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Ray S, Dhali A, Ansari Z, Gupta A, Mukherjee S, Das S, Das S, Mandal TS, Biswas J, Khamrui S, Dhali GK. Predictors of 90-day morbidity and mortality after Frey procedure for chronic pancreatitis. Am J Surg 2023; 225:709-714. [PMID: 36266135 DOI: 10.1016/j.amjsurg.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/04/2022] [Accepted: 10/09/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND The literature on predictors for postoperative complications after Frey procedure (FP) is sparse. The aim of this study is to report our experience with 90-day complications of FP and predictors for complications. METHODS All patients with chronic pancreatitis (CP), who underwent a FP between August 2007 and July 2021, were retrospectively reviewed. Univariate and multivariate analysis were used to identify predictors of 90-day morbidity and mortality. RESULTS Of the total 270 patients, 84 (31%) patients developed at least one postoperative complication. Major complications occurred in 32 (12%) patients. Most common complication was wound infection and it was significantly more common in stented patients (p = 0.017). Pancreatic fistula and post pancreatectomy hemorrhage (PPH) developed in 7.4% of patients. Thirteen patients (4.8%) required early re-operation and the most common cause of re-exploration was PPH. 90-day mortality was 1% (n = 3) and all 3 patients required re-exploration for PPH. Median postoperative hospital stay was 9 (5-51) days. Perioperative blood transfusions was the only independent predictor of postoperative complications after FP. CONCLUSIONS Frey procedure is an acceptable treatment modality with low rates of mortality and reasonable perioperative morbidities. Minimizing blood transfusions may further improve 90-day outcomes.
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Affiliation(s)
- Sukanta Ray
- Division of GI Surgery, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India.
| | - Arkadeep Dhali
- Division of GI Surgery, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India.
| | - Zuber Ansari
- Division of GI Surgery, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Arunesh Gupta
- Division of GI Surgery, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Sreecheta Mukherjee
- Division of GI Surgery, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Suman Das
- Division of GI Surgery, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Somak Das
- Division of GI Surgery, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Tuhin Subhra Mandal
- Division of GI Surgery, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Jayanta Biswas
- Division of GI Surgery, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Sujan Khamrui
- Division of GI Surgery, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Gopal Krishna Dhali
- Division of Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
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Murruste M, Kirsimägi Ü, Kase K, Veršinina T, Talving P, Lepner U. ‘Short’ pancreaticojejunostomy might be a valid option for treatment of chronic pancreatitis in many cases. World J Gastrointest Surg 2021; 13:1673-1684. [PMID: 35070072 PMCID: PMC8727189 DOI: 10.4240/wjgs.v13.i12.1673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/07/2021] [Accepted: 11/03/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The Partington-Rochelle pancreaticojejunostomy (PJ) is an essential management option for patients with chronic pancreatitis (CP) associated with intractable pain and a dilated pancreatic duct (PD). Wide ductotomy and long PJ (L-PJ) have been advocated as the standard of care to ensure full PD decompression. However, the role of short PJ (S-PJ) in a uniformly dilated PD has not yet been evaluated.
AIM To evaluate the possible advantages and disadvantages of S-PJ and L-PJ and to interpret the perspective of S-PJ in the treatment of CP.
METHODS A retrospective review of prospectively collected cohort data was conducted on surgically treated CP patients subjected to side-to-side PJ. The length of the PJ was adapted to anatomical alterations in PD. A comparison was made of S-PJ (< 50 mm) for uniformly dilated PD and L-PJ (50-100 mm) in the setting of multiple PD strictures, calcifications and dilatations. We hypothesized that S-PJ and L-PJ ensure comparable clinical outcomes. The primary outcomes were pain relief and quality of life (QOL); the secondary outcomes were perioperative characteristics, body weight, patients’ satisfaction with treatment, and readmission rate due to CP.
RESULTS Overall, 91 patients underwent side-to-side PJ for CP, including S-PJ in 46 patients and L-PJ in 45 patients. S-PJ resulted in better perioperative outcomes: Significantly shorter operative time (107.5 min vs 134 min), lower need for intraoperative (0% vs 15.6%) and total (2.2% vs 31.1%) blood transfusions, and lower rate of perioperative complications (6.5% vs 17.8%). We noted no significant difference in pain relief, improvement in QOL, body weight gain, patients’ satisfaction with surgical treatment, or readmission rate due to CP.
CONCLUSION Based on our data, in the setting of a uniformly dilated PD, S-PJ provides adequate decompression of the PD. As the clinical outcomes following S-PJ are not inferior to those of L-PJ, S-PJ should be preferred as a surgical option in the case of a uniformly dilated PD.
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Affiliation(s)
- Marko Murruste
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
- Faculty of Medicine, University of Tartu, Tartu 50411, Estonia
| | - Ülle Kirsimägi
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
| | - Karri Kase
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
- Faculty of Medicine, University of Tartu, Tartu 50411, Estonia
| | - Tatjana Veršinina
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
- Faculty of Medicine, University of Tartu, Tartu 50411, Estonia
| | - Peep Talving
- Faculty of Medicine, University of Tartu, Tartu 50411, Estonia
- Division of Acute Care Surgery, Department of Surgery, North-Estonia Medical Centre, Tallinn 13419, Estonia
| | - Urmas Lepner
- Department of Surgery, Tartu University Hospital, Tartu 50406, Estonia
- Faculty of Medicine, University of Tartu, Tartu 50411, Estonia
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Ray S, Das K, Khamrui S, Jana K, Das R, Kumar D, Ansari Z. Short- and long-term outcome of Frey procedure for chronic pancreatitis in adults. Am J Surg 2021; 222:793-801. [PMID: 33608104 DOI: 10.1016/j.amjsurg.2021.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/17/2021] [Accepted: 02/07/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To report our experience with Frey procedure (FP) for chronic pancreatitis (CP) in adults. METHODS Adult patients with CP, who underwent a FP between August 2007 and July 2018, were retrospectively reviewed. RESULTS Of the total 138 patients, 95 (69%) were male. The median age at operation was 36.5 years. The median pain-surgery interval was 48 months. Alcohol abuse was identified in 64 (46%) patients. The major indication for surgery was disabling pain (94%). There was no postoperative mortality. Postoperative complications developed in 43 (31%) patients. Median postoperative hospital stay was 9 days. Over a median follow-up of 65 months, 84% of patients had complete pain relief. Continuous pain and high preoperative Izbicki pain score were associated with incomplete pain control. New-onset diabetes and exocrine insufficiency developed in 31% and 27% of patients respectively. Longer duration of disease and previous pancreatic surgery were associated with the development of new-onset diabetes after the FP. CONCLUSIONS Frey procedure is safe with an acceptable perioperative complications and good long-term pain control.
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Affiliation(s)
- Sukanta Ray
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India.
| | - Kshaunish Das
- Division of Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Sujan Khamrui
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Koustav Jana
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Roby Das
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Dilip Kumar
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Zuber Ansari
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
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Napolitano M, Brody F, Lee KB, Rosenfeld E, Chen S, Murillo-Berlioz AE, Amdur R. 30-Day outcomes and predictors of complications after Puestow procedure. Am J Surg 2020; 220:372-375. [PMID: 31894016 DOI: 10.1016/j.amjsurg.2019.12.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/10/2019] [Accepted: 12/18/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND A lateral pancreaticojejunostomy, or a Puestow procedure, is used in chronic pancreatitis with ductal dilation and pain. The current literature on the Puestow is sparse. This study examines outcomes of Puestow procedures nationwide. METHODS Using ACS-NSQIP database, patients who underwent a Puestow procedure from 2010 to 2016 were identified. Univariate analysis and multivariable regression models were used to identify predictors of mortality and morbidities. Covariates included in the regression models were chosen based on clinical significance. RESULTS The cohort included 524 patients. The 30-day mortality rate was 1.2%(n = 6). At least one major complication occurred in 19.1% of patients including death (1.2%), major organ dysfunction (8.2%), pulmonary embolism (1.3%), and surgical site infections (13.0%). Diabetes, COPD, and transfusions were the strongest predictors of complications. CONCLUSIONS The Puestow procedure is an acceptable treatment modality with low rates of morbidity and mortality. Minimizing transfusions and optimizing pulmonary status may improve 30-day outcomes.
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Affiliation(s)
- Michael Napolitano
- Department of Surgery, Washington D.C. Veterans Affairs Medical Center, Washington D.C., USA; Department of Surgery, George Washington University Hospital, Washington D.C., USA
| | - Fred Brody
- Department of Surgery, Washington D.C. Veterans Affairs Medical Center, Washington D.C., USA.
| | - Kyongjune Benjamin Lee
- Department of Surgery, Washington D.C. Veterans Affairs Medical Center, Washington D.C., USA; Department of Surgery, George Washington University Hospital, Washington D.C., USA
| | - Ethan Rosenfeld
- Department of Surgery, Washington D.C. Veterans Affairs Medical Center, Washington D.C., USA; Department of Surgery, George Washington University Hospital, Washington D.C., USA
| | - Sheena Chen
- Department of Surgery, Washington D.C. Veterans Affairs Medical Center, Washington D.C., USA; Department of Surgery, George Washington University Hospital, Washington D.C., USA
| | - Alejandro Ernesto Murillo-Berlioz
- Department of Surgery, Washington D.C. Veterans Affairs Medical Center, Washington D.C., USA; Department of Surgery, George Washington University Hospital, Washington D.C., USA
| | - Richard Amdur
- Department of Surgery, George Washington University Hospital, Washington D.C., USA
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Nonneoplastic Lesions of the Pancreas: A Retrospective Analysis of 20 Cases. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2018; 52:31-35. [PMID: 32595368 PMCID: PMC7315078 DOI: 10.14744/semb.2017.88598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/23/2017] [Indexed: 12/25/2022]
Abstract
Objectives: In the pancreatic lesion cases, surgery is often planned based only on imaging results and without a preoperative histological diagnosis, due to the high risk of malignancy in combination with the difficulty of invasive interventions and limited cytopathological evaluation. In this study, the records of 20 patients who had undergone a pancreatectomy procedure and who were diagnosed with nonneoplastic pancreatic lesions were retrospectively evaluated according to the clinical and histopathological findings. Methods: A total of 122 cases of patients who underwent a pancreatectomy with suspicious lesions between 2004 and 2016 were retrospectively assessed in detail using the clinical and histopathological findings. Results: Nonneoplastic lesions were observed in 20 (16%) of 122 patients who underwent a pancreatectomy. Histopathological examination revealed 11 cases of chronic pancreatitis, 1 hematoma, 1 instance of hemorrhagic necrosis secondary to trauma, 1 pseudocyst, 1 granulation tissue, 1 retention cyst, 1 bile duct cyst, 1 patient with Castleman disease, and 1 instance of fat necrosis were seen. In 1 patient, no evidence of disease was found. In addition, among the patients with chronic pancreatitis, autoimmune pancreatitis was observed in 1, adenomyoma of the ampulla of Vater was present in 1, and a pseudocyst was found in 1 patient. Conclusion: A clinical and histopathological analysis of nonneoplastic lesions found in pancreatectomy patients was performed.
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Dua MM, Visser BC. Surgical Approaches to Chronic Pancreatitis: Indications and Techniques. Dig Dis Sci 2017; 62:1738-1744. [PMID: 28281166 DOI: 10.1007/s10620-017-4526-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 02/28/2017] [Indexed: 12/11/2022]
Abstract
There are a number of surgical strategies for the treatment of chronic pancreatitis. The optimal intervention should provide effective pain relief, improve/maintain quality of life, preserve exocrine and endocrine function, and manage local complications. Pancreaticoduodenectomy was once the standard operation for patients with chronic pancreatitis; however, other procedures such as the duodenum-preserving pancreatic head resections and its variants have been introduced with good long-term results. Pancreatic duct drainage via a lateral pancreaticojejunostomy continues to be effective in ameliorating symptoms and expediting return to normal lifestyle in many patients. This review summarizes operative indications and gives an overview of the different surgical strategies in treating chronic pancreatitis.
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Affiliation(s)
- Monica M Dua
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.
| | - Brendan C Visser
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
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Kilburn DJ, Chiow AKH, Leung U, Siriwardhane M, Cavallucci DJ, Bryant R, O'Rourke NA. Early Experience with Laparoscopic Frey Procedure for Chronic Pancreatitis: a Case Series and Review of Literature. J Gastrointest Surg 2017; 21:904-909. [PMID: 28025771 DOI: 10.1007/s11605-016-3343-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 12/15/2016] [Indexed: 01/31/2023]
Abstract
The Frey procedure has been demonstrated to be an effective surgical technique to treat patients with painful large duct chronic pancreatitis. More commonly reported as an open procedure, we report our experience with a minimally invasive approach to the Frey procedure. Four consecutive patients underwent a laparoscopic Frey procedure at our institution from January 2012 to July 2015. We herein report our technique and describe short- and medium-term outcomes. The median age was 40 years old. The median duration of pancreatic pain prior to surgery was 12 years. Median operative time and intraoperative blood loss was 130 min (100-160 min) and 60 mL (50-100 mL), respectively. The median length of stay was 7 days (3-40 days) and median follow-up was 26 months (12-30 months). There was one major postoperative complication requiring reoperation. Within 6 months, in all four patients, frequency of pain and analgesic requirement reduced significantly. Two patients appeared to have resolution of pancreatic exocrine insufficiency. The Frey procedure is possible laparoscopically with acceptable short- and medium-term outcomes in well-selected patients.
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Affiliation(s)
- Daniel J Kilburn
- Hepatopancreatobiliary Unit, Department of Surgery, Royal Brisbane Hospital, Brisbane, Queensland, 4029, Australia.,School of Medicine, The University of Queensland, Brisbane, Australia
| | - Adrian K H Chiow
- Hepatopancreatobiliary Unit, Department of Surgery, Changi General Hospital, Singapore, Singapore
| | - Universe Leung
- Hepatopancreatobiliary Unit, Department of Surgery, Royal Brisbane Hospital, Brisbane, Queensland, 4029, Australia
| | - Mehan Siriwardhane
- Hepatopancreatobiliary Unit, Department of Surgery, Royal Brisbane Hospital, Brisbane, Queensland, 4029, Australia
| | - David J Cavallucci
- Hepatopancreatobiliary Unit, Department of Surgery, Royal Brisbane Hospital, Brisbane, Queensland, 4029, Australia.,School of Medicine, The University of Queensland, Brisbane, Australia
| | - Richard Bryant
- Hepatopancreatobiliary Unit, Department of Surgery, Royal Brisbane Hospital, Brisbane, Queensland, 4029, Australia
| | - Nicholas A O'Rourke
- Hepatopancreatobiliary Unit, Department of Surgery, Royal Brisbane Hospital, Brisbane, Queensland, 4029, Australia. .,School of Medicine, The University of Queensland, Brisbane, Australia. .,, Wesley Medical Centre Suite 47, 40 Chasely Street, Auchenflower, Brisbane, Queensland, 4066, Australia.
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Abstract
Chronic pancreatitis is a progressive inflammatory disease resulting in permanent structural damage of the pancreas. It is mainly characterized by recurring epigastric pain and pancreatic insufficiency. In addition, progression of the disease might lead to additional complications, such as pseudocyst formation or development of pancreatic cancer. The medical and surgical treatment of chronic pancreatitis has changed significantly in the past decades. With regard to surgical management, pancreatic head resection has been shown to be a mainstay in the treatment of severe chronic pancreatitis because the pancreatic head mass is known to trigger the chronic inflammatory process. Over the years, organ-preserving procedures, such as the duodenum-preserving pancreatic head resection and the pylorus-preserving Whipple, have become the surgical standard and have led to major improvements in pain relief, preservation of pancreatic function, and quality of life of patients.
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9
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Advances in surgical treatment of chronic pancreatitis. World J Surg Oncol 2015; 13:34. [PMID: 25845403 PMCID: PMC4326204 DOI: 10.1186/s12957-014-0430-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Accepted: 12/24/2014] [Indexed: 12/23/2022] Open
Abstract
The incidence of chronic pancreatitis (CP) is between 2 and 200 per 100,000 persons and shows an increasing trend year by year. India has the highest incidence of CP in the world at approximately 114 to 200 per 100,000 persons. The incidence of CP in China is approximately 13 per 100,000 persons. The aim of this review is to assist surgeons in managing patients with CP in surgical treatment. We conducted a PubMed search for “chronic pancreatitis” and “surgical treatment” and reviewed relevant articles. On the basis of our review of the literature, we found that CP cannot be completely cured. The purpose of surgical therapy for CP is to relieve symptoms, especially pain; to improve the patient’s quality of life; and to treat complications. Decompression (drainage), resection, neuroablation and decompression combined with resection are commonly used methods for the surgical treatment of CP. Before developing a surgical regimen, surgeons should comprehensively evaluate the patient’s clinical manifestations, auxiliary examination results and medical history to develop an individualized surgical treatment regimen.
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D'Haese JG, Ceyhan GO, Demir IE, Tieftrunk E, Friess H. Treatment options in painful chronic pancreatitis: a systematic review. HPB (Oxford) 2014; 16:512-21. [PMID: 24033614 PMCID: PMC4048072 DOI: 10.1111/hpb.12173] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 07/05/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Longlasting and unbearable pain is the most common and striking symptom of chronic pancreatitis. Accordingly, pain relief and improvement in patients' quality of life are the primary goals in the treatment of this disease. This systematic review aims to summarize the available data on treatment options. METHODS A systematic search of MEDLINE/PubMed and the Cochrane Library was performed according to the PRISMA statement for reporting systematic reviews and meta-analysis. The search was limited to randomized controlled trials and meta-analyses. Reference lists were then hand-searched for additional relevant titles. The results obtained were examined individually by two independent investigators for further selection and data extraction. RESULTS A total of 416 abstracts were reviewed, of which 367 were excluded because they were obviously irrelevant or represented overlapping studies. Consequently, 49 full-text articles were systematically reviewed. CONCLUSIONS First-line medical options include the provision of pain medication, adjunctive agents and pancreatic enzymes, and abstinence from alcohol and tobacco. If medical treatment fails, endoscopic treatment offers pain relief in the majority of patients in the short term. However, current data suggest that surgical treatment seems to be superior to endoscopic intervention because it is significantly more effective and, especially, lasts longer.
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Affiliation(s)
- Jan G D'Haese
- Department of Surgery, Rechts der Isar Clinic, Technical University of Munich, Munich, Germany
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11
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Yang L, Shen J, He S, Hu G, Shen J, Wang F, Xu L, Dai W, Xiong J, Ni J, Guo C, Wan R, Wang X. L-cysteine administration attenuates pancreatic fibrosis induced by TNBS in rats by inhibiting the activation of pancreatic stellate cell. PLoS One 2012; 7:e31807. [PMID: 22359633 PMCID: PMC3281011 DOI: 10.1371/journal.pone.0031807] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Accepted: 01/16/2012] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Recent studies have shown that activated pancreatic stellate cells (PSCs) play a major role in pancreatic fibrogenesis. We aimed to study the effect of L-cysteine administration on fibrosis in chronic pancreatitis (CP) induced by trinitrobenzene sulfonic acid (TNBS) in rats and on the function of cultured PSCs. METHODS CP was induced by TNBS infusion into rat pancreatic ducts. L-cysteine was administrated for the duration of the experiment. Histological analysis and the contents of hydroxyproline were used to evaluate pancreatic damage and fibrosis. Immunohistochemical analysis of α-SMA in the pancreas was performed to detect the activation of PSCs in vivo. The collagen deposition related proteins and cytokines were determined by western blot analysis. DNA synthesis of cultured PSCs was evaluated by BrdU incorporation. We also evaluated the effect of L-cysteine on the cell cycle and cell activation by flow cytometry and immunocytochemistry. The expression of PDGFRβ, TGFβRII, collagen 1α1 and α-SMA of PSCs treated with different concentrations of L-cysteine was determined by western blot. Parameters of oxidant stress were evaluated in vitro and in vivo. Nrf2, NQO1, HO-1, IL-1β expression were evaluated in pancreas tissues by qRT-PCR. RESULTS The inhibition of pancreatic fibrosis by L-cysteine was confirmed by histological observation and hydroxyproline assay. α-SMA, TIMP1, IL-1β and TGF-β1 production decreased compared with the untreated group along with an increase in MMP2 production. L-cysteine suppressed the proliferation and extracellular matrix production of PSCs through down-regulating of PDGFRβ and TGFβRII. Concentrations of MDA+4-HNE were decreased by L-cysteine administration along with an increase in GSH levels both in tissues and cells. In addition, L-cysteine increased the mRNA expression of Nrf2, NQO1 and HO-1 and reduced the expression of IL-1β in L-cysteine treated group when compared with control group. CONCLUSION L-cysteine treatment attenuated pancreatic fibrosis in chronic pancreatitis in rats.
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Affiliation(s)
- LiJuan Yang
- Department of Gastroenterology, The First People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - JiaQing Shen
- Department of Gastroenterology, The First People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - ShanShan He
- Department of Gastroenterology, The Tenth People's Hospital of Shanghai, Tongji University, Shanghai, People's Republic of China
| | - GuoYong Hu
- Department of Gastroenterology, The Tenth People's Hospital of Shanghai, Tongji University, Shanghai, People's Republic of China
| | - Jie Shen
- Department of Gastroenterology, The Tenth People's Hospital of Shanghai, Tongji University, Shanghai, People's Republic of China
| | - Feng Wang
- Department of Gastroenterology, The Tenth People's Hospital of Shanghai, Tongji University, Shanghai, People's Republic of China
| | - Ling Xu
- Department of Gastroenterology, The Tenth People's Hospital of Shanghai, Tongji University, Shanghai, People's Republic of China
| | - WeiQi Dai
- Department of Gastroenterology, The Tenth People's Hospital of Shanghai, Tongji University, Shanghai, People's Republic of China
| | - Jie Xiong
- Department of Gastroenterology, The Tenth People's Hospital of Shanghai, Tongji University, Shanghai, People's Republic of China
| | - JianBo Ni
- Department of Gastroenterology, The Tenth People's Hospital of Shanghai, Tongji University, Shanghai, People's Republic of China
| | - ChuanYong Guo
- Department of Gastroenterology, The Tenth People's Hospital of Shanghai, Tongji University, Shanghai, People's Republic of China
| | - Rong Wan
- Department of Gastroenterology, The Tenth People's Hospital of Shanghai, Tongji University, Shanghai, People's Republic of China
| | - XingPeng Wang
- Department of Gastroenterology, The First People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- Department of Gastroenterology, The Tenth People's Hospital of Shanghai, Tongji University, Shanghai, People's Republic of China
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Pancreaticoduodenectomy versus duodenum-preserving pancreatic head resection for the treatment of chronic pancreatitis. Pancreas 2012; 41:147-52. [PMID: 21775913 DOI: 10.1097/mpa.0b013e318221c91b] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The objective of this study was to assess the efficacy and safety of pancreaticoduodenectomy (PD) and duodenum-preserving pancreatic head resection (DPPHR) for the treatment of chronic pancreatitis (CP). METHODS The 123 patients with CP who underwent pancreatic head resection between January 2004 and June 2009 were retrospectively analyzed. The preoperative variables, operative data, postoperative complications, and follow-up information were examined. RESULTS There were no significant differences in clinical and morphological characteristics, pain relief, and jaundice status between the PD and DPPHR groups. The duration of operation was shorter (251.8 [SD, 43.1] vs 324.5 [SD, 41.4] minutes, P < 0.001), blood loss was less (464.4 [SD, 203.6] vs 646.5 [SD, 242.9] mL, P < 0.001), and overall postoperative morbidity was lower (3% vs 19%, P = 0.006) in DPPHR group. The duration of hospital stay was also significantly different (9.9 [SD, 1.8] vs 13.7 [SD, 2.8] days, P < 0.001). Most functional and symptom scales revealed a better quality of life in DPPHR group. The proportion of patients with exocrine and endocrine insufficiency was higher in PD group as compared with DPPHR group. CONCLUSIONS Both procedures are equally effective in pain relief, but DPPHR is superior to PD in operative data, postoperative morbidity, improving quality of life, and preservation of exocrine and endocrine function.
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Abstract
The diagnosis and treatment of patients with pancreatic strictures presents a multitude of clinical challenges. The etiology of pancreatic strictures is varied, including benign strictures subsequent to acute pancreatitis, trauma, postsurgical, post-endoscopic retrograde cholangiopancreatography (ERCP), and malignancy. Patients with strictures usually present with symptoms of recurrent pancreatitis, abdominal pain, weight loss, and/or steatorrhea. The absence of a prior history of pancreatitis or surgery increases the likelihood of malignancy. High-quality imaging studies of the pancreas, CT, MRI/magnetic resonance cholangiopancreatography, or endoscopic ultrasound (EUS) scanning are utilized for better definition. Imaging detects an associated mass and/or demonstrates the ductal anatomy. Invasive procedures such as ERCP are performed to better define the causal relationships of the patient's symptoms or to obtain tissue diagnosis. Treatment goals include ameliorating symptoms, dilating the stricture, and ruling out cancer. The risk of malignancy underlies much of the intervention, which includes serology, cytologic analysis, and serial imaging. EUS has become the procedure of choice to rule out a mass, to evaluate the parenchyma for evidence of chronic pancreatitis, and to obtain fine-needle biopsies for tissue confirmation. In symptomatic patients or patients with indeterminate strictures, ERCP is used for direct pancreatography, tissue acquisition, and endoscopic treatment. Endotherapy includes sphincterotomy, dilation, and stenting to provide drainage. We view ERCP as the optimal first-line treatment modality. ERCP offers the potential of curative treatment and is less invasive than surgery, especially as some patients' symptoms are not severe enough to justify surgery. If patients do not experience relief of symptoms after several sessions of endoscopic therapy, surgery is the logical next step for definitive, long-term treatment.
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14
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van Loo ES, van Baal MCPM, Gooszen HG, Ploeg RJ, Nieuwenhuijs VB. Long-term quality of life after surgery for chronic pancreatitis. Br J Surg 2010; 97:1079-86. [DOI: 10.1002/bjs.7103] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Abstract
Background
Surgery for chronic pancreatitis is indicated for intractable pain or the treatment of complications. This retrospective cohort study evaluated the applicability of pain coping and quality-of-life (QOL) scoring in patients with chronic pancreatitis.
Methods
Between 1995 and 2008, 155 patients underwent surgery for chronic pancreatitis in two Dutch university hospitals. Medical charts were reviewed, and QOL and coping with pain were assessed by two validated questionnaires.
Results
Median follow-up was 5·6 years. The aetiology was alcohol related in 48·3 per cent. Some 111 resections and 46 drainage procedures were performed. Fifty-seven patients had major complications and the hospital mortality rate was 1·3 per cent. After surgery the number of patients needing analgesics was reduced (P < 0·001). Alcohol consumption significantly reduced pain coping mechanisms (P = 0·032). Overall, QOL remained poor after surgery. Scores on three dimensions of the QOL questionnaire were significantly better after drainage than after resection procedures.
Conclusion
In general, QOL after surgery for chronic pancreatitis remains poor, owing to pre-existing lifestyle and co-morbidity. Patients selected for a pancreatic duct drainage procedure have a better postoperative QOL than those undergoing resectional procedures. Alcohol consumption is associated with poor ability to cope with pain after surgery and should be discouraged.
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Affiliation(s)
- E S van Loo
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - M C P M van Baal
- Department of Surgery, University Medical Centre Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - H G Gooszen
- Department of Surgery, University Medical Centre Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - R J Ploeg
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - V B Nieuwenhuijs
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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15
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Andersson R, Börjesson A, Blind PJ, Tingstedt B. Pancreaticojejunostomy: a valid operation in chronic pancreatitis? Scand J Gastroenterol 2008; 43:1000-3. [PMID: 19086168 DOI: 10.1080/00365520801986601] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Patients with chronic pancreatitis and intractable pain may be candidates for surgical intervention and various types of surgery have been described over time. The objective of this study was to describe long-term outcome following pancreaticojejunostomy in patients with chronic pancreatitis. MATERIAL AND METHODS Thirty-two patients with chronic pancreatitis underwent lateral pancreatiocojejunostomy and were then followed-up for 5 years. RESULTS The short-term results on relief of abdominal pain were good, but seemed to deteriorate at long-term follow-up (5 years), as did pancreatic exocrine and endocrine function. A substantial number of patients admitted to continued alcohol abuse at 5-year follow-up (31%). CONCLUSIONS Pancreaticojejunostomy in patients with chronic pancreatitis renders good pain relief. In effect, the deterioration in abdominal pain at long-term follow-up was in parallel with a tendency towards a decline in both exocrine and endocrine function and a continued alcohol abuse.
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Affiliation(s)
- Roland Andersson
- Department of Surgery, Clinical Sciences, Lund University Hospital, Lund, Sweden.
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16
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Köninger J, Seiler CM, Sauerland S, Wente MN, Reidel MA, Müller MW, Friess H, Büchler MW. Duodenum-preserving pancreatic head resection--a randomized controlled trial comparing the original Beger procedure with the Berne modification (ISRCTN No. 50638764). Surgery 2008; 143:490-8. [PMID: 18374046 DOI: 10.1016/j.surg.2007.12.002] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2007] [Accepted: 12/07/2007] [Indexed: 01/27/2023]
Abstract
OBJECTIVE A prospective, randomized study was performed to evaluate two variations of the duodenum-preserving pancreatic head resection (DPPHR), either with (Beger procedure) or without (Berne modification) the division of the pancreas anterior to the portal vein, in patients with chronic pancreatitis. METHODS Randomized, controlled, patient-blinded trial of patients with inflammatory pancreatic head tumors. The primary endpoint was the duration of surgery. Other a priori-ordered endpoints were length of ICU stay, postoperative complication, length of hospital stay, and quality of life after 24 months. RESULTS Sixty-five patients were randomized to the Berne or Beger procedures. The Berne modification could be performed faster (46 minutes difference, P < .05). The median length of stay on the ICU was one day in both groups (P = .97) but the median hospital stay was shorter in the Berne group (11 (8-39) versus 15 (8-47); P = .015). The quality of life two years after surgery did not differ significantly between the two groups (EORTC-QLQ-C30, Beger 65.6% vs. Berne 71.3%, P = .371). Three patients who had received the Berne procedure were reoperated on during the follow-up period due to ongoing pancreatitis and bile duct obstruction (P = .22). CONCLUSION The Berne technique is technically simpler compared with the original Beger procedure, reflected in its significantly shorter operation times and hospital stays. The quality of life is similar after both procedures. The Berne modification of DPPHR adds to our panel of surgical procedures that can be applied with effective early and late outcomes.
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Affiliation(s)
- Jörg Köninger
- Department of General Surgery, University of Heidelberg, Heidelberg, Germany
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17
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van der Gaag NA, Gouma DJ, van Gulik TM, Busch ORC, Boermeester MA. Review article: Surgical management of chronic pancreatitis. Aliment Pharmacol Ther 2007; 26 Suppl 2:221-32. [PMID: 18081665 DOI: 10.1111/j.1365-2036.2007.03486.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The therapeutic approach to patients with chronic pancreatitis (CP) is complicated by the fact that patients are presented to the physician at different stages of disease and in the presence of varying clinical symptoms. Generally, an expectant approach is justified for patients with asymptomatic CP. At present, patients with symptoms related to gland destruction are initially treated by endoscopic means, while surgical treatment of CP is usually reserved for intractable abdominal pain, suspicion of cancer, and complications such as persistent pseudocysts. AIM To review the studies currently available evaluating surgical and/or endoscopic management of CP. RESULTS Improvements in imaging techniques, as well as a better understanding of the pathophysiology of CP and mechanisms causing pain, have led to a more conscious selection of patients for surgery. Type of surgery depends on whether the pancreatic duct is dilated, presence of an inflammatory mass and occurrence of complications (pseudocysts, gastric outlet obstruction). Eventually, after initial endoscopic treatment, a substantial number of patients still need surgery for persistent complaints. CONCLUSIONS For patients with symptomatic CP, a multidisciplinary approach is indicated with low threshold to surgical intervention, since long-term pain relief is accomplished more often after surgical treatment than after endoscopic treatment.
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Affiliation(s)
- N A van der Gaag
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
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18
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Fasanella KE, Davis B, Lyons J, Chen Z, Lee KK, Slivka A, Whitcomb DC. Pain in chronic pancreatitis and pancreatic cancer. Gastroenterol Clin North Am 2007; 36:335-64, ix. [PMID: 17533083 DOI: 10.1016/j.gtc.2007.03.011] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Chronic, debilitating abdominal pain is arguably the most important component of chronic pancreatitis, leading to significant morbidity and disability. Attempting to treat this pain, which is too often unsuccessful, is a frustrating experience for physician and patient. Multiple studies to improve understanding of the pathophysiology that causes pain in some patients but not in others have been performed since the most recent reviews on this topic. In addition, new treatment modalities have been developed and evaluated in this population. This review discusses new advances in neuroscience and the study of visceral pain mechanisms, as well as genetic factors that may play a role. Updates of established therapies, as well as new techniques used in addressing pain from chronic pancreatitis, are reviewed. Lastly, outcome measures, which have been highly variable in this field over the years, are addressed.
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Affiliation(s)
- Kenneth E Fasanella
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Mezzanine level 2, C-wing, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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19
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Abstract
Chronic pancreatitis (CP) is characterized by progressive fibrosis, pain and/or loss of exocrine and endocrine functions. With the identification and characterization of pancreatic stellate cells (PSCs), the pathogenesis of CP and pancreatic fibrosis is now better understood. Molecular mediators shown to regulate the pathogenesis include transforming growth factor-beta, platelet-derived growth factor, and proinflammatory cytokines such as interleukin (IL)-1, IL-6 and tumor necrosis factor-alpha. Besides these, the roles of cyclooxygenase (COX)-2 and apoptosis-related proteins have also been implicated in the pathogenesis. Furthermore, molecular pathways involving mitogen-activated protein kinases, phosphatidylinositol 3-kinase, Ras superfamily G proteins, serine threonine protein kinase Raf-1 and peroxisome proliferator-activated receptor-gamma (PPAR-gamma) have been elucidated. Newer pathobiologic concepts concerning pain generation have also been put forward. Understanding the pathogenesis has led to the identification of novel molecular targets and the development of newer potential therapeutic agents. Those found to retard the progression of experimental CP and fibrosis in animal models include antioxidants, a Japanese herbal medicine called Saiko-keisi-to (TJ 10), the PPAR-gamma ligand troglitazone, the protease inhibitor Camostat mesilate, and Lovastatin.
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Affiliation(s)
- Rupjyoti Talukdar
- Department of Gastroenterology, Pushpawati Singhania Research Institute, New Delhi, India
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20
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Neuhaus H. Pancreatic stents in chronic pancreatitis: do they function as a tube, a wick, or a placebo? Gastrointest Endosc 2006; 63:67-70. [PMID: 16377318 DOI: 10.1016/j.gie.2005.09.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2005] [Accepted: 09/10/2005] [Indexed: 02/08/2023]
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21
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Abstract
Chronic pancreatitis represents a condition that is challenging for clinicians secondary to the difficulty in making an accurate diagnosis and the less than satisfactory means of managing chronic pain. This review emphasises the various manifestations that patients with chronic pancreatitis may have and describes recent advances in medical and surgical therapy. It is probable that many patients with chronic abdominal pain are suffering from chronic pancreatitis that is not appreciated. As the pathophysiology of this disorder is better understood it is probable that the treatment will be more successful.
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Affiliation(s)
- V Gupta
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Room HD 602, PO Box 100214, 1600 SW Archer Road, Gainesville, FL 32610, USA
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22
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Köninger J, Friess H, Müller M, Wirtz M, Martignioni M, Büchler MW. [Duodenum-preserving pancreas head resection-an operative technique for retaining the organ in the treatment of chronic pancreatitis]. Chirurg 2004; 75:781-8. [PMID: 15007527 DOI: 10.1007/s00104-004-0826-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic pancreatitis is an inflammatory disease characterized by the progressive conversion of pancreatic parenchyma to fibrous tissue. The most frequent causes are alcohol overconsumption and anatomic variants such as pancreas divisum, cholelithiasis, and individual genetic predisposition. The process of fibrosis with consecutive loss of pancreatic parenchyma leads to exocrine insufficiency and maldigestion and, in advanced stages of the disease, to diabetes mellitus. Beside exocrine and endocrine malfunction, mechanical complications occur such as the formation of pancreatic pseudocysts and duodenal and common bile duct obstruction. About 50% of patients with chronic pancreatitis need surgical intervention due to untreatable chronic pain. As recent investigations suggest that the head of the pancreas triggers the chronic inflammatory process, resection of this inflammatory mass must be regarded as pivotal in any surgical intervention. Radical techniques such as the Whipple procedure are undoubtedly successful regarding pain reduction but, even in its pylorus-preserving variant, associated with high postoperative morbidity due to a large loss of pancreatic parenchyma and the absence of duodenal passage. Thirty years ago, H.G. Beger described for the first time the technique of duodenum-preserving pancreatectomy, which better combines resection of the pancreatic head with low morbidity. Over the years, different variations of the original Beger technique (Frey, Izbicky, Berne modification) have been developed, and the excellent results obtained with these methods underline that organ-sparing techniques should be preferred in the surgical treatment of chronic pancreatitis.
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Affiliation(s)
- J Köninger
- Abteilung für Allgemein-, Viszeral- und Unfallchirurgie, Universität Heidelberg
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23
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Cunha JEM, Penteado S, Jukemura J, Machado MCC, Bacchella T. Surgical and interventional treatment of chronic pancreatitis. Pancreatology 2004; 4:540-50. [PMID: 15486450 DOI: 10.1159/000081560] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The management of patients with chronic pancreatitis (CP) remains a challenging problem. Main indications for surgery are intractable pain, suspicion of malignancy, and involvement of adjacent organs. The main goal of surgical treatment is improvement of patient quality of life. The surgical treatment approach usually involves proximal pancreatic resection, but lateral pancreaticojejunal drainage may be used for large-duct disease. The newer duodenum-preserving head resections of Beger and Frey provide good pain control and preservation of pancreatic function. Thoracoscopic splanchnicectomy and the endoscopic approach await confirmatory trials to confirm their efficiency in the management of CP. Common bile duct obstruction is addressed by distal Roux-en-Y choledochojejunostomy but when combined with dudodenal obstruction must be treated by pancreatic head resection. Pancreatic ascites due to disrupted pancreatic duct should be treated by internal drainage. The approach to CP is multidisciplinary, tailoring the various therapeutic options to meet each individual patient's needs.
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Affiliation(s)
- J E M Cunha
- Department of Gastroenterology, Surgical Division, São Paulo University Medical School, São Paulo, Brazil.
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24
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Maartense S, Ledeboer M, Bemelman WA, Ringers J, Frolich M, Masclee AAM. Effect of surgery for chronic pancreatitis on pancreatic function: pancreatico-jejunostomy and duodenum-preserving resection of the head of the pancreas. Surgery 2004; 135:125-30. [PMID: 14739846 DOI: 10.1016/j.surg.2003.09.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Resection and drainage procedures are performed for chronic pancreatitis. After resection, pancreatic function deteriorates; however, little is known about the effect of drainage procedures. METHODS Pancreatic function was evaluated prospectively before and after surgery in 27 patients with duodenum-preserving resection of the head of the pancreas (DPRHP), and in 12 patients with pancreatico-jejunostomy (P-JS); 18 patients with chronic pancreatitis served as controls. Results of the 2 groups were not compared because of differences in patient characteristics and indications for surgery. Endpoints were exocrine function (fecal fat excretion, urinary PABA recovery), endocrine function (oral glucose tolerance test, serum C-peptide concentrations), and pancreatic polypeptide secretion. RESULTS Groups were not different with respect to age and duration of symptoms. Median urinary PABA recovery was not altered significantly after surgery: DPRHP, from 40% to 31%; P-JS, from 52% to 44%; and controls, from 43% to 48%. Median fecal fat also did not change significantly: DPRHP, from 6 to 12 g/24 h; P-JS, from 9 to 5 g/24 h; and controls, from 6 to 7 g/24 h. Although the integrated blood glucose value did not change after DPRHP, the integrated serum C-peptide value decreased after DPRHP (P<.02). After P-JS, the integrated blood glucose value decreased (P<.02), but there was no change in integrated serum C-peptide secretion. Neither integrated blood glucose nor C peptide values were affected in controls. Insulin dependency increased (22% to 33%) after DPRHP. Pancreatic polypeptide secretion decreased only after DPRHP (P=.003). CONCLUSIONS Surgery for chronic pancreatitis does not influence exocrine pancreatic function after either a drainage (P-JS) or a resection procedure (DPRHP). Clinical endocrine function is not affected after DPRHP but improves after P-JS.
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Affiliation(s)
- Stefan Maartense
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Amsterdam, The Netherlands
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25
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Pessaux P, Brehant O, Lermite E, Regenet N, Farah E, Arnaud JP. Dérivation pancréaticojéjunale dans le traitement des pancréatites chroniques. ACTA ACUST UNITED AC 2003; 128:610-5. [PMID: 14659615 DOI: 10.1016/j.anchir.2003.09.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION The aim of this retrospective study was to evaluate the immediate and long-term outcome of pancreaticojejunostomy (PJ) in the treatment of chronic pancreatitis. MATERIAL AND METHODS. - From 1980 to 1997, 140 patients with chronic pancreatitis with dilated Wirsung duct were treated by PJ and were studied retrospectively. There were 123 men and 17 women, with a mean age of 46 years (range: 18-79 years). Ongoing alcoholic addiction was present in 116 patients (83%). Chronic pain uncontrolled by major analgesics was the indication of PJ in 126 patients (90%). RESULTS The mortality rate was 1.4% (n = 2). The morbidity rate was 11% (n = 16). Mean hospital stay was 16 days (range: 8-25 days). The mean follow-up was 7.4 years (range: 2-15 years) in 94 patients. Functional results were good or mild in 93% of cases (n = 87). In seven patients (7%), the results were bad with persistence of chronic pain requiring major analgesics. A mean weight increase of 5.8 kg (range: 1-16 kg) was observed in 74 patients (79%). Twelve patients (13%) developed de novo diabetes mellitus. In the 43 patients with preoperative diabetes, 24 patients suffered deterioration of their status. No patient recovered from exocrine insufficiency. CONCLUSIONS In case of dilated Wirsung, PJ must be indicated preferentially because of its good efficiency on pain relief with low mortality and morbidity rates.
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Affiliation(s)
- P Pessaux
- Service de chirurgie viscérale, CHU de Angers, 4, rue Larrey, 49033 Angers, cedex 01, France.
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26
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Abstract
Chronic pancreatitis should be considered in all patients with unexplained abdominal pain. Management of abdominal pain in these patients continues to pose a formidable challenge. The importance of small duct disease without radiographic abnormalities is now a well-established concept. It is meaningful to determine whether patients with chronic pancreatitis have small duct or large duct disease because this distinction has therapeutic implications. Diagnostic evaluation should begin with simple noninvasive and inexpensive tests like serum trypsinogen and fecal elastase, to be followed where appropriate by more complicated measures such as the secretin hormone stimulation test, especially in patients with suspected small duct disease. No universal causal treatment is available. Non-enteric-coated enzyme preparations are useful for treatment of pain, whereas enteric-coated enzyme preparations are preferred for steatorrhea. Octreotide is used increasingly for abdominal pain that is unresponsive to pancreatic enzyme therapy. When medical therapy for chronic pancreatitis pain has failed, endoscopic therapy, endoscopic ultrasound-guided celiac plexus block, and thoracoscopic splanchnicectomy, performed by experts, may be considered for a highly selected patient population. Surgical ductal decompression is appropriate in patients with considerable pancreatic ductal dilation. The role and efficacy of cholecystokinin-receptor antagonists, antioxidants, and antidepressant drugs remain to be defined.
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Affiliation(s)
- Virmeet V Singh
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, PO Box 100214, Gainesville, FL 32610-0214, USA.
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