Surgical Treatment Of Chronic Pancreatitis Research Articles

Transduodenal Extended Sphincteroplasty and Removal of Ventral Duct Pancreatic Calculi

The surgical treatment of chronic pancreatitis and associated ductal calculi typically involves drainage of the main pancreatic duct or parenchymal resection. Treatment of isolated symptomatic pancreatic duct calculi is usually approached by endoscopic techniques. Herein is described a case report of operative transduodenal extraction of symptomatic pancreatic calculi of the ventral pancreas in a patient with a prior distal pancreatectomy. This case represents an uncommon yet valuable option in selected patients in whom endoscopic treatments have failed or are unavailable.

Surgical treatment for chronic pancreatitis: results of pancreatic duct drainage operation and pancreatic resection.

Between 1978 and 1999, 86 patients with chronic pancreatitis were surgically treated at the Surgical Department of Kurume University Hospital. Of these patients, 30 were treated by pancreatic duct drainage operation (drainage operation), while 40 were treated by pancreatic resection, and the results were compared between the two groups. In patients who underwent drainage operation, pain disappeared in 85.7%, slightly relieved in 10.7%, and not relieved in 3.6%. In patients who underwent pancreatic resection, pain disappeared in 73.4%, slightly relieved in 13.3%, and not relieved in 13.3%. Therefore, there was no significant difference in the pain-relieving effect between the two groups. However, the pain-relieving effect was poorer in patients who underwent pancreatic resection than in those who underwent drainage operation. In addition, all patients who showed poor results for pain relief had alcoholic pancreatitis. Endocrine and exocrine functions of the pancreas were improved in 6, maintained in 2, and exacerbated in 4 patients who underwent drainage operation. In patients who underwent pancreatic resection, endocrine and exocrine function of the pancreas were improved in 3, maintained in 3, and exacerbated in 13. Therefore, endocrine and exocrine function of the pancreas were poorer in patients who underwent pancreatic resection than in those who underwent drainage operation. Distant results in patients who underwent drainage operation were good in 75.0%, fair in 15.0%, and poor in 10.0%. In patients who underwent pancreatic resection, distant results were good in 80.0%, fair in 13.3%, and poor in 6.7%. Therefore, favorable distant results were obtained in both groups. These findings suggest that surgical techniques that preserve functions of the pancreas should be selected during surgical treatment for chronic pancreatitis. We consider that the presence or absence of main pancreatic duct dilation and the site of pancreatic lesions are important indices for selecting surgical techniques. Therefore, drainage operation consisting of pancreaticojejunostomy should be indicated for patients with main pancreatic duct dilation, while pancreatic resection should be indicated for those without main pancreatic duct dilation, those with localized pancreatic lesions, and those with suspected pancreatic cancer.

Outcome of Surgical Treatment of Chronic Pancreatitis Associated with Sphincter of Oddi Dysfunction

The clinical management of patients with chronic pancreatitis (CP) associated with sphincter of Oddi dysfunction (SOD) presents many challenges. The aim of this study was to evaluate patient outcome after surgical management of CP associated with SOD intractable to medical management. The records of patients with CP and SOD who underwent surgical treatment between 1994 and 1998 were retrospectively reviewed and analyzed. Manometry of biliary and pancreatic ducts was performed. Basal pressures were considered abnormal if > or = 40 mm Hg for at least 30 seconds. Endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, and clinical criteria were utilized in the diagnosis of CP. Quality-of-life issues were assessed. Twenty-nine patients were identified (21 women and eight men) with a mean age of 43.3 years (range 24-54). Mean basal biliary and pancreatic sphincter pressures were 155.1 and 90.4 mm Hg respectively. Chronic pancreatitis was graded as mild in nine patients, moderate in six, severe in two, and normal or equivocal in 12 patients according to the Cambridge classification. A Whipple procedure was performed in 17 (59%) patients, lateral pancreaticojejunostomy in nine (31%), and distal resections or a combination of procedures in three (10%). The morbidity and mortality rates were 21 and 0 per cent respectively. Mean follow-up was 30 months (range 3-48). Pain relief ranging from fair to excellent was seen in 83 per cent of patients with pain scores decreasing from an average of 9 (scale 1-10) before surgery to 3 postoperatively. Seventy per cent maintained their weight, 45 per cent continued to require pancreatic enzyme supplementation, and there were no changes in the status of diabetes. Rehospitalizations for recurrent pancreatitis or persistent pain were necessary in 24 per cent of patients. Surgical management of patients with CP and SOD who fail medical management is safe and effective in most patients. Operative morbidity and mortality are low, and the majority of patients have improvement in pain, although some require rehospitalization for recurrent pancreatitis and chronic pain.

Operative management of chronic pancreatitis in children.

Chronic pancreatitis in childhood is a rare but potentially debilitating disorder, and failure of conservative therapy with chronic pain medication use is common. We hypothesize that aggressive surgical therapy may hold promise for long-term remission. Retrospective analysis of data collected prospectively for 12 years. Tertiary care children's hospital. Eighteen children (aged 3-13 years, 11 girls) underwent surgical treatment of chronic pancreatitis after 1 to 6 years of various medical therapies (parenteral nutrition, somatostatin, or pain medication). These patients required a mean +/- SD 6 +/- 0 hospitalizations before operation. Pancreatitis was familial in 9 patients, idiopathic in 5, and secondary to trauma and medication use in 2 each. Preoperative endoscopic retrograde cholangiopancreatography showed pancreatic duct dilatation in 7, strictures in 5, ductal stones in 4, and normal findings in 2. The operative therapy consisted of longitudinal pancreaticojejunostomy in 2 children (both children failed pancreaticojejunostomy but improved after undergoing pancreatectomy) and distal pancreatectomy with Roux-en-Y pancreaticojejunostomy in 16 children. Survival, need for rehospitalization or reoperation, and chronic pain medication requirements. All patients survived. Follow-up ranged from 1 to 15 years. Thirteen (72%) of 18 patients have required no further hospitalizations or medications. Two patients required a second operation to convert their longitudinal pancreaticojejunostomy to distal pancreatectomy, and 3 patients have required 2 to 5 additional hospitalizations for recurrent pancreatitis. Endoscopic retrograde cholangiopancreatography on 5 patients 2 to 4 years postoperatively showed patent distal pancreaticojejunostomy. This series suggests that distal pancreatectomy and pancreaticojejunostomy are effective treatments for this difficult group of patients, while longitudinal pancreaticojejunostomy was ineffective. Long-term relief of pain and reduced need for rehospitalization are the usual results after this procedure.

Surgery and Pancreas Divisum: A Dwindling Role?

Pancreas divisum has generated varying enthusiasm regarding operative intervention. Applying similar principles to divisum surgery as for the surgical treatment of chronic pancreatitis will yield a better outcome than using subjective symptoms.

Intraoperative Sonographically Guided Wire Cannulation of the Pancreatic Duct for Patients Undergoing a Puestow Procedure

1639 atients with chronic pancreatitis refractory to medical treatment may be candidates for a lateral pancreaticojejunostomy, also known as the Puestow procedure [1]. In this procedure, the pancreatic duct is marsupialized and anastamosed to a Roux loop of jejunum (Fig. 1). The Puestow procedure was first performed in the 1950s and is the mainstay surgical treatment for chronic pancreatitis because it preserves islet cell function while providing adequate exocrine drainage in patients with multiple pancreatic duct strictures. Patients with chronic pancreatitis often have chronic inflammation and fibrosis in the lesser sac, making surgical exposure of the pancreatic duct time-consuming and technically challenging and increasing the morbidity and mortality associated with the procedure. It is desirable to localize the pancreatic duct with minimal dissection to prevent iatrogenic pancreatitis. Intraoperative sonography is a useful tool for defining the pancreatic duct, pancreatic calcifications, and strictures, as well as adjacent vascular structures [2]. This report describes an intraoperative sonographically guided technique for placement of a guidewire longitudinally through the pancreatic duct, enabling the surgeon to reliably localize the duct and thus minimize operative time and morbidity. Subject and Methods A 44-year-old alcoholic man with multiple episodes of acute relapsing pancreatitis refractory to medical therapy was referred for a lateral pancreaticojejunostomy. Preoperative CT revealed findings consistent with chronic pancreatitis, including pancreatic calcifications and a minimally dilated pancreatic duct. Endoscopic retrograde cholangiopancreatography confirmed the calcifications and also showed ductal strictures and dilatations throughout the pancreatic gland. Intraoperative Sonographically Guided Wire Cannulation of the Pancreatic Duct for Patients Undergoing a Puestow Procedure William W. Mayo-Smith 1 , David A. Iannitti 2 , Damian E. Dupuy 1

Changing trends in operations for chronic pancreatitis: a 22-year experience.

To report the evolution of methods of surgical treatment of chronic pancreatitis. Retrospective analysis. Private clinic, USA. 448 consecutive patients who were operated on for chronic pancreatitis. Resection (n = 286) or drainage of the duct (n = 162). Changes over the 22-year period. There was a change towards resection after 1985 (195/238, 59%, from 1976-90 compared with 91/120, 76%, from 1991-97), partly because of suspicions of malignancy. In recent years (1991-97) pylorus-preserving pancreaticoduodenectomy has come to be preferred over classic resection including antrectomy (22/36, 61%, compared with 11/69, 16%). Eight duodenum-preserving resections have been done since 1994. More resections, particularly proximal pancreatectomies, are done nowadays. Lateral pancreaticojejunostomy has become the preferred drainage procedure, and pylorus-preserving pancreaticoduodenectomy is favoured over classic pancreaticoduodenectomy.

Long-Term Results After Surgery for Chronic Pancreatitis

To determine the early and late morbidity and mortality after surgical treatment of chronic pancreatitis. We determined long-term outcome and early and late morbidity and mortality, respectively, in 484 consecutive patients undergoing surgery for chronic pancreatitis from 1976 through 1997. Sixty-five percent of the patients had small duct disease (main pancreatic duct <7 mm), whereas 35% had large duct disease. Indications for operation were pain (95%), suspicion of malignancy (28%), and complications involving adjacent organs (35%). Pseudocysts were present in 27% of patients. Hospital morbidity (8 vs 23%, p = 0.0002) and mortality (0 vs 1.9%, p = 0.12) were less after drainage procedures (n = 162) than after pancreatic resections (n = 286). Among resectional procedures, total pancreatectomy had the highest 30-d operative mortality (5%) and morbidity rates (47%), followed by pancreatoduodenectomy (3 and 32%, respectively). The best results with pain relief occurred after proximal pancreatic resection (89% after mean follow-up of 6.5 yr). The number of patients able to function normally after surgical treatment increased from 39 to 79% (p < 0.001). Long-term survival of our patients was lower than expected rates based on Minnesota life tables analysis (p < 0.0001) especially in alcoholics. Patients undergoing a ductal drainage procedure had the longest survival, whereas those after total pancreatectomy had the shortest survival (p = 0.06). Pancreatic insufficiency, peptic ulcer, and/or anastomotic ulcers caused significant morbidity after total pancreatectomy and pancreatoduodenectomy. A small percentage (3%) developed pancreatic cancer. Operative treatment of chronic pancreatitis, when indicated, can be performed safely with good results in terms of pain relief and quality of life. Resectional procedures (especially total pancreatectomy) are associated with higher early and late morbidity, greater perioperative mortality, and lower survival rates compared with drainage procedures. Abstinence from alcohol is associated with longer survival rates, which, however, still remain lower than expected rates.

Drainage versus resection in surgical treatment of chronic pancreatitis: Prospective randomized trial comparing the frey procedure with pylorus-preserving pancreatoduodenectomy

Drainage versus resection in surgical treatment of chronic pancreatitis: Prospective randomized trial comparing the frey procedure with pylorus-preserving pancreatoduodenectomy

Surgical Treatment of Chronic Pancreatitis: New Standards

Surgical Treatment of Chronic Pancreatitis: New Standards

First Experiences with Duodenum-Preserving Resection of the Head of the Pancreas in the Treatment of Chronic Pancreatitis

A new procedure, duodenum-preserving resection of the head of the pancreas, has been developed for the surgical treatment of chronic pancreatitis with inflammatory enlargement of the pancreatic head.

The Surgical Spectrum of Hereditary Pancreatitis in Adults

The role of operative intervention for hereditary pancreatitis, a rare form of chronic parenchymal destruction, is unclear. To determine whether surgical therapy is safe and provides prolonged symptomatic relief, the authors reviewed the management of 22 adults (11 men, 11 women) with hereditary pancreatitis treated surgically between 1950 and 1989. Hereditary pancreatitis was defined as a family history of two or more relatives with pancreatitis and clinical, biochemical, or radiologic evidence of pancreatitis. The mean ages at onset of symptoms and at operation were 15 years (range, 3 to 52 years) and 31 years (range, 18 to 54 years), respectively. Pain was the primary indication for operation in all patients. Additional symptoms included nausea, vomiting (73%), weight loss (55%), and diarrhea (41%). Ductal dilatation was present in 68%, pancreatic parenchymal calcifications in 73%, pseudocysts in 36%, and splenic vein thrombosis in 18%. Primary operations included ductal drainage in 10 patients, pancreatic resection alone in three, resection with drainage in three, cholecystectomy plus sphincteroplasty in two, cholecystectomy with or without common bile duct exploration in two, pancreatic abscess drainage in one, and pseudocyst drainage in one. There were no perioperative deaths, and the morbidity rate was 14% (intra-abdominal abscess, wound infection, and urinary tract infection). Symptoms recurred in nine patients. Severity prompted reoperation in five. Secondary operations included pancreatic resection in three, pseudocyst excision in one, and pancreaticolithotomy in one. Follow-up to date is complete and extends for a median of 85 months. Eighteen patients (82%) are clinically improved or asymptomatic. Symptoms have persisted in four patients, and two patients have died of pancreatic carcinoma. Two patients died of unrelated causes. Surgical therapy for patients with hereditary pancreatitis selected on the basis of the traditional indications for surgical treatment of chronic pancreatitis is safe and efficacious.

慢性すい炎の外科治療成績

1971年1月より1990年12月までの慢性膵炎手術症例78例の外科治療成績について検討を加えた.痔痛改善は膵管空腸側々吻合術の81%, 膵切除術の100%, のう胞ドレナージ術の91%, 膵頭切離兼体尾部授動術の100%, 胆道手術の100%にみられ, いずれの術式もほぼ満足すべき結果が得られている.術後耐糖能異常は膵管空腸側々吻合術の11%に対して膵切除術では35%にみられた, 術後の社会活動では膵管空腸側々吻合術の19%に対して膵切除術では, 35%の不良例がみられた.以上より慢性膵炎の外科治療の主目的である除痛に対しては, 膵管拡張症例には膵管空腸側々吻合術を, 膵管非拡張症例には膵頭切離兼体尾部授動術などの膵機能を温存した術式を選択すべきと考える.

Surgical Treatment of Chronic Pancreatitis: Indications and Results in 246 Consecutive Patients

From 1972 to 1986, 246 patients, with a large majority of alcoholics, were operated on for chronic pancreatitis. Mean age was 44.2 ± 23.4 years and the male/female sex ratio was 217/29. In 223, 22 and 1 patients, 1, 2 or 3 laparotomies were performed, respectively. In 12 patients laparotomy was only explorative. In all others, at each laparotomy, 1 surgical procedure was performed in 207 patients, 2 procedures in 42, 3 procedures in 8 and 4 procedures in 1. These various procedures were as follows: external drainage: 17; biliary, gastric, pancreatic, cystic internal diversions: 142; distal pancreatectomy: 51; pancreaticoduodenectomy: 47; total pancreatectomy: 1. Abdominal pain was the most frequent symptom (60%). Morphological features other than pancreatic abnormalities were frequent: biliary and duodenal obstructions account for 40 and 23.5% of the surgical indications, respectively. The choice among these numerous surgical options are presented in detail and discussed. Overall operative mortality was 7.7% (patients), 7% (laparotomy), 9% in the resection group and 5.8% in the other group. Our best long-term results were observed after the Whipple procedure with a 15-year survival rate of 74.5%.

Surgical management of chronic pancreatitis on the continent of Europe

Surgical management of chronic pancreatitis remains a difficult problem. On the continent of Europe, the main etiology of the disease is alcoholism; thus, alcohol withdrawal is mandatory before surgical treatment. Left splanchnicectomy is no longer used. Total and left subtotal pancreatectomy are abandoned due to their high mortality rates and their severe metabolic sequelae. Distal pancreatectomy is presently reserved for the cases in which the head of the pancreas is least involved. The choice between pancreaticojejunostomy and pancreaticoduodenectomy remains debated. The former has a low postoperative mortality rate while reoperation is less frequent after the latter. Current trends in Europe are to perform more anastomoses and less resections than some years ago. Pancreaticoduodenectomy, however, retains an important role in cases with biliary or duodenal involvement. Whatever the choice of the procedure, the surgical treatment of chronic pancreatitis remains palliative and does not alter the natural course of the disease. The quality and duration of the results depend mainly on alcohol withdrawal.

慢性すい炎 すい切除術

慢性すい炎 すい切除術

Follow-Up Results of Surgical Treatment in Chronic Pancreatitis

Between 1968 and 1981, 138 patients (101 male and 37 female) with a mean age of 38 years were operated on for chronic pancreatitis at the Department of General Surgery, University of Göttingen. Pathogenetic factors were alcohol abuse in 65%, biliary diseases in 14% and unknown in 20%. Surgical therapy included 51 resections (37%) (4 total pancreatectomies, 24 Whipple’s procedures and 23 left pancreatectomy). Drainage operations were performed in 68 patients (49%) (24 pancreaticojejunostomies and 44 cystojejunostomies). Intervention of neighboring organs were performed 23 times. The mean follow-up period was 10 years (4–14 years), the late mortality rate in drainage operations (15 and 19%) was twice as high as after resection procedures (7.5%). Recurrences occurred in 16 % after resections but in 41 % after drainage operations. Latent or manifest diabetes was observed in 21 % after drainage operations but in 63% in the resection group. From these data we conclude that both alcohol withdrawal and the type of planned operations are important factors in the prognosis of chronic pancreatitis.

The Role of Surgical Treatment for Chronic Pancreatitis

During the last 25 years, 134 patients with chronic pancreatitis were treated surgically in our clinic. According to intraoperative measurement of the pancreatic intraductal pressure, both perfusion pressure and residual pressure in the patients with dilated pancreatic duct were significantly higher than those in control patients. Operative procedures included side-to-side pancreaticojejunostomy in 47 patients, 40%-80% caudal pancreatectomy in 28, pancreaticoduodenectomy in 16, pancreatic sphincteroplasty in 10, and others. The effect of operation on abdominal pain was noted in 97% of the patients. The study of operative effect on abdominal pain and follow-up results showed the excellent maintenance of operative benefit. Surgical treatment, however, could not help improve impaired function of the pancreas. Ten of 34 late deaths were related to the failure of controlling diabetes. Therefore, long-term follow-up care to the pancreatic dysfunction is considered to be necessary even after complete relief of abdominal pain.

CLINICAL FOLLOW-UP STUDY OF OPERATIVE TREATMENT FOR CHRONIC PANCREATITIS

Follow-up results of operative treatment for chronic pancreatitis were studied with reference to five indicators, i.e., body weight, effect on relief from pain, pancreatic exocrine and endocrine functions, and social rehabilitation, in 34 patients operated on from June 1974 to May 1984 in our institution. Surgical death did not occur in any cases. The interval observed after operation was at least one year in every patient. Increased body weight was observed in 8 patients (23.5%) especially in the group that underwent drainage operation for dilated puncreatic duct (60%). Some of the patients with alcoholic pancreatitis showed an increase when they avoided the use of alcohol. The effect on the removal of pain by surgical treatment in spite of difficulty with palliative control was significant, except for cystogastrostomy or cystojejunostomy. The decrease in exocrine and endocrine functions after surgical treatment was progressive, and those in the group with resected pancreas were the worst, of three patients whe did not achieve normal social rehabilitation, one had abdominal pain and the other two have continued to drink alcohol. It is considered that the appropriate selection of operative procedures and self-control on the part of the patients are important factors in the development of the results of surgical treatment for chronic pancreatitis.

Surgical treatment of chronic pancreatitis

We studied the course of 100 consecutive patients who underwent surgery for pain or biliary obstruction from chronic pancreatitis or both between 1958 and 1982. Patients with pancreatic pseudocysts were excluded. Ten patients had pancreatic resection after previous pancreatic surgery had failed to control pain. Ten of 47 patients (21 percent) studied between 1972 and 1981 had bile duct entrapment from chronic pancreatitis and required biliary bypass operations. The results of longitudinal pancreaticojejunostomy were good in 67 percent of the patients, fair in 18 percent of the patients, and poor in 15 percent of the patients. The results of partial pancreatectomy were good in 60 percent of the patients (all with disease limited to the tail), fair in 20 percent of the patients, and poor in 20 percent of the patients. The results of subtotal pancreatectomy were good in 31 percent of the patients, fair in 37 percent of the patients, and poor in 32 percent of the patients. The results of pancreatic resection in patients with previous unsuccessful surgery for pain relief were good in only 10 percent of the patients. Biliary obstruction is present in many patients with chronic pancreatitis and must be treated surgically to prevent the development of biliary cirrhosis. Hemipancreatectomy is useful in patients with disease limited to the tail. The results of subtotal pancreatectomy are discouraging, especially in patients with a previous unsuccessful operation for pain. When the pancreatic duct is dilated, however, longitudinal pancreaticojejunostomy gives longlasting relief of pain in most patients.