Surgical options for control of abdominal pain in chronic pancreatitis patients

Challenges of Managing Type 3c Diabetes in the Context of Pancreatic Resection, Cancer and Trauma

Type 3c diabetes mellitus (T3cDM), also known as pancreatogenic or pancreoprivic diabetes, is a specific type of DM that often develops as a result of diseases affecting the exocrine pancreas, exhibiting an array of hormonal and metabolic characteristics. Several pancreatic exocrine diseases and surgical procedures may cause T3cDM. Diagnosing T3cDM remains difficult as the disease characteristics frequently overlap with clinical presentations of type 1 DM (T1DM) or type 2 DM (T2DM). Managing T3cDM is likewise challenging due to numerous confounding metabolic dysfunctions, including pancreatic endocrine and exocrine insufficiencies and poor nutritional status. Treatment of pancreatic exocrine insufficiency is of paramount importance when managing patients with T3cDM. This review aims to consolidate the latest information on surgical etiologies of T3cDM, focusing on partial pancreatic resections, total pancreatectomy, pancreatic cancer and trauma.

Pancreatolithiasis: Does Management Depend on Clinical Manifestations?

BACKGROUND Pancreatic calculi (PC) or pancreatolithiasis refers to the presence of stones in the main pancreatic duct (MPD), side branches, or parenchyma of the pancreas. It is highly associated with chronic pancreatitis (CP), and is present in 50-90% of those patients. The stone formation can be attributed to a diversity of factors, all of them leading to obstruction in the duct, hypertension of its distal part, increased intraductal and parenchymal pressure, and inflammation, causing the standard symptom, epigastric pain. Immediate restoration of pancreatic secretion flow is of utmost importance and can be achieved with both endoscopic and surgical techniques. Endoscopic techniques include endoscopic retrograde cholangiopancreatography (ERCP) combined, if possible, with extracorporeal shock wave lithotripsy (ESWL), while surgical techniques consist of drainage and resection procedures. The choice of treatment for PC depends on the location, size, and number of stones, and the existence of other complications. CASE REPORT We present 2 cases that were diagnosed with PC, in which clinical symptoms, laboratory results, and imaging examinations were different, suggesting the variety of manifestations pancreatolithiasis can cause. Each patient was treated differently, according to their clinical situation and the presence or absence of complications. Both patients were discharged and fully recovered. CONCLUSIONS The management of pancreatolithiasis can be demanding in some cases, mostly when there are complications. The purpose of this case report is to indicate the importance of personalized treatment for each patient, as different approaches to the same medical condition should be easily identified and successfully treated.

Complications of chronic pancreatitis prior to and following surgical treatment: A proposal for classification

BACKGROUND

Chronic pancreatitis (CP) is a long-lasting disease frequently associated with complications for which there is no comprehensive pathophysiological classification.

AIM

The aims of this study were to: Propose a pathophysiological classification of the complications of CP; evaluate their prevalence in a surgical cohort prior to, and following surgical management; and assess the impact of the surgical treatment on the occurrence of new complications of CP during follow-up. We hypothesized that optimal surgical treatment can resolve existing complications and reduce the risk of new complications, with the exclusion of pancreatic insufficiency. The primary outcomes were prevalence of complications of CP at baseline (prior to surgical treatment) and occurrence of new complications during follow-up.

METHODS

After institutional review board approval, a prospective observational cohort study with long-term follow-up (up to 20.4 years) was conducted. All consecutive single-center adult patients (≥ 18 years of age) with CP according to the criteria of the American Pancreas Association subjected to surgical management between 1997 and 2021, were included. The prevalence of CP complications evaluated, according to the proposed classification, in a surgical cohort of 166 patients. Development of the pathophysiological classification was based on a literature review on the clinical presentation, course, and complications of CP, as well a review of previous classification systems of CP.

RESULTS

We distinguished four groups of complications: Pancreatic duct complications, peripancreatic complications, pancreatic hemorrhages, and pancreatic insufficiency (exocrine and endocrine). Their baseline prevalence was 20.5%, 23.5%, 10.2%, 31.3%, and 27.1%, respectively. Surgical treatment was highly effective in avoiding new complications in the first and third groups. In the group of peripancreatic complications, the 15-year Kaplan-Meier prevalence of new complications was 12.1%. The prevalence of pancreatic exocrine and endocrine insufficiency increased during follow-up, being 66.4% and 47.1%, respectively, at 15 years following surgery. Pancreatoduodenal resection resulted optimal results in avoiding new peripancreatic complications, but was associated with the highest rate of pancreatic exocrine insufficiency.

CONCLUSION

The proposed complication classification improves the understanding of CP. It could be beneficial for clinical decision making, as it provides an opportunity for more comprehensive judgement on patient’s needs on the one hand, and on the pros and cons of the treatment under consideration, on the other. The presence of complications of CP and the risk of development of new ones should be among the main determinants of surgical choice.

Modified Puestow Procedure for Chronic Pancreatitis in an Adolescent Female

Chronic pancreatitis is an inflammatory condition resulting in fibrosis and consequent destruction of pancreatic tissue and loss of exocrine and endocrine function. Despite being an uncommon disease in adults, its incidence in children is significantly lower. Crucial surgical intervention is considered in pediatric cases where pain management and reducing the risk of future cancer development are of concern. The efficacy of the Rochelle-Partington modification of the Puestow procedure in remedying chronic pancreatitis has shown satisfactory long-term results, especially in pediatric cases, however, not without side effects.

A 13-year-old girl who suffers from recurrent abdominal pain attributed to chronic pancreatitis underwent the Rochelle-Partington modification of the Puestow procedure to mitigate her symptoms. The postoperative course was complicated by small bowel obstruction necessitating revision of the enteroenteric anastomosis. After three years since surgery, the patient remains pain-free, well-nourished, and leads a normal life without the interruption of her daily activities.

While still left to be seen if the modified Puestow procedure serves to be the superior choice in the treatment of chronic pancreatitis, it remains a safe choice for surgical treatment among adolescents. Sustaining pancreatic function is essential in pediatric cases where the long-term quality of life is concerned to reduce chronic pain and maintain nutrition.

‘Short’ pancreaticojejunostomy might be a valid option for treatment of chronic pancreatitis in many cases

BACKGROUND

The Partington-Rochelle pancreaticojejunostomy (PJ) is an essential management option for patients with chronic pancreatitis (CP) associated with intractable pain and a dilated pancreatic duct (PD). Wide ductotomy and long PJ (L-PJ) have been advocated as the standard of care to ensure full PD decompression. However, the role of short PJ (S-PJ) in a uniformly dilated PD has not yet been evaluated.

AIM

To evaluate the possible advantages and disadvantages of S-PJ and L-PJ and to interpret the perspective of S-PJ in the treatment of CP.

METHODS

A retrospective review of prospectively collected cohort data was conducted on surgically treated CP patients subjected to side-to-side PJ. The length of the PJ was adapted to anatomical alterations in PD. A comparison was made of S-PJ (< 50 mm) for uniformly dilated PD and L-PJ (50-100 mm) in the setting of multiple PD strictures, calcifications and dilatations. We hypothesized that S-PJ and L-PJ ensure comparable clinical outcomes. The primary outcomes were pain relief and quality of life (QOL); the secondary outcomes were perioperative characteristics, body weight, patients’ satisfaction with treatment, and readmission rate due to CP.

RESULTS

Overall, 91 patients underwent side-to-side PJ for CP, including S-PJ in 46 patients and L-PJ in 45 patients. S-PJ resulted in better perioperative outcomes: Significantly shorter operative time (107.5 min vs 134 min), lower need for intraoperative (0% vs 15.6%) and total (2.2% vs 31.1%) blood transfusions, and lower rate of perioperative complications (6.5% vs 17.8%). We noted no significant difference in pain relief, improvement in QOL, body weight gain, patients’ satisfaction with surgical treatment, or readmission rate due to CP.

CONCLUSION

Based on our data, in the setting of a uniformly dilated PD, S-PJ provides adequate decompression of the PD. As the clinical outcomes following S-PJ are not inferior to those of L-PJ, S-PJ should be preferred as a surgical option in the case of a uniformly dilated PD.

Disease duration before surgical resection for chronic pancreatitis impacts long-term outcome

Many patients with chronic pancreatitis (CP) undergo a step-up approach with interventional procedures as first-line treatment and resection reserved for later stages. The aim of this study was to identify predictive factors for a significant clinical improvement (SCI) after surgical treatment.All patients operated for CP between September 2012 and June 2017 at our center was retrospectively reviewed. A prospective patient survey was conducted to measure patients postoperative outcome. The primary endpoint SCI was defined as stable health status, positive weight development and complete pain relief without routine pain medication. Additionally, risk factors for relaparotomy were analyzed.A total of 89 patients with a median follow-up of 38 months were included. In most cases, a duodenum-preserving pancreatic head resection (n = 48) or pancreatoduodenectomy (n = 28) was performed. SCI was achieved in 65.3% (n = 47) of the patients after the final medium follow-up of 15.0 months (IQR: 7.0-35.0 months), respectively. Patients with a longer mean delay (7.7 vs 4 years) between diagnosis and surgical resection were less likely to achieve SCI (P = .02; OR .88; 95%CI .80-98). An endocrine insufficiency was a negative prognostic factor for SCI (P = .01; OR .15; 95%CI .04-68). In total, 96.2% of the patients had a complete or major postoperative relief with a mean pain intensity reduction from 8.1 to 1.9 on the visual analogue scale.The results support that surgical resection for CP should be considered at early stages. Resection can effectively reduce postoperative pain intensity and improve long-term success.

Gastric volvulus with perforation 1 year after total pancreatectomy: a case report

Background

Because of its rare indication and relatively simple reconstruction procedure (only choledochojejunostomy and gastrojejunostomy) compared to those for pancreatoduodenectomy, the technical tips and pitfalls of total pancreatectomy are rarely discussed. Herein, we discuss a rare case of gastric volvulus 1 year after total pancreatectomy and provide advice to prevent such cases.

Case presentation

A 66-year-old woman underwent total pancreatectomy with splenectomy for mixed-type intraductal papillary mucinous neoplasm of the pancreas. Choledochojejunostomy (retro-colic route) and gastrojejunostomy (ante-colic route, Billroth II method) were performed for reconstruction. The final diagnosis was mixed-type intraductal papillary mucinous adenoma of the pancreas without malignant neoplasm. She had no clinical symptoms, such as abdominal pain and fever, during postoperative follow-up. However, at 1 year postoperatively, she complained of abdominal pain. Contrast-enhanced abdominal computed tomography showed volvulus and perforation of the stomach. Emergent surgery was performed. The stomach fornix was located on the right side and was partly perforated. We resected the perforation site with a linear cutter® (New Type Linear Cutter, Ethicon, USA) and released the gastric volvulus. Moreover, we fixed the stomach to the left abdominal wall using non-absorbable thread. The cause of the perforation was clinically and pathologically unclear. Her serum albumin and cholinesterase levels temporarily decreased postoperatively, but gradually increased. A recurrence of volvulus-related symptoms has not been observed.

Conclusions

After total pancreatectomy with splenectomy, although the stomach is connected with the jejunum, it is typically fixed only by the pedicle of the left gastric artery and vein. In the present case, this anatomical change may have been a cause of the gastric volvulus. Thus, it might be better to fix the remnant stomach in total pancreatectomy with splenectomy.