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Jagielski M, Bella E, Jackowski M. Endoscopic pancreatogastric anastomosis in the treatment of symptoms associated with inflammatory diseases of the pancreas. World J Gastrointest Endosc 2024; 16:406-412. [PMID: 39072251 PMCID: PMC11271716 DOI: 10.4253/wjge.v16.i7.406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/22/2024] [Accepted: 06/11/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND The outflow of pancreatic juice into the duodenum is often impaired in pancreatic inflammatory diseases. The basis of interventional treatment in these cases is anatomical transpapillary access of the main pancreatic duct during endoscopic retrograde cholangiopancreatography (ERCP), which ensures the physiological outflow of pancreatic juice into the lumen of the digestive tract. However, in some patients, anatomical changes prevent transpapillary drainage of the main pancreatic duct. Surgery is the treatment of choice in such cases. AIM To evaluate the effectiveness and safety of endoscopic pancreaticogastrostomy under endoscopic ultrasound (EUS) guidance. METHODS Retrospective analysis of treatment outcomes of all patients with acute or chronic pancreatitis who underwent endoscopic pancreatogastric anastomosis under EUS guidance in 2018-2023 at the Department of General, Gastroenterological and Oncological Surgery, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Poland. RESULTS In 9 patients [7 men, 2 women; mean age 53.45 (36-66) years], endoscopic pancreatogastric anastomosis under EUS guidance was performed because of the lack of transpapillary access during ERCP. Narrowing of the main pancreatic duct at the head of the pancreas was observed in 4/9 patients (44.44%). Pancreatic fragmentation (disconnected pancreatic duct syndrome) was diagnosed in 3/9 patients (33.33%). In 2/9 patients (22.22%), narrowing of the pancreatoenteric anastomosis was observed after pancreaticoduodenectomy. Technical success of endoscopic pancreaticogastrostomy was observed in 8/9 patients (88.89%). Endotherapeutic complications were observed in 2/9 patients (22.22%). Clinical success was achieved in 8/9 patients (88.89%). The mean follow-up period was 451 (42-988) d. Long-term success of endoscopic pancreatogastric anastomosis was achieved in 7/9 patients (77.78%). CONCLUSION Endoscopic pancreaticogastrostomy under EUS guidance is an effective and safe treatment method, especially in the absence of transpapillary access to the main pancreatic duct.
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Affiliation(s)
- Mateusz Jagielski
- Department of General, Gastroenterological and Oncological Surgery, Nicolaus Copernicus University, Toruń 87-100, Poland
| | - Eryk Bella
- Department of General, Gastroenterological and Oncological Surgery, Nicolaus Copernicus University, Toruń 87-100, Poland
| | - Marek Jackowski
- Department of General, Gastroenterological and Oncological Surgery, Nicolaus Copernicus University, Toruń 87-100, Poland
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Phillips AE, Hughes SJ, Andersen DK, Bell A, Brand R, Coté GA, Cowdin A, Diazgranados N, Dudeja V, Duggan SN, Fogel E, Forsmark CE, Freeman AJ, Gittes G, Hart PA, Jeon C, Nealon W, Neoptolemos J, Palermo TM, Pandol S, Roberts KM, Rosenthal M, Singh VK, Yadav D, Whitcomb DC, Zyromski N. Interventions for Pancreatitis-New Approaches, Knowledge Gaps, and Research Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. Pancreas 2024; 53:e368-e377. [PMID: 38518063 PMCID: PMC10963039 DOI: 10.1097/mpa.0000000000002333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
ABSTRACT There exists no cure for acute, recurrent acute or chronic pancreatitis and treatments to date have been focused on managing symptoms. A recent workshop held by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) focused on interventions that might disrupt or perhaps even reverse the natural course of this heterogenous disease, aiming to identify knowledge gaps and research opportunities that might inform future funding initiatives for NIDDK. The breadth and variety of identified active or planned clinical trials traverses the spectrum of the disease and was conceptually grouped for the workshop into behavioral, nutritional, pharmacologic and biologic, and mechanical interventions. Cognitive and other behavioral therapies are proven interventions for pain and addiction, but barriers exist to their use. Whilst a disease specific instrument quantifying pain is now validated, an equivalent is lacking for nutrition - and both face challenges in ease and frequency of administration. Multiple pharmacologic agents hold promise. Ongoing development of Patient Reported Outcome (PRO) measurements can satisfy Investigative New Drug (IND) regulatory assessments. Despite multiple randomized clinical trials demonstrating benefit, great uncertainty remains regarding patient selection, timing of intervention, and type of mechanical intervention (endoscopic versus surgery). Challenges and opportunities to establish beneficial interventions for patients were identified.
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Affiliation(s)
- Anna Evans Phillips
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Steven J Hughes
- Division of Surgical Oncology, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Dana K Andersen
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Adam Bell
- Translational Medicine and Regulatory Affairs, Theraly Fibrosis, Gaithersburg, MD
| | - Randall Brand
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, School of Medicine, Oregon Health and Science University, Portland, OR
| | | | - Nancy Diazgranados
- National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD
| | - Vikas Dudeja
- Division of Surgical Oncology, Department of Surgery, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Sinead N Duggan
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Evan Fogel
- Digestive and Liver Disorders, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Chris E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, FL
| | - A Jay Freeman
- Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, The Ohio State College of Medicine, Columbus, OH
| | - George Gittes
- Pediatric General and Thoracic Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Christie Jeon
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA
| | - William Nealon
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, NY
| | | | - Tonya M Palermo
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle Children's Research Institute, Seattle, WA
| | - Stephen Pandol
- Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Kristen M Roberts
- School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, OH
| | | | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dhiraj Yadav
- From the Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Nicholas Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
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Singh A, Bush N, Bhullar FA, Faghih M, Moreau C, Mittal R, Seo JH, Talukdar R, Lakhtakia S, Singh VK, Akshintala VS. Pancreatic duct pressure: A review of technical aspects and clinical significance. Pancreatology 2023; 23:858-867. [PMID: 37798192 DOI: 10.1016/j.pan.2023.09.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/12/2023] [Accepted: 09/28/2023] [Indexed: 10/07/2023]
Abstract
Pancreatic duct pressure (PDP) dynamics comprise an intricately modulated system that helps maintain homeostasis of pancreatic function. It is affected by various factors, including the rate of pancreatic fluid secretion, patency of the ductal system, sphincter of Oddi function, and pancreatic fluid characteristics. Disease states such as acute and chronic pancreatitis can alter the normal PDP dynamics. Ductal hypertension or increased PDP is suspected to be involved in the pathogenesis of pancreatic pain, endocrine and exocrine pancreatic insufficiency, and recurrent pancreatitis. This review provides a comprehensive appraisal of the available literature on PDP, including the methods used in the measurement and clinical implications of elevated PDP.
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Affiliation(s)
- Anmol Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Nikhil Bush
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Furqan A Bhullar
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Mahya Faghih
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Chris Moreau
- Division of Gastroenterology, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Rajat Mittal
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Jung-Hee Seo
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Rupjyoti Talukdar
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Vikesh K Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Venkata S Akshintala
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States.
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Falque A, Gasmi M, Barthet M, Gonzalez JM. Safety and efficacy of EUS-guided pancreatic duct drainage in symptomatic main pancreatic duct obstruction: Is there still a place for surgery? Endosc Int Open 2021; 9:E934-E942. [PMID: 34079881 PMCID: PMC8159606 DOI: 10.1055/a-1302-1484] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 10/07/2020] [Indexed: 12/17/2022] Open
Abstract
Abstract
Background and study aims In patients with symptomatic dilation of the main pancreatic duct (MPD) for whom endoscopic retrograde cholangiopancreatography (ERCP) is impossible, surgery has long been the only available treatment. EUS-PD is described as a minimally invasive alternative for ductal decompression surgery. We describe the results of our experience with it.
Patients and methods This was a retrospective single-center study over 9 years. Twenty-seven patients, median age 61.8 years (range 36 to 85) who underwent EUS-PD for symptomatic MPD dilatation were included. The main objective was to evaluate the technical success (placement of a plastic stent between the stomach and the MPD). Secondary objectives were to document clinical success based on pain and quality of life (visual analogic scales and treatments) and complication rates, and to define a standardized management algorithm.
Results The technical success rate was 92.5 %. The rate of minor adverse events was 21 % (4 cases of non-specific postoperative pain and two cases of delayed benign edematous pancreatitis). The clinical success rate was 88 %, and half of patients in whom the procedure was successful had "complete regression" of pain and half "partial regression." Median follow-up was 34.2 months (range 4 to 108). During follow-up, 74 % of patients reported improvement in quality of life and no patients required secondary surgery.
Conclusion Provided it is performed in an expert center, EUS-PD is a minimally invasive, effective, and safe alternative to pancreatic surgical drainage in patients with symptomatic MPD dilatation with failure or in whom ERCP is impossible.
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Affiliation(s)
- Arthur Falque
- Aix-Marseille Université, AP-HM, Hôpital Nord, Gastroenterologie, Marseille, France
| | - Mohamed Gasmi
- Aix-Marseille Université, AP-HM, Hôpital Nord, Gastroenterologie, Marseille, France
| | - Marc Barthet
- Aix-Marseille Université, AP-HM, Hôpital Nord, Gastroenterologie, Marseille, France
| | - Jean-Michel Gonzalez
- Aix-Marseille Université, AP-HM, Hôpital Nord, Gastroenterologie, Marseille, France
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5
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EUS-directed pancreatic duct drainage: Mainstream miracle or proceed with caution? Gastrointest Endosc 2020; 92:1067-1069. [PMID: 33160488 DOI: 10.1016/j.gie.2020.05.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 05/31/2020] [Indexed: 12/11/2022]
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Hobbs PM, Johnson WG, Graham DY. Management of pain in chronic pancreatitis with emphasis on exogenous pancreatic enzymes. World J Gastrointest Pharmacol Ther 2016; 7:370-386. [PMID: 27602238 PMCID: PMC4986390 DOI: 10.4292/wjgpt.v7.i3.370] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 06/13/2016] [Accepted: 07/18/2016] [Indexed: 02/06/2023] Open
Abstract
One of the most challenging issues arising in patients with chronic pancreatitis is the management of abdominal pain. Many competing theories exist to explain pancreatic pain including ductal hypertension from strictures and stones, increased interstitial pressure from glandular fibrosis, pancreatic neuritis, and ischemia. This clinical problem is superimposed on a background of reduced enzyme secretion and altered feedback mechanisms. Throughout history, investigators have used these theories to devise methods to combat chronic pancreatic pain including: Lifestyle measures, antioxidants, analgesics, administration of exogenous pancreatic enzymes, endoscopic drainage procedures, and surgical drainage and resection procedures. While the value of each modality has been debated over the years, pancreatic enzyme therapy remains a viable option. Enzyme therapy restores active enzymes to the small bowel and targets the altered feedback mechanism that lead to increased pancreatic ductal and tissue pressures, ischemia, and pain. Here, we review the mechanisms and treatments for chronic pancreatic pain with a specific focus on pancreatic enzyme replacement therapy. We also discuss different approaches to overcoming a lack of clinical response update ideas for studies needed to improve the clinical use of pancreatic enzymes to ameliorate pancreatic pain.
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7
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Attwell A, Shah RJ. Response. Gastrointest Endosc 2016; 83:1301-2. [PMID: 27206593 DOI: 10.1016/j.gie.2016.03.1488] [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: 03/22/2016] [Accepted: 03/26/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Augustin Attwell
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Raj J Shah
- Division of Gastroenterology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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8
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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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Beneficial Effect of Low-Fat Elemental Diet Therapy on Pain in Chronic Pancreatitis. Int J Chronic Dis 2014; 2014:862091. [PMID: 26464866 PMCID: PMC4590936 DOI: 10.1155/2014/862091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Accepted: 03/25/2014] [Indexed: 11/24/2022] Open
Abstract
Background & Aims. Chronic pancreatitis (CP) is often associated with abdominal pain, which impairs quality of life. The aim of this prospective study was to clarify whether the use of a low-fat elemental diet (ED) is beneficial for managing pain in patients with CP. Methods. Seventeen CP patients with pain despite fat-restricted dietary and conventional medical treatments were enrolled in this prospective study. These patients received low-fat ED therapy in addition to restricting fat intake for 8 weeks. The change of pain severity was examined by interviewing the patient and status of analgesic use. Results. Mean serum levels of amylase and lipase at 8 weeks after the beginning of low-fat ED therapy decreased compared to those before the therapy. At 8 weeks, pain alleviation after low-fat ED therapy was reported in 15 out of 17 patients (88%). Of these 15 patients, 10 patients reported complete pain disappearance. One of 3 patients with severe or moderate pain requiring analgesic was relieved of analgesic use after low-fat ED therapy. Conclusion. Low-fat ED therapy is useful as means of pain control in CP. The therapy is recommended in outpatients with CP who present with pain despite conventional dietary and medical treatments.
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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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11
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Abstract
OBJECTIVE We aimed to determine if intravenous synthetic human secretin (sHS) improves refractory type B pain in patients with chronic pancreatitis (CP). METHODS In a phase II dose escalation trial, patients with CP received sHS of varying doses (0.05-0.8 µg/kg) for 3 days. The primary outcomes were changes in the visual analogue pain score (VAS), short form (SF)-36, and opiate use from baseline at 30 days after infusion. RESULTS Twelve patients (mean age, 42 years, 6 men) were included. Mean pain scores (VAS) were 5.79, 4.80, 4.72, and 4.90, at baseline, day 4, day 10, and day 30, respectively (P = 0.25, 0.19, and 0.27 when compared with baseline, respectively). Daily opiate use (oral morphine equivalents) decreased throughout the study from a baseline value of 136 to 111 mg on day 4 (P = 0.52) and to 104 mg on day 30 (P = 0.34). In subgroup analysis, women had the most improvement (VAS baseline, 5.42 vs. VAS day 30, 3.67; P = 0.07; baseline morphine equivalents, 107 mg vs. 84 mg; P = 0.21). CONCLUSIONS In patients, especially women, with refractory type B pain from CP, intravenous sHS administration demonstrated a trend toward improvement in self-reported pain and opiate use at 30 days after infusion, although statistical significance was not achieved (clinicaltrials.gov registration number NCT01265875).
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12
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Oza VM, Kahaleh M. Endoscopic management of chronic pancreatitis. World J Gastrointest Endosc 2013; 5:19-28. [PMID: 23330050 PMCID: PMC3547116 DOI: 10.4253/wjge.v5.i1.19] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Revised: 09/23/2012] [Accepted: 12/01/2012] [Indexed: 02/05/2023] Open
Abstract
Chronic pancreatitis (CP) is a common gastrointestinal illness, which affects the quality of life with substantial morbidity and mortality. The management includes medical, endoscopic and surgical approaches with the need for interaction between various specialties, calling for a concerted multidisciplinary approach. However, at the time of this publication, guidelines to establish care of these patients are lacking. This review provides the reader with a comprehensive overview of the studies summarizing the various treatment options available, including medical, surgical and endoscopic options. In addition, technological advances such as endoscopic retrograde cholangiopancreatogrophy, endoscopic shock wave lithotripsy and endoscopic ultrasound can now be offered with reasonable success for pancreatic decompression, stricture dilatation with stent placement, stone fragmentation, pseudocyst drainage, and other endoscopic interventions such as celiac plexus block for pain relief. We emphasize the endoscopic options in this review, and attempt to extract the most up to date information from the current literature. The treatment of CP and its complications are discussed extensively. Complications such as biliary strictures. pancreatic pseudocysts, and chronic pain are common issues that arise as long-term complications of CP. These often require endoscopic or surgical management and possibly a combination of approaches, however choosing amongst the various therapeutic and palliative modalities while weighing the risks and benefits, makes the management of CP challenging. Treatment goals should be not just to control symptoms but also to prevent disease progression. Our aim in this paper is to advocate and emphasize an evidence based approach for the management of CP and associated long term complications.
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Affiliation(s)
- Veeral M Oza
- Veeral M Oza, Michel Kahaleh, Division of Gastroenterology and Hepatology, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY 10021, United States
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Bramis K, Gordon-Weeks AN, Friend PJ, Bastin E, Burls A, Silva MA, Dennison AR. Systematic review of total pancreatectomy and islet autotransplantation for chronic pancreatitis. Br J Surg 2012; 99:761-6. [PMID: 22434330 DOI: 10.1002/bjs.8713] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2012] [Indexed: 12/23/2022]
Abstract
BACKGROUND Total pancreatectomy and islet autotransplantation (TP/IAT) is a treatment option in a subset of patients with chronic pancreatitis. A systematic review of the literature was performed to evaluate the outcome of this procedure, with an attempt to ascertain when it is indicated. METHODS MEDLINE (1950 to present), Embase (1980 to present) and the Cochrane Library were searched to identify studies of outcomes in patients undergoing TP/IAT. Cohort studies that reported the outcomes following the procedure were included. The MOOSE guidelines were used as a basis for this review. RESULTS Five studies met the inclusion criteria. The techniques reported for pancreatectomy and islet cell isolation varied between studies. TP/IAT was successful in reducing pain in patients with chronic pancreatitis. Comparing morphine requirements before and after the procedure, two studies recorded significant reductions. Concurrent IAT reduced the insulin requirement after TP; the rate of insulin independence ranged from 46 per cent of patients at 5 years' mean follow-up to 10 per cent at 8 years. The impact on quality of life was poorly reported. The studies reviewed did not provide evidence for optimal timing of TP/IAT in relation to the evolution of chronic pancreatitis. CONCLUSION This systematic review showed that TP/IAT had favourable outcomes with regard to pain reduction. Concurrent IAT enabled a significant proportion of patients to remain independent of insulin supplementation.
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Affiliation(s)
- K Bramis
- Department of Hepatobiliary and Transplant Surgery, Churchill Hospital, Oxford Radcliffe Hospitals NHS Trust, Oxford, UK
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14
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Abstract
Chronic pancreatitis is typically a painful condition and it can be associated with a severe burden of disease. The pathogenesis of pain in this disorder is poorly understood and its treatment has been largely empirical, often consisting of surgical or other invasive methods, with an outcome that is variable and frequently unsatisfactory. Human and experimental studies have indicated a critical role for neuronal mechanisms that result in peripheral and central sensitization. The pancreatic nociceptor seems to be significantly affected in this condition, with increased excitability associated with downregulation of potassium currents. Some of the specific molecules implicated in this process include the vanilloid receptor, TRPV1, nerve growth factor, the protease activated receptor 2 and a variety of others that are discussed in this Review. Studies have also indicated novel therapeutic targets for this condition.
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Affiliation(s)
- Pankaj Jay Pasricha
- Stanford University School of Medicine, 300 Pasteur Drive, M211 Alway Building, Stanford, CA 94305, USA.
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Perwaiz A, Singh A, Chaudhary A. Surgery for chronic pancreatitis. Indian J Surg 2011; 74:47-54. [PMID: 23372307 DOI: 10.1007/s12262-011-0374-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 11/10/2011] [Indexed: 12/27/2022] Open
Abstract
Chronic pancreatitis (CP) is progressive inflammatory process of the pancreas. Abdominal pain remains the most debilitating symptom affecting quality of life, apart from diabetes mellitus, steatorrhoea and weight loss. The treatment options have evolved over the past decades and are aimed to provide durable relief in pain with possible attempt to support or improve the failing endocrine and exocrine functions. Surgical treatment options have shown the potentials to provide superior long term results compared to the pharmacological and endoscopic modalities and are broadly divided in to drainage, resection and combination hybrid procedures. The choice is based on the morphology of the main pancreatic duct, presence of head mass and associated complication of CP. Knowing the basic nature of the disease, total pancreatectomy seems a curative option but not without significant morbidities. There is recent paradigm shift towards organ sparing surgical procedures with reasonable success. Despite recent advancement in the treatment modalities for CP the overall quality of life remains moderate which need further addressal.
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Affiliation(s)
- Azhar Perwaiz
- Department of GI Surgery, GI Oncology and Bariatric Surgery, Room No-10, 11th floor, OPD block, Medanta, The Medicity, Sector-38, 12001 Gurgaon, Haryana India
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Beger's operation and the Berne modification: origin and current results. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2009; 17:735-44. [PMID: 19798464 DOI: 10.1007/s00534-009-0179-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 08/12/2009] [Indexed: 12/22/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this paper is to illuminate the origin and current results of the duodenum-preserving pancreatic head resection (DPPHR) developed by Beger in the 1970s, as well as its simplified Berne modification, for patients suffering from chronic pancreatitis (CP). Indications for the procedures and their results are presented on the basis of available data. METHODS A selected review was made of the available data on the DPPHR developed by Beger and its modifications. RESULTS The organ-sparing DPPHR developed by Beger, and its modifications, provide better pain relief, better preservation of exocrine and endocrine pancreatic function, and a superior quality of life compared with the more radical pancreaticoduodenectomy (PD, with or without pylorus-preservation), once the standard treatment for patients with CP. Recently published data on the long-term follow-up of studies comparing PD to DPPHR indicate that the initial benefits of DPPHR over PD might be less pronounced in the long-run. CONCLUSIONS The organ-preserving DPPHR developed by Beger, and its modifications, have become established and well-evaluated surgical treatment options for patients with CP.
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Abstract
Endoscopic therapy has been increasingly recognized as the effective therapy in selected patients with chronic pancreatitis. Utility of endotherapy in various conditions occurring in chronic pancreatitis is discussed. Its efficacy, limitations, and alternatives are addressed. For the best management of these complex entities, a multidisciplinary approach involving expertise in all pancreatic specialties is essential to achieve the goal.
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Affiliation(s)
- Byung Moo Yoo
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University Medical Center, Indianapolis, IN, USA
| | - Glen A. Lehman
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University Medical Center, Indianapolis, IN, USA
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LeBlanc JK, DeWitt J, Johnson C, Okumu W, McGreevy K, Symms M, McHenry L, Sherman S, Imperiale T. A prospective randomized trial of 1 versus 2 injections during EUS-guided celiac plexus block for chronic pancreatitis pain. Gastrointest Endosc 2009; 69:835-42. [PMID: 19136101 DOI: 10.1016/j.gie.2008.05.071] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2008] [Accepted: 05/27/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND The efficacy of 1-injection versus a 2-injections method of EUS-guided celiac plexus block (EUS-CPB) in patients with chronic pancreatitis is not known. OBJECTIVE To compare the clinical effectiveness and safety of EUS-CPB by using 1 versus 2 injections in patients with chronic pancreatitis and pain. The secondary aim is to identify factors that predict responsiveness. DESIGN A prospective randomized study. INTERVENTIONS EUS-CPB was performed by using bupivacaine and triamcinolone injected into 1 or 2 sites at the level of the celiac trunk during a single EUS-CPB procedure. MAIN OUTCOME MEASUREMENTS Duration of pain relief, onset of pain relief, and complications. RESULTS Fifty [corrected] subjects were enrolled (23 received 1 injection, 27 [corrected] received 2 injections). The median duration of pain relief in the 31 responders was 28 days (range 1-673 days). [corrected] Fifteen [corrected] of 23 (65%) [corrected] subjects who received 1 injection [corrected] had relief from pain compared with 16 of 27 (59%) [corrected] subjects who received 2 injections [corrected] (P = .67). [corrected] The median times to onset in the 1-injection and 2-injections groups were 21 and 14 days, respectively (P = .99). No correlation existed between duration of pain relief and time to onset of pain relief or onset within 24 hours. Age, sex, race, prior EUS-CPB, and smoking or alcohol history did not predict duration of pain relief. LIMITATION Telephone interviewers were not blinded. CONCLUSIONS There was no difference in duration of pain relief or onset of pain relief in subjects with chronic pancreatitis and pain when the same total amount of medication was delivered in 1 or 2 injections during a single EUS-CPB procedure. Both methods were safe.
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Affiliation(s)
- Julia K LeBlanc
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana 46202, USA.
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Abstract
BACKGROUND Pain in chronic pancreatitis chronic pancreatitis is a frustrating and challenging symptom for both the patient and clinician. It is the most frequent and most significant symptom. Many patients fail the currently available conservative options and require opiates or endoscopic/surgical therapy. Aim To highlight the pathophysiology and management of chronic pancreatitis pain, with an emphasis on recent developments and future directions. METHODS Expert review, utilizing in addition a comprehensive search of PubMed utilizing the search terms chronic pancreatitis and pain, treatment or management and a manual search of recent conference abstracts for articles describing pain and chronic pancreatitis. RESULTS Pancreatic pain is heterogenous in its manifestations and pathophysiology. First-line medical options include abstinence from alcohol and tobacco, pancreatic enzymes, adjunctive agents, antioxidants, and non-opiate or low potency opiate analgesics. Failure of these options is not unusual. More potent opiates, neurolysis and endoscopic and surgical options can be considered in selected patients, but this requires appropriate expertise. New and better options are needed. Future options could include new types of pancreatic enzymes, novel antinociceptive agents nerve growth factors, mast cell-directed therapy, treatments to limit fibrinogenesis and therapies directed at the central component of pain. CONCLUSIONS Chronic pancreatitis pain remains difficult to treat. An approach utilizing conservative medical therapies is appropriate, with more invasive therapies reserved for failure of this conservative approach. Treatment options will continue to improve with new and novel therapies on the horizon.
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Affiliation(s)
- J G Lieb
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL, USA
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Abstract
Pain is the most distressing symptom of chronic pancreatitis. Although the pathogenesis of pain is still poorly understood, an increase in intraductal pressure may be the dominant factor. The management of pain can involve medical, endoscopic, neurolytic, and surgical therapies. Endotherapy includes pancreatic sphincterotomy, extraction of stones, placement of stent, and dilatation of strictures, sometimes preceded or followed by extracorporeal shock-wave lithotripsy. Several studies have now shown that endotherapy provides partial or complete relief of pancreatic pain in a majority of patients with an acceptable frequency of early and late complications. Endotherapy should now graduate from an experimental form of treatment to a realistic treatment option in patients with chronic or relapsing pain, particularly in the setting of calcific chronic pancreatitis.
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Affiliation(s)
- Sudeep Khanna
- Department of Gastroenterology, Pushpawati Singhania Reasearch Institute for Liver, Renal & Digestive Diseases, New Delhi, India
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Anaparthy R, Pasricha PJ. Pain and chronic pancreatitis: is it the plumbing or the wiring? Curr Gastroenterol Rep 2008; 10:101-6. [PMID: 18462594 DOI: 10.1007/s11894-008-0029-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Our progress in understanding the biology of chronic pancreatitis has been slow, particularly with respect to the pathogenesis of pain, the cardinal symptom. Although traditional theories have focused on anatomic changes, with interstitial and ductal hypertension as the main inciting factors for pain generation, subsequent studies have not confirmed a correlation between ductal pressure and the severity of pain or its relief after ductal decompression. Empirical approaches directed at anatomic causes are at best of marginal value. Although these phenomena are clearly associated with the disease, they are not likely the root cause of the pain. Instead, they probably are inciting factors on a background of neuronal sensitization induced by damage to the perineurium and subsequent exposure of the nerves to mediators and products of inflammation. In this review, we discuss the inherent limitations in our current therapies and try to identify new targets and approaches for the future, such as TRPV1, nerve growth factor-TrkA signaling, and perhaps protease activator receptor-2.
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Affiliation(s)
- Rajeswari Anaparthy
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building, Room M211, Stanford, CA 94305, USA
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Mihaljevic AL, Kleeff J, Friess H, Büchler MW, Beger HG. Surgical approaches to chronic pancreatitis. Best Pract Res Clin Gastroenterol 2008; 22:167-81. [PMID: 18206820 DOI: 10.1016/j.bpg.2007.10.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Chronic pancreatitis (CP), a benign, inflammatory process of the pancreas, can cause severe pain, diabetes mellitus, steatorrhoea, and weight loss and often leads to a significant reduction in the quality of life. In the past decade our knowledge of the pathophysiology of CP has increased together with the number and quality of treatment options available for this disease. In addition to pharmacological and endoscopic treatment modalities, surgical drainage and resection procedures have become increasingly important since they have the potential to provide superior long-term results in patients with CP. The classical and pylorus-preserving pancreaticoduodenectomy, once the standard operations for patients with CP, have been replaced by organ-sparing procedures like the duodenum preserving pancreatic head resection and its variants. The latter allow better preservation of the exocrine and endocrine pancreatic function, and provide adequate pain relieve and improvement in the quality of life of CP patients.
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Affiliation(s)
- Andre L Mihaljevic
- Department of General Surgery, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany
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23
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Abstract
Abdominal pain is an important clinical symptom in pancreatic diseases. There is increasing evidence that pain in chronic pancreatitis and pancreatic cancer is triggered by pancreatic neuropathy. Damage to intrapancreatic nerves seems to support the maintenance and exacerbation of neuropathic pain. In chronic pancreatitis, intrapancreatic nerves are invaded by immune cells. This observation led to the hypothesis that neuro-immune interactions play a role in the pathogenesis of chronic pancreatitis and the accompanying abdominal pain syndrome. Similarly, pancreatic cancer cells infiltrate the perineurium of local nerves, which may in part explain the severe pain experienced by the patients. Furthermore, perineural invasion extending into extrapancreatic nerves may preclude curative resection and thus often leads to local recurrence. In recent years, the involvement of a variety of neurotrophins and neuropeptides in the pathogenesis of pancreatic pain was discovered. This review summarises recent data on the mechanisms of neuropathy and pain generation in pancreatic disorders.
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Affiliation(s)
- Güralp O Ceyhan
- Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Ismaningerstrasse 22, D-81675 Munich, Germany
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25
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Abstract
PURPOSE OF REVIEW New understanding of the dynamic of acute pancreatitis, the clinical impact of local pathology in chronic pancreatitis and cystic neoplastic lesions bearing high potential for malignant transformation has changed the management of pancreatic diseases. RECENT FINDINGS In acute pancreatitis, risk factors independently determining outcome in severe acute pancreatitis are early and persistent multiorgan failure, infected necrosis and extended sterile necrosis. The management of severe acute pancreatitis is based on early intensive-care treatment and late surgical debridement. In chronic pancreatitis, recent data from randomized controlled clinical trials have demonstrated duodenum-preserving pancreatic head resection with an inflammatory mass of the head as superior to pylorus-preserving Whipple resection. Cystic neoplasms are local lesions of the pancreas with high malignant potential. Local organ-preserving resection techniques have been applied with low morbidity and mortality, replacing a Whipple-type resection. Resection of pancreatic cancer is ineffective to cure patients. After an R0-resection, a significant survival benefit has been achieved when adjuvant chemotherapy has additionally been applied. SUMMARY New knowledge about the nature of inflammatory diseases, cystic neoplastic lesions and malignant pancreatic tumours has changed the indication for surgical treatment and the application of organ-preserving surgical techniques.
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Affiliation(s)
- Hans G Beger
- Department of General Surgery, University of Ulm, Department of Visceral Surgery, Neu-Ulm, Germany.
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26
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Tessier G, Bories E, Arvanitakis M, Hittelet A, Pesenti C, Le Moine O, Giovannini M, Devière J. EUS-guided pancreatogastrostomy and pancreatobulbostomy for the treatment of pain in patients with pancreatic ductal dilatation inaccessible for transpapillary endoscopic therapy. Gastrointest Endosc 2007; 65:233-41. [PMID: 17258981 DOI: 10.1016/j.gie.2006.06.029] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2006] [Accepted: 06/05/2006] [Indexed: 12/13/2022]
Abstract
BACKGROUND EUS-guided pancreatogastrostomy (EPG) is described as an alternative to surgery for ductal decompression in symptomatic patients when endoscopic transpapillary access of the main pancreatic duct (MPD) is impossible. OBJECTIVE To present the midterm clinical response and follow-up of a larger group of patients treated with EPG and a new transbulbar approach, EUS-guided pancreatobulbostomy (EPB). DESIGN Retrospective case review. SETTING Two tertiary referral centers in Brussels and Marseille. PATIENTS From 2000 to 2004, 36 patients (51 years old; range, 14-71 years) were seen. INTERVENTION EPG or EPB. MAIN OUTCOME MEASUREMENTS Pain relief, technical aspects, complications, and clinical follow-up. RESULTS Indications were chronic pancreatitis, with complete obstruction (secondary to a tight stenosis, a stone, or MPD rupture); inaccessible papilla or impossible cannulation (n = 20); anastomotic stenosis after a Whipple procedure (n = 12); complete MPD rupture after acute pancreatitis (AP); or trauma (n = 4). EPG or EPB was unsuccessful in 3 patients; 1 was lost to follow-up. Major complications occurred in 2 patients and included 1 hematoma and 1 severe AP. The median follow-up was 14.5 months (range, 4-55 months). Pain relief was complete or partial in 25 patients (69%, intention to treat). Eight patients treated had no improvement of their symptoms (4 were subsequently diagnosed with cancer). Stent dysfunction occurred in 20 patients (55%) and required a total of 29 repeat endoscopies. LIMITATIONS Technically demanding and requires careful pretherapeutic evaluation. CONCLUSIONS EPG or EPB appears to be an effective and relatively safe treatment for the management of pain secondary to pancreatic ductal hypertension in patients with an MPD not accessible by a transpapillary route.
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Affiliation(s)
- Geneviève Tessier
- Department of Gastroenterology, Université Libre de Bruxelles, Hôpital Erasme, Brussels, Belgium
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Takamido S, Kataoka Y, Tanano A, Cui Y, Ikeura T, Shimatani M, Kubota Y, Okazaki K, Yamada H. Intrapancreatic axonal hyperbranching of dorsal root ganglia neurons in chronic pancreatitis model rats and its relation to pancreatic pain. Pancreas 2006; 33:268-79. [PMID: 17003649 DOI: 10.1097/01.mpa.0000240600.72946.23] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Increase in number of intrapancreatic nerve bundles has been implicated in the generation of persistent pain in chronic pancreatitis. To examine the origin of these nerve fibers and the mechanisms linking neural morphological change to pain generation, we used neuronal tracing techniques in combination with immunohistochemistry in spontaneous chronic pancreatitis in the Wistar Bonn/Kobori (WBN/Kob) rats. METHODS For retrograde tracing, horseradish peroxidase was injected into the pancreas, and labeled neurons in the sensory ganglia were counted. For anterograde tracing, biotinylated dextran amine was injected into the dorsal root ganglia (DRGs), and labeled intrapancreatic sensory fibers were histochemically assessed. For assessment of pain generation, we evaluated c-Fos-positive neurons in the spinal dorsal horn and behavioral changes of the animals. RESULTS In WBN/Kob rats, the numbers of horseradish peroxidase-labeled neurons were decreased in the DRGs, and the numbers of biotinylated dextran amine-labeled intrapancreatic nerve fibers and terminals were increased. Biotinylated dextran amine-labeled nerve fibers contained growth-associated protein 43. The number of c-Fos-positive neurons in the dorsal horn was also increased and was correlated with intrapancreatic growth-associated protein 43 immunoreactivity. Grooming behavior was reduced in WBN/Kob rats, and this reduction was facilitated by exocrine stimulation. CONCLUSIONS Axonal branching in DRG neurons innervating the pancreas increases in WBN/Kob rats, and these morphological changes are likely involved in pain generation in chronic pancreatitis.
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Affiliation(s)
- Shoichiroh Takamido
- Department of Anatomy and Cell Science, Kansai Medical University, Osaka, Japan
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Abstract
Chronic pancreatitis (CP) is characterized by progressive fibrosis, pain and/or loss of exocrine and endocrine functions. With the identification and characterization of pancreatic stellate cells (PSCs), the pathogenesis of CP and pancreatic fibrosis is now better understood. Molecular mediators shown to regulate the pathogenesis include transforming growth factor-beta, platelet-derived growth factor, and proinflammatory cytokines such as interleukin (IL)-1, IL-6 and tumor necrosis factor-alpha. Besides these, the roles of cyclooxygenase (COX)-2 and apoptosis-related proteins have also been implicated in the pathogenesis. Furthermore, molecular pathways involving mitogen-activated protein kinases, phosphatidylinositol 3-kinase, Ras superfamily G proteins, serine threonine protein kinase Raf-1 and peroxisome proliferator-activated receptor-gamma (PPAR-gamma) have been elucidated. Newer pathobiologic concepts concerning pain generation have also been put forward. Understanding the pathogenesis has led to the identification of novel molecular targets and the development of newer potential therapeutic agents. Those found to retard the progression of experimental CP and fibrosis in animal models include antioxidants, a Japanese herbal medicine called Saiko-keisi-to (TJ 10), the PPAR-gamma ligand troglitazone, the protease inhibitor Camostat mesilate, and Lovastatin.
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Affiliation(s)
- Rupjyoti Talukdar
- Department of Gastroenterology, Pushpawati Singhania Research Institute, New Delhi, India
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Ishihara T, Yamaguchi T, Seza K, Tadenuma H, Saisho H. Efficacy of s-type stents for the treatment of the main pancreatic duct stricture in patients with chronic pancreatitis. Scand J Gastroenterol 2006; 41:744-50. [PMID: 16716976 DOI: 10.1080/00365520500383597] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Stents have been used to relieve pancreatic duct stricture and upstream dilatation. However, many of these stents are straight-type stents originally manufactured for biliary use. A plastic stent that was developed for use in the pancreatic duct was used in this study and its usefulness investigated. MATERIAL AND METHODS The stent (s-type stent: 10 Fr in diameter) has two alternate flexions and the shape resembles the tilde mark " approximately " in appearance. After obtaining informed consent, stents were placed in 20 patients with abdominal pain caused by chronic pancreatitis and stricture of the distal main pancreatic duct. The stents were removed according to the clinical manifestations and replaced with new ones if the stricture persisted. RESULTS In total, 33 stents were placed in 20 patients. Pain relief was attained in 19 patients (95%). The stricture improved after one stenting in 8 patients (40%). Owing to persistent stricture, the stenting was repeated in 11 patients. The 50% stent indwelling period was 369.0 days. No proximal or distal migration of the stent occurred and there were no serious complications. CONCLUSIONS In view of its long durability as a stent and no migration, the s-stent is safe and useful for the management of pancreatic ductal strictures in patients with chronic pancreatitis.
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Affiliation(s)
- Takeshi Ishihara
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan.
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30
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Ahmed SA, Wray C, Rilo HLR, Choe KA, Gelrud A, Howington JA, Lowy AM, Matthews JB. Chronic pancreatitis: recent advances and ongoing challenges. Curr Probl Surg 2006; 43:127-238. [PMID: 16530053 DOI: 10.1067/j.cpsurg.2005.12.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Syed A Ahmed
- University of Cincinnati Medical Center, Ohio, USA
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Wilcox CM. Endoscopic therapy for pain in chronic pancreatitis: is it time for the naysayers to throw in the towel? Gastrointest Endosc 2005; 61:582-6. [PMID: 15812412 DOI: 10.1016/s0016-5107(04)02797-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Gabbrielli A, Pandolfi M, Mutignani M, Spada C, Perri V, Petruzziello L, Costamagna G. Efficacy of main pancreatic-duct endoscopic drainage in patients with chronic pancreatitis, continuous pain, and dilated duct. Gastrointest Endosc 2005; 61:576-81. [PMID: 15812411 DOI: 10.1016/s0016-5107(05)00295-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The aim of endoscopic treatment in patients with chronic pancreatitis is to achieve decompression of the pancreatic duct, because duct obstruction with increased pressure within the duct is one of the leading causes of pain in these patients. The majority of patients suffer from relapsing pain, thus making it difficult to evaluate the efficacy of therapy. The outcome of endoscopic treatment on pain has been evaluated in patients with continuous pain (present for more than 1 month, at least 5 days per week, requiring daily analgesic therapy) and dilated duct. METHODS Of 343 patients who underwent endotherapy for chronic pancreatitis in a 15-year period, 22 (6.4%)(19 men, mean age 48 years, alcohol abuse 14) had continuous pain and a dilated pancreatic duct. RESULTS Endotherapy was successful in all patients, with no procedure-related mortality and only mild complications. Pain disappeared, and analgesics could be discontinued in all patients immediately after endotherapy. Six patients are pain free after a mean period of 5.5 years. One pain-free patient died after 3.4 years from myocardial infarction. Five patients were successfully endoscopically re-treated for pain relapses. Four patients underwent surgery for frequent pain relapses after a mean period of 2.5 years. Six patients were lost to follow-up. CONCLUSIONS Endotherapy should be considered as the initial treatment of choice in patients with chronic pancreatitis, dilated duct, and continuous pain.
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Schlosser W, Schwarz A, Beger HG. Surgical treatment of chronic pancreatitis with pancreatic main duct dilatation: long term results after head resection and duct drainage. HPB (Oxford) 2005; 7:114-9. [PMID: 18333173 PMCID: PMC2023934 DOI: 10.1080/13651820510028774] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
UNLABELLED Tissue and duct hypertension is considered as a major factor in the etiology of pain in patients with chronic pancreatitis (CP). Duct dilatation is a consequence of duct obstruction due to scars or duct stones. Nevertheless, the procedure of choice, drainage or resection, is still under discussion. We present long-term results of patients operated with duodenum-preserving pancreatic head resection (DPPHR) combined with a Partington-Rochelle duct drainage in cases of chronic pancreatitis with multiple stenosis and dilatation of the side ducts. METHODS AND PATIENTS From April 1982 to September 2001, in 55 out of 538 patients with chronic pancreatitis, a DPPHR with additionally Partington-Rochelle duct drainage was performed (44 male, 11 female, mean age 45.8 years). Ninety-two percent of the patients suffered from alcoholic pancreatitis. Medical respective pain treatment for chronic pancreatitis was in median 64.5 months prior to surgery. The indications for surgery were in 87% pain, 59% of the patients had an inflammatory mass in the head of the pancreas, 36% a common bile duct stenosis and 5% a severe stenosis of the duodenum. The endocrine function (OGGT) was impaired in 79% of the patients preoperatively. RESULTS Hospital mortality was 0%, postoperative complications occurred in 11 patients. FOLLOW-UP All except 2 patients were followed up in the outpatient clinic with the mean follow-up time of 69.7 months (8-105 months), the late mortality was 9%. Sixty-eight percent of the patients were completely free of pain, 29% had occasional pain, 3% suffered from a further attack of pancreatitis. Body weight increased in 79%, 58% were professionally rehabilitated. Late postoperative endocrine function was unchanged in 85% (improved in 5%, deteriorated in 10%). CONCLUSION The pain control in patients with multiple duct stenosis after duodenum-preserving pancreatic head resection with duct drainage leads to long-standing absence of pain and low recurrence rate of attacks of pancreatitis.
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Affiliation(s)
- W. Schlosser
- Department of General Surgery, University of UlmGermany
| | - A. Schwarz
- Department of General Surgery, University of UlmGermany
| | - H. G. Beger
- Department of General Surgery, University of UlmGermany
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34
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Scolapio JS, Raimondo M, Bishop M. Chronic Pancreatitis. Clin Nutr 2005. [DOI: 10.1016/b978-0-7216-0379-7.50042-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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35
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Abstract
Chronic pancreatitis has been difficult to treat because the origin, pathophysiologic mechanisms and causes of unrelenting pain are so poorly understood. Furthermore, the pharmacologic agents often employed in other diseases with pain appear to be ineffective in many cases. The conservative management of chronic pancreatitis aims at (1) limiting progression and complications of the disease; (2) replacing lost exocrine and endocrine function; and (3) pain control. Thus, life style changes such as cessation of alcohol consumption and tobacco smoking, trials of pancreatic enzymes, treatment of duct obstruction and pseudocysts, and surgical therapies are currently employed. The good news is that the understanding of the underlying pathophysiological mechanisms is now advancing rapidly, and hopefully patient-specific and highly effective therapies will become available in the near future.
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Affiliation(s)
- Asif Khalid
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA
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Abstract
A midline dorsal column lesion has been shown to be an effective surgical treatment for the relief of pelvic visceral pain in patients. The aim of this study was to examine the effectiveness of a dorsal column lesion upon: (i) increased electrophysiological responses of neurons in the ventral posterolateral thalamic nucleus in anesthetized rats evoked by the application of bradykinin to the surface of the pancreas, and (ii) pain-related behaviors observed after pancreatic infusion with bradykinin. In rats anesthetized with pentobarbital, recordings from individual thalamic neurons were made using tungsten electrodes. Brief application of bradykinin (10 microg/ml) to the surface of the pancreas resulted in an increased firing rate in approximately 20% of neurons recorded. A dorsal column lesion or intrathecal administration of morphine greatly reduced the excitatory effects of pancreatic bradykinin application on thalamic neurons. In a separate group of rats, bradykinin was infused into the pancreas through a previously implanted catheter resulting in a decrease in exploratory behavior and an increase in other pain-related behaviors, e.g. licking of the abdomen. A dorsal column lesion made prior (1 week) to the bradykinin infusion reduced the decrease in exploratory behavior but did not return exploratory behavior to control levels. In conclusion, nociceptive information relayed to the thalamus about the pancreas is transmitted from the spinal cord through the dorsal columns, possibly by the post-synaptic dorsal column pathway. However, the dorsal column pathway may not be the sole route for relaying information about noxious stimulation of the pancreas, particularly that impacting complex behavioral responses.
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Affiliation(s)
- A K Houghton
- Department of Anatomy and Neurosciences, Marine Biomedical Institute, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-1069, USA
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37
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Ahmad J, Martin J. Pancreatic Duct Strictures. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2000; 3:371-386. [PMID: 11096598 DOI: 10.1007/s11938-000-0052-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The treatment of pancreatic duct strictures is based on an accurate assessment of the etiology of the disease, and then the degree of symptomatology. Our outline for therapy is as follows: Exclude a diagnosis of malignancy by using radiologic, endoscopic, histologic, and molecular biologic modalities. Once a benign stricture has been demonstrated, we favor a trial of endoscopic dilation and stent placement For the unresectable pancreatic neoplasm, in which an obstructive etiology for pain is suspected, a trial of endoscopic dilation and stent placement also should be considered. In benign pancreatic duct strictures complicated by biliary obstruction, and where the most durable treatment modality is sought, surgical intervention merits earlier consideration. Pancreatic duct stent placement should seldom be considered definitive therapy, and the risk of stent-induced duct injury must be weighed against potential therapeutic benefit.
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Affiliation(s)
- J Ahmad
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, 200 Lothrop St., Pittsburgh, PA 15213, USA
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39
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Renou C, Grandval P, Ville E, Laugier R. Endoscopic treatment of the main pancreatic duct: correlations among morphology, manometry, and clinical follow-up. INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 2000; 27:143-9. [PMID: 10862513 DOI: 10.1385/ijgc:27:2:143] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND AIM During the course of chronic pancreatitis, the gradual increase in the main pancreatic duct pressure is the main pathophysiological factor responsible for pain, but up to now, the intra ductal pressure has never been measured during and after endoscopic stenting and correlated with clinical results. Pressure measurements of this kind could thus provide objective information about the useful duration of stenting period. METHODS Main pancreatic duct pressure was measured by performing endoscopic manometry on 13 chronic pancreatitis symptomatic patients (10 men, 3 women, mean age: 45.1+/-7.9 yr); clinical follow-up was carried out for a period of 29.0+/-16.1 mo. Before treatment, the main anatomical alteration present was a localized stenosis of the main pancreatic duct, i.e., one with a diameter of less than 2 mm (chronic pancreatitis alone), 10 cases; chronic pancreatitis associated with pancreas divisum, 3 cases). Stenosis was treated by endoscopic stenting: 7 F stent (7 cases) and 12 F stent (6 cases). The pressure was measured simultaneously in the duodenum (zero level) and within the main pancreatic duct, using an electronic device, The pancreatico-duodenal gradient was taken to be the difference between the pressure in the main pancreatic duct and the duodenum. RESULTS The endoscopic stenting induced a nonsignificant decrease in the intraductal pressure (p = 0.16). Among the 9 patients with a normal pressure at the end of the stenting and a successful anatomical outcome, 6 were painless during the follow-up period whereas 3 presented with recurrent pancreatic-type pain. The remaining 4 patients were symptom-free during the entire follow-up period, although the main pancreatic duct pressure was high at the end of the stenting and the stenosis was not completely cured. CONCLUSION The intraductal pressure at the end of the stenting period was perfectly correlated with the anatomical result, whether or not it was successful, but was not an accurate predictor of a favorable clinical outcome in patients with a poor anatomical result.
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Affiliation(s)
- C Renou
- Service d'Hepato-Gastroentérologie, Hôpital de la Timone, Marseille, France
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Abstract
Cholecystokinin (CCK) is a major gastrointestinal hormone that plays an important role in stimulation of pancreatic secretion and gall-bladder contraction, regulation of gastrointestinal motility and induction of satiety. Ingestion of fat and protein induces significant increases in plasma CCK. Intraluminal mediators of CCK secretion, luminal CCK releasing factor and diazepam-binding inhibitor, were purified from rat intestinal secretion. These CCK-releasing factors (RF) are secreted tonically by the small intestine and stimulate CCK release. Another kind of CCK-RF named 'monitor peptide' was purified from the rat pancreatic juice that stimulates CCK secretion when introduced into rat intestine. Bile exclusion from the duodenum causes an increase in basal CCK and enhances stimulated plasma CCK release, and bile salt replacement reverses these effects. Thus, the CCK-RF are spontaneously secreted into the intestinal lumen in humans, while the CCK-producing cells are under constant suppression by intraduodenal bile acids. In acute pancreatitis, plasma CCK levels are high in patients with gallstone pancreatitis, but not in patients with pancreatitis from other causes, such as alcoholic and idiopathic pancreatitis. A transient disturbance of bile flow into the duodenum by stones or oedema of the pancreas together with impairment of pancreatic exocrine function might cause the increase in plasma CCK release in gallstone pancreatitis. Patients with chronic pancreatitis with mild to moderate impairment of exocrine function and abdominal pain, had significantly higher plasma CCK concentrations, whereas patients with pancreatic insufficiency had a significantly lower plasma CCK response to a test meal than the healthy subjects. The increased CCK may further aggravate pancreatitis and worsen the prognosis of pancreatitis by stimulating the injured pancreas, resulting in the vicious circle via endogenous CCK release. The CCK-A receptor antagonist might be therapeutically useful in acute pancreatitis by stopping the vicious circle.
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Affiliation(s)
- M Otsuki
- Third Department of Internal Medicine, University of Occupational and Environmental Health, Japan, School of Medicine, Kitakyushu.
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Catalano MF. Endoscopic treatment of pancreatic duct strictures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 1999. [DOI: 10.1016/s1096-2883(99)80005-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
Chronic pancreatitis is characterized by progressive and irreversible loss of pancreatic exocrine and endocrine function. In the majority of cases, particularly in Western populations, the disease is associated with alcohol abuse. The major complications of chronic pancreatitis include abdominal pain, malabsorption, and diabetes. Of these, pain is the most difficult to treat and is therefore the most frustrating symptom for both the patient and the physician. While analgesics form the cornerstone of pain therapy, a number of other treatment modalities (inhibition of pancreatic secretion, antioxidants, and surgery) have also been described. Unfortunately, the efficacy of these modalities is difficult to assess, principally because of the lack of properly controlled clinical trials. Replacement of pancreatic enzymes (particularly lipase) in the gut is the mainstay of treatment for malabsorption; the recent discovery of a bacterial lipase (with high lipolytic activity and resistance to degradation in gastric and duodenal juice) represents an important advance that may significantly increase the efficacy of enzyme replacement therapy by replacing the easily degradable porcine lipase found in existing enzyme preparations. Diabetes secondary to chronic pancreatitis is difficult to control and its course is often complicated by hypoglycaemic attacks. Therefore, it is essential that caution is exercised when treating this condition with insulin. This paper reviews recent research and prevailing concepts regarding the three major complications of chronic pancreatitis noted above. A comprehensive discussion of current opinion on clinical issues relating to the other known complications of chronic pancreatitis such as pseudocysts, venous thromboses, biliary and duodenal obstruction, biliary cirrhosis, and pancreatic cancer is also presented.
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Affiliation(s)
- M V Apte
- Department of Gastroenterology, Prince of Wales Hospital and University of New South Wales, Sydney, Australia
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Abstract
According to the concept of negative feedback regulation of pancreatic enzyme secretion by proteases, treatment with pancreatic extracts has been proposed to lower pain in chronic pancreatitis by decreasing pancreatic duct pressure. The author, however, has demonstrated in healthy volunteers that intraduodenal application of porcine pancreatic extracts does not inhibit but rather stimulates pancreatic enzyme secretion. This is probably because of the high-protein content of porcine pancreatic extracts that may overwhelm a potential inhibitory effect of proteases. In a prospective placebo-controlled, double-blind multicenter study to investigate the effect of acid-protected porcine pancreatic extracts on pain in 43 patients with chronic pancreatitis, pain improved in most patients regardless of whether they started with placebo or verum. There was no significant difference between both treatment arms. In a meta-analysis, which included the author's study, six randomized, double-blind, placebo-controlled studies were evaluated. Statistical analysis demonstrated no benefit of the application of porcine pancreatic extracts to relieve pain in chronic pancreatitis. The author concluded that pancreatic extracts neither inhibit pancreatic enzyme secretion nor are they efficient in lowering pain in chronic pancreatitis.
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Affiliation(s)
- J Mössner
- Department of Internal Medicine, University of Leipzig, Germany
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44
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Norton ID, Petersen BT. Interventional treatment of acute and chronic pancreatitis. Endoscopic procedures. Surg Clin North Am 1999; 79:895-911, xii. [PMID: 10470334 DOI: 10.1016/s0039-6109(05)70050-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The role of therapeutic endoscopy in the treatment of acute and chronic pancreatitis has expanded dramatically over the past 10 years. Drainage of pseudocysts and even organized pancreatic necrosis when localized are becoming commonplace. Other areas in which therapeutic endoscopy has been shown to be efficacious include severe biliary pancreatitis, pancreatic duct disruptions, strictures, and obstructive calculi. Its role in the management of acute recurrent pancreatitis with presumed Oddi's sphincter dysfunction or pancreas divisum continues to be defined. The cost-effectiveness and minimally invasive nature of endoscopic therapy compared with surgery should ensure the continued development of these techniques. More controlled, prospective data are required.
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Affiliation(s)
- I D Norton
- Mayo Clinic and Foundation, Rochester, Minnesota, USA
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46
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Abstract
Abdominal pain, excruciating and recurrent, is the dominant feature of chronic pancreatitis that initially brings most of the patients to the physician's attention. The pathogenesis of pancreatic pain is often multifactorial and explains why not all patients respond to the same mode of therapy. Increased intraductal pressure as a result of ductal stricture and/or calculi is the most frequent cause for pain in the large majority of patients with large duct disease. Interstitial hypertension, ongoing pancreatic ischemia, neuronal inflammation, and extra pancreatic complications may be the sole or additional factors in the pathogenesis of pain. The management of pain is difficult and requires a team approach. Internist, gastroenterologist, radiologist, surgeon, and a psychiatrist may have to work together to achieve maximum success. Drug and alcohol dependency needs vigorous management by a psychiatrist. Supportive therapy with a low-fat diet and antioxidant supplementation are helpful. When analgesic therapy fails, surgery may have to be considered much before a narcotic dependency develops. If at all of use, oral pancreatic enzyme therapy is suitable only in a selected group of patients--women with idiopathic pancreatitis. Endoscopic papillotomy, stent placement, and stone removal, although becoming popular, are under trial only and appear to be suitable in those with obstructive disease mostly localized to the head of the pancreas without much proximal disease. A patient with a dilated duct system is a good candidate for Puestow's pancreatico-jejunal anastamosis, which appears to be the best surgical procedure. Those with small duct diseases are difficult to be managed. Resective procedures and celiac ganglion blocking are suggested but not of much help.
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Affiliation(s)
- C S Pitchumoni
- New York Medical College and Our Lady of Mercy Medical Center, Bronx 10466, USA
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Banks PA, Hughes M, Ferrante M, Noordhoek EC, Ramagopal V, Slivka A. Does allopurinol reduce pain of chronic pancreatitis? INTERNATIONAL JOURNAL OF PANCREATOLOGY : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PANCREATOLOGY 1997; 22:171-6. [PMID: 9444547 DOI: 10.1007/bf02788381] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
CONCLUSION A dosage of 300 mg/d of allopurinol was not effective in reducing pain or improving activities of daily living in chronic pancreatitis. BACKGROUND Allopurinol prevents the generation of oxygen-derived free radicals by inhibiting xanthine oxidase. The purpose of this study was to determine whether allopurinol is effective in reducing pain of chronic pancreatitis. METHODS Thirteen patients with chronic pancreatitis who were experiencing abdominal pain requiring medication at least three times each week entered a randomized, double-blind, two-period crossover clinical trial. Patients evaluated their pain daily using a categorical pain intensity scale, numeric pain intensity scale, and a visual analog scale, and weekly completed a McGill Pain Questionnaire and activities of daily living (ADL) questionnaire. RESULTS The mean baseline score of pain was approx 50% of most severe pain in all scoring systems. There was no significant decrease in pain associated with allopurinol compared to the placebo (p = 0.24-0.75). In addition, there was no benefit in terms of ADL score associated with allopurinol compared with placebo (p = 0.32). Mean uric acid level was decreased by 1.15 mg/dL while patients were taking allopurinol, compared to when they were taking placebo (p = 0.007).
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Affiliation(s)
- P A Banks
- Center for Pancreatic Disease, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Dumonceau JM, Devière J, Le Moine O, Delhaye M, Vandermeeren A, Baize M, Van Gansbeke D, Cremer M. Endoscopic pancreatic drainage in chronic pancreatitis associated with ductal stones: long-term results. Gastrointest Endosc 1996; 43:547-55. [PMID: 8781931 DOI: 10.1016/s0016-5107(96)70189-x] [Citation(s) in RCA: 179] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND In severe chronic pancreatitis associated with intraductal stones, therapeutic endoscopy aims to reduce increased intraductal pressure by pancreatic sphincterotomy and stone clearance. METHODS Results of treatment were evaluated in 70 new patients who underwent pancreatic sphincterotomy and attempted stone removal. Technical results and frequency of pain relief and recurrence are compared. RESULTS Complete ductal clearance of calculi was obtained in 50% of cases. Immediate clinical improvement occurred in 95% of patients with painful attacks. No severe complications or mortality occurred. Fifty-four percent of all patients with painful chronic pancreatitis did not experience any pain recurrence within 2 years. Associations found to be statistically significant by multivariate analysis were ductal clearance and extracorporeal shock wave lithotripsy, pain disappearance and ductal clearance, pain recurrence and long evolution, and severe disease before treatment and presence of a ductal substenosis. CONCLUSIONS In this subset of patients our results indicate that the pain of chronic pancreatitis is mainly related to increased intraductal pressure. Endoscopic management appears to be a safe, conservative, alternative to surgery. The best results are obtained when it is performed early in the course of calcifying chronic pancreatitis.
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Affiliation(s)
- J M Dumonceau
- Department of Gastroenterology/Hepatopancreatology, Erasme University Hospital, Brussels, Belgium
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49
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Pedersen NT, Worning H. Chronic pancreatitis. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1996; 216:52-8. [PMID: 8726279 DOI: 10.3109/00365529609094561] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Chronic pancreatitis is a serious disease with many yet unsolved problems, e.g. pathogenesis, cause of pain and treatment. Danish gastroenterologists have for many years participated actively in the investigation of the disease and have produced many internationally recognized results, especially regarding secretion physiology and pathophysiology, epidemiology, cause of pain and characterization of the secondary diabetes mellitus. In the past 25 years more than 60 Danish papers about chronic pancreatitis have been published in international, reviewed journals. Furthermore six theses on subjects related to chronic pancreatitis have been produced. In this article the Danish contribution to the literature on chronic pancreatitis during the past 25 years is reviewed.
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Affiliation(s)
- N T Pedersen
- Dept. of Medicine, Herning Centralsygehus, Denmark
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50
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Funch-Jensen P, Ebbehøj N. Sphincter of Oddi motility. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1996; 216:46-51. [PMID: 8726278 DOI: 10.3109/00365529609094560] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Technical improvement in endoscopic and manometric technique has allowed direct manometry of the human sphincter of Oddi (SO). The aim of the present review is to describe the present status of physiologic and clinical knowledge of the SO, with emphasis on contributions from Danish Gastroenterology. RESULTS The SO is a zone with an elevated basal pressure with superimposed phasic contractions. It acts mainly as a resistor in the regulation of bile flow. Neurohormonal regulation influences the motility pattern. The contractions are under the control of slow waves. Clinical subgroups show abnormalcy in SO manometric pattern especially in patients with biliary or pancreatic pain without demonstrable organic substrate. Evidence suggests that endoscopic sphincterotomy may be of benefit in these patients.
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Affiliation(s)
- P Funch-Jensen
- Surgical Gastroenterology Dept. 235, Hvidovre Hospital, Denmark
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