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Pottakkat B, Harilal S, Kalayarasan R, Krishna PS. Near total head resection of pancreas in patients with chronic pancreatitis - Outcome of a novel surgical technique. Pancreatology 2024:S1424-3903(24)00683-5. [PMID: 39043488 DOI: 10.1016/j.pan.2024.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 07/12/2024] [Accepted: 07/13/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Chronic pancreatitis (CP) is characterized by debilitating pain which affects patients' quality of life. Early surgical intervention has been shown to mitigate pain and prevent a decline in quality of life. The present study evaluated the impact of bile duct and duodenum preserving pancreatic head resection (BDPPHR), an innovative technique, on pain relief, functional outcomes, postoperative morbidity, and mortality in patients with CP. METHODS Between March 2019 and July 2022, a total of 37 patients underwent bile duct and duodenum preserving pancreatic head resection (BDPPHR) for pain relief in patients with CP. Post-operative outcomes were assessed by Izbicki pain score, exocrine insufficiency, endocrine insufficiency, and return to work. The safety of the surgical procedure was determined by evaluation of postoperative morbidity and mortality as per Clavien-Dindo scores. RESULTS BDPPHR showed a significant reduction in Izbicki pain scores with 30 (81 %) patients experiencing complete or partial pain relief up to 18 months of follow up. 32(86 %) patients ceased narcotic use by the end of the 18-month follow-up period. 33 (89 %) patients were able to resume regular work at the end of 18 months. There were no significant alterations in both exocrine and endocrine statuses post-surgery. The median duration of hospital stay was 4.5 days (3-11). Major complications occurred in 2 (5 %) patients. There was no post-operative mortality. CONCLUSION BDPPHR is a novel and safe technique of near total head resection which results in very good pain relief in 81 % of patients.
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Affiliation(s)
- Biju Pottakkat
- Dept. of Surgical Gastroenterology, JIPMER, Puducherry, India.
| | - S Harilal
- Dept. of Surgical Gastroenterology, JIPMER, Puducherry, India
| | - R Kalayarasan
- Dept. of Surgical Gastroenterology, JIPMER, Puducherry, India
| | - P Sai Krishna
- Dept. of Surgical Gastroenterology, JIPMER, Puducherry, India
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Cui Y, Kozarek RA. Evolution of Pancreatic Endotherapy. Gastrointest Endosc Clin N Am 2023; 33:679-700. [PMID: 37709404 DOI: 10.1016/j.giec.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
In the last half century, endotherapy for pancreatic diseases has changed considerably. Although endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) were introduced initially as diagnostic tools, they quickly evolved into therapeutic tools for preventing and managing complications of pancreatitis. More recently, therapeutic endoscopy has shown potential in palliation and cure of pancreatic neoplasms. This article discusses the changing landscape of pancreatic endotherapy as therapeutic ERCP and EUS were introduced and because they have evolved to treat different diseases.
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Affiliation(s)
- YongYan Cui
- Department of Gastroenterology, Virginia Mason Medical Center
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3
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Kalayarasan R, Shukla A. Changing trends in the minimally invasive surgery for chronic pancreatitis. World J Gastroenterol 2023; 29:2101-2113. [PMID: 37122602 PMCID: PMC10130972 DOI: 10.3748/wjg.v29.i14.2101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 02/21/2023] [Accepted: 03/23/2023] [Indexed: 04/13/2023] Open
Abstract
Chronic pancreatitis is a debilitating pancreatic inflammatory disease characterized by intractable pain resulting in poor quality of life. Conventional management of pancreatic pain consists of a step-up approach with medications and lifestyle modifications followed by endoscopic intervention. Traditionally surgery is reserved for patients who do not improve with other interventions. However, recent studies suggest that early surgical intervention is more beneficial as it can mitigate the progression of the pathological process and prevent loss of pancreatic function. Despite the widespread adoption of minimally invasive approaches in various gastrointestinal surgical disorders, minimally invasive surgery for chronic pancreatitis is slow to evolve. Technical difficulty due to severe inflammatory changes has been the major impediment to the widespread usage of minimally invasive surgery in chronic pancreatitis. With this background, the present review aimed to critically analyze the available evidence on the minimally invasive treatment of chronic pancreatitis. A Pub Med search of all relevant articles was performed using the appropriate keywords, parentheses, and Boolean operators. Most initial laparoscopic series have reported the feasibility of lateral pancreaticojejunostomy, considered an adequate procedure only in a small proportion of patients. The pancreatic head is the pacemaker of pain, so adequate decompression is critical for long-term pain relief. Recent studies have documented the feasibility of minimally invasive duodenum-preserving pancreatic head resection. With improvements in laparoscopic instrumentation and technological advances, minimally invasive surgery for chronic pancreatitis is gaining momentum. However, more high-quality evidence is required to document the superiority of minimally invasive surgery for chronic pancreatitis.
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Affiliation(s)
- Raja Kalayarasan
- Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India
| | - Ankit Shukla
- Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry 605006, India
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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: 0] [Impact Index Per Article: 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, Adler JR. 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
| | - John R Adler
- Department of Hepatobiliary and Liver Transplant Surgery, Hamad Medical Corporation, Doha, QAT
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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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Desai CS, Williams BM, Baldwin X, Vonderau JS, Kumar A, Hyslop WB, Jones MS, Hanson M, Baron TH. Selection of parenchymal preserving or total pancreatectomy with/without islet cell autotransplantation surgery for patients with chronic pancreatitis. Pancreatology 2022; 22:472-478. [PMID: 35414482 DOI: 10.1016/j.pan.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 03/03/2022] [Accepted: 04/03/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The selection of surgery between parenchymal preserving (PPS) and total pancreatectomy (TP) with/without islet cell autotransplantation (IAT) for chronic pancreatitis (CP) patients varies based on multiple factors with a scarcity in literature addressing both at the same time. The aim of this manuscript is to present an algorithm for the surgery selection based on dominant area of disease, ductal dilatation, and glycemic control and compare outcomes. METHODS From 2017 to 2021, CP patients offered surgery at a single institution were retrospectively evaluated. RESULTS 51 patients underwent surgery (20 [39.2%] TPIAT, 4 [7.8%] TP, and 27 [52.9%] PPS - 9 Whipple procedures, 15 distal pancreatectomies, and 3 duct drainage procedures). No significant difference was observed in baseline characteristics or perioperative outcomes except median length of stay (8 days [IQR 6-10] vs. 13 days [IQR 9-15.5], p < 0.001), attributed to insulin requirement and education for TPIAT group. No differences in postoperative complications, such as clinically significant leak and intrabdominal fluid collection (3 [11.1%] vs 2 [10%], p = 1.0), hemorrhage (0 vs. 2 [10.0%], p = 0.2), delayed feeding (1 [3.7%] vs. 5 [25.0%], p = 0.07), or wound infection (4 [14.8%] vs. 0, p = 0.1) between PPS and TPIAT groups, respectively, were observed nor requirement of long-acting insulin at discharge (2 [15.4%] vs. 7 [43.8%], p = 0.1) for pre-operatively non-diabetic patients. No significant difference in weaning off narcotics and no mortality observed. CONCLUSION The most appropriate selection of surgery based on the algorithm yields good and comparable outcomes.
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Affiliation(s)
- Chirag S Desai
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.
| | | | - Xavier Baldwin
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | | | - Aman Kumar
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | | | - Morgan S Jones
- Department of Endocrinology, University of North Carolina, Chapel Hill, NC, USA
| | - Marilyn Hanson
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Todd H Baron
- Department of Gastroenterology, University of North Carolina, Chapel Hill, NC, USA
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8
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O'Brien SJ, Bhutiani N, Young JI, Phillips P, Weaver KH, Kline D, Vitale GC. Impact of myopenia and myosteatosis in patients undergoing abdominal surgery for chronic pancreatitis. Surgery 2022; 172:310-318. [PMID: 35246331 DOI: 10.1016/j.surg.2022.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 01/09/2022] [Accepted: 01/15/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Surgery for chronic pancreatitis is associated with major morbidity and mortality. The aim of this study is to examine the role of preoperative muscle volume and quality on postoperative outcomes in patients with chronic pancreatitis. METHODS All patients who underwent abdominal surgery for chronic pancreatitis between 2011 and 2018 were identified from an institutional surgical database. Patient demographics, clinical indices, and perioperative computed tomography scans were collected. Myopenia and myosteatosis were measured at the L3 vertebral level. Regression analysis was used to identify risk factors for major complications (Clavien-Dindo ≥3a) and length of stay. RESULTS Seventy-five patients were identified. Toxic-metabolic or obstructive causes were the main underlying etiologies. Thirty patients were myopenic (40%), and 36 patients were myosteatotic (48%). Sixteen patients (21%) had a major complication. Median length of stay was 10 days. Both myopenia and myosteatosis were associated with major complications (hazard ratio = 7.85, 95% confidence interval: 1.91-32.29, P = .004 and hazard ratio = 4.351, 95% confidence interval: 1.22-15.52, P = .023). Myosteatosis was associated with increased length of stay (parameter estimate = 0.297, 95% confidence interval: 0.012-0.583, P = .041). CONCLUSION Myopenia and myosteatosis were common and significant risk factors for adverse postoperative events. Preoperative muscle assessment may help in the risk stratification of surgical patients and identify patients that require preoperative nutritional and physical optimization.
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Affiliation(s)
- Stephen J O'Brien
- Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, KY; Department of Surgery, Cork University Hospital, Wilton, Cork, Ireland.
| | - Neal Bhutiani
- Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, KY
| | - J Isaac Young
- Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, KY
| | - Prejesh Phillips
- Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, KY
| | - Kalyn H Weaver
- Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, KY
| | - David Kline
- Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, KY
| | - Gary C Vitale
- Hiram C. Polk Jr. MD Department of Surgery, University of Louisville School of Medicine, KY
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9
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Phillips AE, Steel JL, Amin A, Wijkstrom M, Zureikat A, Tillman E, Jones R, Patel S, Fehrman N, Starinsky S, Nalitt H, Yadav D, Slivka A, Bellin MD, Carroll A, Humar A. Psychosocial outcomes 1-year post total pancreatectomy and autologous islet cell transplant. Pediatr Transplant 2022; 26:e14167. [PMID: 34668626 DOI: 10.1111/petr.14167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/01/2021] [Accepted: 10/02/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND A paucity of research regarding the psychosocial outcomes after TPIAT exists. METHODS Adults (>18 years), adolescents (13-18 years), and children (5-12 years) with their parents were administered questionnaires at the time of evaluation for TPIAT and 1-year postsurgery to assess psychosocial outcomes. RESULTS A total of 13 adults (6 male, 46%; mean age 35.2 years) and 9 children/adolescents (4 female, 44.4%; mean age 11.78 years) with CP were included in the study. A total of 69.2% of the adults and 66.7% of the children and adolescents were insulin dependent at 1-year postsurgery. In adults, improvements on the SF-36 pain (p = .001) and general health (p = .045) subscales were generally observed 1-year postsurgery. Adult patients who underwent robotic-assisted surgery compared to open surgery specifically reported better general health on the SF-36 (p < .05) at 1 year. For children and adolescents, reductions in average pain in the last week (p < .05), pain interference (p < .001), and fatigue were observed (p < .05) at 1-year postsurgery. For the entire sample, using repeated measures ANOVA and covarying for age, significant differences were found 1-year postsurgery in average pain in the last week (p = .034) and pain interference with the following categories: general activity (p < .001), walking (p = .04), normal work (p = .003), sleep (p = .002), and enjoyment in life (p = .007). CONCLUSIONS While few transplant centers offer this treatment, the improvement in quality of life suggests this may be a viable treatment option for those with CP complicated by intractable pain. (IRB Approval PRO 19080302).
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Affiliation(s)
- Anna E Phillips
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jennifer L Steel
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Psychology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Aarshati Amin
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Martin Wijkstrom
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Amer Zureikat
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Emily Tillman
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rachel Jones
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Seema Patel
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Nicole Fehrman
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Stefanie Starinsky
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Hailey Nalitt
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Adam Slivka
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Melena D Bellin
- Division of Pediatric Endocrinology and Schulze Diabetes Institute, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Antoinette Carroll
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Abhinav Humar
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Surgery for chronic pancreatitis: the comparison of two high-volume centers reveals lack of a uniform operative management. Langenbecks Arch Surg 2021; 406:2669-2677. [PMID: 34596765 PMCID: PMC8803624 DOI: 10.1007/s00423-021-02335-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/17/2021] [Indexed: 12/17/2022]
Abstract
Purpose Many aspects of surgical therapy for chronic pancreatitis (CP), including the correct indication and timing, as well as the most appropriate operative techniques, are still a matter of debate in the surgical community and vary widely across different centers. The aim of the present study was to uncover and analyze these differences by comparing the experiences of two specialized surgical units in Italy and Austria. Methods All patients operated for CP between 2000 and 2018 at the two centers involved were included in this retrospective analysis. Data regarding the clinical history and the pre- and perioperative surgical course were analyzed and compared between the two institutions. Results Our analysis showed a progressive decrease in the annual rate of pancreatic surgical procedures performed for CP in Verona (no. = 91) over the last two decades (from 3% to less than 1%); by contrast, this percentage increased from 3 to 9% in Vienna (no. = 77) during the same time frame. Considerable differences were also detected with regard to the timing of surgery from the first diagnosis of CP — 4 years (IQR 5.5) in the Austrian series vs two (IQR 4.0) in the Italian series -, and of indications for surgery, with a 12% higher prevalence of groove pancreatitis among patients in the Verona cohort. Conclusion The comparison of the surgical attitude towards CP between two surgical centers proved that a consistent approach to this pathology still is lacking. The identification of common guidelines and labels of surgical eligibility is advisable in order to avoid interinstitutional treatment disparities.
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Sled NY, Sled ON, Merzlikin NV, Tskhai VF, Narkevich AN, Bushlanov PS. [Analysis of the short and long-term results of traditional duodenum-saving resections of the pancreas head and the original resection-draining method of treatment of chronic pancreatitis]. Khirurgiia (Mosk) 2021:116-124. [PMID: 34363454 DOI: 10.17116/hirurgia2021081116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM Compare the short and long-term results of traditional duodenum-saving resections of the pancreas head and the original resection-draining method of the surgery of chronic pancreatitis. MATERIALS AND METHODS There has been the analysis of the immediate and long-term results of various types of duodenum-saving operations in 48 patients with chronic pancreatitis since 2011 to 2020. The patients were divided into two groups: the control group (n=26) where typical duodenum-saving operations were performed, and the study group (n=22) - the original resection-draining method of surgery. RESULTS The groups had no difference in gender, age, clinical manifestations. After typical duodenum-saving operations, the number of postoperative complications was higher than after original resection-draining method (31 [14; 52]% and 23 [8; 45]% respectively). In the control group the incidence of pancreatic fistula 19% [7; 39], hemorrhagic complications 12% [2; 30] was higher. In both groups, one patient died in the early postoperative period. However, these differences were statistically insignificant. 12 (52% [31; 73]; p<0.001) patients have died in the control group for the 9-year observation period, mainly (7 cases) as a result of the progression of chronic pancreatitis against the background of alcoholism. The groups had no difference in the level of pain reduction, development of dyspeptic syndrome and diabetes mellitus. CONCLUSIONS The proposed original technique of subtotal resection of the head, ventral part of the body and tail of the pancreas with longitudinal pancreatojejunoanastomosis made it possible to improve the short-term results and reduce the incidence of pancreatic fistula formation. Taking into account the level of compliance the selection of patients permitted to achieve a better quality of life according to the results of the SF - 36 questionnaire and to reduce the lethality to 5 [0; 25]% (p<0.001) in the long-term period. Statistically significant difference was obtained for three of the five criteria, the total value of the physical (PCS, p=0.033) and mental (MCS, p=0.032) health components.
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Affiliation(s)
- N Yu Sled
- Regional state budget institution of Health «Krasnoyarsk inter-regional clinical hospital N20 named for I.S. Berzona», Krasnoyarsk, Russia
| | - O N Sled
- Regional state budget institution of Health «Krasnoyarsk inter-regional clinical hospital N20 named for I.S. Berzona», Krasnoyarsk, Russia
| | - N V Merzlikin
- Siberian State Medical University of the Ministry of Health of the Russian Federation, Tomsk, Russia
| | - V F Tskhai
- Siberian State Medical University of the Ministry of Health of the Russian Federation, Tomsk, Russia
| | - A N Narkevich
- Vojno-Jaseneckiy Krasnoyarsk State Medical University of the Ministry of Health of the Russian Federation, Krasnoyarsk, Russia
| | - P S Bushlanov
- Siberian State Medical University of the Ministry of Health of the Russian Federation, Tomsk, Russia
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12
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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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13
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Ray S, Das K, Khamrui S, Jana K, Das R, Kumar D, Ansari Z. Short- and long-term outcome of Frey procedure for chronic pancreatitis in adults. Am J Surg 2021; 222:793-801. [PMID: 33608104 DOI: 10.1016/j.amjsurg.2021.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/17/2021] [Accepted: 02/07/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To report our experience with Frey procedure (FP) for chronic pancreatitis (CP) in adults. METHODS Adult patients with CP, who underwent a FP between August 2007 and July 2018, were retrospectively reviewed. RESULTS Of the total 138 patients, 95 (69%) were male. The median age at operation was 36.5 years. The median pain-surgery interval was 48 months. Alcohol abuse was identified in 64 (46%) patients. The major indication for surgery was disabling pain (94%). There was no postoperative mortality. Postoperative complications developed in 43 (31%) patients. Median postoperative hospital stay was 9 days. Over a median follow-up of 65 months, 84% of patients had complete pain relief. Continuous pain and high preoperative Izbicki pain score were associated with incomplete pain control. New-onset diabetes and exocrine insufficiency developed in 31% and 27% of patients respectively. Longer duration of disease and previous pancreatic surgery were associated with the development of new-onset diabetes after the FP. CONCLUSIONS Frey procedure is safe with an acceptable perioperative complications and good long-term pain control.
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Affiliation(s)
- Sukanta Ray
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India.
| | - Kshaunish Das
- Division of Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Sujan Khamrui
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Koustav Jana
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Roby Das
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Dilip Kumar
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
| | - Zuber Ansari
- Division of Surgical Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, 244 A. J. C. Bose Road, Kolkata, 700020, West Bengal, India
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14
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Zhang YJ, Duan DD, Yuan H. Efficacy and safety of islet autotransplantation after total pancreatectomy in chronic pancreatitis: A systematic review and meta-analysis including 17 studies. Clin Res Hepatol Gastroenterol 2020; 44:598-608. [PMID: 31523018 DOI: 10.1016/j.clinre.2019.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/20/2019] [Accepted: 08/14/2019] [Indexed: 02/06/2023]
Abstract
AIMS Islet autotransplantation (IAT), in conjunction with total pancreatectomy (TP), is used to relieve pain in patients with chronic pancreatitis (CP), while reducing the incidence of brittle diabetes. We aimed to evaluate the efficacy and safety of IAT after TP (TPIAT) in this setting. METHODS We searched PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials since 1977. Data were extracted from published papers. Random-effects meta-analysis and meta-regression models were built to assess the outcomes and effect of different factors. Subgroup and sensitivity analyses were conducted to examine the between-study heterogeneity, which was assessed using Cochrane's Q and I2 statistic. RESULTS A total of 17 studies, including 1024 patients, met the eligibility criteria. The median cohort size was 21 patients (range: 5-409). The pooled incidence rates of insulin independence, narcotic independence and mortality at last follow-up were 11.47 per 100 patient-years (95% CI: 6.79-21.60, I2=91.0%), 18.11 per 100 patient-years (95% CI: 5.29-62.04, I2=98.8%) and 2.88 per 100 patient-years (95% CI: 1.75-4.74, I2=46.8%), respectively. However, the heterogeneity level of our results was high, which was due to differences in research methods and definitions of outcomes between studies. Therefore, our results should be interpreted with caution. CONCLUSIONS TPIAT can effectively relieve pain and reduce the risk of surgical diabetes with no increase in mortality or morbidity. Prospective, randomized, clinical trials are required to further evaluate selection of patients and the timing of TPIAT.
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Affiliation(s)
- Ya-Jun Zhang
- Department of Pharmacy, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, 24 Jinghua Road, Jianxi District, Luoyang 471003, China.
| | - Dan-Dan Duan
- Department of Pharmacy, Henan Provincial Corps Hospital of Chinese People's Armed Police Force, Zhengzhou 450000, China
| | - Hang Yuan
- Department of Liver Surgery and Organ Transplantation, Changzheng Hospital, Naval Medical University, Shanghai 200003, China
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15
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Müller-Debus CF, Wellner UF, Bösch F, Belyaev O, Brunner M, Radulova-Mauersberger O, Grützmann R, Uhl W, Witzigmann H, Werner J, Keck T. [Indications for Surgical Therapy in Chronic Pancreatitis]. Zentralbl Chir 2020; 145:383-389. [PMID: 32726816 DOI: 10.1055/a-1168-7314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chronic pancreatitis is a recurrent disease with repeating exacerbations of inflammation of the pancreatic gland - associated with belt-like back pain. Without treatment, recurrent chronic pancreatitis leads to development of opioid-dependent pain. The chronic pancreatitis leads to recurrent hospital stays for the affected patient and socioeconomic challenges. In progress it can lead to local complications of chronic pancreatitis, such as formation of pseudocysts, biliary duct obstruction, duodenal obstruction or portal hypertension. The aim of this article is a detailed description of the indication for surgical therapy in chronic pancreatitis. The underlying analysis was a systematic literature research and evaluation, the formulation of key questions according to the PICO system and the evaluation of indications and key statements and questions, as implemented in a three level Delphi process among the members of the pancreas research group and the indications for the surgery group of the German Society of General and Visceral Surgery (DGAV). Surgical resection of the inflammatory pancreatic head pseudotumour, after initial conservative therapy, is a highly efficient therapy for the control of pain and the avoidance of complications in chronic pancreatitis. For this purpose, well evaluated surgical strategies are available. Delay in surgical therapy can lead to chronic pain, kachexia and malnutrition and increase complications of surgical therapy.
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Affiliation(s)
| | | | - Florian Bösch
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, Deutschland
| | - Orlin Belyaev
- Klinik für Chirurgie, Ruhr-Universität Bochum, Deutschland
| | | | - Olga Radulova-Mauersberger
- Klinik und Poliklinik für Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
| | | | - Waldemar Uhl
- Klinik für Chirurgie, Ruhr-Universität Bochum, Deutschland
| | - Helmut Witzigmann
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Städtisches Klinikum Dresden-Friedrichstadt, Deutschland
| | - Jens Werner
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, Deutschland
| | - Tobias Keck
- Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Deutschland
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16
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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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17
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Abstract
Chronic pancreatitis is a complex and irreversible disease of the pancreas and is associated with significant morbidity and mortality. Nutrition deficiencies in chronic pancreatitis are common and can be atypical in nature. As such, the management of these deficiencies can be individualized for patients. The aim of this review is to discuss the components of nutrition deficiencies in chronic pancreatitis, their management, and the current areas of research that are being explored. The clinical guidelines of major national and international societies were analyzed for recommendations on the nutrition management of chronic pancreatitis. The etiology of nutrition deficiencies in chronic pancreatitis is multifactorial and includes aspects of exocrine and/or endocrine dysfunction, significant abdominal pain, often persistent alcohol consumption, and increased metabolic activity. A large number of patients with nutrition deficiencies are underrecognized and undertreated. Although the majority of these patients can be managed by oral and pancreatic enzyme supplementation, some patients may require enteral tube feeding and, in rare cases, parenteral feeding. Current areas of research include the accurate identification of patients at risk for nutrition deficiencies, optimization of feeding regimens, and research into islet cell autotransplantation.
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Affiliation(s)
- Stephen J O'Brien
- Price Institute of Surgical Research, The Hiram C. Polk Jr., MD Department of Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Endashaw Omer
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
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18
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Zhang JY, Deng ZH, Gong B. Pancreaticopleural fistula in children with chronic pancreatitis: a case report and literature review. BMC Pediatr 2020; 20:274. [PMID: 32493299 PMCID: PMC7268358 DOI: 10.1186/s12887-020-02174-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/27/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pancreaticopleural fistula (PPF) is a very rare and critical complication of pancreatitis in children. The majority of publications relevant to PPF are case reports. No pooled analyses of PPF cases are available. Little is known about the pathogenesis and optimal therapeutic schedule. The purpose of this study was to identify the pathogenesis and optimal therapeutic schedule of PPF in children. CASE PRESENTATION The patient was a 13-year-old girl who suffered from intermittent chest tightness and dyspnea for more than 3 months; she was found to have chronic pancreatitis complicated by PPF. The genetic screening revealed SPINK1 mutation. She was treated with endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic retrograde pancreatic drainage (ERPD); her symptoms improved dramatically after the procedures. CONCLUSIONS PPF is a rare pancreatic complication in children and causes significant pulmonary symptoms that can be misdiagnosed frequently. PPF in children is mainly associated with chronic pancreatitis (CP); therefore, we highlight the importance of genetic testing. Endoscopic treatment is recommended when conservative treatment is ineffective.
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Affiliation(s)
- Jia-Yu Zhang
- Department of Pediatric Digestive Diseases, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Zhao-Hui Deng
- Department of Pediatric Digestive Diseases, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Biao Gong
- Department of Digestive Diseases, Shanghai Shuguang Hospital, Shanghai University of Chinese Medicine, Shanghai, 201203, China.
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19
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Olesen SS, Drewes AM. Bias towards surgery for pain in chronic pancreatitis. Pancreatology 2020; 20:305-306. [PMID: 32184068 DOI: 10.1016/j.pan.2020.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 03/08/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Søren S Olesen
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| | - Asbjørn M Drewes
- Centre for Pancreatic Diseases, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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20
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Lara LF, Bellin MD, Ugbarugba E, Nathan JD, Witkowski P, Wijkstrom M, Steel JL, Smith KD, Singh VK, Schwarzenberg SJ, Pruett TL, Naziruddin B, Long-Simpson L, Kirchner VA, Gardner TB, Freeman ML, Dunn TB, Chinnakotla S, Beilman GJ, Adams DB, Morgan KA, Abu-El-Haija MA, Ahmad S, Posselt AM, Hughes MG, Conwell DL. A Study on the Effect of Patient Characteristics, Geographical Utilization, and Patient Outcomes for Total Pancreatectomy Alone and Total Pancreatectomy With Islet Autotransplantation in Patients With Pancreatitis in the United States. Pancreas 2019; 48:1204-1211. [PMID: 31593020 PMCID: PMC7952005 DOI: 10.1097/mpa.0000000000001405] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES A selective therapy for pancreatitis is total pancreatectomy and islet autotransplantation. Outcomes and geographical variability of patients who had total pancreatectomy (TP) alone or total pancreatectomy with islet autotransplantation (TPIAT) were assessed. METHODS Data were obtained from the Healthcare Cost and Utilization Project National Inpatient Sample database. Weighed univariate and multivariate analyses were performed to determine the effect of measured variables on outcomes. RESULTS Between 2002 and 2013, there were 1006 TP and 825 TPIAT in patients with a diagnosis of chronic pancreatitis, and 1705 TP and 830 TPIAT for any diagnosis of pancreatitis. The majority of the TP and TPIAT were performed in larger urban hospitals. Costs were similar for TP and TPIAT for chronic pancreatitis but were lower for TPIAT compared with TP for any type of pancreatitis. The trend for TP and TPIAT was significant in all geographical areas during the study period. CONCLUSIONS There is an increasing trend of both TP and TPIAT. Certain groups are more likely to be offered TPIAT compared with TP alone. More data are needed to understand disparities and barriers to TPIAT, and long-term outcomes of TPIAT such as pain control and glucose intolerance need further study.
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Affiliation(s)
- Luis F. Lara
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Melena D. Bellin
- Division of Pediatric Endocrinology, University of Minnesota Medical School, Minneapolis, MN
| | - Emmanuel Ugbarugba
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jaimie D. Nathan
- Department of Surgery, Cincinnati Children’s Hospital, Cincinnati, OH
| | | | - Martin Wijkstrom
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jennifer L. Steel
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kerrington D. Smith
- Division of Surgical Oncology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Vikesh K. Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Center, Baltimore, MD
| | | | - Timothy L. Pruett
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Bashoo Naziruddin
- Islet Cell Laboratory, Baylor Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | | | - Varvara A. Kirchner
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Timothy B. Gardner
- Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Martin L. Freeman
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Medical School, Minneapolis, MN
| | - Ty B. Dunn
- Division of Transplant Surgery, The University of Pennsylvania, Philadelphia, PA
| | - Srinath Chinnakotla
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Gregory J. Beilman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - David B. Adams
- Department of Surgery, Medical University of South Carolina, Charleston, SC
| | | | | | - Syed Ahmad
- Department of Surgery, University of Cincinnati, Cincinnati, OH
| | - Andrew M. Posselt
- Department of Surgery, University of California-San Francisco, San Francisco, CA
| | | | - Darwin L. Conwell
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
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21
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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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22
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Ferri V, Vicente E, Quijano Y, Ielpo B, Duran H, Diaz E, Fabra I, Caruso R. Diagnosis and treatment of pancreas divisum: A literature review. Hepatobiliary Pancreat Dis Int 2019; 18:332-336. [PMID: 31155429 DOI: 10.1016/j.hbpd.2019.05.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 05/13/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Pancreas divisum is a congenital embryological disease caused by a lack of fusion between the ventral and dorsal pancreatic ducts in the early stages of embryogenesis. Recurrent acute pancreatitis, chronic pancreatitis or chronic abdominal pain are the main clinical syndromes at presentation and occur in only 5% of the patients with pancreas divisum. This review aimed to discuss diagnosis and treatment strategies in patients with symptomatic pancreas divisum. DATA SOURCES We report a literature review from 1990 up to January 2018 to explore the various diagnostic modalities and surgical techniques and results reported in the surgical treatment of pancreas divisum. RESULTS There are limited reports available on this topic in the literature. We analyzed and described the main indications in the treatment of pancreas divisum, focusing on surgical treatment and a discussion of the different approaches. Furthermore, we report the results from our experience in two cases of pancreas divisum treated by pancreatic head resection with segmental duodenectomy (the Nakao procedure). CONCLUSIONS Pancreas divisum is a common pancreatic malformation in which only a few patients develop a symptomatic disease. Surgical treatment is needed in case of endoscopic drainage failure and in cases complicated with chronic pancreatitis and local complications. Many techniques, of greater or lesser complexity, have been proposed.
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Affiliation(s)
- Valentina Ferri
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, calle oña 10, 28050 Madrid, Spain.
| | - Emilio Vicente
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, calle oña 10, 28050 Madrid, Spain
| | - Yolanda Quijano
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, calle oña 10, 28050 Madrid, Spain
| | - Benedetto Ielpo
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, calle oña 10, 28050 Madrid, Spain
| | - Hipolito Duran
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, calle oña 10, 28050 Madrid, Spain
| | - Eduardo Diaz
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, calle oña 10, 28050 Madrid, Spain
| | - Isabel Fabra
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, calle oña 10, 28050 Madrid, Spain
| | - Riccardo Caruso
- Division of General Surgery, Sanchinarro Hospital, San Pablo University, calle oña 10, 28050 Madrid, Spain
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23
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Nassar A, Quintini C, Costa G, Lennon E, Bottino R, Hatipoglu B, Hashimoto K, Fujiki M, Kandeel F, Walsh RM, Abu-Elmagd K. Total pancreaticoduodenectomy with autologous islet transplantation 14 years after liver-contained composite visceral transplantation. Am J Transplant 2018; 18:2068-2074. [PMID: 29673066 DOI: 10.1111/ajt.14880] [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: 02/06/2018] [Revised: 03/18/2018] [Accepted: 04/03/2018] [Indexed: 01/25/2023]
Abstract
Chronic pancreatitis (CP) is a severely disabling disorder with potential detrimental effects on quality of life, gut function, and glucose homeostasis. Disease progression often results in irreversible morphological and functional abnormalities with development of chronic pain, mechanical obstruction, and pancreatic insufficiency. Along with comprehensive medical management, the concept of total pancreatectomy and islet autotransplantation (TP-AIT) was introduced 40 years ago for patients with intractable pain and preserved beta-cell function. With anticipated technical difficulties, total excision of the inflamed-disfigured gland is expected to alleviate the incapacitating visceral pain and correct other associated abdominal pathology. With retrieval of sufficient islet-cell mass, the autologous transplant procedure has the potential to maintain an euglycemic state without exogenous insulin requirement. The reported herein case of CP-induced recalcitrant pain and foregut obstruction is exceptional because of the technical challenges in performing native pancreaticoduodenectomy in close proximity to the composite visceral allograft with complex vascular and gut reconstructions. Equally novel is transplanting the auto-islets in the liver-contained visceral allograft. Despite intravenous nutrition shortly after birth, liver transplantation at age 13, retransplantation with liver-contained visceral allograft at age 17 and TP-AIT at age 31, the 38-year-old recipient is currently pain free with full nutritional autonomy and normal glucose homeostasis.
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Affiliation(s)
- Ahmed Nassar
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Cristiano Quintini
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Guilherme Costa
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Elizabeth Lennon
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rita Bottino
- Institute of Cellular Therapeutics, Allegheny Health Network, Pittsburgh, PA, USA
| | - Betul Hatipoglu
- Department of Endocrinology, Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Koji Hashimoto
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Masato Fujiki
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Fouad Kandeel
- Department of Internal Medicine, City of Hope Health System, Los Angeles, CA, USA
| | - R Matthew Walsh
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kareem Abu-Elmagd
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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24
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Jiang L, Ning D, Cheng Q, Chen XP. Endoscopic versus surgical drainage treatment of calcific chronic pancreatitis. Int J Surg 2018; 54:242-247. [DOI: 10.1016/j.ijsu.2018.04.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 03/22/2018] [Accepted: 04/13/2018] [Indexed: 01/10/2023]
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25
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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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26
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Plagemann S, Welte M, Izbicki JR, Bachmann K. Surgical Treatment for Chronic Pancreatitis: Past, Present, and Future. Gastroenterol Res Pract 2017; 2017:8418372. [PMID: 28819358 PMCID: PMC5551531 DOI: 10.1155/2017/8418372] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 07/02/2017] [Accepted: 07/05/2017] [Indexed: 02/07/2023] Open
Abstract
The pancreas was one of the last explored organs in the human body. The first surgical experiences were made before fully understanding the function of the gland. Surgical procedures remained less successful until the discovery of insulin, blood groups, and finally the possibility of blood donation. Throughout the centuries, the surgical approach went from radical resections to minimal resections or only drainage of the gland in comparison to an adequate resection combined with drainage procedures. Today, the well-known and standardized procedures are considered as safe due to the high experience of operating surgeons, the centering of pancreatic surgery in specialized centers, and optimized perioperative treatment. Although surgical procedures have become safer and more efficient than ever, the overall perioperative morbidity after pancreatic surgery remains high and management of postoperative complications stagnates. Current research focuses on the prevention of complications, optimizing the patient's general condition preoperatively and finding the appropriate timing for surgical treatment.
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Affiliation(s)
- Stephanie Plagemann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Maria Welte
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Jakob R. Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Kai Bachmann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
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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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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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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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Hafezi-Nejad N, Singh VK, Johnson SI, Makary MA, Hirose K, Fishman EK, Zaheer A. Surgical approaches to chronic pancreatitis: indications and imaging findings. Abdom Radiol (NY) 2016; 41:1980-96. [PMID: 27207476 DOI: 10.1007/s00261-016-0775-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chronic pancreatitis (CP) is an irreversible, inflammatory process characterized by progressive fibrosis of the pancreas that can result in abdominal pain, exocrine insufficiency, and diabetes. Inadequate pain relief using medical and/or endoscopic therapies is an indication for surgery. The surgical management of CP is centered around three main operations including pancreaticoduodenectomy (PD), duodenum-preserving pancreatic head resection (DPPHR) and drainage procedures, and total pancreatectomy with islet autotransplantation (TPIAT). PD is the method of choice when there is a high suspicion for malignancy. Combined drainage and resection procedures are associated with pain relief, higher quality of life, and superior short-term and long-term survival in comparison with the PD. TPIAT is a reemerging treatment that may be promising in subjects with intractable pain and impaired quality of life. Imaging examinations have an extensive role in pre-operative and post-operative evaluation of CP patients. Pre-operative advanced imaging examinations including CT and MRI can detect hallmarks of CP such as calcifications, pancreatic duct dilatation, chronic pseudocysts, focal pancreatic enlargement, and biliary ductal dilatation. Post-operative findings may include periportal hepatic edema, pneumobilia, perivascular cuffing and mild pancreatic duct dilation. Imaging can also be useful in the detection of post-operative complications including obstructions, anastomotic leaks, and vascular lesions. Imaging helps identify unique post-operative findings associated with TPIAT and may aid in predicting viability and function of the transplanted islet cells. In this review, we explore surgical indications as well as pre-operative and post-operative imaging findings associated with surgical options that are typically performed for CP patients.
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31
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Sinha A, Patel YA, Cruise M, Matsukuma K, Zaheer A, Afghani E, Yadav D, Makary MA, Hirose K, Andersen DK, Singh VK. Predictors of Post-Operative Pain Relief in Patients with Chronic Pancreatitis Undergoing the Frey or Whipple Procedure. J Gastrointest Surg 2016; 20:734-40. [PMID: 26813017 DOI: 10.1007/s11605-016-3081-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 01/12/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Post-operative pain relief in chronic pancreatitis (CP) is variable. Our objective was to determine clinical imaging or histopathologic predictor(s) of post-operative pain relief in CP patients undergoing the Whipple or Frey procedure. METHODS All patients who underwent a Whipple (n = 30) or Frey procedure (n = 30) for painful CP between January 2003 and September 2013 were evaluated. A toxic etiology was defined as a history of alcohol use and/or smoking. The pre-operative abdominal CT was evaluated for calcification(s) and main pancreatic duct (MPD) dilation (≥5 mm). The post-operative histopathology was evaluated for severe fibrosis. Clinical imaging and histopathologic features were evaluated as predictors of post-operative pain relief using univariable and multivariable regression analysis. RESULTS A total of 60 patients (age 51.6 years, 53% males) were included in our study, of whom 42 (70%) reported post-operative pain relief over a mean follow-up of 1.1 years. There were 37 (62%) patients with toxic etiology, 36 (60%) each with calcification(s) and MPD dilation. A toxic etiology, calcifications, and severe fibrosis were associated with post-operative pain relief on univariable analysis (all p < 0.01). However, only a toxic etiology was an independent predictor of post-operative pain relief (OR 5.7, 95% CI 1.3, 24.5, p = 0.02). CONCLUSION Only a toxic etiology, and not imaging or histopathologic findings, independently predicts post-operative pain relief in CP patients undergoing the Whipple or Frey procedure.
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Affiliation(s)
- Amitasha Sinha
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Yuval A Patel
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Michael Cruise
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Karen Matsukuma
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Atif Zaheer
- Department of Radiology and Radiological Science, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Pancreatitis Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Elham Afghani
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Martin A Makary
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Pancreatitis Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Kenzo Hirose
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Pancreatitis Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Dana K Andersen
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, USA. .,Pancreatitis Center, Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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32
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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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Anderson MA, Akshintala V, Albers KM, Amann ST, Belfer I, Brand R, Chari S, Cote G, Davis BM, Frulloni L, Gelrud A, Guda N, Humar A, Liddle RA, Slivka A, Gupta RS, Szigethy E, Talluri J, Wassef W, Wilcox CM, Windsor J, Yadav D, Whitcomb DC. Mechanism, assessment and management of pain in chronic pancreatitis: Recommendations of a multidisciplinary study group. Pancreatology 2016; 16:83-94. [PMID: 26620965 PMCID: PMC4761301 DOI: 10.1016/j.pan.2015.10.015] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 10/29/2015] [Accepted: 10/31/2015] [Indexed: 12/11/2022]
Abstract
DESCRIPTION Pain in patients with chronic pancreatitis (CP) remains the primary clinical complaint and source of poor quality of life. However, clear guidance on evaluation and treatment is lacking. METHODS Pancreatic Pain working groups reviewed information on pain mechanisms, clinical pain assessment and pain treatment in CP. Levels of evidence were assigned using the Oxford system, and consensus was based on GRADE. A consensus meeting was held during PancreasFest 2012 with substantial post-meeting discussion, debate, and manuscript refinement. RESULTS Twelve discussion questions and proposed guidance statements were presented. Conference participates concluded: Disease Mechanism: Pain etiology is multifactorial, but data are lacking to effectively link symptoms with pathologic feature and molecular subtypes. Assessment of Pain: Pain should be assessed at each clinical visit, but evidence to support an optimal approach to assessing pain character, frequency and severity is lacking. MANAGEMENT There was general agreement on the roles for endoscopic and surgical therapies, but less agreement on optimal patient selection for medical, psychological, endoscopic, surgical and other therapies. CONCLUSIONS Progress is occurring in pain biology and treatment options, but pain in patients with CP remains a major problem that is inadequately understood, measured and managed. The growing body of information needs to be translated into more effective clinical care.
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Affiliation(s)
| | | | - Kathryn M Albers
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Inna Belfer
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Randall Brand
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Suresh Chari
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Greg Cote
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Brian M Davis
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Luca Frulloni
- Department of Medicine, University of Verona, Verona, Italy
| | - Andres Gelrud
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Nalini Guda
- Department of Gastroenterology, Aurora St. Luke's Medical Center, Milwaukee, WI, USA
| | - Abhinav Humar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Adam Slivka
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Eva Szigethy
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jyothsna Talluri
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wahid Wassef
- Department of Medicine, University of Massachusetts, Worcester, MA, USA
| | - C Mel Wilcox
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John Windsor
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - David C Whitcomb
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Cell Biology & Molecular Physiology, University of Pittsburgh, Pittsburgh, PA, USA; Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA, USA.
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe recent developments in paediatric pancreatitis and to discuss causes and current management. RECENT FINDINGS Although recent studies have estimated the annual incidence of paediatric acute pancreatitis approaching that of adults, there are no established guidelines about its diagnosis and treatment in children. Genetic and structural/congenital abnormalities are emerging as the primary risk factors for paediatric acute recurrent and chronic pancreatitis. Specifically, chronic pancreatitis is associated with a significant socioeconomic burden in children. Both medical and surgical therapies are proposed for paediatric chronic pancreatitis, but there is little evidence that they are beneficial. SUMMARY Acute recurrent and chronic pancreatitis create significant health issues in the paediatric population. Medical and surgical therapies exist to potentially treat these conditions, but the paediatric data are limited and the cohorts are small. A multidisciplinary and multicentre approach is necessary to better determine pancreatic disease processes and treatment options in children.
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Affiliation(s)
- John F. Pohl
- Department of Pediatric Gastroenterology, Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City, Utah
| | - Aliye Uc
- Department of Pediatric Gastroenterology, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Abstract
OBJECTIVES To examine if surgery performed for pain of chronic pancreatitis (CP) within 3 years diagnosis has greater odds of achieving complete pain relief than later surgery and to find optimal surgical timing for attaining pain relief in CP. METHODS Retrospective review of records at a tertiary institution 2003 to 2011 for CP where the operative indication was pain. Outcomes were pain-free status, opioid use, and pancreatic insufficiency at 3-year follow-up. Univariate analysis by Fisher exact tests. Receiver operating curve to calculate cutoff threshold time for surgery. RESULTS Outcomes for 66 patients were included. Median preoperative CP duration was 28 months (interquartile range, 12, 67). Twenty-six patients (39.4%) were free of pain at the 3-year follow-up. Thirty-four patients (51.5%) were opioid users at follow-up. Postoperatively, 34 patients (51.5%) demonstrated endocrine, and 32 patients (48.5%) demonstrated exocrine insufficiency. The optimal cutoff point for preoperative CP duration was 26.5 months (area under the curve, 0.66). Shorter duration of CP before surgery was a predictor of pain-free status and reduced postoperative opioid use at follow-up. CONCLUSIONS Results from a single institution analysis suggest early surgical intervention of 26.5 months or less of diagnosis is associated with improved pain control, and optimal timing for surgery may be earlier than previously thought.
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Haider M, Makary MA, Singh VK, Hirose K, Fishman EK, Zaheer A. Total pancreatectomy and islet autotransplantation for chronic pancreatitis: spectrum of postoperative CT findings. ACTA ACUST UNITED AC 2015; 40:2411-23. [DOI: 10.1007/s00261-015-0479-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Zach S, Wilhelm TJ, Rückert F, Herrle F, Niedergethmann M. Redo Surgery After Duodenum-Preserving Pancreatic Head Resection for Chronic Pancreatitis: High Incidence in Long-Term Follow-up. J Gastrointest Surg 2015; 19:1078-85. [PMID: 25903850 DOI: 10.1007/s11605-015-2791-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Accepted: 03/02/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Duodenum-preserving pancreatic head resection is a safe procedure with a more favorable short-term outcome compared to pancreaticoduodenectomy. However, some patients develop mechanical complications or suspicion of malignancy during follow-up and need reoperation years after primary surgery. Aim of this study was to evaluate incidence, techniques, and complication rates of redo operations. MATERIALS AND METHODS We reviewed short- and long-term outcomes of 33 patients who underwent duodenum-preserving pancreatic head resection for chronic pancreatitis from 1997 to 2010 at our department from a prospective database. RESULTS Short-term outcome after duodenum-preserving pancreatic head resection was comparable with previous data. Follow-up (mean 89 months) was achieved for 26 patients. Eight patients (30.1 %) needed a redo operation of which seven were performed. Indications were obstructive jaundice (four patients) and suspicion of cancer of pancreatic head (four patients; carcinoma confirmed in three patients). Mean interval between initial and redo operation was seven years for benign stenoses and 4 years for cancer. Three of seven operated patients needed revision. CONCLUSION Need for redo operations after duodenum-preserving pancreatic head resection is high and these operations have high complication rates. In most cases, redo operations can be avoided by performing pancreaticoduodenectomy as initial operation.
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Affiliation(s)
- Sebastian Zach
- Department of Surgery, University Hospital Mannheim, University of Heidelberg, Heidelberg, Germany
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40
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Fischer TD, Gutman DS, Warner EA, Trevino JG, Hughes SJ, Behrns KE. Local pancreatic head resection: the search for optimal indications through quality of life assessments. Am J Surg 2015; 210:417-23. [PMID: 26003202 DOI: 10.1016/j.amjsurg.2014.12.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 12/10/2014] [Accepted: 12/23/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Local pancreatic head resection (LPHR) for chronic pancreatitis has had limited adoption in the United States perhaps because of sparse outcomes and quality of life data. METHODS Forty-four patients underwent LPHR and retrospective evaluation of patient outcomes and quality of life assessment was performed. RESULTS The mean age was 49 ± 11 years (50% men) with chronic alcohol use as the etiology in 79% of patients. One patient (2%) died within 90 days. The intensive care unit stay was 1.8 ± 3.1 days and postoperative length of stay was 12.6 ± 9.4 days with 96% of patients discharged home. Ten (22%) patients had major perioperative complications. Biliary stricture was the most common late complication (14%). Quality of life assessment results showed that global status (47/100) and physical (66/100), cognitive (68/100), and social (52/100) functions were acceptable. Prevalent postoperative symptoms were pain (52/100), insomnia (56/100), and digestive disturbance (60/100). CONCLUSIONS LPHR is safe and effective for a substantial proportion of patients with chronic pancreatitis. Further refinement in the selection of patients most likely to benefit from this operation is warranted.
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Affiliation(s)
- Trevan D Fischer
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Daniel S Gutman
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | | | - Jose G Trevino
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Steven J Hughes
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Kevin E Behrns
- Department of Surgery, University of Florida, Gainesville, FL, USA.
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41
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Advances in surgical treatment of chronic pancreatitis. World J Surg Oncol 2015; 13:34. [PMID: 25845403 PMCID: PMC4326204 DOI: 10.1186/s12957-014-0430-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Accepted: 12/24/2014] [Indexed: 12/23/2022] Open
Abstract
The incidence of chronic pancreatitis (CP) is between 2 and 200 per 100,000 persons and shows an increasing trend year by year. India has the highest incidence of CP in the world at approximately 114 to 200 per 100,000 persons. The incidence of CP in China is approximately 13 per 100,000 persons. The aim of this review is to assist surgeons in managing patients with CP in surgical treatment. We conducted a PubMed search for “chronic pancreatitis” and “surgical treatment” and reviewed relevant articles. On the basis of our review of the literature, we found that CP cannot be completely cured. The purpose of surgical therapy for CP is to relieve symptoms, especially pain; to improve the patient’s quality of life; and to treat complications. Decompression (drainage), resection, neuroablation and decompression combined with resection are commonly used methods for the surgical treatment of CP. Before developing a surgical regimen, surgeons should comprehensively evaluate the patient’s clinical manifestations, auxiliary examination results and medical history to develop an individualized surgical treatment regimen.
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Olesen SS, Juel J, Nielsen AK, Frøkjær JB, Wilder-Smith OHG, Drewes AM. Pain severity reduces life quality in chronic pancreatitis: Implications for design of future outcome trials. Pancreatology 2014; 14:497-502. [PMID: 25455540 DOI: 10.1016/j.pan.2014.09.009] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 09/10/2014] [Accepted: 09/24/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Chronic pancreatitis (CP) is a disabling disease characterised by abdominal pain, and various pancreatic and extra-pancreatic complications. We investigated the interactions between pain characteristics (i.e. pain severity and its pattern in time), complications, and quality of life (QOL) in patients with CP. METHODS This was a cross-sectional study of 106 patients with CP conducted at two North European tertiary medical centres. Detailed information on clinical patient characteristics was obtained from interviews and through review of the individual patient records. Pain severity scores and pain pattern time profiles were extracted from the modified brief pain inventory short form and correlated to QOL as assessed by the EORTC QLQ-C30 questionnaire. Interactions with exocrine and endocrine pancreatic insufficiency, as well as pancreatic and extra-pancreatic complications were analysed using regression models. RESULTS Pain was the most prominent symptom in our cohort and its severity was significantly correlated with EORTC global health status (r = -0.46; P < 0.001) and most functional and symptom subscales. In contrast the patterns of pain in time were not associated with any of the life quality subscales. When controlling for interactions from exocrine and endocrine pancreatic insufficiency no effect modifications were evident (P = 0.72 and P = 0.85 respectively), while the presence of pancreatic and extra-pancreatic complications was associated with an almost 15% decrease in life quality (P = 0.004). CONCLUSIONS Pain severity and disease related complications significantly reduce life quality in patients with CP. This information is important in order to design more accurate and clinical meaningful endpoints in future outcome trials.
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Affiliation(s)
- Søren Schou Olesen
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Denmark.
| | - Jacob Juel
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Denmark
| | | | | | - Oliver H G Wilder-Smith
- Pain and Nociception Neuroscience Research Group, Department of Anaesthesiology, Pain and Palliative Care, Radboud University Medical Centre, The Netherlands; Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Denmark; Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Denmark
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Yang CJ, Bliss LA, Schapira EF, Freedman SD, Ng SC, Windsor JA, Tseng JF. Systematic review of early surgery for chronic pancreatitis: impact on pain, pancreatic function, and re-intervention. J Gastrointest Surg 2014; 18:1863-9. [PMID: 24944153 DOI: 10.1007/s11605-014-2571-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 06/06/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgical intervention has traditionally been reserved as the last management option for pain in chronic pancreatitis. Recently, there has been a call for surgery to be offered earlier in the disease process. The objectives of this review were to evaluate the effect of early surgery on postoperative pain, pancreatic function, and re-intervention rates in chronic pancreatitis. METHODS A systematic literature search through EMBASE, Cochrane Review, and PubMed from January 1950 to January 2014 was conducted. Citations found in relevant papers are hand-searched. Data which could be pooled were analyzed using Revman (v5.2). Risk of bias analysis was conducted. RESULTS Of the 2,886 potentially eligible studies identified, 11 studies met the inclusion criteria. There was large heterogeneity in the study designs, and studies were conducted over a lengthy time span. Seven studies examined pain, three studies examined pancreatic function, and three studies examined rates of re-intervention. Meta-analysis of the three studies with comparative raw data regarding complete pain relief showed that early surgery was associated with an increased likelihood of complete postoperative pain relief (RR = 1.67, 95% CI 1.09-2.56, p = 0.02). Early surgery was also associated with reduced risk of pancreatic insufficiency and low re-intervention rates. CONCLUSIONS Data from this study supports considering early surgery for pain management in patients with chronic pancreatitis, with the potential of a reduced risk of pancreatic insufficiency and the need for further intervention. Further prospective randomized studies are warranted comparing early surgery against conservative step-up approaches.
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Affiliation(s)
- Catherine J Yang
- Surgical Outcomes Analysis & Research, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Stoneman 9, Boston, MA, USA
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Abstract
Autologous islet cell transplantation is a procedure performed to prevent or reduce the severity of diabetes after pancreatic resection. Autologous islet cell transplantation is being used almost exclusively in patients undergoing pancreatectomy because of painful, chronic pancreatitis, or multiple recurrent episodes of pancreatitis that is not controlled by standard medical and surgical treatments. Here, we discuss the possibility of extending the clinical indications for this treatment on the basis of our experience in patients undergoing pancreatic surgery for both nonmalignant and malignant diseases, including patients undergoing completion pancreatectomy because of anastomosis leakage after pancreaticoduodenectomy and those with pancreatic anastomosis deemed at high risk for failure.
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Affiliation(s)
- Gianpaolo Balzano
- Pancreatic Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Roch A, Teyssedou J, Mutter D, Marescaux J, Pessaux P. Chronic pancreatitis: A surgical disease? Role of the Frey procedure. World J Gastrointest Surg 2014; 6:129-135. [PMID: 25068010 PMCID: PMC4110530 DOI: 10.4240/wjgs.v6.i7.129] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 04/26/2014] [Accepted: 07/14/2014] [Indexed: 02/06/2023] Open
Abstract
Although medical treatment and endoscopic interventions are primarily offered to patients with chronic pancreatitis, approximately 40% to 75% will ultimately require surgery during the course of their disease. Although pancreaticoduodenectomy has been considered the standard surgical procedure because of its favorable results on pain control, its high postoperative complication and pancreatic exocrine or/and endocrine dysfunction rates have led to a growing enthusiasm for duodenal preserving pancreatic head resection. The aim of this review is to better understand the rationale underlying of the Frey procedure in chronic pancreatitis and to analyze its outcome. Because of its hybrid nature, combining both resection and drainage, the Frey procedure has been conceptualized based on the pathophysiology of chronic pancreatitis. The short and long-term outcome, especially pain relief and quality of life, are better after the Frey procedure than after any other surgical procedure performed for chronic pancreatitis.
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Nechutova H, Dite P, Hermanova M, Novotny I, Martinek A, Klvana P, Kianicka B, Soucek M. Pancreatic pain. Wien Med Wochenschr 2014; 164:63-72. [DOI: 10.1007/s10354-014-0265-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 01/27/2014] [Indexed: 12/16/2022]
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47
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Bouwense SA, Ahmed Ali U, ten Broek RP, Issa Y, van Eijck CH, Wilder-Smith OH, van Goor H. Altered central pain processing after pancreatic surgery for chronic pancreatitis. Br J Surg 2014; 100:1797-804. [PMID: 24227367 DOI: 10.1002/bjs.9322] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic abdominal pain is common in chronic pancreatitis (CP) and may involve altered central pain processing. This study evaluated the relationship between pain processing and pain outcome after pancreatic duct decompression and/or pancreatic resection in patients with CP. METHODS Patients with CP underwent quantitative sensory testing. Pain processing was measured via electrical pain detection (ePDT) and electrical pain tolerance (ePTT) thresholds in dermatomes C5 and L4. Inhibitory descending pain control mechanisms were assessed using the conditioned pain modulation (CPM) paradigm. Healthy controls and patients with CP were compared, and patients with CP and a poor pain outcome (visual analogue scale (VAS) score greater than 30) were compared with those with a good pain outcome (VAS score 30 or less). RESULTS Forty-eight patients with CP had lower ePDT, ePTT and CPM responses compared with values in 15 healthy controls (P < 0·030). The sum of ePDT values was lower in patients with a poor pain outcome than in those with a good outcome (median 7·1 versus 11·2 mA; P = 0·008). There was a correlation with the VAS score and the sum of ePDT values (rs = -0·45, P = 0·016) and ePTT values (rs = -0·46, P = 0·011), and CPM response (rs = -0·43, P = 0·006) in patients with CP. CONCLUSION After pain-relieving pancreatic surgery, patients with CP exhibit altered central pain processing compared with that in healthy controls. Poor pain outcomes are associated with more central sensitization and more pronociceptive descending pain modulation, and this should be considered when managing persistent pain after pain-relieving surgery for CP.
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Affiliation(s)
- S A Bouwense
- Department of Surgery, Rotterdam, The Netherlands
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48
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Winny M, Paroglou V, Bektas H, Kaltenborn A, Reichert B, Zachau L, Kleine M, Klempnauer J, Schrem H. Insulin dependence and pancreatic enzyme replacement therapy are independent prognostic factors for long-term survival after operation for chronic pancreatitis. Surgery 2013; 155:271-9. [PMID: 24287147 DOI: 10.1016/j.surg.2013.08.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Accepted: 08/12/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND This retrospective, single-center, observational study on postoperative long-term results aims to define yet unknown factors for long-term outcome after operation for chronic pancreatitis. PATIENTS AND METHODS We analyzed 147 consecutive patients operated for chronic pancreatitis from 2000 to 2011. Mean follow-up was 5.3 years (range, 1 month to 12.7 years). Complete long-term survival data were provided by the German citizen registration authorities for all patients. A quality-of-life questionnaire was sent to surviving patients after a mean follow-up of 5.7 years. RESULTS Surgical principles were resection (n = 86; 59%), decompression (n = 29; 20%), and hybrid procedures (n = 32; 21%). No significant influences of different surgical principles and operative procedures on survival, long-term quality of life and pain control could be detected. Overall 30-day mortality was 2.7%, 1-year survival 95.9%, and 3-year survival 90.8%. Multivariate Cox regression analysis revealed that only postoperative insulin dependence at the time of hospital discharge (P = .027; Exp(B) = 2.111; 95% confidence interval [CI], 1.089-4.090) and the absence of pancreas enzyme replacement therapy at the time of hospital discharge (P = .039; Exp(B) = 2.102; 95% CI, 1.037-4.262) were significant, independent risk factors for survival with significant hazard ratios for long-term survival. Long-term improvement in quality of life was reported by 55 of 76 long-term survivors (73%). CONCLUSION Pancreatic enzyme replacement should be standard treatment after surgery for chronic pancreatitis at the time of hospital discharge, even when no clinical signs of exocrine pancreatic failure exist. This study underlines the potential importance of early operative intervention in chronic pancreatitis before irreversible endocrine dysfunction is present.
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Affiliation(s)
- Markus Winny
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Vagia Paroglou
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Hüseyin Bektas
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Alexander Kaltenborn
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany; Federal Armed Forces Medical Center Hannover, Hannover, Germany
| | - Benedikt Reichert
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany; Department of General and Thoracic Surgery, Universitätsklinikum Schleswig Holstein, Kiel, Germany
| | - Lea Zachau
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Moritz Kleine
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Harald Schrem
- General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany.
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Dunderdale J, McAuliffe JC, McNeal SF, Bryant SMJ, Yancey BD, Flowers G, Christein JD. Should pancreatectomy with islet cell autotransplantation in patients with chronic alcoholic pancreatitis be abandoned? J Am Coll Surg 2013; 216:591-6; discussion 596-8. [PMID: 23521936 DOI: 10.1016/j.jamcollsurg.2012.12.043] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 12/11/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Pancreatectomy or drainage has been advocated for pain due to chronic pancreatitis. Islet cell autotransplantation (IAT) may improve quality of life (QOL); optimal patient selection has not been established. STUDY DESIGN Outcomes of 100 patients who underwent pancreatectomy with islet isolation between 2005 and 2012 were assessed by etiology (alcoholic pancreatitis [AP] 30%, and nonalcoholic pancreatitis [NAP] 70%). Insulin requirement, Short Form-36, and McGill Pain Questionnaires were assessed. Data were analyzed using SASv9.2. RESULTS Of the 100 patients, isolation was unsuccessful in 9 patients due to fibrosis. Alcoholic pancreatitis was associated with 7 of 9 failed isolations (23% vs 3%, p < 0.01), and all of these patients are now diabetic. Ninety-one patients (age 44 years, follow-up 19 months, 23% AP) underwent resection with IAT. Total islet yield (islet cell equivalents [IEQ]) and IEQ/kg body weight were less for patients with AP (81,000 vs 150,000, p < 0.01; 1,260 vs 2,190, respectively, p = 0.01) overall and more specifically, for total pancreatectomy (92,000 vs 188,000, respectively, p = 0.02). Twenty-eight (34%) of all patients who had resections and 15% of those undergoing total pancreatectomy are insulin free. Multivariate analysis identified AP as an independent predictor of insulin units/day (p = 0.01). Complete pre- and postoperative QOL and pain surveys were available on 69 patients. Patients with AP had less QOL improvement (1 of 8 vs 5 of 8 domains, p < 0.01) and "present pain" improvement at 2 years from preoperative levels in those with NAP; no improvement in QOL was seen in those with AP (NAP 2.7 to 1.2, p < 0.01; AP 2.7 to 2.2, p > 0.05). CONCLUSIONS After pancreatic resection with planned IAT, AP resulted in failed isolations, lower yields, higher insulin requirements, poor long-term QOL improvement, and no improvement in pain scores compared with NAP. Further studies should define criteria for resection and IAT for patients with alcoholic chronic pancreatitis.
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Affiliation(s)
- Julie Dunderdale
- University of Alabama at Birmingham, Department of Surgery, Birmingham, AL 35294-0016, USA
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50
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Berry AJ. Pancreatic surgery: indications, complications, and implications for nutrition intervention. Nutr Clin Pract 2013; 28:330-57. [PMID: 23609476 DOI: 10.1177/0884533612470845] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Pancreatic surgery is a complicated procedure leaving postoperative patients with an altered gastrointestinal (GI) anatomy and a potential for further surgical complications such as leaks and fistulas. Beyond surgical complications, these patients are prone to delayed gastric emptying, fat malabsorption, and hyperglycemia, with early satiety and poor appetite further compromising nutrition status. Many of these patients are malnourished prior to this major surgical procedure, and significant weight loss is common postoperatively. Does this affect their outcome? There seems to be a lack of consensus in this patient population regarding how to optimize nutrition and limit potential deleterious effects of this surgery. It is important to first understand the underlying disease condition and the effects to the gland, different forms of surgery with subsequent GI alterations, and common surgical and digestive complications. Once this is reviewed, existing nutrition support literature will be explored in attempts to determine the best nutrition management in this patient population.
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Affiliation(s)
- Amy J Berry
- University of Virginia Health System, Surgical Nutrition Support/Nutrition Services, Charlottesville, VA 22908-0673, USA.
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