Surgery For Chronic Pancreatitis Research Articles

A retrospective analysis of opioid use before and after surgery for chronic pancreatitis in a South African Tertiary Hospital

A retrospective analysis of opioid use before and after surgery for chronic pancreatitis in a South African Tertiary Hospital

Alpha-1 Antitrypsin Augmentation Therapy in Chronic Pancreatitis Patients Undergoing Total Pancreatectomy and Islet Autotransplantation: A Randomized, Controlled Study.

Stress-induced islet graft loss during the peri-transplantation period reduces the efficacy of islet transplantation. In this prospective, randomized, double-blind clinical trial, we evaluated the safety and efficacy of 60 mg/kg human alpha-1 antitrypsin (AAT) or placebo infusion weekly for four doses beginning before surgery in chronic pancreatitis (CP) patients undergoing total pancreatectomy and islet autotransplantation (TP-IAT). Subjects were followed for 12 months post-TP-IAT. The dose of AAT was safe, as there was no difference in the types and severity of adverse events in participants from both groups. There were some biochemical signals of treatment effect with a higher oxygen consumption rate in AAT islets before transplantation and a lower serum C-peptide (an indicator of islet death) in the AAT group at 15 min after islet infusion. Findings per the statistical analysis plan using a modified intention to treat analysis showed no difference in the C-peptide area under the curve (AUC) following a mixed meal tolerance test at 12 months post-TP-IAT. There was no difference in the secondary and exploratory outcomes. Although AAT therapy did not show improvement in C-peptide AUC in this study, AAT therapy is safe in CP patients and there are experiences gained on optimal clinical trial design in this challenging disease.

Is extended venous thromboembolism prophylaxis warranted after surgery for chronic pancreatitis?

Is extended venous thromboembolism prophylaxis warranted after surgery for chronic pancreatitis?

Glycemic control and surgery for chronic pancreatitis

Glycemic control and surgery for chronic pancreatitis

Postoperative epidural vs ketamine in patients undergoing surgery for chronic pancreatitis

Postoperative epidural vs ketamine in patients undergoing surgery for chronic pancreatitis

Peri-operative outcome in patients undergoing surgery for chronic pancreatitis in a South African Tertiary Hospital

Peri-operative outcome in patients undergoing surgery for chronic pancreatitis in a South African Tertiary Hospital

The Role of Surgery in Chronic Pancreatitis.

Chronic pancreatitis is an inflammatory disease characterized by the progressive replacement of the functional pancreatic parenchyma with fibrotic tissue. This leads to exocrine and endocrine insufficiency. A typical clinical feature is recurrent, severe upper abdominal pain, which negatively affects the patient's quality of life. Conservative treatment as the method of first choice does not prevent irreversible changes in the pancreatic tissue. While endoscopic drainage can have some benefits in the early stages of the disease, it is generally unsuccessful in the long term. Based on recent studies, surgical intervention appears to be the most suitable treatment option for improving the patient's quality of life. It currently includes a wide range of effective, proven drainage and resection procedures. Advances in surgical techniques and postsurgical intensive care have increased the frequency of pancreatic surgeries, while improvements in diagnostic methods have increased the number of patients who meet the indications for such surgery, including elderly and chronically ill patients. However, despite mortality rates decreasing, high morbidity rates remain a problem. Currently, in patients with an inflammatory mass in the head of the pancreas, pyloric and duodenal-preserving resection offers the best results. Different variants of these techniques appear to produce similar results. Various techniques have shown similar outcomes in terms of mortality, morbidity, pain relief, life expectancy and improved quality of life. The optimal timing of surgery has been addressed by several studies and most surgeons now favor early surgical intervention in order to prevent extensive destruction of pancreatic tissue.

Surgery in chronic pancreatitis after implementation of multidisciplinary team assessment - a single centre prospective study from Oslo

Surgery in chronic pancreatitis after implementation of multidisciplinary team assessment - a single centre prospective study from Oslo

Enhanced recovery after surgery in chronic pancreatitis

Aim . To improve surgical outcomes in patients with chronic pancreatitis by means of enhanced recovery after surgery. Materials and methods. 112 patients with chronic pancreatitis underwent surgery over the past 5 years. Pancreatic head resection in different variants was performed in 78 patients (69.6%), and 34 patients (30.4%) underwent lateral pancreaticojejunostomy. All interventions were carried out through the midline laparotomy. Enhanced recovery after surgery was carried out for 48 patients (39.6%). The control group included 60 patients. Results. After pancreatic resection, patients in the main group were in the intensive care unit only on the day of surgery. As soon as the pancreaticojejunoanastomosis was formed, the patients were immediately transferred to the surgical department. Patients in the control group were in the intensive care unit for at least two days. Intestinal motility was revealed in patients of the main group on day 2, in the control group – on days 3–4. Four patients (7.7%) of the main group and 11 in the control group (18.3%) developed complications. No lethal outcomes were registered in the main group. One patient (1.7%) died in the control group. The average length of hospital stay comprised 9 ± 2.5 days in the main group and 15 ± 4.7 days in the control group ( p < 0.05). Conclusion . Enhanced recovery after surgery in patients with chronic pancreatitis reduces the number of postoperative complications, the duration of stay in the intensive care unit, the length of hospital stay and, therefore, improves immediate postoperative outcomes.

Objective Research Priorities in Pancreatic Surgery – Results of a Worldwide Online Expert Survey

Abstract Background Several evidence gaps still need to be addressed in pancreatic surgery research. In our times of scarcity of resources in finances and time, research activities should be prioritized according to their clinical and political relevance. Aims Prioritize research topics in pancreatic surgery based on existing evidence and expert voting. Methods A digital survey among national and international pancreatic societies was performed over the course of six months. International experts were asked to rate their “Top 5” research topics requiring an RCT based on the 76 research topics from the Evidence Map of Pancreatic Surgery. Moreover, experts rated the importance of having an RCT for existing evidence gaps i.e. from the eleven research topics currently without an existing RCT. Results A total of 149 surgeons from 30 countries contributed to this study. Currently, the most relevant research topic is vascular resection in pancreatic surgery (39 votes). Radical antegrade modular pancreatosplenectomy (RAMPS) versus standard distal pancreatectomy was ranked second (30 votes). Celiac axis resection versus standard resection and spleen management in distal pancreatectomy were ranked third and fourth (both 27 votes). Finally, the time point for surgery for chronic pancreatitis was ranked fifth with 25 votes. With regard to the eleven evidence gaps, the topic of RAMPS versus standard distal pancreatectomy and total versus partial pancreatectomy were both rated as having “very high priority” to have an RCT. Conclusions Research activities should be based on objective prioritization. The current study allows researchers and funding bodies to address the most relevant research questions based on a systematic evidence overview evaluated by pancreatic surgeons worldwide. This will allow for clinically relevant, high-quality evidence while also saving resources.

Changing trends in the minimally invasive surgery for chronic pancreatitis

Chronic pancreatitis is a debilitating pancreatic inflammatory disease characterized by intractable pain resulting in poor quality of life. Conventional management of pancreatic pain consists of a step-up approach with medications and lifestyle modifications followed by endoscopic intervention. Traditionally surgery is reserved for patients who do not improve with other interventions. However, recent studies suggest that early surgical intervention is more beneficial as it can mitigate the progression of the pathological process and prevent loss of pancreatic function. Despite the widespread adoption of minimally invasive approaches in various gastrointestinal surgical disorders, minimally invasive surgery for chronic pancreatitis is slow to evolve. Technical difficulty due to severe inflammatory changes has been the major impediment to the widespread usage of minimally invasive surgery in chronic pancreatitis. With this background, the present review aimed to critically analyze the available evidence on the minimally invasive treatment of chronic pancreatitis. A Pub Med search of all relevant articles was performed using the appropriate keywords, parentheses, and Boolean operators. Most initial laparoscopic series have reported the feasibility of lateral pancreaticojejunostomy, considered an adequate procedure only in a small proportion of patients. The pancreatic head is the pacemaker of pain, so adequate decompression is critical for long-term pain relief. Recent studies have documented the feasibility of minimally invasive duodenum-preserving pancreatic head resection. With improvements in laparoscopic instrumentation and technological advances, minimally invasive surgery for chronic pancreatitis is gaining momentum. However, more high-quality evidence is required to document the superiority of minimally invasive surgery for chronic pancreatitis.

Complicated visceral artery aneurysms in chronic pancreatitis

Visceral artery aneurysms are rare and occur only in 0.01-0.2% of people. According to various authors, incidence of aneurysm rupture is 10-20% with mortality rate of 20-70% depending on localization and dimensions. One of the causes of visceral artery aneurysms, in particular common hepatic artery aneurysm, is chronic pancreatitis. Incidence of this complication is 2-10%. The first clinical manifestation is often hemorrhagic shock following false aneurysm rupture and bleeding into abdominal cavity, gastrointestinal tract or retroperitoneal space. Common hepatic artery aneurysm is complicated by bleeding in 35% of cases, and mortality may be up to 75%. Treatment of visceral artery aneurysm following chronic pancreatitis and post-necrotic parapancreatic cyst includes several stages. Endovascular methods are the first stage of treatment. The second stage is elimination of the cause of visceral artery false aneurysm (surgery for chronic pancreatitis). We present 3 patients with visceral artery aneurysms and chronic pancreatitis.

Tailored surgery in chronic pancreatitis after implementation of a multidisciplinary team assessment; a prospective observational study

IntroductionOptimal management of chronic pancreatitis involves several specialties. Selection of patients for surgery may benefit from evaluation by a multidisciplinary team (MDT), similar to cancer care. The aim of this study was to evaluate outcomes in patients selected for surgery after MDT decision. MethodsA prospective, observational study of consecutive patients operated for pain due to chronic pancreatitis after implementation of a MDT. The main outcome was Quality of life (QoL) assessed by EORTC-QLQ C30 and pain relief in patients followed >3 months. Complications were registered and predictive factors for pain relief analyzed. ResultsOf 269 patients evaluated by the MDT, 60 (22%) underwent surgery. Postoperative surgical complications occurred in five patients (8.3%) and reoperation within 30 days in two. There was no 90-days mortality. Complete or partial pain relief was achieved in 44 of 50 patients followed >3 months (88%). Preoperative duration of pain predicted lower probability of success. Postoperative improvement in QoL was most prominent for pain, appetite and nausea. ConclusionsAfter MDT evaluation, one in five patients was selected for surgery. Pain relief was obtained in a majority of patients with improved QoL. A tailored approach through a MDT seems warranted and efficient.

Surgery for chronic pancreatitis and different methods of surgeries

Objectives: Chronic pancreatitis, a benign inflammatory process of the pancreas resulting in exocrine and endocrine in sufficiency. Pain is the most devastating symptom, for which patient seeks medical advice. Even though these problems are addressed medically, surgery is indicated in many cases of intractable pain. Methods: Thirty- patients who are managed surgically during November 2018 to October 2020 at our institute. Data is collected and analyzed. Various surgical procedures for chronic pancreatitis and their indications are noted. Pain relief, improvement of exocrine and endocrine in sufficiency and improvement of quality of life are studied. Results: Various operative procedures are done including intra operative Celiac plexus block in some. Puestow’s, Frey’s and Whipples PD are done in these patients, which are selected according to the pathological anatomy. We observed long lasting pain relief is observed in 90% of our patients. In two of the patient’s surgery was done in acute condition with edematous pancreas. In these cases, intra operative celiac plexus block was added. Conclusions: Surgery is effective in Chronic Pancreatitis with intractable pain and better results can be obtained with selection of procedure tailor made to the patient. Exocrine and endocrine functions may become better in some patients.

Long-Term Follow-Up after Surgery for Chronic Pancreatitis: A Bicentric Retrospective Experience

Introduction: The impact of surgery on nutritional status, pancreatic function, and symptoms of patients affected by chronic pancreatitis (CP) has not been unequivocally determined. This study aimed to evaluate clinical follow-up after surgery for CP in an Italian-Austrian population. Materials and Methods: Patients operated for CP at two high-volume centers between 2000 and 2018 were analyzed. The following parameters were compared between the pre- and postoperative period: nutritional status, endocrine and exocrine pancreatic functions, and chronic pain. Results: Overall, 186 patients underwent surgery for CP. Among these, 68 (40%) answered a specific follow-up questionnaire. The body mass index showed a significant increase between pre- and postoperative assessments (21.1 vs. 22.5 p = 0.003). Furthermore, a 60% decrease in the prevalence of chronic pain (81 vs. 21%, p < 0.001) was observed. On the contrary, both exocrine and endocrine pancreatic functions pointed toward a worsening after surgery, with consistent higher rates of patients presenting with diabetes mellitus, as well as patients requiring insulin therapy and oral intake of pancreatic enzymes. The analysis of body composition performed on 40 (24%) patients with a complete imaging pack revealed no significant change in the nutritional status after surgery. Discussion/Conclusion: Despite the good results observed in terms of pain relief, the surgical approach led to a consistent worsening of the global pancreatic function. No significant influence of surgery on the nutritional status of patients was detected.

Surgical Outcomes and Trends for Chronic Pancreatitis: An Observational Cohort Study from a High-Volume Centre.

Surgery for chronic pancreatitis (CP) is considered as a last resort treatment. The present study aims to determine the short- and medium-term outcomes of surgical treatment for CP with a comparison between duodenum-preserving pancreatic head resection (DPPHR) and pancreatoduodenectomy (PD). The trends in surgical procedures were also examined. This was a retrospective cohort study of patients who underwent surgery for CP between 2000 and 2019 at the Karolinska University Hospital. One hundred and sixty-two patients were included. Surgery performed included drainage procedures (n = 2), DPPHR (n = 35), resections (n = 114, of these PD in n = 65) and other procedures (n = 11). Morbidity occurred in 17%, and the 90-day mortality was 1%. Complete or partial pain relief was achieved in 65% of patients. No significant difference in morbidity was observed between the DPPHR and PD groups: 17% vs. 20% (p = 0.728). Pain relief did not differ between the groups (62% for DPPHR vs. 73% for PD, p = 0.142). The frequency of performed DPPHR decreased, whereas the rate of PD remained unaltered. Surgical treatment for CP is safe and effective. DPPHR and PD are comparable regarding post-operative morbidity and are equally effective in achieving pain relief. Trends over time revealed PD as more commonly performed compared to DPPHR.

The Role of Surgical Management in Chronic Pancreatitis in Children: A Position Paper From the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Pancreas Committee.

Chronic pancreatitis (CP) is rare in childhood but impactful because of its high disease burden. There is limited literature regarding the management of CP in children, specifically about the various surgical approaches. Herein, we summarize the current pediatric and adult literature and provide recommendations for the surgical management of CP in children. The literature review was performed to include the scope of the problem, indications for operation, conventional surgical options as well as total pancreatectomy with islet autotransplantation, and outcomes following operations for CP. Surgery is indicated for children with debilitating CP who have failed maximal medical and endoscopic interventions. Surgical management must be tailored to the patient's unique needs, considering the anatomy and morphology of their disease. A conventional surgical approach (eg, drainage operation, partial resection, combination drainage-resection) may be considered in the presence of significant and uniform pancreatic duct dilation or an inflammatory head mass. Total pancreatectomy with islet autotransplantation is the best surgical option in patients with small duct disease. The presence of genetic risk factors often portends a suboptimal outcome following a conventional operation. The morphology of disease and the presence of genetic risk factors must be considered while determining the optimal surgical approach for children with CP. Surgical outcomes for CP are variable and depend on the type of intervention. A multidisciplinary team approach is needed to assure that the best possible operation is selected for each patient, their recovery is optimized, and their immediate and long-term postoperative needs are well-met.

Impact of myopenia and myosteatosis in patients undergoing abdominal surgery for chronic pancreatitis

BackgroundSurgery for chronic pancreatitis is associated with major morbidity and mortality. The aim of this study is to examine the role of preoperative muscle volume and quality on postoperative outcomes in patients with chronic pancreatitis. MethodsAll patients who underwent abdominal surgery for chronic pancreatitis between 2011 and 2018 were identified from an institutional surgical database. Patient demographics, clinical indices, and perioperative computed tomography scans were collected. Myopenia and myosteatosis were measured at the L3 vertebral level. Regression analysis was used to identify risk factors for major complications (Clavien-Dindo ≥3a) and length of stay. ResultsSeventy-five patients were identified. Toxic-metabolic or obstructive causes were the main underlying etiologies. Thirty patients were myopenic (40%), and 36 patients were myosteatotic (48%). Sixteen patients (21%) had a major complication. Median length of stay was 10 days. Both myopenia and myosteatosis were associated with major complications (hazard ratio = 7.85, 95% confidence interval: 1.91–32.29, P = .004 and hazard ratio = 4.351, 95% confidence interval: 1.22–15.52, P = .023). Myosteatosis was associated with increased length of stay (parameter estimate = 0.297, 95% confidence interval: 0.012–0.583, P = .041). ConclusionMyopenia and myosteatosis were common and significant risk factors for adverse postoperative events. Preoperative muscle assessment may help in the risk stratification of surgical patients and identify patients that require preoperative nutritional and physical optimization.

LigaSure Vessel Sealing System for Small Bowel Transection During Roux Limb Construction.

Roux limb construction is an essential part of several major reconstructive hepatobiliary and upper gastrointestinal surgeries. This can be achieved with a stapling device or suturing. For over two decades, the LigaSure vessel sealing systems (Medtronic, MN, USA) have been in use for omental division, mesenteric transection, and sealing of vessels. We used the LigaSure vessel sealing system with a ForceTriad energy platform (Medtronic) for transection of the bowel during the formation of the Roux limb for a Roux-en-Y reconstruction. Between July 2019 and December 2020, patients who had Roux limb construction as part of a pancreato-enteric anastomosis in surgery for chronic pancreatitis were analysed. The data was reviewed from a prospectively maintained database. Fifteen patients had undergone surgery for chronic pancreatitis. The mentioned technique takes approximately eight minutes to construct a Roux limb. There was no bleeding from the gut ends that had been transected. There was no breach in the bowel’s seal. The field was free of enteric contamination. In the post-operative course of these individuals, there was no Roux limb-related morbidity. This procedure is useful because it is cost-effective, time-saving, dependable, and prevents contamination and blood loss. It is also simple to learn and apply.

Optimal time for surgical treatment of chronic pancreatitis or optimal surgery?

Background. The majority of studies on the surgical treatment of chronic pancreatitis (CP) compare treatment outcomes by the type of the procedure. However, some studies, especially systematic reviews and meta-analyses, indicate the equality of different surgeries by their long-term results. During last 5–9 years, several studies showed advantages of early surgery in chronic pancreatitis, within three years after symptoms onset. Objective: to analyze the short- and long-term results of surgical treatment for chronic pancreatitis regarding timing and, accordingly, the neglect of the disease. Materials and methods. Retrospective analysis of data of 147 patients from 2001 to 2020, the main intervention was surgery aimed at the main manifestations of CP, such as pancreatic ductal and/or parenchymal hypertension. Patients who suffered from CP symptoms 3 years or more were included in the control group (late surgery), and those who noted symptoms of CP for less than 3 years were included in the study group (early surgery). All patients completed the EORTC QLQ-30, SF-36 questionnaires, as well as the questionnaire developed by the study authors, via telephone or mail, or during the visit. Results. According to all scales of the SF-36 questionnaire, except for Physical functioning, the group of early surgery prevails over the group of late surgery. The early surgery group had the best average scores on all functional scales of the EORTC QLQ-30 questionnaire compared to the late surgery group, except for the Cognitive functioning. Of the symptomatic scales, the early surgery group had the best averages on Pain and Diarrhea. The average Health/Quality of life scale was significantly better in the early surgery group. Conclusions. The quality of life, pain control, pancreatic function in patients operated within 3 years from the onset of CP symptoms were better compared to those with longer disease duration, with the same short-term results. The duration of the disease is a major factor for the success of surgical treatment of chronic pancreatitis in terms of long-term results. The early surgery is effective approach to obtain better long-term outcomes in chronic pancreatitis.