analysis was performed over a wide ranges of estimates.

RESULTS

The no surveillance strategy was the least costly, but also the least effective, while the surgery strategy was the most costly and most effective. Compared to the no surveillance strategy, the surveillance strategy cost an additional $20,096 per QALY. The incremental cost-effectiveness ratio of the surgery strategy compared with the surveillance strategy was $132,436 per QALY. In a probabilistic sensitivity analysis, if society was willing to pay $50,000 per quality-adjusted life year gained, then 88.1% of patients using the surveillance strategy would be within budget.

CONCLUSIONS

Immediate surgery is the most effective, but may be prohibitively expensive. The surveillance strategy is a cost-effective option compared to no surveillance.

Duodenum-preserving total pancreatic head resection for cystic neoplasm: a limited but cancer-preventive procedure

BACKGROUND

Cystic neoplastic lesions of the pancreas are found in up to 10% of all pancreatic lesions. A malignant transformation of cystic neoplasia is observed in intraductal papillary mucinous tumor (IPMN) lesions in 60% and in mucinous cystic tumor (MCN) lesions in up to 30%. For cystic neoplasia located monocentrically in the pancreatic head and that do not have an association with an invasive pancreatic cancer, the duodenum-preserving total head resection has been used in recent time as a limited surgical procedure.

PATIENTS

An indication to duodenum-preserving total pancreatic head resection is considered for patients who do not have clinical signs of an advanced cancer in the lesion and who have main-duct IPMN and monocentric MCN lesions. In 104 patients with cystic neoplastic lesions in the Ulm series, 32% finally had a carcinoma in situ or an advanced pancreatic cancer. The application of a duodenum-preserving total pancreatic head resection in patients with asymptomatic cystic lesion is based on the size of the tumor and the tumor relation to the pancreatic ducts. For patients who have preoperatively clinical signs of malignancy, a Kausch-Whipple type of oncologic resection is recommended.

RESULTS

Duodenum-preserving total pancreatic head resection is used in several modifications. The surgical procedure is a limited pancreatic head resection which necessitates segmental resection of the peripapillary duodenum. Hospital mortality is very low; in most published series it is 0%. The long-term outcome is determined by completeness of resection for both -- benign and malignant -- entities. Careful evaluation of the frozen section results has a pivotal role for intraoperative decision making.

CONCLUSION

A duodenum-preserving total pancreatic head resection is a limited surgical procedure for patients who suffer a local monocentric, cystic neoplastic lesion in the pancreatic head. Absence of an advanced pancreatic cancer and completeness of extirpation of the benign tumor determine the long-term outcome. In regards to the location of the lesion in the pancreatic head, several modifications have been applied with low hospital morbidity and mortality below 1%.

Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS)

BACKGROUND

Delayed gastric emptying (DGE) is one of the most common complications after pancreatic resection. In the literature, the reported incidence of DGE after pancreatic surgery varies considerably between different surgical centers, primarily because an internationally accepted consensus definition of DGE is not available. Several surgical centers use a different definition of DGE. Hence, a valid comparison of different study reports and operative techniques is not possible.

METHODS

After a literature review on DGE after pancreatic resection, the International Study Group of Pancreatic Surgery (ISGPS) developed an objective and generally applicable definition with grades of DGE based primarily on severity and clinical impact.

RESULTS

DGE represents the inability to return to a standard diet by the end of the first postoperative week and includes prolonged nasogastric intubation of the patient. Three different grades (A, B, and C) were defined based on the impact on the clinical course and on postoperative management.

CONCLUSION

The proposed definition, which includes a clinical grading of DGE, should allow objective and accurate comparison of the results of future clinical trials and will facilitate the objective evaluation of novel interventions and surgical modalities in the field of pancreatic surgery.

Treatment for painful calcified chronic pancreatitis: extracorporeal shock wave lithotripsy versus endoscopic treatment: a randomised controlled trial

BACKGROUND

In chronic pancreatitis, obstruction of the main pancreatic duct (MPD) may contribute to the pathogenesis of pain. Pilot studies suggest that extracorporeal shock wave lithotripsy (ESWL) alone relieves pain in calcified chronic pancreatitis.

AIM

To compare ESWL alone with ESWL and endoscopic drainage of the MPD for treatment of pain in chronic pancreatitis.

SUBJECTS

Patients with uncomplicated painful chronic pancreatitis and calcifications obstructing the MPD.

METHODS

55 patients were randomised to ESWL alone (n = 26) or ESWL combined with endoscopy (n = 29).

RESULTS

2 years after trial intervention, 10 (38%) and 13 (45%) patients of the ESWL alone and ESWL combined with endoscopy group, respectively, had presented pain relapse (primary outcome) (OR 0.77; 95% CI 0.23 to 2.57). In both groups, a similar decrease was seen after treatment in the MPD diameter (mean decrease 1.7 mm; 95% CI 0.9 to 2.6; p<0.001), and in the number of pain episodes/year (mean decrease, 3.7; 95% CI 2.6 to 4.9; p<0.001). Treatment costs per patient were three times higher in the ESWL combined with endoscopy group compared with the ESWL alone group (p = 0.001). The median delay between the onset of chronic pancreatitis and persistent pain relief for both groups was 1.1 year (95% CI 0.7 to 1.6), as compared with 4 years (95% CI 3 to 4) for the natural history of chronic pancreatitis in a reference cohort (p<0.001).

CONCLUSIONS

ESWL is a safe and effective preferred treatment for selected patients with painful calcified chronic pancreatitis. Combining systematic endoscopy with ESWL adds to the cost of patient care, without improving the outcome of pancreatic pain.

Symptoms and quality of life in chronic pancreatitis assessed by structured interview and the EORTC QLQ-C30 and QLQ-PAN26

BACKGROUND AND AIMS

Chronic pancreatitis (CP) produces disabling symptoms and requires major clinical interventions over a number of years. There is consensus that quality-of-life (QoL) assessment should be part of assessing the treatment and outcome of CP. These symptoms and treatments resemble those of pancreatic cancer, for which there are validated QoL assessment instruments. The aim of our study was to assess the appropriateness of using the EORTC QoL assessment system for pancreatic cancer (the EORTC QLQ-C30 and QLQ-PAN26) for patients with CP, and to document important issues that affect QoL in these patients.

METHODS

A structured literature review was undertaken to determine current approaches to QoL in pancreatic disease. Sixty-six patients with newly diagnosed or treated CP were asked to complete the EORTC QLQ-C30 and QLQ-PAN26 in four countries (Germany, Italy, South Africa, and United Kingdom). Patients were asked to review the appropriateness of the content and structure of the instruments, during a directed interview. Standard psychometric tests were used to assess the reliability and validity of the instruments. Peer review was undertaken to review findings and adapt the QLQ-PAN26 on the basis of the responses obtained.

RESULTS

The literature review highlighted the potential value of the EORTC QLQ-C30 and identified the lack of a CP-specific instrument, which had been appropriately developed. There was overwhelming consensus among experts that the EORTC assessment system appeared suitable for use in CP patients. This was endorsed by all patients. Patients identified additional issues related to guilt about the use of alcohol and the burden of trying to abstain. All but one scale (jaundice) exhibited adequate internal consistency (r > 0.70) Construct validity of the QLQ-C30 and QLQ-PAN26 showed strong associations between conceptually related scales (r > 0.6, p < 0.001) and significantly discriminated between patients on the basis of performance status and requirement for opiate analgesia. Significant issues affecting QoL in CP patients, in addition to recognized symptoms of the disease, were fear of future health problems, difficulty sleeping, and fatigue.

CONCLUSION

The EORTC QLQ-C30 and QLQ-PAN26 appear to be an appropriate assessment system for CP, with the addition of items to cover guilt about alcohol consumption, and the burden of abstention. Patients' QoL is adversely affected by the fear of future health problems, difficulty sleeping, and fatigue.

Surgical anatomy of the innervation of the major duodenal papilla in human and Suncus murinus, from the perspective of preserving innervation in organ-saving procedures

OBJECTIVES

Few studies have focused on the detailed surgical anatomy of the innervation of the major duodenal papillary region, especially in relation to duodenum-preserving pancreatic head resection (DPPHR) and its modified procedures, which is crucial to preserving the innervation of the papillary region. The aim of this study is to clarify the neural distribution of the major duodenal papilla in humans.

METHODS

The pancreas, duodenum, and surrounding structures were dissected in 10 cadavers and immersed in a 0.001% solution of alizarin red S in ethanol to stain the peripheral nerves. The details of the innervation in the above areas were confirmed using a binocular microscope. Similarly, the distribution in 10 Suncus murinus was examined by whole mount immunohistochemistry method with antineurofilament protein antibody.

RESULTS

The innervation of the papillary region in humans involved 2 systems. One arose from the celiac plexus, which through the anterior hepatic plexus running along the arcades of the superior pancreaticoduodenal arteries and through the posterior hepatic plexus running along or accompanying the common bile duct (CBD) or Wirsung's duct, innervated the papillary region. The other arose from the superior mesenteric plexus wound around the arcades of the inferior pancreaticoduodenal arteries innervating the papillary region. The results in S. murinus supported those in humans.

CONCLUSIONS

We emphasize the importance of the nervus-preserving of the major duodenal papilla and CBD by a suitable pancreatic head remnant, preserving the pancreaticoduodenal arterial arcades and avoiding kocherization of the CBD in DPPHR and its modified procedures.