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Van Veldhuisen CL, Leseman CA, De Rijk FEM, Dekker EN, Wellens MJ, Michiels N, Stommel MWJ, Krikke C, Hofker HS, Mieog JSD, Bouwense SA, Van Eijck CH, Groot Koerkamp B, Haen R, Boermeester MA, Busch OR, Van Santvoort HC, Besselink MG. Nationwide Outcome of Tailored Surgery for Symptomatic Chronic Pancreatitis based on Pancreatic Morphology: Validation of the International guidelines. Ann Surg 2023:00000658-990000000-00724. [PMID: 38088187 DOI: 10.1097/sla.0000000000006176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
OBJECTIVE To determine the nationwide use and outcome of tailored surgical treatment for symptomatic chronic pancreatitis (CP) as advised by recent guidelines. SUMMARY BACKGROUND DATA Randomized trials have shown that surgery is superior to endoscopy in patients with symptomatic CP, although endoscopy remains popular Recent guidelines advice to "tailor surgery" based on pancreatic morphology meaning that the least extensive procedure should be selected based on pancreatic morphology. However, nationwide, and multicenter studies On tailored surgery for symptomatic CP are lacking. METHODS Nationwide multicenter retrospective analysis of consecutive patients undergoing surgical treatment for symptomatic CP in all seven Dutch university medical centers (2010-2020). Outcomes included volume trend, major complications, 90-day mortality, postoperative opioid use and clinically relevant pain relief. Surgical treatment was tailored based on the size of the main pancreatic duct and pancreatic head (e.g. surgical drainage for a dilated pancreatic duct, and normal size pancreatic head). RESULTS Overall, 381 patients underwent surgery for CP: 127 surgical drainage procedures ( 33%; mostly extended lateral pancreaticojejunostomy), 129 duodenum-preserving pancreatic head resections (DPPHR, 34%, mostly Frey), and 125 formal pancreatic resections (33%, mostly distal pancreatectomy). The annual surgical volume increased slightly (Pearson r=0.744). Mortality (90-day) occurred in 6 patients (2%), and was non-significantly lower after surgical drainage (0%, 3%, 2%; P =0.139). Major complications (12%, 24%, 26%; P =0.012), postoperative pancreatic fistula grade B/C (0%, 3%, 22%; P =0.038), surgical reintervention (4%, 16%, 12%; P =0.006), and endocrine insufficiency ( 14%, 21%, 43%; P <0.001) occurred less often after surgical drainage. After a median follow-up of 11 months [IQR 3-23] good rates of clinically relevant pain relief ( 83%, 69%, 80%; P =0.082) were observed and 81% of opioid users had stopped using (83%, 78%, 84%, P =0.496). CONCLUSION The use of surgery for symptomatic CP increased over the study period. Drainage procedures were associated with the best safety profile and excellent functional outcome, highlighting the importance of tailoring surgery based on pancreatic morphology.
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Affiliation(s)
- Charlotte L Van Veldhuisen
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam
- Department of Research and Development, St. Antonius Hospital, Nieuwegein
| | - Charlotte A Leseman
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam
| | - Fleur E M De Rijk
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam
| | - E Nicole Dekker
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam
| | - Martine J Wellens
- Department of Gastroenterology and Hepatology, Isala Hospital Zwolle
| | - Nynke Michiels
- Department of Surgery, Leiden University Medical Centre, Leiden
| | | | - Christina Krikke
- Departments of Surgery, University Medical Center Groningen, University of Groningen, Groningen
| | - H Sijbrand Hofker
- Departments of Surgery, University Medical Center Groningen, University of Groningen, Groningen
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden
| | - Stefan A Bouwense
- Department of Surgery, Maastricht University Medical Center+, Maastricht
| | - Casper H Van Eijck
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam
| | - Bas Groot Koerkamp
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam
| | - Roel Haen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam
| | - Marja A Boermeester
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam
| | - Olivier R Busch
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam
| | - Hjalmar C Van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein
- Department of Surgery, University Medical Center Utrecht, Regional Academic Cancer Center Utrecht All: The Netherlands
| | - Marc G Besselink
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam
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Haal S, Wielenga MCB, Fockens P, Leseman CA, Ponsioen CY, van Soest EJ, van Wanrooij RLJ, Sieswerda E, Voermans RP. Antibiotic Therapy of 3 Days May Be Sufficient After Biliary Drainage for Acute Cholangitis: A Systematic Review. Dig Dis Sci 2021; 66:4128-4139. [PMID: 33462749 PMCID: PMC8589797 DOI: 10.1007/s10620-020-06820-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/31/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND The optimal antibiotic therapy duration for cholangitis is unclear. Guideline recommendations vary between 4 and 14 days after biliary drainage. Clinical observations and some evidence however suggest that shorter antibiotic therapy may be sufficient. OBJECTIVE To compare the effectiveness and safety of short-course therapy of ≤ 3 days with long-course therapy of ≥ 4 days after biliary drainage in cholangitis patients. METHODS We searched the databases PubMed, EMBASE, Cochrane Library, and trial registers for literature up to August 5, 2020. RCTs and observational studies including case series reporting on antibiotic therapy duration for acute cholangitis were eligible for inclusion. Two reviewers independently evaluated study eligibility, extracted data, assessed risk of bias and quality of evidence. A meta-analysis was planned if the included studies were comparable with regard to important study characteristics. Primary outcomes included recurrent cholangitis, subsequent other infection, and mortality. RESULTS We included eight studies with 938 cholangitis patients. Four observational studies enrolled patients treated for ≤ 3 days. Recurrent cholangitis occurred in 0-26.8% of patients treated with short-course therapy, which did not differ from long-course therapy (range 0-21.1%). Subsequent other infection and mortality rates were also comparable. Quality of available evidence was very low. CONCLUSION There is no high-quality evidence available to draw a strong conclusion, but heterogeneous observational studies suggest that antibiotic therapy of ≤ 3 days is sufficient in cholangitis patients with common bile duct stones.
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Affiliation(s)
- Sylke Haal
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
- Department of Internal Medicine, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Mattheus C. B. Wielenga
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Charlotte A. Leseman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Cyriel Y. Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Ellert J. van Soest
- Department of Gastroenterology, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Roy L. J. van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Elske Sieswerda
- Department of Medical Microbiology and Infection Control, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Rogier P. Voermans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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