Inhibition of pancreatic secretion under long-term octreotide treatment in humans

Somatostatin analogues and the risk of post-operative pancreatic fistulas after pancreatic resection - A systematic review & meta-analysis

BACKGROUND

Post-operative pancreatic fistula (POPF) is a common complication of pancreatic resection. Somatostatin analogues (SA) have been used as prophylaxis to reduce its incidence. The aim of this study is to appraise the current literature on the effects of SA prophylaxis on the prevention of POPF following pancreatic resection.

METHODS

The review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data from studies that reported the effects of SA prophylaxis on POPF following pancreatic resection were extracted, to determine the effect of SA on POPF morbidity and mortality.

RESULTS

A total of 15 studies, involving 2221 patients, were included. Meta-analysis revealed significant reductions in overall POPF (Odds ratio: 0.65 (95% CI 0.53-0.81, p < 0.01)), clinically significant POPF (Odds ratio: 0.53 (95% CI 0.34-0.83, p < 0.01)) and overall morbidity (OR: 0.69 (95% CI: 0.50-0.95, p = 0.02)) following SA prophylaxis. There is no evidence that SA prophylaxis reduces mortality (OR: 1.10 (95%CI: 0.68-1.79, p = 0.68)).

CONCLUSION

SA prophylaxis following pancreatic resection reduces the incidence of POPF. However, mortality is unaffected.

A rare case of acute pancreatitis due to very severe hypertriglyceridemia treated with subcutaneous insulin and lipid lowering drugs

The diagnosis of acute pancreatitis in a patient requires the presence of two of the following three criteria: (I) acute onset of persistent, severe; (II) epigastric pain often radiating to the back, elevation in serum lipase or amylase to three times or greater than the upper limit of normal; (III) characteristic radiographic evidence hypertriglyceridemia is a potential cause of acute pancreatitis when levels are greater than 1,000 mg/dL. Very severe hypertriglyceridemia is classified as levels above 2,000 mg/dL. Management includes targeting pancreatitis with intravenous fluids, pain control, and nutritional support. While apheresis with therapeutic plasma exchange is a known option for severe hypertriglyceridemia, we present a rare case with management with intravenous fluids, subcutaneous insulin, statins, and fibrates in a patient with a triglyceride level of 12,234 mg/dL who presented with severe epigastric pain radiating to her back.

A Novel Method for Pain Relief in Chronic Pancreatitis: an Old Drug in a New Pack: a Controlled Study

Most of pain-relieving agents in chronic pancreatitis are nonspecific and unpredictable. Omeprazole induces hypergastrinemia due to reduced gastric acidity. Raised serum gastrin, in turn, modulates to reduce secretin level. Secretin is responsible for secretion of almost 80 % bicarbonate-rich pancreatic juice from the ductular epithelium without affecting enzyme output. It is a prospective randomized study in patients with CT-confirmed chronic pancreatitis. The control group got the standard care and 60 mg of omeprazole twice daily was added to the test group. Absence of pain relief at 14 days was considered as failure. Pain relief, weight gain and any toxic effect of omeprazole were reviewed at 12 months. One hundred thirty-seven cases were included, with an age range of 19 to 72 years. (mean 42.67). The majority of them were alcoholic males. At 2 weeks, pain relief was noted in 47/69(68.1 %) and 63/65(96.96 %) in the control and omeprazole group, respectively. At the end of 1 year, the omeprazole group had greater weight gain (95 %) than the control group (69.5 %). All the pseudocysts in the omeprazole group and most in the control group resolved. No side effect of omeprazole was seen. The high-dose omeprazole (HDO) group of patients had significantly better pain relief in chronic pancreatitis than those treated with conventional therapy. A high number of cases gained weight in the HDO group than the controlled group. No patient had clinical, endoscopic, biochemical, or haematological toxicity of HDO. More studies are necessary.

Management of blunt pancreatic trauma: what's new?

Pancreatic injuries are relatively uncommon but present a major challenge to the surgeon in terms of both diagnosis and management. Pancreatic injuries are associated with significant mortality, primarily due to associated injuries, and pancreas-specific morbidity, especially in cases of delayed diagnosis. Early diagnosis of pancreatic trauma is a key for optimal management, but remains a challenge even with more advanced imaging modalities. For both penetrating and blunt pancreatic injuries, the presence of main pancreatic ductal injury is the major determinant of morbidity and the major factor guiding management decisions. For main pancreatic ductal injury, surgery remains the preferred approach with distal pancreatectomy for most injuries and more conservative surgical management for proximal ductal injuries involving the head of the pancreas. More recently, nonoperative management has been utilized, especially in the pediatric population, with the potential for increased rates of pseudocyst and pancreatic fistulae and the potential for the need for further intervention and increased hospital stay. This review presents recent data focusing on the diagnosis, management, and outcomes of blunt pancreatic injury.

Systematic review and meta-analysis of the role of somatostatin and its analogues in the treatment of enterocutaneous fistula

OBJECTIVE

Somatostatin analogues may help pancreatic fistula although it remains unclear whether they help nonpancreatic fistula. This study involved meta-analysis of somatostatin analogues for treatment of enterocutaneous fistula.

METHODS

Meta-analysis of studies was undertaken, to estimate the effect of somatostatin analogues on spontaneous closure, time to closure and mortality.

RESULTS

Results showed significant associations between somatostatin and both spontaneous closure rate [odds ratio (OR) 6.61, 95% (CI) confidence interval 1.35-32.43] and time to closure (standardized mean difference -0.80, 95% CI: -1.34 to -0.26). Octreotide reduced closure time (standardized mean difference -0.57, 95% CI: -0.95 to -0.20) but not spontaneous closure (OR: 1.74, 95% CI: 0.64-4.76). Lanreotide also improved time to closure (mean of 17 days vs. 26 days, standard deviation not stated) but not spontaneous closure (OR: 0.94, 95% CI: 0.42-2.12). Somatostatin, octreotide and lanreotide did not significantly affect mortality (OR: 0.30, 0.82, and 0.48; 95% CI: 0.03-3.47, 0.38-1.78, and 0.04-5.07 respectively).

CONCLUSION

Somatostatin and octreotide improved fistula closure time but only somatostatin improved spontaneous closure rate.

The role of somatostatin in 67 consecutive pancreatectomies: a randomized clinical trial

BACKGROUND

Somatostatin has been found to be effective in the prevention of postoperative complications in pancreatic surgery. It can inhibit the pancreatic secretions that, quite often, are responsible for complications during the postoperative period.

METHODS

We randomized 67 patients in 2 groups. In the study group (n = 35), somatostatin was administered 30 minutes prior to surgery as well as intraoperatively and postoperatively. No medication was given to the control group (n = 32). Biopsies were taken and processed for electron microscopy and ultrastructural morphometric analysis.

RESULTS

Administration of somatostatin reduced the exocrine granule number, and the patients suffered from fewer postoperative complications.

CONCLUSIONS

Somatostatin reduces granule number and size of pancreatic cells, which can partially explain the prophylactic effect of the drug on early complications of pancreatic surgery, and which is confirmed by the clinical findings.

Somatostatin analogues in the prevention of pancreas-related complications after pancreatic resection

BACKGROUND/PURPOSE

The Achilles' heel of operative pancreatectomies is the pancreaticoenterostomy for proximal resections and the pancreatic parenchymal closure for distal resections. Inhibition of pancreatic exocrine secretions by somatostatin analogues has been suggested to decrease pancreas-specific complications, but this topic remains controversial.

METHODS

We performed a randomized, prospective, placebo-controlled, multicenter trial of the use of perioperative vapreotide, a potent somatostatin analogue, in pancreatic resections for presumed neoplasms in 381 patients without chronic pancreatitis. We also reviewed the literature on the use of somatostatin and its analogues after pancreatectomy.

RESULTS

When compared to the placebo, perioperative vapreotide had no effect on overall pancreas-specific complications (30.4% vs 26.4%), mortality (0% vs 1.4%), overall complications (40% vs 42%), and duration of hospitalization; there were no differences in complications per type of resection with use of vapreotide--proximal versus distal resection. Seven other prospective, randomized trials provide differing results.

CONCLUSIONS

Our study with vapreotide failed to show any benefit when administered perioperatively (and for 7 days postoperatively) on pancreas-specific complications after major pancreatectomy in patients without chronic pancreatitis. The use of perioperative analogues that suppress pancreatic exocrine secretion seems not to be warranted as routine treatment.

Role of somatostatin in the prevention of pancreatic stump-related morbidity following elective pancreaticoduodenectomy in high-risk patients and elimination of surgeon-related factors: prospective, randomized, controlled trial

A prospective, randomized, controlled trial was performed to determine the efficacy of somatostatin in the prevention of pancreatic stump-related complications with elimination of surgeon-related factors in high-risk patients undergoing pancreaticoduodenectomy. From August 1997 to December 2000, 54 patients, 28 men and 26 women, with age ranged from 32 to 89 years, were randomly assigned to somatostatin group ( n = 27) or placebo group ( n = 27). Ninety-four percent of the patients had pancreatic and periampullary lesions; 6% had secondary lesion involving the duodenum such as local recurrent colon carcinoma and renal cell carcinoma. These patients received either standard pancreaticoduodenectomy or pylorus-preserving pancreaticoduodenectomy. An experienced surgeon performed all operations in same fashion to minimize the surgical factor. A transanastomotic tube was inserted into the pancreatic duct for diversion of pancreatic juice in the pancreaticojejunostomy for a 3-weeks period postoperatively. Intravenous infusion of somatostatin was given at a dose of 250 microg/hr in the somastotatin group and normal saline was given to the control group for 7 days postoperatively. There was one perioperative death in each group, resulting in a 3.7% mortality rate. In the somastotatin group, as compared to the placebo group, the incidence of overall morbidity and pancreatic stump related complications were significantly lower with a mean decrease of 50% pancreatic juice output and a slightly shorter duration of hospital stays. In conclusion, after excluding surgeon related factor, prophylactic use of somatostatin reduces the incidence and severity of pancreatic stump related complications in high-risk patients having pancreaticoduodenectomy via decreased secretion of pancreatic exocrine.

[Natural history of the pancreatic stump after duodenopancreatectomy of the pancreatic head]

Major complications following pancreaticoduodenectomy are thought to be chiefly associated with exocrine secretion of the pancreatic remnant which is not well known. This work aims to assess the exocrine secretion of the pancreatic remnant within the early post-operative period.

PATIENTS AND METHODS

Seventy-five patients undergoing pancreaticoduodenectomy for presumed tumour were included in a prospective multicentre study. A tube was inserted in the pancreatic duct at the time of construction of the pancreatic anastomosis. Peripancreatic drainage was routinely used. Pancreatic juice and peripancreatic drainage fluid were collected and measured and pancreatic enzyme monitored. For 7 days patients received total parenteral nutrition and continuous infusion of randomly Somatostatin 14 (S-14) at a dose of 6 mg/24 h (days 1-6) and 3 mg/24 h (day 7) or matching placebo. Pancreatic fistula was defined as a daily drainage of more than 100 cc of amylase-rich fluid after day 3, persisting after day 12 or associated with symptoms or needing specific treatment.

RESULTS

Daily output of pancreatic juice was low during the first postoperative day and then increased gradually until day 5. A high enzyme concentration was observed in pancreatic juice on the first post-operative day. S-14 infusion resulted in a significant decrease of both pancreatic fistula rate and enzyme concentration in peripancreatic fluid.

CONCLUSIONS

During the first postoperative days, the outflow of the exocrine secretion of the pancreatic remnant is low but contains a high enzyme concentration with significant leaks within the peripancreatic area. S-14 infusion results in a decrease of pancreatic juice leaks from the pancreatic remnant.

Randomized controlled multicentre trial of somatostatin infusion after pancreaticoduodenectomy

BACKGROUND

It remains debatable whether somatostatin can prevent pancreatic fistula and other pancreatic stump-related complications following pancreaticoduodenectomy. This study assessed the effects of somatostatin-14 (S-14) on pancreatic remnant exocrine secretion.

METHODS

This was a double-blind, randomized, placebo-controlled trial in patients undergoing pancreaticoduodenectomy for malignancy. Patients received a continuous infusion of S-14 (n = 38) or placebo (n = 37) for 7 days. Pancreatic juice and peripancreatic drainage fluid was collected and measured, and pancreatic enzymes were monitored daily. Postoperative complications were recorded.

RESULTS

S-14 infusion was associated with a decrease in median daily pancreatic juice and pancreatic amylase output. Amylase concentration and output in the peripancreatic drain fluid were significantly lower after S-14 infusion than in the control group (both P < 0.05). The incidence of clinical pancreatic fistula (two of 38 versus eight of 37; P < 0.05) and total pancreatic stump-related complications (five of 38 versus 12 of 37; P < 0.05) was lower in patients treated with S-14. Duration of hospital stay was shorter after S-14 (18 versus 26 days; P = 0.01).

CONCLUSION

Although the effect of S-14 on exocrine secretion remains difficult to demonstrate, it did reduce pancreatic juice leakage from the pancreatic remnant.

Randomized controlled multicentre study of the prevention of complications by octreotide in patients undergoing surgery for chronic pancreatitis

A randomized double-blind placebo-controlled multicentre trial was carried out in 247 patients undergoing major elective surgery for chronic pancreatitis to clarify whether the perioperative application of octreotide prevents postoperative complications. Eleven complications were defined, including death, anastomotic leakage, pancreatic fistula, abscess, fluid collection, shock, sepsis, bleeding, pulmonary insufficiency, renal insufficiency and postoperative pancreatitis. A total of 124 patients underwent pancreatic head resection, 55 left resection, 61 pancreaticojejunostomy and seven had other procedures. The overall mortality rate was 1.2 per cent (octreotide group 1.6 per cent, placebo group 0.8 per cent [corrected] (P not significant)). The postoperative complication rate in the octreotide group was 16.4 per cent (20 of 122 patients) and in the placebo group 29.6 per cent (37 of 125) (P < 0.007). The perioperative application of octreotide substantially reduces the risk of postoperative complications in patients undergoing major pancreatic surgery for chronic pancreatitis.

Review article: the relative effectiveness of somatostatin and octreotide therapy in pancreatic disease

Somatostatin and octreotide inhibit basal and stimulated pancreatic secretion, stimulate reticuloendothelial system activity, modulate the cytokine cascade and are cytoprotective with respect to the pancreas. These effects of somatostatin and octreotide suggest that both drugs may be useful either in the treatment of pancreatic disorders, or in preventing acute pancreatitis following procedures on the pancreas. In recent years it has become clear that somatostatin is a useful and effective therapy for severe acute pancreatitis and in preventing complications following endoscopic retrograde cholangiopancreatography (ERCP), whereas octreotide has no beneficial effect and may be deleterious in both these indications. The differences in the therapeutic efficacy of somatostatin and octreotide in acute pancreatitis and ERCP appears to be related to their differential effects on sphincter of Oddi motility--the native hormone relaxing, and the analogue increasing, its contractility. Consequently, any beneficial effects of octreotide in both acute pancreatitis and ERCP are offset by the increased contractility of the sphincter of Oddi, which results in retention of activated enzymes within the pancreas and further autodigestion of the gland. Somatostatin and octreotide are equally effective in promoting the closure of pancreatic fistulae. However, the time to closure after commencement of therapy is much more variable and longer in patients treated with subcutaneous octreotide than those receiving intravenous somatostatin, possibly as a result of fluctuations in pancreatic enzyme secretion between consecutive administrations of the hormone. Furthermore, the initial potent inhibitory effect of octreotide on pancreatic secretion is lost after 7 days of continuous subcutaneous administration. Therefore, in terms of cost-effectiveness, somatostatin would appear to be the treatment of choice for pancreatic fistulae. Octreotide markedly reduces the complication rates after elective pancreatic surgery. It remains to be established whether somatostatin is as effective as octreotide in this indication.