Abstract
PurposeTotal pancreatectomy for severe pain in end-stage chronic pancreatitis may be the only option, but with vascular involvement, this is usually too high risk and/or technically not feasible. The purpose of the study was to present the clinical outcomes of a novel procedure in severe chronic pancreatitis complicated by uncontrollable pain and vascular involvement.MethodsWe describe an in situ near-total pancreatectomy that avoids peripancreatic vascular dissection (Livocado procedure) and report on surgical and clinical outcomes.ResultsThe Livocado procedure was carried out on 18 (3.9%) of 465 patients undergoing surgery for chronic pancreatitis. There were 13 men and 5 women with a median (IQR) age of 48.5 (42.4–57) years and weight of 60.7 (58.0–75.0) kg. All had severe pain and vascular involvement; 17 had pancreatic parenchymal calcification; the median (IQR) oral morphine equivalent dose requirement was 86 (33–195) mg/day. The median (IQR) maximal pain scores were 9 (9–10); the average pain score was 6 (IQR 4–7). There was no peri-operative or 90-day mortality. At a median (IQR) follow-up of 32.5 (21–45.75) months, both maximal and average pain scores were significantly improved post-operatively, and at 12 months, two-thirds of patients were completely pain free. Six (33%) patients had employment pre-operatively versus 13 (72%) post-operatively (p = 0.01).ConclusionsThe Livocado procedure was safe and carried out successfully in patients with chronic pancreatitis with vascular involvement where other procedures would be contraindicated. Perioperative outcomes, post-operative pain scores, and employment rehabilitation were comparable with other procedures carried out in patients without vascular involvement.
Highlights
Chronic pancreatitis is a complex inflammatory syndrome of the pancreas with pain as the predominant symptom [1]
The in situ near-total pancreatectomy procedure was first introduced on 30 December 2014, and the last procedure was undertaken on 11 February 2020
Between January 1997 and May 2020, approximately 1200 patients with a diagnosis of chronic pancreatitis were referred to the Liverpool Pancreas Centre for further evaluation
Summary
Chronic pancreatitis is a complex inflammatory syndrome of the pancreas with pain as the predominant symptom [1]. It affects individuals with genetic, environmental, and/or other risk factors who develop persistent pathological responses to parenchymal injury or stress [2, 3]. Chronic pancreatitis carries a heavy disease burden including chronic pain; pancreatic endocrine and exocrine failure leading to diabetes mellitus and malnutrition; lower quality of life; serious long-term complications including a 5–25-fold risk of pancreatic cancer; and social stigma, with a reduced life expectancy [8,9,10]. Duodenum- preserving pancreatic head resection (DPPHR) notably the Beger, Frey, and Berne procedures are effective for head-dominant disease, providing decompression of the duodenum, hepatic portal vein, main pancreatic duct, and intra-pancreatic bile duct [19,20,21,22]
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