Longitudinal Pancreatojejunostomy Research Articles

Long-term outcomes of laparoscopic longitudinal pancreatojejunostomy and modified Frey's procedure for patients of chronic pancreatitis: A 10-year experience.

To mitigate the morbidity associated with open procedures for chronic pancreatitis (CP), there is a paradigm shift towards the laparoscopic approach. However, since these procedures are technically demanding, literature is still limited. We present our experience and long-term outcomes in the management of CP with laparoscopic surgical procedures. This is a retrospective observational study of patients who underwent a laparoscopic surgery for CP between 2009 and 2019. Pain scores using the Visual Analogue Scale (VAS) were compared pre- and postoperatively. In patients with diabetes, the pre- and post-operative insulin requirement was compared. Data of 62 patients were analysed. The mean duration of follow-up was 69 (±22) months. All patients had pain relief post-surgery. The relief of pain was sustained, with the median VAS scores being 1 at 3- and 5-year follow-up. There was a decrease in the median insulin requirement of diabetic patients, which was significant at 3-month and 1-year follow-up ( P < 0.05). Our study demonstrates that laparoscopic surgical procedures offer long-term pain control with low morbidity. Effective ductal decompression may result in a short-term improvement of the endocrine function of the gland.

A CLINICAL CASE OF LATE SEVERE BLEEDING FROM THE AREA OF PANCREATICOJEJUNOANASTOMOSIS AFTER PANCREATICODUODENAL RESECTION

Abstract. Virsungorrhagia is characterized by bleeding from the ampulla of the nipple through the pancreatic duct and occurs in 1 in 1500 patients with gastrointestinal bleeding from the upper parts of the gastrointestinal tract. It most often occurs as a result of the formation of a pseudoaneurysm due to chronic pancreatitis.&#x0D; The purpose of the work: to present a clinical case of severe bleeding from the area of pancreatico-jejunoanastomosis after pancreaticoduodenal resection.&#x0D; Materials and methods: There were 5 patients with virsungorrhagia in the Center for Gastrointestinal Bleedings of the Vinnytsia Regional Clinical Hospital named after M.I. Pyrogov from 2014 to 2023. All patients are male. Age from 45 to 67 years. Four patients had longitudinal pancreatojejunostomy in the past. One has Pancreatoduodenal resections according to Whipple. All of them had recurrent bleeding.&#x0D; Discussion: The presentation of a clinical case of late heavy bleeding from the area of pancreaticojejunal anastomosis after pancreaticoduodenal resection in a patient with complicated fibrotic-degenerative chronic pancreatitis is presented.&#x0D; Conclusions: Virsungoragia is a rather rare complication of surgical interventions on the pancreas, which is difficult to diagnose. The most effective way to stop bleeding is to stitch the bleeding vessel.

“OUTCOME OF FREY'S PROCEDURE FOR CHRONIC PANCREATITIS”

Background:- Chronic pancreatitis is (CP) is a progressive inammatory disease of the pancreas associated with disabling abdominal pain and gradual deterioration of exocrine and endocrine function. Up to 50% of patients with CP may require surgery during the course of the disease. The main indication for surgery is intractable abdominal pain not amenable to medical and endoscopic therapy. The type of surgery depends on pancreatic ductal diameter and associated parenchymal pathology like inammatory head mass. Frey procedure (FP) is an effective method for control of pain in patients with enlarged pancreatic head. FP can be performed with a very low mortality and an acceptable morbidity. Compared with pancreaticoduodenectomy (PD), FP has favourable outcomes in terms of operation time, blood loss, morbidity, post-operative hospital stay, intensive care unit stay, and quality of life. FP has shorter operation time and lower morbidity in comparison to Beger procedure. But, long-term pain control and exocrine and endocrine dysfunctions are comparable between PD, Beger and FP. FP is technically easier than PD and Beger procedure. FP is thus a widely acceptable procedure for CP with enlarged pancreatic head in absence of a neoplasia. Methods: Prospective observational study conducted in R. D. GARDI MEDICAL COLEGE UJJAIN (M.P.) 1AUGUST 2018 TO 1 AUGUST 2019. The diagnosis of chronic pancreatitis was based on the ndings of clinical history, physical examination and radiological investigation. Radiological investigation consisted of a combination of ultrasonography (US), computed tomography (CT) and MRCP.Surgically treated cases of Chronic Pancreatitis who underwent Frey's procedure and had minimum 3 months and maximum 12 months of follow up were included in the study A total number of 17 patients were studied in one year. Post-operatively all patients were a Results: sked to classify their pain as mild, moderate and severe or no pain. Patients were also asked to repeat endocrine and exocrine function tests. Only patients with at least 12 months of post-operative follow-up were included. At the time of the last follow-up visit, 91%(n = 15) of patients described complete pain relief, 7% (n = 2) described occasional episodic pain but did not take analgesics routinely. Only one patient had pain recurrence 1year after surgery; he had been abusing alcohol and drugs. Conclusions- The results of the study conrmed that local resection of the head with longitudinal pancreatojejunostomy as proposed by Frey has high effectiveness in the treatment of pain in long-term follow-up, combined with little interference in the disease course (endocrine and exocrine function).Frey's procedure should be considered as the primary operation in patients with disabling pain as a result of CP because it is safer, easier and presents less morbidity and mortality than alternative techniques.

Laparoscopic operations in patients with chronic pancreatitis

Aim: To demonstrate the experience of laparoscopic operations (longitudinal pancreatojejunostomy, Frey and Beger procedure). Materials and Methods: From January 2014 to January 2021 laparoscopic longitudinal pancreatojejunostomy, Frey and Beger procedures were performed in 67 patients (46 (68.7%) male, 21 (31.3%) female) with chronic pancreatitis type C (classification of M.Buchler). The age of the patients was 48 (21-68) years. The size of the pancreatic head was 48 (16-69) mm, the diameter of the main pancreatic duct was 8 (4-14) mm. Results: The operating time was 390 (190-680) minutes. Blood loss was 150 (30-800) ml. The conversion was required in 5 (7.4%) cases. Complications developed in the postoperative period in 13 (20.9%) patients. The length of the postoperative stay period was 4 (3-28) days. The follow-up ranged from 2 months to 80 months Pain relief was complete in 62 (92.5%) patients. Conclusions: The short-time outcomes show that laparoscopic operations (longitudinal pancreatojejunostomy, Frey and Beger procedure) for chronic pancreatitis are safe and feasible.

World-wide variation in reporting of the longitudinal pancreatojejunostomy with partial pancreatic head resection (Frey Procedure)

World-wide variation in reporting of the longitudinal pancreatojejunostomy with partial pancreatic head resection (Frey Procedure)

Analysis of the results of surgical procedures advisable for chronic pancreatitis with the isolated lesion of the pancreatic head

Recently, studies comparing various variants of operations to establish the optimal method of surgical treatment or chronic pancreatitis with pancreatic head lesions from the point of view of evidence-based medicine have been carried out in the world. However, these comparative studies do not take into account diff erences in the clinical and morphological forms of the disease, in particular, chronic pancreatitis with a predominant and isolated lesion of the head. Thus, performing a subtotal resection of the pancreatic head with longitudinal pancreatojejunoanastomosis or Frey surgery, which is advisable for chronic pancreatitis with predominant head lesion, in case of an isolated lesion of the head will be an excess of the volume of surgical intervention due to the fact that the outfl ow of secretion along the main pancreatic duct of the distal part of the gland does not disturb, the parenchyma of this part of the body practically does not participate in the pathological process and is changed minimally, and can respond to such an operation with pancreatic necrosis. Based on the studies performed, it is impossible to say with certainty about the reliable advantages of one type of operations on another. To obtain reliable results, it’s necessary to conduct evidence-based studies comparing subtotal resection of the pancreatic head with longitudinal pancreatojejunostomy with other types of interventions o nly for chronic pancreatitis with a isolated head lesion, excluding from the study patients with chronic pancreatitis with predominant head lesion.

Immediate and Long-Term Results of Original Methods of Longitudinal Pancreatojejunostomy With The Expansion of the Area of Pancreatojejunal Anastomosis

RELEVANCE. The dependency results of draining operations on the efficcacy of drainig of ductal system of the pancreas and adequate outflow of the pancreatic juce through anastomosis are undoubtful, therefore the development of new techniques of longitudinal pancreatojejunostomy (LPJ) extending area of anastomosis is an actual challenge.AIM OF STUDY. To compare the immediate and long-term results of longitudinal pancreatojejunostomy with the expansion of the area of anastomosis in patients with chronic pancreatitis.MATERIAL AND METHODS. We analysed immediate and long-term results of LPJ in 58 patients with chronic pancreatitis with impaired patency of the major pancreatic duct (MPD) without the head enlargement.RESULTS. All patients were divided into two groups: comparison group ( n=26, operated up to 2008 ) and main group (n=32, operated stumps during the MPD diastasis and posterior pancreatic surface (n=3) into anastomosis, with resection of the anterior pancreatic surface in the form of triangular fragments (n=11), with circulation of the small intestine loop during the recovery phase (n=19). The original LPJ in the study group of patients did not lengthened the surgery (160 [135, 185]) and intraoperative blood loss (265 [175, 340]). In the main group of patients there was no postoperative complications and fatal outcomes, but the average duration postoperative hospital treatment (18 [16; 20.5]) exceeded some data of foreign and domestic authors. Pain within 5 years after surgery in patients of the main group exceeded 26.6% and the appearance of diarrheal syndrome with dependance from reception of enzyme preparations was twice lower than in patients og the comparison group. According to questionnaire EORTC QLQ-C30, 5 years after surgery statistically significant differences between groups in terms of scales CF, NV, DY (p=0.03, 0.02, 0.006 respectively), indicating the advantage of intervention performed in the mail group.CONCLUSIONS. 1. An indication for longitudinal pancreatojejunostomy in chronic pancreatitis is impaired patency of the main pancreatic duct in the absence of an increase and inflammatory mass in the pancreatic head.2. The width of the main pancreatic duct is less than 5 mm and the presence of diastasis between its proximal and distal stumps with the posterior surface of the pancreas preserved, is not a reason for refusing longitudinal pancreatic jujunostomy in favor of the resection method.3. The expansion of pancreatojejunal anastomosis when performing longitudinal pancreatojejunostomy can improve the immediate and longterm results of surgical treatment for chronic pancreatitis.

Laparoscopic longitudinal pancreaticojejunostomy for chronic pancreatitis: Systematic review of the literature

BackgroundLongitudinal pancreaticojejunostomy, also known as modified Puestow or Partington-Rochelle procedure, is a technique for the treatment of chronic pancreatitis. It is usually performed by laparotomy, but in a very small number of cases it has been performed using a laparoscopic or robot-assisted approach. We carried out a systematic literature review to clarify the current status of laparoscopic longitudinal pancreatojejunostomy (LLPJ). MethodsAdhering to the PRISMA guidelines, a systematic search for LLPJ was performed in PubMed, Embase, and Cochrane Library, for articles published up to 31 December 2017. Results357 articles were evaluated for eligibility and 17 were included for critical appraisal: eight case reports, eight retrospective case series, and one series of cases and controls without randomization. All of them had a grade of recommendation C and a level of evidence 4 according to the CEBM. Patients were relatively young (mean age 37 years), with a slight preponderance of males (ratio 1.3: 1). All had long-standing disease, ERCP prior to surgery and a dilated pancreatic duct (mean 11 mm). The surgery was usually performed laparoscopically using four trocars; the conversion rate was low (5%), bleeding was minimal, the morbidity rate was 11% and no mortality was reported. Mean hospital stay was 5.6 days. The follow-up period varied but was usually short (less than two years). The results for pain control were very good since 90% of patients reported no pain, although visual analog scales were rarely used. ConclusionsIn conclusion, LLPJ seems to be a safe, feasible and effective technique in patients with chronic pancreatitis. However, the number of descriptions published to date is very small, and there are no studies with high scientific evidence comparing LLPJ with open surgery or with endoscopic treatment that would allow us to draw firmer conclusions at the present time.

Laparoscopic longitudinal pancreatojejunostomy and modified Frey's operation for chronic calcific pancreatitis.

BackgroundChronic pancreatitis is a debilitating disease presenting with pain, diabetes and steatorrhoea. Surgery offers better long‐term pain relief than other interventions, but there is still uncertainty about the optimal surgical procedure and approach and a lack of long‐term follow‐up data in patients with chronic calcific pancreatitis selected for laparoscopic surgical treatment.MethodsThis was an observational cohort study of patients who underwent laparoscopic surgery for chronic calcific pancreatitis between January 2006 and April 2017, and had completed a minimum follow‐up of 1 year at a tertiary‐care teaching institute. Eligibility for the laparoscopic approach was main duct diameter greater than 7 mm, absence of extensive head calcification, size of head less than 3·5 cm, absence of local complications, and ASA grade I or II status. The primary outcome variable was a reduction in pain score by 1 year. Secondary outcomes were hospital stay, complications, pain score at 3 and 5 years, and the development or progression of exocrine and endocrine insufficiency.ResultsSome 57 patients were scheduled to undergo laparoscopic surgery for chronic pancreatitis: longitudinal pancreatojejunostomy (39), modified Frey's procedure (15) and pancreatoduodenectomy for suspicion of malignancy (3). The latter three patients were excluded from the analysis. Conversion to open surgery was needed in ten of the 57 patients (18 per cent). The mean(s.d.) age of the analysed cohort was 34·2(3·7) years and there was a predominance of men (34, 63 per cent). Adequate pain relief was achieved in 91, 89 and 88 per cent of patients at 1, 3 and 5 years of follow‐up respectively.ConclusionLaparoscopic surgical management of chronic calcific pancreatitis with longitudinal pancreatojejunostomy or modified Frey's procedure is feasible, safe and effective in selected patients for the relief of pain.

CARBOHYDRATE METABOLISM IMPROVEMENT IN DIABETES PATIENTS AFTER SURGICAL TREATMENT OF PANCREATIC HEAD CANCER

The article describes the patient with pancreatic cancer, calculous pancreatitis and diabetes mellitus. The patient underwent pancreatoduodenectomy followed by longitudinal pancreatojejunostomy. Surgery resulted improvement of diabetes mellitus.

Combined Puestow and choledocoduodenostomy for concomitant large pancreatic duct and primary choledochal stones: A case series

IntroductionMultiple and large pancreatic duct stones concomitant with primary choledochal stones is a rare case. Patients usually present with recurrent jaundice and signs of pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) is the leading method to manage the patients. But ERCP has difficulties when facing the multiple and large stones Presentation of caseOur first case was a 51-years-old man who was admitted to our surgery unit with a diagnosis of chronic pancreatitis. Plain abdominal radiogram, Abdominal MSCT and Magnetic Resonance Cholangiopancreatography (MRCP) showed opacity suspected as stone at the pancreatic duct and distal part of the common bile duct. The second case was a 48-years-old female with the clinical presentation of left upper quadrant pain and history of chronic pancreatitis and intermittent jaundice. Plain abdominal radiogram and MRCP revealed multiple stones in the main pancreatic duct and common bile duct stones. Our third case was female, 60-years-old, who was hospitalized with jaundice and recurrent upper abdominal pain with a history of open cholecystectomy one month previously. Radiologic examination showed multiple stones in the main pancreatic duct and common bile duct. Combined longitudinal pancreatojejunostomy Roux-en-Y and Choledoco-duodenostomy were performed successfully in all cases. Postoperative follow-up showed good recovery of all patients. DiscussionSince ERCP is not proper to be used for multiple and large pancreatic duct stones, we performed a combination of longitudinal pancreatojejunostomy Roux-en-Y and choledoco-duodenostomy to treat the patients and prevent the recurrence. ConclusionThe incidence of multiple pancreatic duct stones and large choledochal stones is infrequent. Surgical treatment with combined longitudinal pancreatojejunostomy Roux-en-Y and Choledoco-duodenostomy is safe and effective to resolve jaundice and recurrent pain caused by chronic pancreatitis.

TREATMENT OF CHRONIC PANCREATITIS COMPLICATED BY BLEEDING

Aim. To analyze the causes of bleeding in chronic pancreatitis patients and efficacy of different hemostatic techniques. Material and Methods. The study included 632 patients with chronic pancreatitis operated in 1981–2016. Pancreatic pseudocysts were observed in 404 cases (63.9%), bleeding – in 70 cases (17.3%). Conventional surgical treatment was applied in 49 cases (group 1), endovascular approach was used for 21 patients and 10 of them underwent additional surgery in the future (group 2). Bleeding into cyst’s cavity was in 22 patients (31.4%); cyst wall rupture followed by bleeding into gastrointestinal tract – in 30 (42.8%), into abdominal cavity – in 10 (14.3%), into retroperitoneal space – in 6 (8.6%), into pleural cavity – in 2 (2.8%) cases. Results. In group 1 18 (36.8%) patients underwent conventional surgical ligation of the vessels, drainage and tamponade of the pseudocyst; 8 (17.0%) patients – external drainage of pancreatic duct; 7 (14.5%) – vessel ligation followed by longitudinal pancreatojejunostomy; 8 (15.5%) – distal pancreatectomy; 2 (4.1%) – pancreatoduodenectomy; 2 (4.1%) – middle pancreatectomy; 4 (8.1%) – splenic artery ligation, splenectomy and external drainage of the pseudocyst. 4 patients with severe bleeding died in this group. Endovascular approach was applied in 21 cases of the 2nd group: embolization of splenic artery – in 11 (52.4%) cases, gastroduodenal artery – in 7 (33.3%) cases, gastroduodenal arch – in 3 (14.3%) cases. In 11 (52.4%) cases isolated false aneurysm embolization was performed. In another 10 (47.6%) cases endovascular approach was combined with open surgery. 1 (4.7%) patient died from severe posthemorrhagic complications and delayed endovascular treatment. Overall mortality due to hemorrhagic complications was 7.1%. Conclusion. Hemorrhagic complications developed in view of exacerbation of chronic pancreatitis. Surgical tactics was aimed at hemostasis, elimination of ductal hypertension and drainage of pseudocyst. Endovascular treatment is the most reliable that however does not exclude subsequent open pancreatic surgery. Minimally invasive drainage of ducts and pseudocysts was also useds.

Results of surgical treatment of chronic pancreatitis and cysts of the pancreas in view of their morphological condition during surgery

Background. To date, reasonable indications and contraindications have not yet been developed for the implementation of draining, resection-draining and resection procedures with preoperative consideration of risk factors of their performance, there are no modern diagnostic and treatment algorithms for the treatment of patients with complications of chronic pancreatitis and pancreatic pseudocysts. Therefore, a retrospective analysis of failures during the surgical interventions on the pancreas would contribute to the creation of diagnostic and therapeutic algorithm with maximum consideration of the risk factors that would enable the individualization of treatment program and provide a long therapeutic effect to the patient with minimal risk of disease recurrence and minimal surgical trauma. This is an actual problem of modern surgery. The aim of the study was to define principal causes, which resulted in failures at surgical treatment for complications of chronic pancreatitis and cysts of the pancreas. Materials and methods. There was performed the retrospective analysis of 108 follow-up cards of patients operated for complications of chronic pancreatitis (n = 66) and pseudocysts of the pancreas (n = 42) with application of draining, resection-draining and resection surgical interventions. During the retrospective analysis, we took into account the morphological state of pancreatic parenchyma and presence of pseudocysts of the pancreas at the time of operation, blood loss during the surgery, the incidence and nature of intra- and postoperative complications depending on the type of surgical interventions, extent and adequacy of the operation, lethality. Results. The nature of the complications of chronic pancreatitis and pancreatic pseudocysts: a constant or recurrent pain, dilatation of pancreatic duct, calculus of pancreatic duct, calcifications of the parenchyma of the pancreas, stenosis of the intrapancreatic part of the common bile duct, biliary hypertension, obstructive jaundice, duodenal obstruction, segmental suprahepatic or subhepatic portal hypertension, ascites, abscess of the pancreas, external pancreatic fistula, fistula choledochoduodenalis. Failures during the surgical treatment for complications of chronic pancreatitis and pseudocysts of the pancreas were detected in 57 (57.0 %) cases, including 33 (57.9 %) cases in the treatment for complications of chronic pancreatitis and in 24 (42.1 %) cases during the treatment of pseudocysts of the pancreas. Lethal cases were registered in 4 (3.7 %) patients at the implementation of draining (longitudinal pancreatojejunostomy, cystopancreatojejunostomy) and resection surgical interventions (pancreatoduodenal resection). The nature of failures in most cases (64.9 %) was presented by impossibility of performing adequate surgical intervention (n = 21), insufficiency of seams of anastomosis (n = 6), postoperative bleeding (n = 5) and significant blood loss during the surgery (n = 5). Most of the major causes of failure of surgical treatment for complications of chronic pancreatitis and pancreatic pseudocysts were related to the morphological state of the pancreas and pancreatic pseudocysts during the operation: active inflammation and its combination with varying degrees of fibrosis of pancreatic parenchyma (n = 47); early fibrosis of pancreatic parenchyma (n = 15), immature pancreatic pseudocyst (n = 5), as well as soft “juicy” pancreas (lipomatosis on the background of active inflammation of the pancreatic parenchyma) (n = 8). Conclusions. Basic factors, which determine the risks and failures of surgical treatment for complications of chronic pancreatitis and pseudocysts of the pancreas, are: a) activity of inflammation, degree of fibrosis of pancreatic parenchyma at the time of surgery; b) maturity of the wall of pancreatic pseudocysts, its connection with pancreatic duct, localization, size and nature of complications of pseudocysts of the pancreas; c) inadequately chosen term and type of surgical intervention; d) inadequate performance of surgical intervention.

Анализ результатов лечения больных хроническим панкреатитом

The comparative analysis of results of treatment of patients with chronic pancreatitis. The study included 73 patients with chronic pancreatitis, who underwent surgery: pancreatoduodenal resection, longitudinal pancreatojejunostomy, Frey korporokaudalnaya resection, drainage, Billroth 2, cistoduodenostomiya, cystectomy. The largest number of postoperative complications were observed in patients after pancreatoduodenectomy after the same operation deaths greatest. More gentle and effective kind of surgical treatment is surgery Frey, but it is not standard in chronic pancreatitis, because of the possibility of undetected tumor metastasis.

Surgical Success in Chronic Pancreatitis: Sequential Endoscopic Retrograde Cholangiopancreatography and Surgical Longitudinal Pancreatojejunostomy (Puestow Procedure)

Introduction Chronic pancreatitis (CP) can be a cause of recurrent, severe, disabling abdominal pain in children. Surgery has been suggested as a useful therapy, although experience is limited and the results unpredictable. We reviewed our experience of a two-stage protocol-preliminary endoscopic retrograde cholangiopancreatography (ERCP) and duct stenting, and if symptoms resolved, definitive surgical decompression by longitudinal pancreatojejunostomy (LPJ) (Puestow operation). Patients and Methods This is a single-center, retrospective review of children with established CP who underwent an LPJ between February 2002 and September 2012. A questionnaire was completed (incorporating visual analog scale pain and lifestyle scores) to assess functional outcome. Data are expressed as median (range). Results In this study, eight (M:F ratio of 4:4) children underwent an LPJ and one female child had a more limited pancreatojejunostomy anastomosis following preliminary ERCP and stent placement where possible. Diagnoses included hereditary pancreatitis (n = 3), idiopathic or structural pancreatitis (n = 5), and duct stricture following radiotherapy (n = 1). Median duct diameter presurgery was 5 (4-11) mm. Endoscopic placement of a Zimmon pancreatic stent was possible in six with relief of symptoms in all. Median age at definitive surgery was 11 (range, 7-17) years with a median postoperative stay of 9 (range, 7-12) days and a follow-up of 6 (range, 0.5-12) years. All children reported markedly reduced episodes of pain postprocedure. One developed diabetes mellitus, while three had exocrine deficiency (fecal elastase < 200 µg/g) requiring enzyme supplementation. The child with limited LPJ had symptomatic recurrence and required restenting and further surgery to widen the anastomosis to become pain free. Conclusion ERCP and stenting provide a therapeutic trial to assess possible benefit of a definitive duct drainage procedure. LPJ-the modified Puestow operation was safe and complication-free with good medium-term relief of symptoms. We were not able to identify a consistent etiology-associated outcome.

Surgical Treatment of Chronic Pancreatitis

Treatment of chronic pancreatitis (CP) is a challenging disease for surgeons. During the last several decades, increasing knowledge about pathophysiology of CP, improved results of major pancreatic resections, and development of sophisticated diagnostic methods in clinical practice have resulted in significant changes in surgery for CP. Main indications of CP for surgery are intractable pain, suspicion of malignancy, and involvement of adjacent organs. The goal of surgical treatment is to improve the quality of life of patients. The surgical approach to CP should be individualized according to pancreatic anatomy and pathophysiology, pain characteristics, baseline exocrine and endocrine function, and medical co-morbidity. The approach usually involves pancreatic duct drainage and resection including longitudinal pancreatojejunostomy, pancreatoduodenectomy (Whipple`s procedure), pylorus-preserving pancreatoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum preserving pancreatic head resection (Beger`s procedure), and local resection of the pancreatic head with longitudinal pancreatojejunostomy (Frey`s procedure). Surgical procedures provide long-term pain relief, a good postoperative quality of life with preservation of endocrine and exocrine pancreatic function, and are associated with low early and late mortality and morbidity. Even though available results from randomized controlled trials were published, new studies are needed to determine which procedure is the most effective for the management of patients with CP.

PANCREATIC STENTS IN THE MANAGEMENT OF CHRONIC PANCREATITIS

Elevated pancreatic duct pressure is a potential source of pain in patients with chronic pancreatitis. Endoscopic pancreatic duct stenting is a minimally invasive way of reducing this pressure and may be a useful adjunct to surgery in these patients. We prospectively reviewed a series of nine symptomatic patients with obstructive chronic pancreatitis and relative contraindications to open surgery, who were managed by attempted endoscopic placement of a pancreatic stent. Stents were successfully inserted endoscopically into the main or accessory duct in six patients and into a pseudocyst, transduodenally, in one patient. Of the two unsuccessful insertions, one proceeded to longitudinal pancreato-jejunostomy and in the other a stent was inserted at distal pancreatic cyst-jejunostomy. Median follow up was 21 months (range 14-43). In all eight cases with stent insertion there was rapid pain resolution, pain scores falling from 9/10 (8-10) to 2 (1-5) after 2 days (1-7). Associated symptoms of weight loss, nausea and vomiting settled in all eight cases. In one patient with a persistent pancreatic fistula, the fistula resolved. In the three with pseudocysts, the cysts resolved on computed tomography (CT) (one recurred). Five patients subsequently proceeded to stent removal after 6 months (5-23). In three of these, the stent was removed endoscopically, and replaced endoscopically in two cases, with pain resolution. Two patients underwent transduodenal pancreatic duct septectomy (one had stent change prior) and one proceeded to pseudocyst-gastrostomy, with pain resolution. the remaining three patients with stents in situ remain symptom-free. No patient suffered acute pancreatitis. In selected patients with obstructive chronic pancreatitis, insertion of a pancreatic stent is a safe procedure, which can lead to rapid symptomatic control over the intermediate period. A significant proportion will need further intervention.

The role of pancreatojejunostomy in patients without dilated pancreatic ducts

To determine the safety and efficacy of longitudinal pancreatojejunostomy in patients with chronic pancreatitis and intractable pain who do not have a markedly dilated pancreatic duct. Ductal decompression by side-to-side, longitudinal pancreatojejunostomy has become the operation of choice for patients with chronic pancreatitis and intractable pain when the pancreatic duct is markedly dilated. However, markedly dilated pancreatic ducts are found in less than 40% of patients with disabling pain. Twenty-eight consecutive patients with intractable pain from chronic pancreatitis, most of whom had minimal or no dilation of the pancreatic duct, were treated with side-to-side, longitudinal pancreatojejunostomy between 1970 and 1993. There were 18 (64%) males and 10 (36%) females. The mean age was 41 years (range 11 to 72). The etiologies for chronic pancreatitis were alcohol (82%), gallstones (7%), trauma (7%), and familial trait (4%). Intractable pain was present for a mean of 4 years (range 0.5 to 12). Thirteen patients (46%) were dependent on narcotics prior to surgery. Twenty-five patients (89%) had minimal (< 8 mm) or no dilation of the pancreatic duct and 3 (11%) had markedly dilated pancreatic ducts (> 10 mm). All experienced complete pain relief in the immediate postoperative period. Twenty-four patients (86%) have remained free of pain after a mean follow-up of 3.5 years (range 1 to 8). In patients with chronic pancreatitis and intractable pain, small pancreatic duct size should not be considered a contraindication to side-to-side, longitudinal pancreatojejunostomy.

Selective drainage for pancreatic, biliary, and duodenal obstruction secondary to chronic fibrosing pancreatitis.

Twenty-eight patients underwent surgery for intractable pain, duodenal or extrahepatic biliary obstruction secondary to chronic pancreatitis. Eleven had pancreatic duct obstruction alone, six biliary obstruction alone, seven combined pancreatic and biliary, two combined biliary and duodenal, one combined pancreatic and duodenal, and one simultaneous pancreatic, biliary, and duodenal obstruction. Pancreatitis was secondary to alcohol in all but one case. The following operations were performed: longitudinal pancreatojejunostomy (20), choledochoduodenostomy (8), choledochojejunostomy (7), cholecystojejunostomy (1), and gastrojejunostomy (4). Of the 20 patients with pancreatic duct drainage, pain relief was complete in 11 and partial in six. Initial incomplete relief of pain, or recurrence, stimulated further diagnostic procedures, leading to improvement or correction of the problem in five patients. A significant (p less than 0.01) fall in alkaline phosphatase (935 +/- 228 to 219 +/- 61 U/L) occurred following surgery. One patient was subsequently found to have pancreatic carcinoma. Two patients were lost to follow-up and four patients died (one perioperative and three late). In conclusion, the possibility of pancreatic, biliary, and duodenal obstruction must be considered in symptomatic patients with chronic pancreatitis. Surgery must be individualized. Drainage procedures, either alone or in combination, are associated with a low morbidity and improved clinical condition and may be preferable to resection in the surgical management of these patients.

The choice of the method of surgery for chronic pancreatitis

The analysis of the surgical treatment of patients with primary chronic pancreatitis showed that the most justified operations are distal resection of the altered part of the pancreas, longitudinal pancreatojejunostomy with expansion and deformation of the Wirsung duct, cystectomy and cystojejunostomy with non-removable cysts of the gland. Adequate operations on the biliary tract in chronic cholecystopancreatitis restore the outflow of bile, pancreatic juice and pancreatic function.