Frey procedure in the treatment of chronic pancreatitis: short-term results

Predictors of 90-day morbidity and mortality after Frey procedure for chronic pancreatitis

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.

Tailored surgery in chronic pancreatitis after implementation of a multidisciplinary team assessment; a prospective observational study

INTRODUCTION

Optimal management of chronic pancreatitis involves several specialties. Selection of patients for surgery may benefit from evaluation by a multidisciplinary team (MDT), similar to cancer care. The aim of this study was to evaluate outcomes in patients selected for surgery after MDT decision.

METHODS

A prospective, observational study of consecutive patients operated for pain due to chronic pancreatitis after implementation of a MDT. The main outcome was Quality of life (QoL) assessed by EORTC-QLQ C30 and pain relief in patients followed >3 months. Complications were registered and predictive factors for pain relief analyzed.

RESULTS

Of 269 patients evaluated by the MDT, 60 (22%) underwent surgery. Postoperative surgical complications occurred in five patients (8.3%) and reoperation within 30 days in two. There was no 90-days mortality. Complete or partial pain relief was achieved in 44 of 50 patients followed >3 months (88%). Preoperative duration of pain predicted lower probability of success. Postoperative improvement in QoL was most prominent for pain, appetite and nausea.

CONCLUSIONS

After MDT evaluation, one in five patients was selected for surgery. Pain relief was obtained in a majority of patients with improved QoL. A tailored approach through a MDT seems warranted and efficient.

Frey procedure for chronic pancreatitis: A narrative review

Chronic pancreatitis is (CP) is a progressive inflammatory disease of the pancreas associated with disabling abdominal pain and gradual deterioration of exocrine and endocrine function. Up to 50% of patients with CP may require surgery during the course of the disease. The main indication for surgery is intractable abdominal pain not amenable to medical and endoscopic therapy. The type of surgery depends on pancreatic ductal diameter and associated parenchymal pathology like inflammatory head mass. Frey procedure (FP) is an effective method for control of pain in patients with enlarged pancreatic head. FP can be performed with a very low mortality and an acceptable morbidity. Compared with pancreaticoduodenectomy (PD), FP has favourable outcomes in terms of operation time, blood loss, morbidity, post-operative hospital stay, intensive care unit stay, and quality of life. FP has shorter operation time and lower morbidity in comparison to Beger procedure. But, long-term pain control and exocrine and endocrine dysfunctions are comparable between PD, Beger and FP. FP is technically easier than PD and Beger procedure. FP is thus a widely acceptable procedure for CP with enlarged pancreatic head in absence of a neoplasia.

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Frey procedure for chronic pancreatitis is associated with acceptable perioperative.

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morbidity and a low mortality.

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It provides excellent pain control.

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It is an effective procedure for chronic pancreatitis with enlarged pancreatic head.

ALCOHOLIC VS. NON-ALCOHOLIC CHRONIC PANCREATITIS: SURGEONS' PERSPECTIVE FROM A TERTIARY CENTRE IN INDIA

Background:

Although alcohol is the most common cause for chronic pancreatitis worldwide, idiopathic type is prevalent in India. Natural history and disease progression are different between these two groups. There is paucity of data comparing surgical outcome and quality of life in these patients.

Aim:

To evaluate clinical features, surgical outcome and quality of life between these two groups of patients.

Method:

All patients with chronic pancreatitis who underwent surgery were prospectively reviewed.

Results:

From 98 patients, 42 were alcoholic. Number of male and the mean age at the time of operation was significantly more in alcoholic patients. Smoking, preoperative hospital admission rate and the prevalence of local complications like inflammatory pancreatic head mass, biliary stricture and left sided portal hypertension were distinctly more common in alcoholic group. Frey procedure was required more commonly in alcoholic group. Mean postoperative hospital stay and overall postoperative complication rate were comparable between the two groups. Over a median follow up of 18 months there was significant improvement in quality of life and pain score in both the groups. Improvement of physical functioning score at follow-up was significantly more in alcoholic group but the requirement for analgesic medications were significantly more in alcoholic group. However, appetite loss was more perceived by non-alcoholic group.

Conclusion:

Alcoholic chronic pancreatitis presents with more local complications associated with chronic pancreatitis. Frey procedure is a safe and well accepted surgery in this group. Though they required more analgesic requirement in short term follow up, other aspects of quality of life are similar to non-alcoholic group.

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

BACKGROUND

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

DATA SOURCES

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND/OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Effect of Frey's procedure on islet cell function in patients with chronic calcific pancreatitis

BACKGROUND

Frey's procedure involves both drainage and resection of the pancreas in subjects with chronic calcific pancreatitis (CCP). The procedure may affect the pancreatic endocrine function after surgery. The present study was to evaluate the effect of Frey's procedure on both beta and alpha cell function in CCP patients.

METHODS

Thirty CCP patients who underwent Frey's procedure were included. According to the glycemic status, patients were divided into the diabetes mellitus (DM), prediabetes, and normal glucose tolerance (NGT) groups. Islet cell function was assessed before and 3 months after surgery.

RESULTS

At baseline, there was a significant difference in beta cell function among the three groups [NGT group 1.71 (1.64-2.07) vs prediabetes group1.50 (0.83-1.61) vs DM group 0.33 (0.12-0.55), P < 0.0001], but the insulin resistance was not different among them. Post glucose hyperglucagonemia representing alpha-cell dysfunction during oral glucose tolerance test was present in all of them, but showed no significant difference [NGT group 0.15 (0.06-0.31) vs prediabetes group 0.32 (0.05-0.70) vs DM group 0.07 (0.02-0.18), P = 0.20]. Frey's procedure did not change beta cell function and insulin resistance. However, alpha-cell dysfunction deteriorated after surgery [0.10 (0.03-0.27) vs 0.33 (0.09-0.68), P = 0.004].

CONCLUSIONS

Although Frey's procedure does not affect the beta cell function and insulin resistance in CCP patients, the alpha-cell dysfunction deteriorates after surgery.

Operative management of chronic pancreatitis: A review

BACKGROUND

Pain secondary to chronic pancreatitis is a difficult clinical problem to manage. Many patients are treated medically or undergo endoscopic therapy and surgical intervention is often reserved for those who have failed to gain adequate pain relief from a more conservative approach.

RESULTS

There have been a number of advances in the operative management of chronic pancreatitis over the last few decades and current therapies include drainage procedures (pancreaticojejunostomy, etc.), resection (pancreticoduodenectomy, etc.) and combined drainage/resection procedures (Frey procedure, etc.). Additionally, many centers currently perform total pancreatectomy with islet autotransplantation, in addition to minimally invasive options that are intended to tailor therapy to individual patients.

DISCUSSION

Operative management of chronic pancreatitis often improves quality of life, and is associated with low rates of morbidity and mortality. The decision as to which procedure is optimal for each patient should be based on a combination of pathologic changes, prior interventions, and individual surgeon and center experience.

Quality of Life after Frey's Procedure in Patients with Chronic Pancreatitis

INTRODUCTION

Chronic pancreatitis is a debilitating disease, associated with excruciating abdominal pain, exocrine and endocrine pancreatic insufficiency. Different types of surgical techniques have been described for the management of complications of this disease. The most common procedure which has been adopted for improving the quality of life of the patients with chronic pancreatitis is Frey's Procedure. It is an organ preserving procedure in which the main pancreatic duct is drained by lateral pancreatico-jejunostomy along with coring of the head of the pancreas.

AIM

In this study, we have assessed the outcome of Frey's procedure in terms of quality of life in patients with chronic pancreatitis.

MATERIALS AND METHODS

This was a prospective observational study done at a tertiary care center in West Bengal, India. The study period was from 2010 to 2014. All the patients who have undergone Frey's Procedure during the study duration and with the postoperative histopathology of chronic pancreatitis were included in this study. The preoperative and postoperative pain and quality of life assessment was done using VAS score (0-100) and EORTC QLQ-C30 (Version 3) respectively. The statistical analysis was performed with the help of Epi Info (TM) 3.5.3.

RESULTS

A total of 35 patients with chronic pancreatitis underwent Frey's procedure during the study period. The mean age (mean ± s.e) of the 33 patients included in the study was 38.48±5.55 years with a range of 29-49 years. The mean preoperative Physical Functional Domain (PFD), Physical Domain (PD), Emotional Domain (ED), Social Domain (SD) and general health raw score with standard errors were 32.06±0.40, 37.86±0.36, 15.18±0.32, 8.63±0.31 and 4.48±0.26 respectively. ANOVA showed that there was significant differences in PFD, PD, ED, SD and GH values during different time period of follow up (p<0.0001) and as per Critical Difference the postoperative values of PFD, PD, ED and SD decreased while postoperative value of GH increased significantly in different months compared to the preoperative values.

CONCLUSION

We conclude that Frey's procedure is a low risk surgery, which significantly improves the quality of life of the patients with chronic pancreatitis in all the domains and can be recommended as a surgical therapy for such patients.

Frey procedure for chronic pancreatitis: Evidence-based assessment of short- and long-term results in comparison to pancreatoduodenectomy and Beger procedure: A meta-analysis

BACKGROUND AND OBJECTIVE

Patients with chronic pancreatitis often require surgical treatment. The aim of this study was to evaluate the published evidence for Frey procedure in patients with chronic pancreatitis.

METHODS

Literature search was undertaken to identify eligible studies until February 2015. Using meta-analytical techniques, Frey procedure was compared with pancreatoduodenectomy or Beger procedure, and the short- and long-term outcomes were analysed.

RESULTS

Twenty-three studies comprising a total of 800 patients were reviewed. The postoperative morbidity and mortality were 23.2% and 0.4% respectively. The percentage of postoperative pain-relief patients was 89.4%. New onset of diabetes and exocrine insufficiency was present in 17.3% and 30.7% of patients, respectively. Compared with pancreatoduodenectomy, Frey procedure had favorable outcomes in terms of operation time, blood transfusion, overall morbidity, length of hospital and intensive care unit stay, pancreatic function and quality of life. Compared with Beger procedure, Frey procedure had shorter operation time and lower morbidity.

CONCLUSIONS

Frey procedure is a safe and effective surgical procedure for chronic pancreatitis with dilated duct in the absence of neoplasia.

Chronic pancreatitis: A surgical disease? Role of the Frey procedure

Although medical treatment and endoscopic interventions are primarily offered to patients with chronic pancreatitis, approximately 40% to 75% will ultimately require surgery during the course of their disease. Although pancreaticoduodenectomy has been considered the standard surgical procedure because of its favorable results on pain control, its high postoperative complication and pancreatic exocrine or/and endocrine dysfunction rates have led to a growing enthusiasm for duodenal preserving pancreatic head resection. The aim of this review is to better understand the rationale underlying of the Frey procedure in chronic pancreatitis and to analyze its outcome. Because of its hybrid nature, combining both resection and drainage, the Frey procedure has been conceptualized based on the pathophysiology of chronic pancreatitis. The short and long-term outcome, especially pain relief and quality of life, are better after the Frey procedure than after any other surgical procedure performed for chronic pancreatitis.

Frey procedure for the treatment of chronic pancreatitis associated with common bile duct stricture

BACKGROUND

The Frey procedure (FP) is the treatment of choice for symptomatic chronic pancreatitis (CP). In cases of biliary stricture, biliary derivation can be performed by choledochoduodenostomy, Roux-en-Y choledochojejunostomy or, more recently, reinsertion of the common bile duct (CBD) into the resection cavity. The objective of the present study was to evaluate the outcomes associated with each of these three types of biliary derivation.

METHODS

We retrospectively analyzed demographic, CP-related, surgical and follow-up data for patients having undergone FP for CP with biliary derivation between 2004 and 2012 in our university medical center. The primary efficacy endpoint was the rate of CBD stricture recurrence. The secondary endpoints were surgical parameters, postoperative complications, postoperative follow-up and the presence of risk factors for secondary CBD stricture.

RESULTS

Eighty patients underwent surgery for CP during the study period. Of these, 15 patients received biliary derivation with the FP. Eight of the FPs (53.3%) were combined with choledochoduodenostomy, 4 (26.7%) with choledochojejunostomy and 3 (20.0%) with reinsertion of the CBD into the resection cavity. The mean operating time was 390 minutes. Eleven complications (73.3%) were recorded, including one major complication (6.7%) that necessitated radiologically-guided drainage of an abdominal collection. The mean (range) length of stay was 17 days (8-28) and the median (range) follow-up time was 35.2 months (7.2-95.4). Two patients presented stricture after CBD reinsertion into the resection cavity; one was treated with radiologically-guided dilatation and the other underwent revisional Roux-en-Y choledochojejunostomy. Three patients presented alkaline reflux gastritis (37.5%), one (12.5%) cholangitis and one CBD stricture after FP with choledochoduodenostomy. No risk factors for secondary CBD stricture were identified.

CONCLUSIONS

As part of a biliary derivation, the FP gave good results. We did not observe any complications specifically related to surgical treatment of the biliary tract. However, CBD reinsertion into the resection cavity appeared to be associated with a higher stricture recurrence rate. In our experience, choledochojejunostomy remains the "gold standard" for the surgical treatment for CBD strictures.

Frey procedure in patients with chronic pancreatitis: short and long-term outcome from a prospective study

BACKGROUND

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

METHODS

From September 2000 to November 2009, 44 consecutive patients underwent the Frey procedure. Patients were included in the study before surgery and followed prospectively with assessment of pain relief, weight gain and exocrine/endocrine insufficiency. Twenty-one patients (47.7%) were followed for more than 5 years.

RESULTS

This study included 40 men (91 %) and four women (9 %) (mean age: 49 years) with a mean follow-up of 51.5 months. The primary etiology of chronic pancreatitis was chronic alcohol abuse in 38 patients (86.4 %). The major indication for surgery was disabling pain (95.5 %). There was no postoperative mortality. Postoperative morbidity occurred in 15 patients (34.1 %), with specific surgical complications in 11 patients (25 %). The percentage of pain-free patients after surgery was 68.3 %. Eight patients (18.1 %) and seven patients (16 %) developed diabetes de novo and exocrine insufficiency, respectively. The Body Mass Index showed statistically significant improvement during follow-up. Similar beneficial results concerning pain relief and weight gain persisted after the initial 5-year follow-up.

CONCLUSIONS

The Frey procedure is an appropriate, safe and effective technique for management of patients with chronic pancreatitis in the absence of neoplasia, based on long-term follow-up.

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

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

Surgical treatment of chronic pancreatitis using Frey's procedure: a Brazilian 16-year single-centre experience

BACKGROUND

Surgical treatment of chronic pancreatitis is indicated for intractable pain. Frey's procedure is an accepted treatment for this disease. The aim of the present study was to describe a single-centre experience in the treatment of chronic pancreatitis using Frey's procedure.

METHODS

A retrospective analysis of 73 patients who underwent a Frey's procedure between 1991 to 2007 and had at least 1 year of follow-up. Demographics, indication for surgery, peri-operative complications and late outcomes were analysed.

RESULTS

The median age was 39.9 years. Seventy out of the 73 (95.8%) patients were male. The median pre-operative body mass index (BMI) was 19.1 kg/m(2). All patients had abdominal pain, 34 (46.6%) of them daily and 13 (17.8%) weekly, with moderate or severe intensity in 98.6% (n= 72). The aetiology was secondary to alcohol in 70 patients (95.9%), with a median consumption of 278 g per day. The surgical morbidity rate was 28.7%; there were no deaths. Median post-operative follow-up was 77.0 months; 64 patients (91.4%) had complete pain relief and post-operative BMI was 22.4 kg/m(2) (P<0.001). All patients with pre-operative endocrine and exocrine insufficiencies showed no reversal of the situation. New onset insufficiencies appeared late.

CONCLUSIONS

Frey's procedure was a safe and effective therapeutic option for the surgical treatment of patients with intractable pain caused by chronic pancreatitis.

Chronic pancreatitis: modern surgical management

INTRODUCTION

Chronic pancreatitis (CP) is a disease with enormous social and personal impact. It is most commonly caused by the abuse of alcohol combined with nicotine. CP is usually characterised by an inflammatory mass located in the pancreatic head. Its natural course is characterised by persistent or recurrent painful attacks as well as progressive loss of pancreatic function due to fibrosis of the parenchyma with consecutive endocrine and exocrine insufficiency.

CONCLUSIONS

The only success parameter of any treatment is the effective long-lasting pain relief and improvement in the quality of life. The surgical armamentarium includes simple drainage procedures, resections of different extents or a combination of both. Duodenum-preserving resection of the pancreas offers the best short-term outcome according to trials conducted so far. It has the benefit of combining the highest safety with the highest efficiency. Additionally, the extent of the operation can be adapted to the morphology of the individual patient.

A Modern Review of the Operative Management of Chronic Pancreatitis

Chronic pancreatitis is a debilitating disease resulting in pain, intestinal malabsorption, endocrine dysfunction, and poor quality of life (QoL). Our aim was to analyze surgical outcomes for patients with chronic pancreatitis. Data for patients undergoing operations for chronic pancreatitis between 1990 and 2009 were reviewed. Demographics, operative and perioperative data, and survival were catalogued. QoL was determined (Short Form 36 and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire + PAN-26) and compared with historical controls. The mean age was 51 ± 2 years, 38 patients were male (53%), the most common indication was pain (71%), the etiology of pancreatitis often was alcohol, and most patients underwent a Whipple procedure (56%). Operative time was 316 ± 17 minutes and blood loss was 363 ± 75 mL. There were 34 complications in 30 patients (42%) and one death. QoL surveys were administered for 25 of 55 (45%) surviving patients at a mean follow-up of 72 ± 16 months. Mean survival was 99 ± 9 months, whereas 5- and 10-year survival were 86 and 75 per cent. QoL scores were uniformly better than historical controls. Our data demonstrate that operations for chronic pancreatitis can be performed with acceptable morbidity and mortality. Patients have excellent survival and improved QoL compared with historical controls. Surgery is an effective and durable treatment option for patients with chronic pancreatitis.

Surgical treatment in chronic pancreatitis timing and type of procedure

Pain relief and improvement in the quality of life are of paramount importance for any intervention in chronic pancreatitis. In several trial good results have been published after different drainage procedures and resections. An optimal surgical intervention should manage mainly the intractable pain, resolve the complications of the adjacent organs and achieve the drainage of the main pancreatic duct. An optimal procedure should guarantee a low relapse rate, preserve a maximum of endocrine and exocrine function, and most importantly, restore quality of life. Thus an ideal operation should representing a one-stop-shopping. According to the trials conducted so far, Duodenum-preserving resection of the pancreatic head offers the best short-term outcome. It combines the highest safety of all surgical procedures with the highest efficacy. By varying the extent of the cephalic resection, it offers the possibility of customizing surgery according to the individual patient's morphology.

Walled-off pancreatic necrosis

Walled-off pancreatic necrosis (WOPN), formerly known as pancreatic abscess is a late complication of acute pancreatitis. It can be lethal, even though it is rare. This critical review provides an overview of the continually expanding knowledge about WOPN, by review of current data from references identified in Medline and PubMed, to September 2009, using key words, such as WOPN, infected pseudocyst, severe pancreatitis, pancreatic abscess, acute necrotizing pancreatitis (ANP), pancreas, inflammation and alcoholism. WOPN comprises a later and local complication of ANP, occurring more than 4 wk after the initial attack, usually following development of pseudocysts and other pancreatic fluid collections. The mortality rate associated with WOPN is generally less than that of infected pancreatic necrosis. Surgical intervention had been the mainstay of treatment for infected peripancreatic fluid collection and abscesses for decades. Increasingly, percutaneous catheter drainage and endoscopic retrograde cholangiopancreatography have been used, and encouraging results have recently been reported in the medical literature, rendering these techniques invaluable in the treatment of WOPN. Applying the recommended therapeutic strategy, which comprises early treatment with antibiotics combined with restricted surgical intervention, fewer patients with ANP undergo surgery and interventions are ideally performed later in the course of the disease, when necrosis has become well demarcated.

Total pancreatectomy with and without islet cell transplantation for chronic pancreatitis: a series of 85 consecutive patients

OBJECTIVES

This study examined 85 consecutive patients undergoing total pancreatectomy (+/-islet cell transplant), examining pain relief, insulin requirements, and glycemic control postoperatively.

METHODS

A prospective database of all patients undergoing total pancreatectomy for chronic pancreatitis was used to record preoperative and postoperative details from 1996 to 2006.

RESULTS

There were 3 postoperative deaths (1 islet recipient and 2 nonislet patients). The median number of acute admissions for pain fell from 5 to 2 after pancreatectomy, and the median length of stay from 6.2 days to 3.3 days. At 12 months postoperatively, the number of patients on regular opiate analgesia fell from 90.6% to 40.2% and by 5 years to 15.9%. There was a significant reduction in the patients' visual analogue pain score after surgery from 9.7 to 3.7 (P < 0.001). Five patients were insulin independent at 5 years. Median 24-hour insulin requirements were significantly lower in the islet group (15.5 vs 40 units at 5 years postoperatively; P < 0.001).

CONCLUSIONS

Total pancreatectomy is effective in reducing pain and dependence on opioid analgesia in patients with chronic pancreatitis. The addition of an islet cell transplant results in a reduction in 24-hour insulin demands, as well as potentially achieving insulin independence.

Factors affecting outcome after Frey procedure for chronic pancreatitis

BACKGROUND

Debilitating abdominal pain remains the most common presentation of chronic pancreatitis and the treatment remains challenging.

OBJECTIVE

This prospective study analyzed the outcome of Frey's procedure in patients with inflammatory head mass.

METHODS

For the period between 2002 and 2007, 77 patients with chronic pancreatitis underwent Frey procedure for intractable abdominal pain. The mean follow-up was 14 months. For the purpose of analysis of the outcome, patients were grouped as poor pain control (19%) and good pain control groups (81%) based on the pain scores during follow-up.

RESULTS

There was no 30-day mortality. The logistic regression analysis showed that decreased volume percentage (48%) of head mass resected (p=0.003) and small diameter of the pancreatic duct (p=0.05) were associated with poor pain outcome. Subgroup analysis revealed that patients with small duct disease were associated with increased operative time (p=0.001), poor pain scores (p=0.001), and increased weight loss (p=0.003) during follow-up.

CONCLUSIONS

Frey procedure can be performed with zero mortality and low morbidity in a high-volume center. It provides good pain relief in majority of the patients. Volume of the head mass cored affects pain outcome. Correlation between poor results in terms of pain relief and weight loss following Frey's procedure, and small duct disease supports the view that duct diameter is an important predictor of pain relief.

Results of decompression surgery for pain in chronic pancreatitis

INTRODUCTION

A vast majority of patients with chronic pancreatitis require regular opiate/opioid analgesia and recurrent hospital admission for pain. However, the role and timing of operative strategies for pain in chronic pancreatitis is controversial. This study hypothesized that pancreatic decompression surgery reduces analgesia requirement and hospital readmission for pain in selected patients.

PATIENTS AND METHODS

This was a retrospective review of patients undergoing longitudinal pancreatico-jejunostomy (LPJ), with or without coring of the pancreatic head (Frey's procedure), between 1995 and 2007 in a single UK centre. Surgery was performed for chronic pain with clinical/radiological evidence of chronic pancreatitis amenable to decompression/head coring.

RESULTS

Fifty patients were identified. Thirty-six were male with a median age of 46 years and median follow-up of 30 months. Twenty-eight underwent LPJ and 22 underwent Frey's procedure. No significant difference in reduction of analgesia requirement (71% vs 64%, p=0.761) or hospital readmission for pain (21% vs 23%, p=1.000) was observed when comparing LPJ and Frey's procedure. Patients were significantly more likely to be pain-free following surgery if they required non-opiate rather than opiate analgesia preoperatively (75% vs 19%, p=0.0002). Fewer patients required subsequent hospital readmission for pain if taking non-opiate rather than opiate analgesia preoperatively (12.5% vs 31%, p=0.175).

CONCLUSIONS

In selected patients, LPJ and Frey's procedure have equivalent benefit in short-term pain reduction. Patients should be selected for surgery before the commencement of opiate analgesia.