Surgical Therapy Of Chronic Pancreatitis Research Articles

Surgery for chronic pancreatitis: the comparison of two high-volume centers reveals lack of a uniform operative management

PurposeMany aspects of surgical therapy for chronic pancreatitis (CP), including the correct indication and timing, as well as the most appropriate operative techniques, are still a matter of debate in the surgical community and vary widely across different centers. The aim of the present study was to uncover and analyze these differences by comparing the experiences of two specialized surgical units in Italy and Austria.MethodsAll patients operated for CP between 2000 and 2018 at the two centers involved were included in this retrospective analysis. Data regarding the clinical history and the pre- and perioperative surgical course were analyzed and compared between the two institutions.ResultsOur analysis showed a progressive decrease in the annual rate of pancreatic surgical procedures performed for CP in Verona (no. = 91) over the last two decades (from 3% to less than 1%); by contrast, this percentage increased from 3 to 9% in Vienna (no. = 77) during the same time frame. Considerable differences were also detected with regard to the timing of surgery from the first diagnosis of CP — 4 years (IQR 5.5) in the Austrian series vs two (IQR 4.0) in the Italian series -, and of indications for surgery, with a 12% higher prevalence of groove pancreatitis among patients in the Verona cohort.ConclusionThe comparison of the surgical attitude towards CP between two surgical centers proved that a consistent approach to this pathology still is lacking. The identification of common guidelines and labels of surgical eligibility is advisable in order to avoid interinstitutional treatment disparities.

II-4．外科治療に関する改訂点と病態進行阻止に向けた外科治療の役割

2015年に改訂された慢性膵炎診療ガイドラインの外科治療に関する改訂の要点を紹介した．内視鏡ステント治療施行不能例や不成功例には，外科治療が推奨される点に関しては，2009年の旧ガイドラインに比較して大きな改訂点はない．ただし，膵管拡張を伴い膵頭部病変を伴う症例の難治性腹痛に対する術式選択として，Frey手術のほうがBeger手術よりも周術期合併症の頻度が少なく，我が国ではBeger手術はほとんど行われていないことから，Frey手術が推奨されている．また，慢性膵炎の機能温存を目的とした外科治療の適応としての記載がなされ，代償期慢性膵炎に対して，膵内外分泌機能障害の進行を遅らせる目的で膵管ドレナージ術を行うことが提案されている．

Is TPIAT the answer for treatment of chronic pancreatitis?

Traditional surgical therapy for chronic pancreatitis includes drainage of the dilated pancreatic duct or segmental resection of affected pancreas. Another option gaining increasing favour is that of total pancreatectomy with islet autotransplantation (TPIAT). A consensus conference, with proceedings published in 2013, discusses the current state-of-the-art information surrounding this procedure, and outstanding questions.

Perioperative and follow-up results in chronic pancreatitis patients after pancreatic resection

Surgical therapy for chronic pancreatitis is reserved for patients with intractable abdominal pain, complications of the disease, or suspected underlying carcinoma. Pancreatic resection can be performed safety with good postoperative results. Between January 1996 and December 2009, the findings for 90 consecutive patients suffering from chronic pancreatitis were analyzed in prospective trial. Short-term results - postoperative complications were investigated 30 days after surgery. Long-term follow-up results, including quality of life (QoL) assessment using visual analog scale of pain (VAS), Karnofsky performance scale (KPS), and EORTC Quality of Life Questionnaire (QoL-C30) were carried out. The influence of postoperative complications on long-term quality of life was documented. The overall mortality rate and morbidity rate were 3.3% (3 patients) and 27.7% (25 patients), respectively. Surgically related morbidity rate was 21.1% (19 patients). Long-term follow-up was investigated in 65 patients (72%). The median pain score decreased using VAS from 8 to 1 and using KPS increased from 50 to 100 (p < 0.0001). During the follow-up, the median global QoL improved by 100%. Apart from the cognitive functioning, the physical status, working ability, and emotional and social functioning all improved significantly (p < 0.0001). The presence of postoperative complications had no significant influence on long-term quality of life. Surgery for patients with chronic pancreatitis can be performed safely with minimal morbidity and very good long-term results.

What Drives Pain in Chronic Pancreatitis?

Purpose: Considering the often persistent pain despite endoscopic or surgical therapy of chronic pancreatitis (CP), we hypothesized that pain and opioid use are significantly affected by factors other than pancreatic disease. Methods: Medical records of patients with established CP seen in the Digestive Disorders Center of the University of Pittsburgh Medical Center between April 2008 and December 2009 were reviewed. Information was collected on demographics, etiology, presence of pain, pain rating, opoid use, self-assessed quality of life (HLQ4), psychiatric and medical co-morbidities, medication use, diagnostic testing, prior surgeries, local complications, emergency room (ER) visits and hospitalizations. Results: A total of 150 patients (53% men; age: 50.1±1.3 years) were identified. The etiologies included alcohol (n=50), idiopathic (n=48), hereditary (n=17), autoimmune (n=10), and miscellaneous causes (n=26). The average pain rating for the entire group was 2.5±0.3 with 41% of the patients complaining about moderate or severe pain. More than half of the patients (57%) received opioids (average morphine equivalent: 42.0±7.1 mg/day) with 22% taking long-acting agents. In univariate analysis, only pancreatic pseudocysts (r2=0.22) but neither etiology of CP nor other morphological changes correlated significantly with pain severity. Pain ratings significantly correlated with opioid use (r2=0.47), coexisting anxiety and/or depression (r2=0.18) and a prior diagnosis of illnesses associated with pain (r2=0.25), such as migraine and fibromyalgia. Results were similar after stratification of data by presence of pain. A subgroup of 111 patients was followed for 9.5±0.5 months amounting to a total of 1051 patient-months. During this period, patients had 108 ER visits, were hospitalized 88 times, underwent 176 CT scans, 53 ERCPs, 29 MRCPs, 24 EUS and a total of 20 abdominal surgeries. Pain rating (2.4±0.3) and opioid use during the follow up period remained stable. Focusing on hospitalizations, only disease duration (r2= -0.172) and psychiatric comorbidity (r2=0.21), but not pain correlated with inpatients days or the use of diagnostic testing. Conclusion: Consistent with current approaches to pancreatic disease, pseudocysts are associated with pain. However, none of the other changes in pancreatic morphology, from ductal dilation to stones, predicted pain presence or severity. The correlation between pain in CP and other illnesses defined by chronic pain, suggests that emotional and cognitive factors play an important role in the clinical manifestations of CP. Successful management thus needs to go beyond treatment of changes in pancreatic morphology to effectively improve quality of life and perhaps even reduce utilization of resources.

The Evolution of the Surgical Treatment of Chronic Pancreatitis

To establish the current status of surgical therapy for chronic pancreatitis, recent published reports are examined in the context of the historical advances in the field. The basis for decompression (drainage), denervation, and resection strategies for the treatment of pain caused by chronic pancreatitis is reviewed. These divergent approaches have finally coalesced as the head of the pancreas has become apparent as the nidus of chronic inflammation. The recent developments in surgical methods to treat the complications of chronic pancreatitis and the results of recent prospective randomized trials of operative approaches were reviewed to establish the current best practices. Local resection of the pancreatic head, with or without duct drainage, and duodenum-preserving pancreatic head resection offer outcomes as effective as pancreaticoduodenectomy, with lowered morbidity and mortality. Local resection or excavation of the pancreatic head offers the advantage of lowest cost and morbidity and early prevention of postoperative diabetes. The late incidences of recurrent pain, diabetes, and exocrine insufficiency are equivalent for all 3 surgical approaches. Local resection of the pancreatic head appears to offer best outcomes and lowest risk for the management of the pain of chronic pancreatitis.

Is portal vein obstruction with cavernomatous transformation of the portal vein a contraindication for surgical therapy of chronic pancreatitis?.

Is portal vein obstruction with cavernomatous transformation of the portal vein a contraindication for surgical therapy of chronic pancreatitis?.

Surgical options in the patient with chronic pancreatitis.

There are a number of indications for surgical intervention in chronic pancreatitis, but the most common is intractable pain. Many surgical procedures can be applied in the patient with chronic pain, and the variety of procedures reflects the fact that no single procedure is ideal for all patients. Duct drainage procedures are safe and have a significant response rate, but only about one third of patients experience long-lasting complete relief of pain. Procedures that combine resection and duct drainage are generally more effective, with long-term success rates in the 80% range. The development of the Frey and Beger procedures, two methods for pancreatic head resection that preserve the anatomy of the stomach, duodenum, and bile duct, represents an advance in surgical therapy of chronic pancreatitis. Total pancreatectomy with islet autotransplantation is a procedure that may be appropriate in certain subsets of patients. Thoracoscopic splanchnicectomy is a new, minimally invasive procedure, still in evaluation, which may become a very valuable method when the sole indication for surgery is intractable pain.

Surgical therapy of chronic pancreatitis: the devil's advocate commentary

Chronic pancreatitis is despite increasing incidence a rare disease. Studies about its natural history are sparse. Undisputed indication for operative intervention are local complications. Intractable pain without such local complications should only seldom be an indication for pancreatic surgery. Since very different surgical procedures are performed in similar anatomical situations randomized prospective studies are needed. The problems of controlled studies in surgery are discussed.

Differences in the (Nonalcoholic) and Natural History of Idiopathic Alcoholic Chronic Pancreatitis. A Comparative Long-Term Study of 287 Patients

Controversies in the literature regarding definition, diagnosis, and therapy of chronic pancreatitis may be related in part to differences in the natural history of alcoholic and idiopathic (nonalcoholic) chronic pancreatitis. In order to evaluate this problem the long-term course of 205 patients with alcoholic (85.4% with calcifications) (group A) and 82 patients with idiopathic (nonalcoholic) chronic pancreatitis (76.8% with calcifications) (group B) has been analyzed prospectively since 1963. The patients were studied at regular intervals with particular regard to pain, pancreatic exocrine, and endocrine function and calcifications. The observation time was 2 years or longer in 230 patients with a median observation time of 6.7 years from diagnosis in group A and 10.6 years in group B. In group B over 50% of the cases had primary painless chronic pancreatitis. Progressive deterioration of exocrine and endocrine function was observed in both groups. However, in group A the rate of progression of exocrine dysfunction after diagnosis was more rapid and the incidence of diabetes in relation to marked exocrine insufficiency was much higher than in group B. Steatorrhea preceded diabetes in 56% (group A) and 80% (group B), respectively. Onset of pancreatic calcifications was closely associated with pancreatic exocrine insufficiency in group A in contrast to group B. In addition lasting pain relief occurred spontaneously in about 30% of patients in group B despite a normal exocrine function for 6 years or longer which is in disaccord with the results in alcoholic chronic pancreatitis. In conclusion group A and B have many features in common, in particular the high incidence of pancreatic calcifications and the progressive pancreatic dysfunction. However, the long-term profile of both groups differs in some important aspects, particularly in the clinical pattern and in the rate of progression of pancreatic dysfunction and morphology. These differences should be appreciated in the discussion of problems regarding definition, diagnosis, and surgical therapy of chronic pancreatitis.

Surgical therapy for chronic pancreatitis: Selecting the appropriate approach

Surgical therapy of 37 patients with chronic pancreatitis is reviewed. Procedures included longitudinal pancreaticojejunostomy (10), DuVal (5), distal resection (4), pancreaticoduodenectomy (2), sphincteroplasty (7), pseudocyst drainage (6) and other miscellaneous procedures. Complication rates were 30 percent for lateral pancreaticojejunostomy, 28.5 percent for sphincteroplasty and 72.7 percent for resection procedures. The overall complication rate was 54.5 percent, and there were two deaths (5.4 percent). Follow-up is presented on 20 patients, of whom 16 are improved, 2 are unchanged and 2 are worse. Eight patients are dead and nine are lost to follow-up. Ductal anatomy is the most important consideration in the selection of a procedure. Lateral pancraticojejunostomy, when applicable, is the procedure of choice. Resection should be considered when pancreaticojejunostomy has failed or is not indicated with pancreaticoduodenectomy, the procedure of choice in the diffusely diseased gland. Sphincteroplasty should be reserved for use in stenosing papillitis or as an ancillary procedure. Splanchnicectomy can be used for temporary palliation.