Duodenum-preserving Pancreatic Head Research Articles

Pancreas-preserving duodenal resections as a surgery of choice for the isolated form of cystic dystrophy of the duodenal wall (pure form of groove pancreatitis)

Background:Management of the isolated form of cystic dystrophy of the duodenal wall (CDDW), or pure form of groove pancreatitis, is controversial. Pancreatoduodenectomy is considered to be the most suitable procedure for CDDW. Pancreas-preserving procedures (PPDR) have been described as surgical options for the cases where only the duodenum has been involved. There are no studies comparing pancreas-preserving vs. pancreas-resecting procedures for this disease.Aim:To analyze the results and outcomes of PPDR and other treatment approaches to CDDW and to review the literature.Materials and methods:We performed a retrospective analysis of 82 patients with CDDW who received treatment from February 2004 to April 2019. We compared short-term and long-term results of treatment of 15 patients with isolated CDDW after PPDR and 42 patients with CDDW after pancreatoduodenectomy.Results:The preoperative diagnosis was correct in 81 of the cases (98.8%). The patients experienced abdominal pain (100%), weight loss (76%), vomiting (30%), and jaundice (18%). CT, MRI, and endoUS were the most useful diagnostic modalities. Twelve patients with CDDW took conservative treatment due to rejection of the operation. The other patients underwent cystoenterostomies (8), duodenum-preserving pancreatic head (DPPH) resections (6), pancreatoduodenectomy (42) and PPDR (15) with zero mortality. Full pain control was achieved after PPDR in 93%, after pancreatoduodenectomy in 83%, and after draining procedures in 18% of the cases. Newly onset diabetes mellitus (7) and severe exocrine insufficiency (5) were common after pancreatoduodenectomy and never occurred after DPPH resections and PPDR. Weight gain was significantly higher after pancreatoduodenectomy and PPDR, compared to other treatment modalities.Conclusion:PPDR is the optimal surgical procedure for the isolated form of CDDW. Early detection of CDDW allows for preservation of the pancreas. The pure form of groove pancreatitis is a disease of the duodenum, and the Whipple procedure should be considered excessive for this disease.

Limited Parenchyma-Sparing Pancreatic Head Resection for Benign Neuroendocrine Tumors and Cystic Neoplasms—the Use of Duodenum-Preserving Head Resection

Treating benign tumors of the pancreatic head by using duodenum-preserving total or subtotal pancreatic head resection (DPPHRt/s) has proven to reduce mortality and morbidity with a positive postoperative outcome, when compared with the standard approach which is represented by pancreaticoduodenectomy (PD). We present three cases of DPPHRs for benign tumors, in which pancreaticojejunostomy (PJ) and pancreaticogastrostomy (PG) were used. The long-term outcome of these patients was favorable; with a single case that presents a rapid onset of an acute pancreatitis, with postoperative pancreatic fistula that necessitate reoperation. The best results on early postoperative outcome were recorded in the case of pancreaticogastrostomy, with rapid onset of digestive tolerance and short period of hospital stay. These cases come in aiding modern surgery by ensuring an alternative to reintegrate the pancreatic remnant into the digestive tract after limited pancreatic head resection, with lower rates of postoperative complications.

“Duodenal dystrophy”, or “groove pancreatitis”, or “paraduodenal pancreatitis?” Does it matter which name you choose? Lessons of 76 cases

Background: The term “paraduodenal pancreatitis (PP)“ was proposed as an umbrella for cystic dystrophy in heterotopic pancreas (duodenal dystrophy,DD), paraduodenal cyst and groove pancreatitis, by reasoning that these conditions mimic pancreatic head tumors and share certain histological evidences. The reasons for amalgamation of these terms are unclear. Methods: Prospective analysis of 76 cases of DD (2004-2016), comparing 65 preoperative and 57 histopathological findings; Assessment of clinical presentation and the results of DD treatment. Results: Preoperative diagnosis was correct in all cases except one (1,9%). Patients were presented with abdominal pain(100%), weight loss(76%), vomiting(30%) and jaundice(18%). CT, MRI and endoUS were the most useful diagnostic modalities. Nine patients were treated conservatively, 35 underwent pancreaticoduodenectomies(PD), pancreatico- and cystoenterostomies(8), Nakao procedures(4), duodenum-preserving pancreatic head (DPPH) resections(5), and 14 pancreas-preserving duodenal resections(PPDR). No mortality. Full pain control was achieved after PPRDs in 93%, PDs in 83%, and after PPPH resections and draining procedures in 18% of cases. Diabetes mellitus developed thrice after PD. In 3 PD cases only moderate pancreatitis was revealed in specimen Conclusion: The diagnosis of DD can be confidently determined by modern methods preoperatively;Early diagnosis of DD saves pancreas The efficacy of PPDR proves DD is an entity of duodenal, but not paraduodenal origin

“Duodenal dystrophy”, or “groove pancreatitis”, or “paraduodenal pancreatitis?” Does it matter which name you choose? Lessons of 76 cases.

Background: The term “paraduodenal pancreatitis (PP)“ was proposed as an umbrella for cystic dystrophy in heterotopic pancreas (duodenal dystrophy,DD), paraduodenal cyst and groove pancreatitis, by reasoning that these conditions mimic pancreatic head tumors and share certain histological evidences. The reasons for amalgamation of these terms are unclear. Methods: Prospective analysis of 76 cases of DD (2004-2016), comparing 65 preoperative and 57 histopathological findings;Assessment of clinical presentation and the results of DD treatment. Results: Preoperative diagnosis was correct in all cases except one (1,9%). Patients were presented with abdominal pain(100%), weight loss(76%), vomiting(30%) and jaundice(18%). CT, MRI and endoUS were the most useful diagnostic modalities. Nine patients were treated conservatively, 35 underwent pancreaticoduodenectomies(PD), pancreatico- and cystoenterostomies(8), Nakao procedures(4), duodenum-preserving pancreatic head (DPPH) resections(5), and 14 pancreas-preserving duodenal resections(PPDR). No mortality. Full pain control was achieved after PPRDs in 93%, PDs in 83%, and after PPPH resections and draining procedures in 18% of cases. Diabetes mellitus developed thrice after PD. In 3 PD cases only moderate pancreatitis was revealed in specimen. Conclusion: The diagnosis of DD can be confidently determined by modern methods preoperatively;Early diagnosis of DD saves pancreas The efficacy of PPDR proves DD is an entity of duodenal, but not paraduodenal origin.

Benign Tumors of the Pancreas – Limited Local Surgical Treatment for Cystic Neoplasms and Neuroendocrine Tumors – an Overview

Background. Benign tumors of the pancreas are intraductal papillary mucinous neoplasia, mucinous cystic neoplasia, serous cystic adenoma, solid pseudopapillary neoplasia and endocrine tumors, most frequently insulinomas. The evolution of limited local surgical procedures for benign pancreatic lesions like enucleation (EN), pancreatic middle segment resection (CP) and duodenum-preserving total or partial pancreatic head resection (DPPHRt/p) shifted options of surgical treatment to application of local techniques. Objectives. Surgical treatment of benign cystic neoplasms and neuroendocrine tumors using local surgical extirpation techniques are evaluated based on present knowledge about indication to surgery, early postoperative complications and late outcome perspectives. Results. Tumor enucleation is recommended for all symptomatic neuroendocrine adenomas of a size up to 3 cm and non-adherence to pancreatic main ducts. EN was applied predominantly for neuroendocrine tumors and less frequently for cystic neoplasms. About 20% of enucleations are performed as minimal invasive procedures. Surgery-related severe postoperative complications with the need of reintervention are observed in 11%, pancreatic fistula in 33%, but hospital mortality was below 1%. Major advantages of EN are low procedure-related early postoperative morbidity and a very low hospital mortality. CP is applied in two thirds for symptomatic cystic neoplasms and in one third for neuroendocrine tumors. The high level of pancreatic fistula and severe postoperative complications are associated with management of the proximal pancreatic stump. Hospital mortality of 0.8% is a benefit of this procedure. DPPHRt/p has been applied in about 50% as total pancreatic head resection with segment resection of the peripapillary duodenum and the intrapancreatic common bile duct. Two thirds of patients suffered symptomatic or asymptomatic cystic neoplasms and 10% neuroendocrine tumors. Major advantages of local pancreatic head resection compared to Whipple type pancreatico duodenectomy are highly significant preservation of the exo- and endocrine functions and a low hospital mortality below 0.5%. The level of evidence for EN and CP is low, because of retrospective data evaluation and absence of results from controlled studies. For DPPHRt/p results of 9 prospective controlled studies, 3 case controlled studies and 2 retrospective controlled studies underline the advantages of DPPHRt/p compared to partial pancreaticoduoden ectomy. Conclusion. The application of tumor enucleation, pancreatic middle segment resection and duodenum-preserving total or partial pancreatic head resection are associated with low level of surgery-related early postoperative complications and a very low hospital mortality. The major advantages of the limited procedures are preservation of exo- and endocrine pancreatic functions and maintenance of peripancreatic GI-tract tissue

Surgical treatment of chronic pancreatitis in young patients.

The main treatment strategies for chronic pancreatitis in young patients include therapeutic endoscopic retrograde cholangio-pancreatography (ERCP) intervention and surgical intervention. Therapeutic ERCP intervention is performed much more extensively for its minimally invasive nature, but a part of patients are referred to surgery at last. Historical and follow-up data of 21 young patients with chronic pancreatitis undergoing duodenum-preserving total pancreatic head resection were analyzed to evaluate the outcomes of therapeutic ERCP intervention and surgical intervention in this study. The surgical complications of repeated therapeutic ERCP intervention and surgical intervention were 38% and 19% respectively. During the first therapeutic ERCP intervention to surgical intervention, 2 patients developed diabetes, 5 patients developed steatorrhea, and 5 patients developed pancreatic type B pain. During the follow-up of surgical intervention, 1 new case of diabetes occurred, 1 case of steatorrhea recovered, and 4 cases of pancreatic type B pain were completely relieved. In a part of young patients with chronic pancreatitis, surgical intervention was more effective than therapeutic ERCP intervention on delaying the progression of the disease and relieving the symptoms.

43-jähriger Patient mit Wesensveränderung, rezidivierenden Bewusstseinsstörungen und retrograder Amnesie

A 43-year-old male patient with recurring impaired consciousness and retrograde amnesia was admitted to the department of neurology. During the neurological evaluation no pathological findings could initially be revealed but one day the patient was confused again and presented with inadequate behavior: at this time a blood glucose value of 40 mg/dl was measured. For further evaluation the patient was transferred to our department. As the reason for the impaired consciousness was suspected to be of neuroglucopenic origin a rapid adrenocorticotropic hormone (ACTH) stimulation test was first performed to rule out adrenal insufficiency. For further evaluation a fasting test was conducted: after 48 h an episode with neuroglucopenic symptoms occurred again which disappeared after intravenous administration of glucose. The laboratory results of glucose, insulin and c-peptide determined at this point in time led to the diagnosis of an insulinoma. By ultrasound examination a hypoechogenic lesion 1.5 cm in size could be shown in the head of the pancreas and was confirmed by magnetic resonance imaging (MRI). After duodenum-preserving partial pancreatic head resection with enucleation of the insulinoma no further neuroglucopenic symptoms occurred.

Changes in the diagnostic and therapeutic methods for insulinoma

Insulinoma is derived from beta cells, and the yearly incidence of insulinoma is 1-4 per one million. Insulinoma patients were often misdiagnosed with epilepsy or cerebrovascular diseases because of the clinical and epidemiological features of insulinoma. The diagnosis of the insulinoma is usually made biochemically with the presence of low blood glucose ( <2.5 mmol/L), elevated insulin ( ≥6 mU/L) and C-peptide levels ( ≥ 200 pmol/L), and no sulfonylureas in the blood.Supervised 72-hour fasting test has been verified as the gold standard in establishing a biochemical diagnosis of insulinoma.Localization of insulinoma is useful for selecting surgical procedures, and the methods for localization can be divided into noninvasive (transabdominal ultrasound, computed tomography,magnetic resonance imaging and endoscopic ultrasound), invasive (angiography and arterial stimulation venous sampling) and intraoperative diagnosis. Surgical treatment is the only curative method at present, and the common approaches include enuclea tion, partial pancreatic resection, resection of the body and tail of pancreas and duodenum-preserving pancreatic head resection.Most patients with sporadic insulinoma had long-term survival after the surgery. For insulinoma patients with multiple endocrine neoplasia type 1, an aggressive surgical approach is recommended. Key words: Insulinoma; Pancreatectomy; Diagnosis

Bern procedure in duodenum-preservingpancreatic head resection

Eight patients with chronic pancreatitis or benign pancreatic head tumors were investigate to evaluate the use of Bern procedure in duodenum-preserving pancreatic head resection.Our data indicated no periopemtive deaths and serious complications.During median follow-up of 10 monks(range,6 to 14 monks),all patients reported impmvod clinical symptoms,and those with chronic pancreatitis had weight increased by 7.9 kg(range,4 to 18 kg).Pancreatic exocfine function wag improved,although the endocrine function showed no change.The Bern procedure might be a relatively safe and effective procedure for the treatment of chronic pancreatitis or benign pancreatic head tumors. Key words: Panereatitis,chmmc; Panereaticojejunostomy

Duodenum-preserving total pancreatic head resection without segment resection of the duodenum for chronic pancreatitis

The purpose of this study was to describe a duodenum-preserving total pancreatic head resection procedure without segment resection of the duodenum for the treatment of chronic pancreatitis with an enlarged pancreatic head. Between January 1999 and December 2006, 35 patients with chronic pancreatitis were operated on by duodenum-preserving total pancreatic head resection procedure without segment resection of the duodenum. These patients were followed up to estimate the outcomes of the surgical procedure. The mortality of the surgical procedure was 0. The overall morbidity was 17%. One patient developed pancreatic fistula, three patients developed bile leakage, and no patient developed duodenal fistula. Twenty-one patients who suffered abdominal pain in preoperative stage obtained complete pain relief, the mean European Organization for Research and Treatment of Cancer QLQ-C30 pain scale decreased from 59 +/- 27 to 13 +/- 21. In the postoperative stage, the endocrine function of the patients compared equally to the preoperative stage. The modified procedure obtains acceptable postoperative outcomes and benefits on extirpation of inflammatory lesions and avoidance of the anastomosis of the residual pancreatic head and the jejunum.