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Milano RV, Morneault-Gill K, Kamal HY, Barkin JA, Chadwick CB. Pancreatitis in cystic fibrosis: Presentation, medical and surgical management, and the impact of modulator therapies. Pediatr Pulmonol 2024; 59 Suppl 1:S53-S60. [PMID: 38501345 DOI: 10.1002/ppul.26958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 01/19/2024] [Accepted: 03/01/2024] [Indexed: 03/20/2024]
Abstract
Patients with Cystic Fibrosis (CF) are at increased risk of acute (AP) and chronic (CP) pancreatitis, and their complications. The extent of remaining healthy pancreatic parenchyma determines the risk of developing future episodes of pancreatitis, as well as pancreatic exocrine or endocrine insufficiency. Pancreatitis may be the presenting symptom of CF, and genetic testing is especially important in pediatrics. AP and recurrent AP are managed with intravenous fluid hydration and pain control, in addition to early refeeding and treatment of complications. With the use of modulator therapy in CF, pancreatic function may be restored to some extent. CP related pain is managed with analgesics and neuromodulators, with surgery if indicated in specific situations including TPIAT as a possible type of surgical intervention. Long-term sequelae of CP in patients with CF include exocrine pancreatic insufficiency treated with pancreatic enzyme replacement therapy, fat-soluble vitamin deficiencies and associated metabolic complications such as bone disease/osteoporosis, pancreatogenic diabetes, and less commonly, pancreatic cancer. We review the presentation and etiologies of pancreatitis in CF patients as well as the management of AP and CP primarily in children.
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Affiliation(s)
- Reza V Milano
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Kayla Morneault-Gill
- Department of Pediatrics, Division of Gastroenterology, University of Florida, College of Medicine, Gainesville, Florida, USA
| | - Hebat Y Kamal
- Department of Pediatrics, Division of Gastroenterology, University of Florida, College of Medicine, Gainesville, Florida, USA
| | - Jodie A Barkin
- Department of Medicine, Division of Digestive Health and Liver Diseases, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Christina Baldwin Chadwick
- Department of Pediatrics, Division of Gastroenterology, University of Florida, College of Medicine, Gainesville, Florida, USA
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Kawka M, Lucas A, Riad AM, Hawkins D, de Madaria E, West H, Jakaityte I, Lee MJ, Kouli O, Ruanne R, Gujjuri RR, Brown S, Cambridge WA, Pandanaboyana S, Kamarajah SK, McLean KA. Quality of life instruments in acute and chronic pancreatitis: a consensus-based standards for the selection of health measurement instruments (COSMIN) approach. HPB (Oxford) 2024; 26:859-872. [PMID: 38735815 DOI: 10.1016/j.hpb.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 04/07/2024] [Accepted: 04/18/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Pancreatitis is a common surgical emergency, associated with pain and poor quality of life for patients. However, assessment of patient-reported outcome measures in these patients is unclear. This study aimed to identify and evaluate the methodological quality of the health-related quality of life instruments used for patients with acute or chronic pancreatitis. METHODS Prospective studies that evaluated health-related quality of life in acute or chronic pancreatitis were identified from systematic review of MEDLINE, EMBASE, and Web of Science until 28th June 2023 (PROSPERO: CRD42021274743). Instrument characteristics were extracted, and methodological quality assessed using COSMIN (COnsensus-based Standards for the selection of health status Measurement Instruments) guidelines and GRADE approach. Narrative synthesis was conducted, with recommendations for use based on COSMIN criteria, evaluated according to World Health Organisation (WHO) quality of life domains. RESULTS From 3850 records screened, 41 quality of life instruments were identified across 138 studies included. The majority (69.8%, n = 26) were designed to assess general health-related quality of life, whereas the remainder were abdominal-specific (n = 5) or pancreas-specific (n = 10). Only ten instruments (24.3%) demonstrated sufficient content validity, incorporating items in ≥5 WHO quality of life domains. However, only nine instruments (21.9%) incorporated public and patient involvement. Only the Gastrointestinal Quality of Life Index and PAN-PROMISE met the criteria to be recommended for use based on COSMIN methodological assessment. CONCLUSION There is significant heterogeneity in instruments used to assess quality of life after pancreatitis, with almost all instruments considered insufficient. Robust, validated, and relevant instruments are needed to better understand and determine appropriate interventions to improve quality of life for these patients.
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3
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Bardenhagen J, Izbicki JR. Total Pancreatectomy Is a Questionable Choice for Treatment of Chronic Pancreatitis. J Am Coll Surg 2024; 238:1166-1167. [PMID: 38251725 DOI: 10.1097/xcs.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
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Ashfaq A, Kolanu ND, Mohammed M, Oliveira Souza Lima SR, Rehman A, Shehryar A, Fathallah NA, Abdallah S, Abougendy IS, Raza A. Surgical Interventions in Chronic Pancreatitis: A Systematic Review of Their Impact on Quality of Life. Cureus 2024; 16:e53989. [PMID: 38476813 PMCID: PMC10928306 DOI: 10.7759/cureus.53989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2024] [Indexed: 03/14/2024] Open
Abstract
This systematic review evaluates the efficacy of surgical interventions in improving the quality of life for patients with chronic pancreatitis (CP). A thorough literature search, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identified 11 studies that focused on patient-reported outcomes after surgical treatments, including pancreatic resections, drainage procedures, and duodenum-preserving head resections. The findings indicate that organ-preserving procedures, notably the Frey and Beger operations, significantly enhance pain control and overall quality of life while reducing analgesic dependency. This review provides crucial insights into the long-term efficacy and comparative benefits of different surgical approaches, highlighting the need for personalized surgical strategies in CP management. It emphasizes the necessity for standardized outcome measures and further comparative research to refine CP treatment protocols.
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Affiliation(s)
- Abdullah Ashfaq
- Surgery, Gujranwala Medical Teaching Hospital, Gujranwala, PAK
| | | | - Mathani Mohammed
- General Surgery, Sudan Medical Specialization Board Hospital, Khartoum, SDN
| | | | | | | | - Nader A Fathallah
- Accident and Emergency, Nasr City Hospital for Health Insurance, Cairo, EGY
| | | | | | - Ali Raza
- Internal Medicine, Nishtar Medical University, Multan, PAK
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Cassar N, Cromwell P, Duggan S, van Veldhuisen C, Boermeester M, Besselink M, Conlon K. Surgery versus Endoscopy for the Management of Painful Chronic Pancreatitis: A Systematic Review and Meta-Analysis of Randomized Trials. Dig Surg 2024; 41:1-11. [PMID: 38190810 DOI: 10.1159/000535588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/21/2023] [Indexed: 01/10/2024]
Abstract
BACKGROUND Debate exists regarding the optimal treatment for painful chronic pancreatitis (CP). This meta-analysis aims to determine the outcomes of surgical intervention as compared to endoscopy in patients with painful CP. METHODS A systematic review and meta-analysis including studies from PubMed, Embase, Web of Science, and Cochrane Databases (1995 onwards) was done by two independent reviewers using PRISMA guidelines. Primary outcome was pain relief. RESULTS Among 8,479 studies, three were randomized trials, comprising a total of 199 patients. Compared with endoscopy, surgery was associated with a lower Izbicki score, both at medium term (mean difference (MD) 21.46, 95% confidence interval (CI) 13.48-29.43, p < 0.00001) and long term (MD: 17.80, 95% CI: 8.36-27.23, p = 0.0002). A higher proportion of surgical patients had some sort of pain relief compared with those who had endoscopy, both at medium term (72% vs. 46%, RR: 1.51, 95% CI: 1.19-1.90, p = 0.0006) and long term (73% vs. 47%, RR: 1.50, 95% CI: 1.19-1.89, p = 0.0007). Complete pain relief was more common in the surgical group compared to the endoscopy group, both at medium term (33% vs. 17%, RR: 1.97, 95% CI: 1.16-3.36, p = 0.01) and long term (35% vs. 18%, RR: 1.92, 95% CI: 1.15-3.20, p = 0.01). The pooled crossover rate from endoscopy to surgery was 22% (22/99). CONCLUSIONS Surgical treatment in patients with painful CP leads to better pain control, requiring fewer interventions as compared to endoscopic treatment.
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Affiliation(s)
- Noel Cassar
- Department of Hepatobiliary Surgery and Liver Transplantation, St Vincent's University Hospital, Dublin, Ireland
| | - Paul Cromwell
- Department of Hepatobiliary Surgery and Liver Transplantation, St Vincent's University Hospital, Dublin, Ireland
| | - Sinead Duggan
- Professorial Surgical Unit, Department of Surgery, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Charlotte van Veldhuisen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Marja Boermeester
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Marc Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Kevin Conlon
- Department of Hepatobiliary Surgery and Liver Transplantation, St Vincent's University Hospital, Dublin, Ireland
- Professorial Surgical Unit, Department of Surgery, School of Medicine, Trinity College Dublin, Dublin, Ireland
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Leonhardt CS, Niesen W, Pils D, Angelova Y, Hank T, Kaiser J, Scheele C, Hinz U, Hackert T, Büchler MW, Strobel O. Patient reported outcomes of duodenum-preserving pancreatic head resection in chronic pancreatitis: high effectivity is impaired by prolonged non-surgical management. HPB (Oxford) 2024; 26:73-82. [PMID: 37865592 DOI: 10.1016/j.hpb.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/20/2023] [Accepted: 10/01/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Chronic pancreatitis (CP) causes suffering and socioeconomic burden. This study evaluated perioperative results and patient-reported outcomes (PRO) in CP patients treated with duodenum-preserving pancreatic head resection (DPPHR). METHODS Data were analyzed of CP patients undergoing DPPHR between 01/2001-10/2014. PROs were measured using a specifically designed questionnaire and the EORTC QLQ-C30/PAN26. Associations between treatment variables and PROs were examined. RESULTS Of 332 patients who received DPPHR, most (n = 251, 75.6%) underwent the Berne modification. Surgical morbidity was 21.5% (n = 71) and 90-day mortality 1.5% (n = 5). Median follow-up was 79.9 months, 5-year survival 90.5%, and 1.8% of patients developed pancreatic cancer. Of 283 patients alive, 178 (62.9%) returned questionnaires. Referral for surgery was self-initiated (38.0% of cases), by gastroenterologists (27.5%) and by general practitioners (21.1%). QoL improved in 78.7% of patients, remained stable in 12.1%, and worsened in 9.1%. Median Izbicki scores decreased from 90 to 5 points after surgery (p < 0.0001). Time from diagnosis to DPPHR was an independent, proportional predictor of a higher postoperative Izbicki score (p = 0.04). CONCLUSION DPPHR is an effective, safe treatment for CP. A delay in surgery decreases surgical effectivity, hence CP patients should be referred to surgery early to ensure satisfactory outcomes.
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Affiliation(s)
- Carl-Stephan Leonhardt
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Willem Niesen
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dietmar Pils
- Department of General Surgery, Division of Visceral Surgery, Medical University Vienna, Vienna, Austria
| | - Yoana Angelova
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Hank
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Jörg Kaiser
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Scheele
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Oliver Strobel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.
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Coluzzi M, Takita M, Saracino G, Rub Hakim Mohammed A, Darden CM, Testa G, Beecherl E, Onaca N, Naziruddin B. Improved Quality of Life Among Chronic Pancreatitis Patients Undergoing Total Pancreatectomy With Islet Autotransplantation-Single Center Experience With Large Cohort of Patients. Transpl Int 2023; 36:11409. [PMID: 37727384 PMCID: PMC10505652 DOI: 10.3389/ti.2023.11409] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 08/22/2023] [Indexed: 09/21/2023]
Abstract
Total pancreatectomy with islet autotransplantation (TPIAT) is the treatment of choice to preserve pancreatic endocrine function, alleviate pain, and improve quality of life (QoL) when other strategies are ineffective for chronic pancreatitis (CP) patients. This study utilized pancreatic disease-specific surveys developed by the European Organisation for Research and Treatment of Cancer (EORTC) to conduct a comprehensive, single-center examination of a large cohort of patients to gain understanding of QoL post-TPIAT. Two validated QoL surveys of the EORTC-QLQ-C30 and QLQ-PAN26-were administered in a prospective cohort of CP patients during pre-and post-operative scheduled visits. A total of 116 patients responded to the preoperative survey and were included in this study. The global health scale of QLQ-C30 was significantly improved after TPIAT when compared to baseline with delta scores of 24.26, 20.54, and 26.7 at 1, 2, and 3 years post-TPIAT (p < 0.001). The EORTC-PAN26 revealed significant improvements in symptom scales for pancreatic pain, bloating, digestive symptoms, taste, indigestion, weight loss, body image, and future worries. The comprehensive surveys in such a large cohort expands the QoL criterion in CP patients and indicates significant improvement in QoL post-TPIAT, further validating TPIAT as a treatment option for refractory CP.
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Affiliation(s)
- Mariagrazia Coluzzi
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
- Unit of General and Emergency Surgery, Azienda Ospedaliera Regionale San Carlo, Potenza, Italy
| | - Morihito Takita
- Department of Radiation Health Management, Fukushima Medical University, Fukushima, Japan
| | - Giovanna Saracino
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | | | - Carly M. Darden
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Giuliano Testa
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | - Ernest Beecherl
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
| | | | - Bashoo Naziruddin
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, United States
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Guo S, Zhou Q, Yang J, Tao J, Zhang J, Wang H. Duodenum-preserving pancreatic head resection compared to pancreaticoduodenectomy: A systematic review and network meta-analysis of surgical outcomes. Front Surg 2023; 10:1107613. [PMID: 37066008 PMCID: PMC10090510 DOI: 10.3389/fsurg.2023.1107613] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 03/10/2023] [Indexed: 03/31/2023] Open
Abstract
ObjectivesIn this systemic review and network meta-analysis, we investigated pancreaticoduodenectomy (PD), pylorus-preserving pancreaticoduodenectomy (PPPD), and different modifications of duodenum-preserving pancreatic head resection (DPPHR) to evaluate the efficacy of different surgical procedures.MethodsA systemic search of six databases was conducted to identify studies comparing PD, PPPD, and DPPHR for treating pancreatic head benign and low-grade malignant lesions. Meta-analyses and network meta-analyses were performed to compare different surgical procedures.ResultsA total of 44 studies were enrolled in the final synthesis. Three categories of a total of 29 indexes were investigated. The DPPHR group had better working ability, physical status, less loss of body weight, and less postoperative discomfort than the Whipple group, while both groups had no differences in quality of life (QoL), pain scale scores, and other 11 indexes. Network meta-analysis of a single procedure found that DPPHR had a larger probability of best performance in seven of eight analyzed indexes than PD or PPPD.ConclusionDPPHR and PD/PPPD have equal effects on improving QoL and pain relief, while PD/PPPD has more severe symptoms and more complications after surgery. PD, PPPD, and DPPHR procedures exhibit different strengths in treating pancreatic head benign and low-grade malignant lesions.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/, identifier: CRD42022342427.
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Affiliation(s)
- Shixiang Guo
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China
- Chongqing School, University of Chinese Academy of Sciences, Chongqing, China
| | - Qiang Zhou
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China
| | - Jiali Yang
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China
| | - Junyu Tao
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China
| | - Junfeng Zhang
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China
| | - Huaizhi Wang
- Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China
- Correspondence: Huaizhi Wang
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Zafar HB. Surgical Management of Chronic Pancreatitis: A Systemic Review. Cureus 2023; 15:e35806. [PMID: 36891174 PMCID: PMC9986717 DOI: 10.7759/cureus.35806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/08/2023] Open
Abstract
Chronic pancreatitis is a debilitating disease. It is caused by the progressive destruction of normal pancreatic parenchyma, which is replaced by fibrous tissue causing pain in addition to pancreatic insufficiency. There is no single mechanism of pain in chronic pancreatitis. Several medical, endoscopic, and surgical treatment strategies are available to control this disease. Surgical techniques are divided into resection, drainage, and hybrid procedures. The review aimed to compare various surgical procedures used in the management of chronic pancreatitis. The ideal operation is the one that effectively and persistently relieves the pain and has the least morbidity with favorable pancreatic reserve. All the randomized control trials from inception to January 2023, which fulfilled the inclusion criteria, were extensively searched on PubMed and a systemic review was conducted comparing the surgical outcomes of the variety of operations used in chronic pancreatitis. Duodenum-preserving pancreatic head resection is the common procedure done with favorable outcomes.
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Affiliation(s)
- Hafiz Bilal Zafar
- Department of Hepatobiliary and Liver Transplant Surgery, Hamad Medical Corporation, Doha, QAT
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10
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Ray S, Basu C, Dhali A, Dhali GK. Frey procedure for chronic pancreatitis: A narrative review. Ann Med Surg (Lond) 2022; 80:104229. [PMID: 36045829 PMCID: PMC9422204 DOI: 10.1016/j.amsu.2022.104229] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/16/2022] [Accepted: 07/20/2022] [Indexed: 11/03/2022] Open
Abstract
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. Frey procedure for chronic pancreatitis is associated with acceptable perioperative. morbidity and a low mortality. It provides excellent pain control. It is an effective procedure for chronic pancreatitis with enlarged pancreatic head.
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Nathan JD, Ellery K, Balakrishnan K, Bhatt H, Ganoza A, Husain SZ, Kumar R, Morinville VD, Quiros JA, Schwarzenberg SJ, Sellers ZM, Uc A, Abu-El-Haija M. The Role of Surgical Management in Chronic Pancreatitis in Children: A Position Paper From the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Pancreas Committee. J Pediatr Gastroenterol Nutr 2022; 74:706-719. [PMID: 35258494 PMCID: PMC10286947 DOI: 10.1097/mpg.0000000000003439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Chronic pancreatitis (CP) is rare in childhood but impactful because of its high disease burden. There is limited literature regarding the management of CP in children, specifically about the various surgical approaches. Herein, we summarize the current pediatric and adult literature and provide recommendations for the surgical management of CP in children. METHODS The literature review was performed to include the scope of the problem, indications for operation, conventional surgical options as well as total pancreatectomy with islet autotransplantation, and outcomes following operations for CP. RESULTS Surgery is indicated for children with debilitating CP who have failed maximal medical and endoscopic interventions. Surgical management must be tailored to the patient's unique needs, considering the anatomy and morphology of their disease. A conventional surgical approach (eg, drainage operation, partial resection, combination drainage-resection) may be considered in the presence of significant and uniform pancreatic duct dilation or an inflammatory head mass. Total pancreatectomy with islet autotransplantation is the best surgical option in patients with small duct disease. The presence of genetic risk factors often portends a suboptimal outcome following a conventional operation. CONCLUSIONS The morphology of disease and the presence of genetic risk factors must be considered while determining the optimal surgical approach for children with CP. Surgical outcomes for CP are variable and depend on the type of intervention. A multidisciplinary team approach is needed to assure that the best possible operation is selected for each patient, their recovery is optimized, and their immediate and long-term postoperative needs are well-met.
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Affiliation(s)
- Jaimie D. Nathan
- Nationwide Children’s Hospital, Department of Abdominal Transplant and Hepatopancreatobiliary Surgery, The Ohio State University College of Medicine, Department of Surgery, Columbus, Ohio, United States
| | - Kate Ellery
- University of Pittsburgh Medical Center, Division of Gastroenterology, Hepatology and Nutrition, Pittsburgh, Pennsylvania, United States
| | - Keshawadhana Balakrishnan
- Texas Children’s Hospital, Section of Pediatric Gastroenterology, Baylor College of Medicine, Department of Pediatrics, Houston, Texas, United States
| | - Heli Bhatt
- University of Minnesota, Masonic Children’s Hospital, Minneapolis, Minnesota, United States
| | - Armando Ganoza
- University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Hillman Center for Pediatric Transplantation, Pittsburgh, Pennsylvania, United States
| | - Sohail Z. Husain
- Lucile Packard Children’s Hospital at Stanford, Pediatric Gastroenterology, Hepatology and Nutrition and Department of Pediatrics, Stanford University, Palo Alto, California, United States
| | - Rakesh Kumar
- Promedica Russell J. Ebeid Children’s Hospital, Toledo, Ohio, United States
| | - Veronique D. Morinville
- McGill University Health Center, Montreal Children’s Hospital, Division of Pediatric Gastroenterology and Nutrition, Montreal, Quebec, Canada
| | - J. Antonio Quiros
- Icahn School of Medicine, Mount Sinai Kravis Children’s Hospital, New York, New York, United States
| | - Sarah J. Schwarzenberg
- University of Minnesota, Masonic Children’s Hospital, Minneapolis, Minnesota, United States
| | - Zachary M. Sellers
- Lucile Packard Children’s Hospital at Stanford, Pediatric Gastroenterology, Hepatology and Nutrition and Department of Pediatrics, Stanford University, Palo Alto, California, United States
| | - Aliye Uc
- University of Iowa, Carver College of Medicine, Stead Family Department of Pediatrics, Iowa City, Iowa, United States
| | - Maisam Abu-El-Haija
- Cincinnati Children’s Hospital Medical Center, Division of Gastroenterology, Hepatology and Nutrition, University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, United States
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Beyer G, Hoffmeister A, Michl P, Gress TM, Huber W, Algül H, Neesse A, Meining A, Seufferlein TW, Rosendahl J, Kahl S, Keller J, Werner J, Friess H, Bufler P, Löhr MJ, Schneider A, Lynen Jansen P, Esposito I, Grenacher L, Mössner J, Lerch MM, Mayerle J. S3-Leitlinie Pankreatitis – Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – September 2021 – AWMF Registernummer 021-003. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:419-521. [PMID: 35263785 DOI: 10.1055/a-1735-3864] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Georg Beyer
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, Deutschland
| | - Albrecht Hoffmeister
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Deutschland
| | - Patrick Michl
- Universitätsklinik u. Poliklinik Innere Medizin I mit Schwerpunkt Gastroenterologie, Universitätsklinikum Halle, Deutschland
| | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Deutschland
| | - Wolfgang Huber
- Comprehensive Cancer Center München TUM, II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Hana Algül
- Comprehensive Cancer Center München TUM, II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Albrecht Neesse
- Klinik für Gastroenterologie, gastrointestinale Onkologie und Endokrinologie, Universitätsmedizin Göttingen, Deutschland
| | - Alexander Meining
- Medizinische Klinik und Poliklinik II Gastroenterologie und Hepatologie, Universitätsklinikum Würzburg, Deutschland
| | | | - Jonas Rosendahl
- Universitätsklinik u. Poliklinik Innere Medizin I mit Schwerpunkt Gastroenterologie, Universitätsklinikum Halle, Deutschland
| | - Stefan Kahl
- Klinik für Innere Medizin m. Schwerpkt. Gastro./Hämat./Onko./Nephro., DRK Kliniken Berlin Köpenick, Deutschland
| | - Jutta Keller
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Jens Werner
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, Deutschland
| | - Helmut Friess
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar, München, Deutschland
| | - Philip Bufler
- Klinik für Pädiatrie m. S. Gastroenterologie, Nephrologie und Stoffwechselmedizin, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Deutschland
| | - Matthias J Löhr
- Department of Gastroenterology, Karolinska, Universitetssjukhuset, Stockholm, Schweden
| | - Alexander Schneider
- Klinik für Gastroenterologie und Hepatologie, Klinikum Bad Hersfeld, Deutschland
| | - Petra Lynen Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Irene Esposito
- Pathologisches Institut, Heinrich-Heine-Universität und Universitätsklinikum Duesseldorf, Duesseldorf, Deutschland
| | - Lars Grenacher
- Conradia Radiologie München Schwabing, München, Deutschland
| | - Joachim Mössner
- Bereich Gastroenterologie, Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Deutschland
| | - Markus M Lerch
- Klinik für Innere Medizin A, Universitätsmedizin Greifswald, Deutschland.,Klinikum der Ludwig-Maximilians-Universität (LMU) München, Deutschland
| | - Julia Mayerle
- Medizinische Klinik und Poliklinik II, LMU Klinikum, Ludwig-Maximilians-Universität München, Deutschland
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13
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Mou Y, Song Y, Chen HY, Wang X, Huang W, Liu XB, Ke NW. Which Surgeries Are the Best Choice for Chronic Pancreatitis: A Network Meta-Analysis of Randomized Controlled Trials. Front Surg 2022; 8:798867. [PMID: 35187048 PMCID: PMC8850358 DOI: 10.3389/fsurg.2021.798867] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/20/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundSurgery is an effective choice for the treatment of chronic pancreatitis (CP). However, there is no clear consensus regarding the best choice among the surgical procedures. The aim of this study is to conduct a network meta-analysis of randomized controlled trials comparing treatment outcomes to provide high-quality evidences regarding which is the best surgery for CP.MethodsA systematic search of the PubMed (MEDLINE), SCIE, EMBASE, CENTRAL, and CDSR databases were performed to identify studies comparing surgeries for CP from the beginning of the databases to May 2020. Pain relief and mortality were the primary outcomes of interest.ResultsTen studies including a total of 680 patients were identified for inclusion. PPPD had a better postoperative short-term pain relief and quality of life (QOL), but a worse pancreatic exocrine function deficiency and high morbidity. Berne had a significant postoperative long-term pain relief and mortality with a lower risk of pancreatic exocrine function deficiency.ConclusionThe main surgical procedures including the PPPD, Beger procedure, Frey modification and Berne modification can efficaciously treat CP. The Berne modification may be first choice with better efficacy and less complications in pancreatic function, but the impact of postoperative QOL cannot be ignored. Furthermore, when the CP patients have a mass in the pancreatic head which cannot be distinguished from pancreatic cancer, the only legitimate choice should be PPPD or classical pancreaticoduodenectomy.
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Affiliation(s)
- Yu Mou
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Song
- Geriatrics Center, West China Hospital, Sichuan University, Chengdu, China
| | - Hong-Yu Chen
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xing Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Huang
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Xu-Bao Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Neng-Wen Ke
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Neng-Wen Ke
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14
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Jana K, Ray S, DAS R, Kumar D, Mandal TS, DAS S. ALCOHOLIC VS. NON-ALCOHOLIC CHRONIC PANCREATITIS: SURGEONS' PERSPECTIVE FROM A TERTIARY CENTRE IN INDIA. ACTA ACUST UNITED AC 2021; 34:e1595. [PMID: 34669885 PMCID: PMC8521776 DOI: 10.1590/0102-672020210002e1595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/04/2021] [Indexed: 11/21/2022]
Abstract
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.
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Affiliation(s)
- Koustav Jana
- Department of Surgical Gastroenterology, SSKM Hospital and IPGMER, Kolkata, West Bengal-700020, India
| | - Sukanta Ray
- Department of Surgical Gastroenterology, SSKM Hospital and IPGMER, Kolkata, West Bengal-700020, India
| | - Roby DAS
- Department of Surgical Gastroenterology, SSKM Hospital and IPGMER, Kolkata, West Bengal-700020, India
| | - Dilip Kumar
- Department of Surgical Gastroenterology, SSKM Hospital and IPGMER, Kolkata, West Bengal-700020, India
| | - Tuhin S Mandal
- Department of Surgical Gastroenterology, SSKM Hospital and IPGMER, Kolkata, West Bengal-700020, India
| | - Somak DAS
- Department of Surgical Gastroenterology, SSKM Hospital and IPGMER, Kolkata, West Bengal-700020, India
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15
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Kimura K, Adachi E, Toyohara A, Omori S, Ezaki K, Ihara R, Higashi T, Ohgaki K, Ito S, Maehara SI, Nakamura T, Maehara Y. Successful outcome of retrograde pancreatojejunostomy for chronic pancreatitis and infected pancreatic cysts: A case report. World J Clin Cases 2021; 9:7224-7230. [PMID: 34540982 PMCID: PMC8409187 DOI: 10.12998/wjcc.v9.i24.7224] [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: 04/06/2021] [Revised: 04/14/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Chronic pancreatitis occasionally requires surgical treatment that can be performed with various techniques. Often, this type of surgery presents with postoperative complications. We report a case of a successful retrograde pancreatojejunostomy for chronic pancreatitis and infected pancreatic cysts.
CASE SUMMARY A 62-year-old male with a 10-year history of chronic pancreatitis presented with epigastric pain for one week and a 20 kg weight loss over one year. Computed tomography showed stones in the pancreas (mainly the head), expansion of the main pancreatic duct, and thinning of the pancreatic parenchyma. Magnetic resonance imaging showed infected pancreatic cysts connected to the stomach with a fistula from the splenic hilum to the caudal portion of the liver’s lateral segment. An endoscopic retrograde pancreatography was performed; the guide wires could not pass through the stones in the pancreas and therefore, drainage of the main pancreatic duct was not achieved. Next, a distal pancreatomy and splenectomy were performed; however, the pancreatic juice in the remaining parenchyma was blocked by the stones. Hence, we performed a retrograde pancreatojejunostomy and Roux-en-Y anastomosis. The patient had no postoperative complications and was discharged from the hospital on postoperative day 14.
CONCLUSION A distal pancreatomy, retrograde pancreatojejunostomy, and Roux-en-Y anastomosis could be an effective surgical procedure for intractable chronic pancreatitis.
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Affiliation(s)
- Koichi Kimura
- Department of Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka 815-8588, Japan
| | - Eisuke Adachi
- Department of Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka 815-8588, Japan
| | - Ayako Toyohara
- Department of Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka 815-8588, Japan
| | - Sachie Omori
- Department of Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka 815-8588, Japan
| | - Kaoru Ezaki
- Department of Internal Medicine, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka 815-8588, Japan
| | - Ryo Ihara
- Department of Internal Medicine, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka 815-8588, Japan
| | - Takahiro Higashi
- Department of Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka 815-8588, Japan
| | - Kippei Ohgaki
- Department of Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka 815-8588, Japan
| | - Shuhei Ito
- Department of Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka 815-8588, Japan
| | - Shin-ichiro Maehara
- Department of Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka 815-8588, Japan
| | - Toshihiko Nakamura
- Department of Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka 815-8588, Japan
| | - Yoshihiko Maehara
- Department of Surgery, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka 815-8588, Japan
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16
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Morphologic Factors Predict Pain Relief Following Pancreatic Head Resection in Chronic Pancreatitis Description of the Chronic Pancreatitis Pain Relief (CPPR) Score. Ann Surg 2021; 273:800-805. [PMID: 31348039 DOI: 10.1097/sla.0000000000003439] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study analyzes the clinicopathologic findings and their impact on outcome of patients so as to identify which patients benefit most from surgical treatment in chronic pancreatitis, especially in regard to pain relief. SUMMARY BACKGROUND DATA The predominant symptom of chronic pancreatitis is chronic pain resulting in reduced quality of life. It is well known that the main reason for development of the disease is abuse of alcohol and nicotine, but only little data on factors influencing outcome are available. METHODS One thousand one hundred forty-six consecutive patients who underwent surgery for chronic pancreatitis were included. Clinicopathologic data, including morphology of the pancreas in preoperative diagnostics and the histopathologic results, were evaluated. A long-term follow-up including Quality of Life and pain scores was performed. Additionally, we describe the novel Chronic Pancreatitis Pain Relief Score (CPPR-Score) as a tool for prediction of pain relief. RESULTS Overall the rate of pain relief was 79.8% after surgery. The presence of an inflammatory mass in the pancreatic head larger than 4 cm (P < 0.001), presence of a dilated main pancreatic duct of over 4 mm (P < 0.001), histopathologically detected severe calcifications (P = 0.001) and severe fibrosis (P < 0.001) as well as ethanol induced disease (P < 0.001) found to be strong independent prognostic factors for pain relief. The CPPR-Score (0-5 points) proved to be a very good predictive score for pain-relief (P < 0.001). CONCLUSIONS The rate of pain relief after surgical treatment in chronic pancreatitis is high and the commonly used procedures can be performed with acceptable morbidity and mortality. The Chronic Pancreatitis Pain Relief Score allows identifying patients who will benefit most from surgery.
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17
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Maatman TK, Zyromski NJ. In Brief. Curr Probl Surg 2021. [DOI: 10.1016/j.cpsurg.2020.100859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Maatman TK, Zyromski NJ. Chronic Pancreatitis. Curr Probl Surg 2020; 58:100858. [PMID: 33663691 DOI: 10.1016/j.cpsurg.2020.100858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Thomas K Maatman
- Resident in General Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Nicholas J Zyromski
- Professor of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA..
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19
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Matsumoto I, Kamei K, Murase T, Yoshida Y, Kawaguchi K, Matsumoto M, Satoi S, Takebe A, Nakai T, Takeyama Y. Surgical treatment for chronic pancreatitis: A single-center retrospective study in Japan. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:632-639. [PMID: 32603018 DOI: 10.1002/jhbp.795] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 06/13/2020] [Accepted: 06/23/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND/PURPOSE To determine the short- and long-term results of surgical treatments for chronic pancreatitis (CP) at a high-volume center in Japan. METHODS The records of 151 consecutive patients undergoing surgery for CP were retrospectively reviewed. Selection of surgical procedures used had been according to the Japanese Clinical Practice Guidelines for CP 2015. Long-term (≥1 year) follow-up was performed in 100 patients (median of 37 months). RESULTS Surgical drainage procedures were performed in 107 patients (Frey operation in 81, longitudinal pancreaticojejunostomy in 26), pancreatic resection in 37 (subtotal stomach-preserving pancreaticoduodenectomy in 11, distal pancreatectomy in 26), and other procedures in six. The rates of postoperative mortality and morbidity were 1% and 26%, respectively. The rates of complete and partial pain relief were 62% and 37%. The frequency of occurrence of severe morbidity was significantly higher after pancreatic resection than in patients receiving drainage procedures (13% vs 2%, P = .019). The rate of new-onset diabetes was also significantly higher after resection than drainage (60% vs 25%, P = .017). CONCLUSIONS Surgical treatment for painful chronic pancreatitis can be safe and effective. An optimal procedure should guarantee pain relief and preserve a maximum of pancreatic function.
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Affiliation(s)
- Ippei Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Keiko Kamei
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Takaaki Murase
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Yuta Yoshida
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Kohei Kawaguchi
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Masataka Matsumoto
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Shumpei Satoi
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Atsushi Takebe
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Takuya Nakai
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kindai University Faculty of Medicine, Osaka-sayama, Japan
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20
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Abu-El-Haija M, Anazawa T, Beilman GJ, Besselink MG, Del Chiaro M, Demir IE, Dennison AR, Dudeja V, Freeman ML, Friess H, Hackert T, Kleeff J, Laukkarinen J, Levy MF, Nathan JD, Werner J, Windsor JA, Neoptolemos JP, Sheel ARG, Shimosegawa T, Whitcomb DC, Bellin MD. The role of total pancreatectomy with islet autotransplantation in the treatment of chronic pancreatitis: A report from the International Consensus Guidelines in chronic pancreatitis. Pancreatology 2020; 20:762-771. [PMID: 32327370 DOI: 10.1016/j.pan.2020.04.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 03/18/2020] [Accepted: 04/06/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Advances in our understanding of total pancreatectomy with islet autotransplantation (TPIAT) have been made. We aimed to define indications and outcomes of TPIAT. METHODS Expert physician-scientists from North America, Asia, and Europe reviewed the literature to address six questions selected by the writing group as high priority topics. A consensus was reached by voting on statements generated from the review. RESULTS Consensus statements were voted upon with strong agreement reached that (Q1) TPIAT may improve quality of life, reduce pain and opioid use, and potentially reduce medical utilization; that (Q3) TPIAT offers glycemic benefit over TP alone; that (Q4) the main indication for TPIAT is disabling pain, in the absence of certain medical and psychological contraindications; and that (Q6) islet mass transplanted and other disease features may impact diabetes mellitus outcomes. Conditional agreement was reached that (Q2) the role of TPIAT for all forms of CP is not yet identified and that head-to-head comparative studies are lacking, and that (Q5) early surgery is likely to improve outcomes as compared to late surgery. CONCLUSIONS Agreement on TPIAT indications and outcomes has been reached through this working group. Further studies are needed to answer the long-term outcomes and maximize efforts to optimize patient selection.
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Affiliation(s)
- Maisam Abu-El-Haija
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Takayuki Anazawa
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Japan
| | - Gregory J Beilman
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Marco Del Chiaro
- Department of Surgery, University of Colorado Anschutz Medical Campus, Denver, CO, USA
| | - Ihsan Ekin Demir
- Department of Surgery, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Ashley R Dennison
- Department of Hepatobiliary and Pancreatic Surgery, University of Leicester, UK
| | - Vikas Dudeja
- Department of Surgery, University of Miami, Miami, FL, USA
| | - Martin L Freeman
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Helmut Friess
- Department of Surgery, Klinikum Rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Germany
| | - Jorg Kleeff
- Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Faculty of Medicine and Health Technology, Tampere University, Finland
| | - Marlon F Levy
- Division of Transplant Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Jaimie D Nathan
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, University of Munich, LMU, Germany
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - John P Neoptolemos
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Andrea R G Sheel
- Department of Molecular and Clinical Cancer Medicine, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Tooru Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - David C Whitcomb
- Department of Medicine, Cell Biology & Physiology, and Human Genetics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melena D Bellin
- Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, USA; Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA.
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21
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Kempeneers MA, Issa Y, Ali UA, Baron RD, Besselink MG, Büchler M, Erkan M, Fernandez-Del Castillo C, Isaji S, Izbicki J, Kleeff J, Laukkarinen J, Sheel ARG, Shimosegawa T, Whitcomb DC, Windsor J, Miao Y, Neoptolemos J, Boermeester MA. International consensus guidelines for surgery and the timing of intervention in chronic pancreatitis. Pancreatology 2020; 20:149-157. [PMID: 31870802 DOI: 10.1016/j.pan.2019.12.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 12/03/2019] [Accepted: 12/11/2019] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- M A Kempeneers
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Y Issa
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - U Ahmed Ali
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands; Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - R D Baron
- Department of Surgery, Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - M G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - M Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - M Erkan
- Department of Surgery, Koc University, Istanbul, Turkey
| | | | - S Isaji
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Japan
| | - J Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Germany
| | - J Kleeff
- Department of Visceral, Vascular, and Endocrine Surgery, Martin Luther University Halle-Wittenberg, Germany
| | - J Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Faculty of Medicine and Health Technology, Tampere University, Finland
| | - A R G Sheel
- Institute of Translational Medicine, University of Liverpool, United Kingdom
| | - T Shimosegawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - D C Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, PA, USA
| | - J Windsor
- HBP/Upper GI Unit, Auckland City Hospital/Department of Surgery, University of Auckland, New Zealand
| | - Y Miao
- Pancreas Center, The First Affiliated Hospital of Nanjing Medical University, China
| | - J Neoptolemos
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Germany
| | - M A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, the Netherlands.
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22
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Drewes AM, Kempeneers MA, Andersen DK, Arendt-Nielsen L, Besselink MG, Boermeester MA, Bouwense S, Bruno M, Freeman M, Gress TM, van Hooft JE, Morlion B, Olesen SS, van Santvoort H, Singh V, Windsor J. Controversies on the endoscopic and surgical management of pain in patients with chronic pancreatitis: pros and cons! Gut 2019; 68:1343-1351. [PMID: 31129569 PMCID: PMC6691929 DOI: 10.1136/gutjnl-2019-318742] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/01/2019] [Accepted: 05/07/2019] [Indexed: 01/09/2023]
Affiliation(s)
- Asbjørn Mohr Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology, Aalborg University Hospital & Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Marinus A Kempeneers
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lars Arendt-Nielsen
- Center for Sensory-Motor Interactions (SMI), Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Stefan Bouwense
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marco Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Martin Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnessota Medical School, Minneapolis, Minnesota, USA
| | - Thomas M Gress
- Department of Gastroenterology, Philipps University & University Hospital of Marburg, Marburg, Germany
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bart Morlion
- The Leuven Centre for Algology & Pain Management, University Hospitals Leuven, Leuven, Belgium
| | - Søren Schou Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology, Aalborg University Hospital & Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Hjalmar van Santvoort
- Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Vikesh Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - John Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Tian X, Ma Y, Gao H, Zhuang Y, Yang Y. Surgical options for control of abdominal pain in chronic pancreatitis patients. J Pain Res 2019; 12:2331-2336. [PMID: 31440077 PMCID: PMC6666366 DOI: 10.2147/jpr.s208212] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 07/02/2019] [Indexed: 01/10/2023] Open
Abstract
Background Long lasting and unbearable abdominal pain is the most common symptom of chronic pancreatitis (CP). This study aimed to evaluate surgical options for the control of chronic pancreatic pain based on anatomical morphological changes. Methods A retrospective review of patients who underwent surgery for treatment of chronic pancreatic pain in Peking University First Hospital between January 2000 and December 2017 was performed. The surgical options included modified Puestow procedure, Frey procedure, Beger procedure, pancreaticoduodenectomy (PD) or pylorus preserving pancreaticoduodenectomy (PPPD), distal pancreatectomy and total pancreatectomy. Results Among 116 patients, pain relief rate after surgery was 82.6% (95/115) while 22 (23.2%) cases suffered recurrent chronic pancreatic pain during follow-up. Pain relief rate was 83.1% (54/65) after modified Puestow procedure, 63.6% (7/11) after distal pancreatectomy, 83.3% (10/12) after PD/PPPD, 86.7% (13/15) after Frey procedure, and 90% (9/10) after Beger procedure. Pain recurrence rate was 27.8% (15/54) after modified Puestow procedure, 42.9% (3/7) after distal pancreatectomy, 10% (1/10) after PD/PPPD, 15.4% (2/13) after Frey procedure, and 11.1% (1/9) after Beger procedure. Conclusion The surgical options for the control of chronic pancreatic pain according to the anatomical morphological changes of CP is reasonable and effective. The procedure of distal pancreatectomy alone should be cautiously used for pain relief.
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Affiliation(s)
- Xiaodong Tian
- Department of General Surgery, Peking University First Hospital, Beijing 100034, People's Republic of China
| | - Yongsu Ma
- Department of General Surgery, Peking University First Hospital, Beijing 100034, People's Republic of China
| | - Hongqiao Gao
- Department of General Surgery, Peking University First Hospital, Beijing 100034, People's Republic of China
| | - Yan Zhuang
- Department of General Surgery, Peking University First Hospital, Beijing 100034, People's Republic of China
| | - Yinmo Yang
- Department of General Surgery, Peking University First Hospital, Beijing 100034, People's Republic of China
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Frola C, Somasundaram M, Hariharan D, Kolaityte V, Mohandas S, Stättner S, Yip VS. The role of surgery in chronic pancreatitis. Eur Surg 2019. [DOI: 10.1007/s10353-019-0591-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Bellon E, Roswora MD, Melling N, Grotelueschen R, Grupp K, Reeh M, Ghadban T, Izbicki JR, Bachmann K. Duodenum-preserving pancreatic head resection: A retrospective analysis of the Hamburg Modification. Surgery 2019; 165:938-945. [DOI: 10.1016/j.surg.2018.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 11/07/2018] [Accepted: 11/16/2018] [Indexed: 12/28/2022]
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Abstract
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.
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Zakharova MA, Smirnov AV, Gorin DS, Vorobyeva EA, Kriger AG. [Quality of life as an efficiency index of surgical treatment of chronic pancreatitis]. Khirurgiia (Mosk) 2019:42-51. [PMID: 31714529 DOI: 10.17116/hirurgia201911142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To evaluate quality of life in long-term postoperative period in patients with chronic pancreatitis. MATERIAL AND METHODS There were 31 (21 males and 10 females) patients with complicated forms of chronic pancreatitis who underwent surgery in 2015-2017. Mean age was 49 (44; 53) years, body mass index - 22.4 (20.4; 24) kg/m2. HR-QOL was determined using the questionnaires SF-36, QLQ EORTS C30, VAS. Postoperative control was made no earlier than 6 months after surgery. Median follow-up 11.5 months. The data were analyzed using non-parametric methods. Quantitative data are shown as median with interquartile range. Differences between quantitative values were determined using the Mann-Whitney test. RESULTS Physical status value (SF-36) before surgery was 30.5 (24.8; 37.5), after surgery - 50.8 (46.7; 56.5). Mental status value was 30.2 (26.7; 36.4) prior to surgery and 53.8 (48.7; 57.3) after operation. Improvement of QoL (QLQ C30) from 29.17 (0; 50.0) before surgery to 75.0 (54.2; 83.3) after operation was observed. VAS-score of pain severity was 8 (8; 10) prior to surgery and 3 (2; 5) after surgery. Differences were significant (p<0.05). CONCLUSION Surgical treatment of complicated chronic pancreatitis significantly reduces pain and improves HR-QoL. However, recurrent symptoms of chronic pancreatitis in long-term period cannot be excluded due to short follow-up period (median less than one year). The further investigation is needed.
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Affiliation(s)
- M A Zakharova
- Vishnevsky National Medical Research Center for Surgery of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - A V Smirnov
- Vishnevsky National Medical Research Center for Surgery of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - D S Gorin
- Vishnevsky National Medical Research Center for Surgery of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - E A Vorobyeva
- Vishnevsky National Medical Research Center for Surgery of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - A G Kriger
- Vishnevsky National Medical Research Center for Surgery of the Ministry of Health of the Russian Federation, Moscow, Russia
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Peculiarities of diagnostics of billiary hypertension in patients with complicated forms of chronic pancreatitis. GASTROENTEROLOGY REVIEW 2018; 13:143-149. [PMID: 30002774 PMCID: PMC6040102 DOI: 10.5114/pg.2018.75823] [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: 10/16/2017] [Accepted: 12/19/2017] [Indexed: 11/17/2022]
Abstract
Introduction The morbidity of chronic pancreatitis (CP) remains at a high level. In cases of CP, prepapillary stenosis of the common bile duct (CBD) complicates the course of disease in 30-60% of patients. Aim To improve the detection of biliary hypertension (BH) in patients with complicated forms of CP by increasing the accuracy of preoperative and intraoperative diagnostics using modern diagnostic methods. Material and methods We analysed the results of surgical treatment of 573 patients with complicated forms of CP. In 163 (28.5%) patients, CP was complicated by BH. The method of intraoperative monitoring of biliary pressure (IOM BP) was developed and introduced for intraoperative control and determination of the adequacy of intervention regarding biliary decompression. Results Mechanical jaundice was diagnosed by clinical methods in 101 (61.9%) CP patients with BH, and by laboratory methods in 108 (66.2%) patients. Such methods as magnetic resonance cholangiopancreatography (95.6%), endoscopic retrograde cholangiopancreatography (93.7%), and computed tomography (93.8%) proved to have the highest sensitivity for the diagnostics of BH in cases of CP. Conclusions The application of an integrated approach with extensive use of modern non-invasive preoperative methods of assessment allowed an approximation of the reliability of preoperative diagnostics of BH in CP patients to 95.6%. The use of the IOM BP method enables us to increase the sensitivity of intraoperative diagnostics of BH to 97.3% and choose the method of surgical intervention, which significantly reduces the risk of BH recurrence in the distant postoperative period by 15.1% (χ2 = 4.22, p = 0.04).
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Kleeff J, Stöß C, Mayerle J, Stecher L, Maak M, Simon P, Nitsche U, Friess H. Evidence-Based Surgical Treatments for Chronic Pancreatitis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 113:489-96. [PMID: 27545699 DOI: 10.3238/arztebl.2016.0489] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 04/21/2016] [Accepted: 04/21/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND If conservative treatment of chronic pancreatitis is unsuccessful, surgery is an option. The choice of the most suitable surgical method can be difficult, as the indications, advantages, and disadvantages of the available methods have not yet been fully documented with scientific evidence. METHODS In April 2015, we carried out a temporally unlimited systematic search for publications on surgery for chronic pancreatitis. The target parameters were morbidity, mortality, pain, endocrine and exocrine insuffi - ciency, weight gain, quality of life, length of hospital stay, and duration of urgery. Differences between surgical methods were studied with network meta-analysis, and duodenum-preserving operations were compared with partial duodenopancreatectomy with standard meta-analysis. RESULTS Among the 326 articles initially identified, 8 randomized controlled trials on a total of 423 patients were included in the meta-analysis. The trials were markedly heterogeneous in some respects. There was no significant difference among surgical methods with respect to perioperative morbidity, pain, endocrine and exocrine insufficiency, or quality of life. Duodenumpreserving procedures, compared to duodenopancreatectomy, were associated with a long-term weight gain that was 3 kg higher (p <0.001; three trials), a mean length of hospital stay that was 3 days shorter (p = 0.009; six trials), and a duration of surgery that was 2 hours shorter (p <0.001; five trials). CONCLUSION Duodenum-preserving surgery for chronic pancreatitis is superior to partial duodenopancreatectomy in multiple respects. Only limited recommendations can be given, however, on the basis of present data. The question of the best surgical method for the individual patient, in view of the clinical manifestations, anatomy, and diagnostic criteria, remains open.
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Affiliation(s)
- Jörg Kleeff
- Department of General, Visceral, and Pediatric Surgery, Düsseldorf University Hospital, Düsseldorf; Department of Sur gery, The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom; and Department of Molecular and Clinical Cancer Medi cine, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom, Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Department of Internal Medicine A, Faculty of Medicine, University of Greifswald, Institute of Medical Statistics and Epidemiology, Klinikum rechts der Isar, Technische Universität München, Munich, Department of Surgery, University Hospital Erlangen
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THE USE OF WHIPPLE OPERATION IN PATIENTS WITH COMPLICATED FORMS OF CHRONIC PANCREATITIS. WORLD OF MEDICINE AND BIOLOGY 2018. [DOI: 10.26724/2079-8334-2018-1-63-64-69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
Pancreatic pain is the most frequent symptom of chronic pancreatitis (CP) and is difficult to treat. This retrospective study aimed to determine the risk factors for pain in CP.From January 2009 and March 2014, 75 consecutive patients with CP who underwent Frey's procedure were reviewed for this study. According to Izbicki pain scores, these patients were divided into 2 groups: (1) pain (Izbicki pain score of >10 after a decrease of >50%) and (2) pain-free (Izbicki pain score of ≤10). Demographic data, medical history, postoperative variables, and follow-up evaluations of the patients were documented.The postoperative pain score (11.8) was significantly lower than the preoperative score (51.8) after a median follow-up of 4.2 years. Alcoholism (odds ratio [OR] 7.767, P = .002) and preoperative analgesic medication use (OR 4.113, P = .030) were independent risk factors for pain.Frey's procedure is an effective operation for pain relief in patients with CP. Alcoholism and preoperative analgesic medication use were 2 factors for failure to achieve complete pain relief.
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Affiliation(s)
- Shao-jun Li
- Department of Pain Management, Wuhan First Hospital, Wuhan, Hubei Province
| | - Chun-lu Tan
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Bo-le Tian
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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Tillou JD, Tatum JA, Jolissaint JS, Strand DS, Wang AY, Zaydfudim V, Adams RB, Brayman KL. Operative management of chronic pancreatitis: A review. Am J Surg 2017; 214:347-357. [PMID: 28325588 DOI: 10.1016/j.amjsurg.2017.03.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 11/26/2016] [Accepted: 03/08/2017] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- John D Tillou
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jacob A Tatum
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Joshua S Jolissaint
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA
| | - Victor Zaydfudim
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Reid B Adams
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Kenneth L Brayman
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA.
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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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Suzumura K, Hatano E, Okada T, Asano Y, Uyama N, Nakamura I, Hai S, Fujimoto J. Short- and long-term outcomes of the Frey procedure for chronic pancreatitis: a single-center experience and summary of outcomes in Japan. Surg Today 2017; 48:58-65. [DOI: 10.1007/s00595-017-1548-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 05/18/2017] [Indexed: 01/29/2023]
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Pancreatic head excavation for tissue diagnosis may reduce unnecessary pancreaticoduodenectomies in the setting of chronic pancreatitis. Hepatobiliary Pancreat Dis Int 2017; 16:315-322. [PMID: 28603101 DOI: 10.1016/s1499-3872(17)60015-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The necessity to obtain a tissue diagnosis of cancer prior to pancreatic surgery still remains an open debate. In fact, a non-negligible percentage of patients undergoing pancreaticoduodenectomy (PD) for suspected cancer has a benign lesion at final histology. We describe an approach for patients with diagnostic uncertainty between cancer and chronic pancreatitis, with the aim of minimizing the incidence of PD for suspicious malignancy finally diagnosed as benign disease. METHODS Eighty-eight patients (85.4%) with a clinicoradiological picture highly suggestive for malignancy received formal PD (group 1). Fifteen patients (14.6%) in whom preoperative diagnosis was uncertain between pancreatic cancer and chronic pancreatitis underwent pancreatic head excavation (PHEX) for intraoperative tissue diagnosis (group 2): those diagnosed as having cancer received PD, whereas those with chronic pancreatitis received pancreaticojejunostomy (PJ). RESULTS No patient received PD for benign disease. All patients in group 1 had adenocarcinoma on final histology. Eight patients of group 2 (53.3%) received PD after intraoperative diagnosis of cancer, whereas 7 (46.7%) received PJ because no malignancy was found at introperative frozen sections. No signs of cancer were encountered in patients receiving PHEX and PJ after a median follow-up of 42 months. Overall survival did not differ between patients receiving PD for cancer in the group 1 and those receiving PD for cancer after PHEX in the group 2 (P=0.509). CONCLUSION Although the described technique has been used in a very selected group of patients, our results suggest that PHEX for tissue diagnosis may reduce rates of unnecessary PD, when the preoperative diagnosis is uncertain between cancer and chronic pancreatitis.
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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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Zhao X, Cui N, Wang X, Cui Y. Surgical strategies in the treatment of chronic pancreatitis: An updated systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017; 96:e6220. [PMID: 28248878 PMCID: PMC5340451 DOI: 10.1097/md.0000000000006220] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Chronic pancreatitis (CP) is a common and frequently occurring disease. Pancreaticoduodenectomy (PD), pylorus-preserving pancreaticoduodenectomy (PPPD), and duodenum-preserving pancreatic head resection (DPPHR) are important treatment options for patients with chronic pancreatitis. The Beger and Frey procedures are 2 main duodenum-preserving techniques in duodenum-preserving pancreatic head resection (DPPHR) strategies. We conducted this systematic review and meta-analysis to compare the clinical efficacy of DPPHR versus PD, the Beger procedure versus PD, the Frey procedure versus PD, and the Beger procedure versus the Frey procedure in the treatment of pancreatitis. The optimal surgical option for chronic pancreatitis is still under debate. The aim of this systematic review and meta-analysis was to evaluate the clinical efficacy of different surgical strategies for chronic pancreatitis. METHODS Five databases (PubMed, Medline, SinoMed, Embase, and Cochrane Library) were searched with the limitations of human subjects and randomized controlled trials (RCTs) text. Data were extracted by 2 of the coauthors independently and analyzed using the RevMan statistical software, version 5.3. Weighted mean differences (WMDs), risk ratios (RRs), and 95% confidence intervals (CIs) were calculated. Cochrane Collaboration's Risk of Bias Tool was used to assess the risk of bias. RESULTS Seven studies involving a total of 385 patients who underwent the surgical treatments were assessed. The methodological quality of the trials ranged from low to moderate and included PD (n = 134) and DPPHR (n = 251 [Beger procedure = 100; Frey procedure = 109; Beger or Frey procedure = 42]). There were no significant differences between DPPHR and PD in post-operation mortality (RR = 2.89, 95% CI = 0.31-26.87, P = 0.36), pain relief (RR = 1.09, 95% CI = 0.94-1.25, P = 0.26), exocrine insufficiency (follow-up time > 60 months: RR = 0.91, 95% CI = 0.72-1.15, P = 0.41), and endocrine insufficiency (RR = 0.75, 95% CI = 0.52-1.08, P = 0.12). Concerning the follow-up time < 60 months, the DPPHR group had better results of exocrine insufficiency (RR = 0.22, 95% CI = 0.08-0.62, P = 0.04). However, operation time (P < 0.0001), blood transfusion (P = 0.02), hospital stay (P = 0.0002), postoperation morbidity (P = 0.0007), weight gain (P < 0.00001), quality of life (P = 0.01), and occupational rehabilitation (P = 0.007) were significantly better for patients who underwent the DPPHR procedure compared with the PD procedure. The comparison results of the Frey procedure and PD showed that both procedures had an equal effect in the pain relief, postoperation mortality, exocrine and endocrine function, and quality of life (QoL) (P > 0.05), whereas patients who underwent the Frey procedure had significantly reduced operative times (P < 0.05) and less blood transfusions (P < 0.05). Comparing the Beger procedure to the PD procedure, there were no significant differences in hospital stay, blood transfusion, postoperation morbidity or mortality, pain relief, weight gain, exocrine insufficiency, and occupational rehabilitation (P > 0.05). Two studies comparing the Beger and Frey procedures showed no differences in postoperative morbidity, pain relief, exocrine insufficiency, and quality of life (P > 0.05). In terms of operative time, blood transfusion, hospital stay, postoperation morbidity, weight gain, quality of life, and occupational rehabilitation, the results also favored duodenum-preserving pancreatic head resection (DPPHR) strategies. CONCLUSION All procedures are equally effective for the management of pain, postoperation morbidity, exocrine insufficiency, and endocrine insufficiency for chronic pancreatitis. Improved short- and long-term outcomes, including operative time, blood transfusion, hospital stay, quality of life, weight gain, and occupational rehabilitation make DPPHR a more favorable surgical strategy for patients with chronic pancreatitis. Further, relevant trails are eager to prove these findings.
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Affiliation(s)
- Xin Zhao
- Department of Surgery, Tianjin Nankai Hospital, Tianjin, China
- Nankai Clinical College, Tianjin Medical University, Tianjin, China
| | - Naiqiang Cui
- Department of Surgery, Tianjin Nankai Hospital, Tianjin, China
| | - Ximo Wang
- Department of Surgery, Tianjin Nankai Hospital, Tianjin, China
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Tianjin, China
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Tan CL, Zhang H, Yang M, Li SJ, Liu XB, Li KZ. Role of original and modified Frey's procedures in chronic pancreatitis. World J Gastroenterol 2016; 22:10415-10423. [PMID: 28058022 PMCID: PMC5175254 DOI: 10.3748/wjg.v22.i47.10415] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/30/2016] [Accepted: 10/31/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To retrospectively review patients with chronic pancreatitis (CP) treated with Frey’s procedures between January 2009 and January 2014.
METHODS A retrospective review was performed of patients with CP treated with Frey’s procedures between January 2009 and January 2014 in the Department of Pancreatic Surgery. A cross-sectional study of postoperative pain relief, quality of life (QoL), and alcohol and nicotine abuse was performed by clinical interview, letters and telephone interview in January 2016. QoL of patients was evaluated with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) version 3.0. The patients were requested to fill in the questionnaires by themselves via correspondence or clinical interview.
RESULTS A total of 80 patients were enrolled for analysis, including 44 who underwent the original Frey’s procedure and 36 who underwent a modified Frey’s procedure. The mean age was 46 years in the original group and 48 years in the modified group. Thirty-five male patients (80%) were in the original group and 33 (92%) in the modified group. There were no differences in the operating time, blood loss, and postoperative morbidity and mortality between the two groups. The mean follow-up was 50.3 mo in the original group and 48.7 mo in the modified group. There were no differences in endocrine and exocrine function preservation between the two groups. The original Frey’s procedure resulted in significantly better pain relief, as shown by 5-year follow-up (P = 0.032), better emotional status (P = 0.047) and fewer fatigue symptoms (P = 0.028). When stratifying these patients by the M-ANNHEIM severity index, no impact was found on pain relief after the two types of surgery.
CONCLUSION The original Frey’s procedure is as safe as the modified procedure, but the former yields better pain relief. The severity of CP does not affect postoperative pain relief.
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Sabater L, Ausania F, Bakker OJ, Boadas J, Domínguez-Muñoz JE, Falconi M, Fernández-Cruz L, Frulloni L, González-Sánchez V, Lariño-Noia J, Lindkvist B, Lluís F, Morera-Ocón F, Martín-Pérez E, Marra-López C, Moya-Herraiz Á, Neoptolemos JP, Pascual I, Pérez-Aisa Á, Pezzilli R, Ramia JM, Sánchez B, Molero X, Ruiz-Montesinos I, Vaquero EC, de-Madaria E. Evidence-based Guidelines for the Management of Exocrine Pancreatic Insufficiency After Pancreatic Surgery. Ann Surg 2016; 264:949-958. [PMID: 27045859 DOI: 10.1097/sla.0000000000001732] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations for the management of exocrine pancreatic insufficiency (EPI) after pancreatic surgery. BACKGROUND EPI is a common complication after pancreatic surgery but there is certain confusion about its frequency, optimal methods of diagnosis, and when and how to treat these patients. METHODS Eighteen multidisciplinary reviewers performed a systematic review on 10 predefined questions following the GRADE methodology. Six external expert referees reviewed the retrieved information. Members from Spanish Association of Pancreatology were invited to suggest modifications and voted for the quantification of agreement. RESULTS These guidelines analyze the definition of EPI after pancreatic surgery, (one question), its frequency after specific techniques and underlying disease (four questions), its clinical consequences (one question), diagnosis (one question), when and how to treat postsurgical EPI (two questions) and its impact on the quality of life (one question). Eleven statements answering those 10 questions were provided: one (9.1%) was rated as a strong recommendation according to GRADE, three (27.3%) as moderate and seven (63.6%) as weak. All statements had strong agreement. CONCLUSIONS EPI is a frequent but under-recognized complication of pancreatic surgery. These guidelines provide evidence-based recommendations for the definition, diagnosis, and management of EPI after pancreatic surgery.
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Affiliation(s)
- Luis Sabater
- *Department of Surgery, Hospital Clinico, University of Valencia, Valencia, Spain †Department of Surgery, Complejo Hospitalario Universitario de Vigo, Vigo, Spain ‡Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands §Department of Gastroenterology, Consorci Sanitari de Terrassa, Terrassa, Spain ¶Department of Gastroenterology, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain ||Department of Surgery, Università Vita e Salute, Ospedale San Raffaele IRCCS, Milano, Italy **Department of Surgery, Institut de Malalties Digestives I Metabòliques, Hospital Clínic, IDIBAPS, Barcelona, Spain ††Department of Medicine, Pancreas Center, University of Verona, Verona, Italy ‡‡Department of Endocrinology and Nutrition, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain. §§Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden ¶¶Department of Surgery, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain. ||||Department of Surgery, Hospital Universitario de La Princesa, Madrid, Spain ***Department of Gastroenterology, Complejo Hospitalario de Navarra, Pamplona, Spain †††Unidad de Cirugía Hepato-bilio-pancreática y Trasplante, Hospital Universitari i Politecnic. La Fe, Valencia, Spain ‡‡‡NIHR Pancreas Biomedical Research Unit, Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK §§§Department of Gastroenterology, Hospital Clinico, University of Valencia, Valencia, Spain ¶¶¶Unit of Digestive Disease, Agencia Sanitaria Costa del Sol, Marbella, Málaga ||||||Department Digestive System, Sant'Orsola-Malpighi Hospital, Bologna, Italy ****Department of Surgery, Hospital Universitario de Guadalajara, Guadalajara, Spain ††††Department of HPB Surgery and Liver Transplantation, Hospital Carlos Haya, Malaga, Spain ‡‡‡‡Exocrine Pancreas Research Unit, Hospital Universitari Vall d'Hebron, Institut de Recerca, Universitat Autònoma de Barcelona, CIBEREHD, Barcelona, Spain §§§§Department of Digestive Surgery- Division of HBP Surgery, Hospital Universitario Donostia, San Sebastián, Spain ¶¶¶¶Department of Gastroenterology, Institut de Malalties Digestives i Metabòliques, Hospital Clínic, IDIBAPS, CiberEHD, Barcelona, Spain ||||||||Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain
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40
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Abstract
Despite major advances in the management of patients with chronic pancreatitis, yet the disease remains an enigmatic process of uncertain pathogenesis, unpredictable clinical course, and unclear treatment. In most of the cases intractable pain is the main indication for surgical intervention. Furthermore complications related to adjacent organs, endoscopically not permanently controlled pancreatic pseudocysts, ductal pathology, conservatively intractable internal pancreatic fistula or suspected malignancy also require surgery. The ideal surgical approach should address all these problems — tailoring the various therapeutic options to meet the individual patient's needs. In our opinion, the ideal procedure for chronic pancreatitis is the duodenum preserving pancreatic head resection in terms of an extended drainage procedure, were the extent of the pancreatic head resection may be tailored to the morphology of the pancreatic gland, thus allowing a tailored concept (to resect and/or drain as much as necessary but as little as possible). Looking at the present data, there is no need to transsect the pancreatic axis above the portal vein. If portal vein thrombosis is present, an extended drainage procedure is mandatory without transsection of the neck of the pancreas.
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Affiliation(s)
- O Mann
- Department of General-, Visceral- Thoracic Surgery, University Medical Center Hospital Eppendorf, Hamburg, Germany.
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Merdrignac A, Bergeat D, Rayar M, Harnoy Y, Turner K, Courtin-Tanguy L, Boudjema K, Meunier B, Sulpice L. Frey procedure combined with biliary diversion in chronic pancreatitis. Surgery 2016; 160:1264-1270. [PMID: 27320066 DOI: 10.1016/j.surg.2016.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 04/29/2016] [Accepted: 05/05/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND The Frey procedure has become the standard operative treatment in chronic painful pancreatitis. Biliary diversion could be combined when associated with common bile duct obstruction. The aim of the present study was to evaluate the impact of the type of biliary diversion combined with the Frey procedure on late morbidity. METHODS The data from consecutive patients undergoing the Frey procedure and having a minimum follow-up of 2 years were extracted from a maintained prospective database. The mean endpoint was the rate of secondary biliary stricture after the Frey procedure combined with biliary diversion (bilioenteric anastomosis or common bile duct reinsertion in the resection cavity). RESULTS Between 2006 and 2013, 55 consecutive patients underwent the Frey procedure. Twenty-nine patients had common bile duct obstruction (52.7%). The technique of biliary diversion resulted in bilioenteric anastomosis in 19 patients (65.5%) and common bile duct reinsertion in 10 patients (34.5%). Preoperative characteristics and early surgical outcomes were comparable. Pain control was similar. There was significantly more secondary biliary stricture after common bile duct reinsertion than after bilioenteric anastomosis (60% vs 11%, P = .008). CONCLUSION Combined bilioenteric anastomosis during the Frey procedure is an efficient technique for treating common bile duct obstruction that complicates chronic painful pancreatitis. Bilioenteric anastomosis was associated with less secondary biliary stricture than common bile duct reinsertion in the pancreatic resection cavity.
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Affiliation(s)
- Aude Merdrignac
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France; Université Rennes1, Faculté de médecine Rennes, Rennes, France; INSERM UM991, Foie métabolismes et cancer, Universite Rennes 1, Rennes, France
| | - Damien Bergeat
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France; Université Rennes1, Faculté de médecine Rennes, Rennes, France; INSERM UM991, Foie métabolismes et cancer, Universite Rennes 1, Rennes, France
| | - Michel Rayar
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France; Université Rennes1, Faculté de médecine Rennes, Rennes, France
| | - Yann Harnoy
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France; Université Rennes1, Faculté de médecine Rennes, Rennes, France; INSERM UM991, Foie métabolismes et cancer, Universite Rennes 1, Rennes, France
| | - Kathleen Turner
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France; Université Rennes1, Faculté de médecine Rennes, Rennes, France
| | - Laetitia Courtin-Tanguy
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France; Université Rennes1, Faculté de médecine Rennes, Rennes, France; INSERM UM991, Foie métabolismes et cancer, Universite Rennes 1, Rennes, France
| | - Karim Boudjema
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France; Université Rennes1, Faculté de médecine Rennes, Rennes, France
| | - Bernard Meunier
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France; Université Rennes1, Faculté de médecine Rennes, Rennes, France
| | - Laurent Sulpice
- CHU Rennes, Service de Chirurgie Hépatobiliaire et Digestive, Rennes, France; Université Rennes1, Faculté de médecine Rennes, Rennes, France; INSERM UM991, Foie métabolismes et cancer, Universite Rennes 1, Rennes, France.
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Abstract
PURPOSE OF REVIEW Surgery for pancreatic diseases is one of the most studied fields in general surgery and continues to evolve. This review focuses on recent advances in pancreatic surgery and summarizes the published research. RECENT FINDINGS Surgery for pancreatic diseases is an evolving field with a wide range of innovations. Especially, contributions by high-volume pancreas centers have greatly improved outcomes in pancreatic surgery. In chronic pancreatitis, recent studies demonstrate that early surgical treatment should be favored over repeated endoscopic interventions, and local organ-preserving resection techniques should be preferred over classic Whipple resection. Major advances have also been made on the diagnosis of pancreatic cystic lesions; however, the assessment of the current guidelines is still evolving. In pancreatic cancer, neoadjuvant treatment regimens appear to be promising, and extended pancreatic resections with vascular resection can now be offered with lower mortality and morbidity rates. Minimal-invasive laparoscopic and robotic surgical techniques are being used more frequently for the resection of pancreatic tumors and have seen major progress. SUMMARY In recent years, the outcome of patients undergoing pancreatic surgery improved due to better knowledge about the biology of the disease, more accurate diagnostic modalities, the application of organ-preserving surgical techniques in benign disorders and new advances in management strategies.
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Duodenum-preserving pancreatic head resection: 10-year follow-up of a randomized controlled trial comparing the Beger procedure with the Berne modification. Surgery 2016; 160:127-135. [DOI: 10.1016/j.surg.2016.02.028] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 02/02/2016] [Accepted: 02/24/2016] [Indexed: 12/14/2022]
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Chronic Pancreatitis: A Review. Indian J Surg 2016; 77:1348-58. [PMID: 27011563 DOI: 10.1007/s12262-015-1221-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 01/05/2015] [Indexed: 10/23/2022] Open
Abstract
This is to incorporate the recent trends in chronic pancreatitis. Extensive literature search was done from Pubmed and Ovid SP. Full text articles and abstracts related to chronic pancreatitis were reviewed and the article was prepared. Chronic pancreatitis is evolving fast on its etiology and treatment areas. The main etiological factors are pointing towards genetic, alcohol, and smoking. Autoimmune has also been added as a cause. Endoscopic ultra sound (EUS) becoming the standard diagnostic procedure. Surgery is becoming the treatment of choice for pain and mechanical complications and not the endotherapy in the long-term follow-up. The numbers of surgeries are getting narrowed down. The two etiological groups of chronic pancreatitis namely alcohol + smoking and genetic getting clearer, where the later group present at an early age. Endoscopic ultrasound and imaging with secretin is diagnostic of chronic pancreatitis before the structural changes. Endotherapy is found to be inferior to surgery in long-term pain relief. Diagnostic criteria for autoimmune pancreatitis are established. Pancreaticogenic diabetes (Type3c) and its problem associated with fat malabsorption are being understood.
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Jawad ZAR, Tsim N, Pai M, Bansi D, Westaby D, Vlavianos P, Jiao LR. Short and long-term post-operative outcomes of duodenum preserving pancreatic head resection for chronic pancreatitis affecting the head of pancreas: a systematic review and meta-analysis. HPB (Oxford) 2016; 18:121-128. [PMID: 26902130 PMCID: PMC4814624 DOI: 10.1016/j.hpb.2015.10.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 10/21/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND To evaluate the short and long term outcomes of duodenum preserving pancreatic head resection (DPPHR) procedures in the treatment of painful chronic pancreatitis. METHODS A systematic literature search was performed to identify all comparative studies evaluating long and short term postoperative outcomes (pain relief, morbidity and mortality, pancreatic exocrine and endocrine function). RESULTS Five published studies fulfilled the inclusion criteria including 1 randomized controlled trial comparing the Beger and Frey procedure. In total, 323 patients underwent surgical procedures for chronic pancreatitis, including Beger (n = 138) and Frey (n = 99), minimal Frey (n = 32), modified Frey (n = 25) and Berne's modification (n = 29). Two studies comparing the Beger and Frey procedure were entered into a meta-analysis and showed no difference in post-operative pain (RD = -0.06; CI -0.21 to 0.09), mortality (RD = 0.01; CI -0.03 to 0.05), morbidity (RD = 0.12; CI -0.00 to 0.24), exocrine insufficiency (RD = 0.04; CI -0.10 to 0.18) and endocrine insufficiency (RD = -0.14 CI -0.28 to 0.01). CONCLUSION All procedures are equally effective for the management of pain for chronic pancreatitis. The choice of procedure should be determined by other factors including the presence of secondary complications of pancreatitis and intra-operative findings. Registration number CRD42015019275. Centre for Reviews and Dissemination, University of York, 2009.
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Affiliation(s)
- Zaynab A R Jawad
- Hepato-Pancreato-Biliary Surgical Unit, Department of Surgery and Cancer Imperial College, Hammersmith Hospital Campus, Du Cane Road, London, W12 0HS, UK
| | - Nicole Tsim
- Hepato-Pancreato-Biliary Surgical Unit, Department of Surgery and Cancer Imperial College, Hammersmith Hospital Campus, Du Cane Road, London, W12 0HS, UK
| | - Madhava Pai
- Hepato-Pancreato-Biliary Surgical Unit, Department of Surgery and Cancer Imperial College, Hammersmith Hospital Campus, Du Cane Road, London, W12 0HS, UK
| | - Dev Bansi
- Department of Gastroenterology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - David Westaby
- Department of Gastroenterology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Panagiotis Vlavianos
- Department of Gastroenterology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Long R Jiao
- Hepato-Pancreato-Biliary Surgical Unit, Department of Surgery and Cancer Imperial College, Hammersmith Hospital Campus, Du Cane Road, London, W12 0HS, UK.
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Jawad ZAR, Kyriakides C, Pai M, Wadsworth C, Westaby D, Vlavianos P, Jiao LR. Surgery remains the best option for the management of pain in patients with chronic pancreatitis: A systematic review and meta-analysis. Asian J Surg 2016; 40:179-185. [PMID: 26778832 DOI: 10.1016/j.asjsur.2015.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 08/31/2015] [Accepted: 09/30/2015] [Indexed: 12/16/2022] Open
Abstract
Controversy related to endoscopic or surgical management of pain in patients with chronic pancreatitis remains. Despite improvement in endoscopic treatments, surgery remains the best option for pain management in these patients.
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Affiliation(s)
- Zaynab A R Jawad
- Hepato-Pancreato-Biliary Surgical Unit, Department of Surgery & Cancer, Hammersmith Hospital Campus, Imperial College London, Du Cane Road, London, W12 0HS, UK
| | - Charis Kyriakides
- Hepato-Pancreato-Biliary Surgical Unit, Department of Surgery & Cancer, Hammersmith Hospital Campus, Imperial College London, Du Cane Road, London, W12 0HS, UK
| | - Madhava Pai
- Hepato-Pancreato-Biliary Surgical Unit, Department of Surgery & Cancer, Hammersmith Hospital Campus, Imperial College London, Du Cane Road, London, W12 0HS, UK
| | - Chris Wadsworth
- Department of Gastroenterology, Imperial College NHS Trust, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - David Westaby
- Department of Gastroenterology, Imperial College NHS Trust, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Panagiotis Vlavianos
- Department of Gastroenterology, Imperial College NHS Trust, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Long R Jiao
- Hepato-Pancreato-Biliary Surgical Unit, Department of Surgery & Cancer, Hammersmith Hospital Campus, Imperial College London, Du Cane Road, London, W12 0HS, UK.
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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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48
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Abstract
The pain of chronic pancreatitis represents a major challenge to those working in the field, including pain specialists, gastroenterologists and surgeons. This article describes the different aetiologies of chronic pancreatitis and lists the models for the pathogenesis of pain, including novel ideas such as the role of the immune system in the modulation of pain. The patient profile in chronic pancreatitis is discussed along with the social impact of the disease in relation to alcohol misuse. The range of treatment strategies including medical, endoscopic and surgical approaches are evaluated. Common analgesic regimes and their limitations are reviewed. The pain of chronic pancreatitis remains refractory to effective treatment in many cases and further study and understanding of the underlying pathophysiology are required.
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Parekh D, Natarajan S. Surgical Management of Chronic Pancreatitis. Indian J Surg 2015; 77:453-69. [PMID: 26722211 DOI: 10.1007/s12262-015-1362-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 09/30/2015] [Indexed: 12/13/2022] Open
Abstract
Advances over the past decade have indicated that a complex interplay between environmental factors, genetic predisposition, alcohol abuse, and smoking lead towards the development of chronic pancreatitis. Chronic pancreatitis is a complex disorder that causes significant and chronic incapacity in patients and a substantial burden on the society. Major advances have been made in the etiology and pathogenesis of this disease and the role of genetic predisposition is increasingly coming to the fore. Advances in noninvasive diagnostic modalities now allow for better diagnosis of chronic pancreatitis at an early stage of the disease. The impact of these advances on surgical treatment is beginning to emerge, for example, patients with certain genetic predispositions may be better treated with total pancreatectomy versus lesser procedures. Considerable controversy remains with respect to the surgical management of chronic pancreatitis. Modern understanding of the neurobiology of pain in chronic pancreatitis suggests that a window of opportunity exists for effective treatment of the intractable pain after which central sensitization can lead to an irreversible pain syndrome in patients with chronic pancreatitis. Effective surgical procedures exist for chronic pancreatitis; however, the timing of surgery is unclear. For optimal treatment of patients with chronic pancreatitis, close collaboration between a multidisciplinary team including gastroenterologists, surgeons, and pain management physicians is needed.
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Affiliation(s)
- Dilip Parekh
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Los Angeles, CA 90033 USA
| | - Sathima Natarajan
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Los Angeles, CA 90033 USA ; Department of Pathology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA USA
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50
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Abstract
Chronic pancreatitis can lead to intractable pain, pancreatic duct obstruction, duodenal stenosis and vascular compression syndromes. Surgical interventions can effectively treat these symptoms. Endoscopic procedures are principally possible but rarely lead to a lasting relief of symptoms. The type of surgical intervention should be selected depending on the morphological changes of the pancreas. Up to 90 % of patients present with an inflammatory mass in the head of the pancreas. In these cases a duodenum-preserving pancreatic head resection (DPPHR) modified according to Beger, Frey or Berne should be preferred. These procedures are comparable in terms of the postoperative course. The Kausch-Whipple procedure is indicated in all cases where malignancy is suspected. According to the current literature, patients with an inflammatory mass in the pancreatic head benefit more from a DPPHR than a Kausch-Whipple procedure. Drainage procedures may be useful for the treatment of pseudocysts or in rare situations with purely ductal obstructions. The decision as to which procedure is appropriate should be taken in an interdisciplinary cooperation between gastroenterologists and surgeons.
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