Surgical Treatment Of Chronic Pancreatitis Research Articles

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.

Mo1335 - Short- and Long-Term Results of Surgical Treatment for Chronic Pancreatitis: A Single-Center Retrospective Experience in Japan

Mo1335 - Short- and Long-Term Results of Surgical Treatment for Chronic Pancreatitis: A Single-Center Retrospective Experience in Japan

CASE REPORT OF ERRONEOUS SURGICAL TACTICS IN PATIENT WITH CHRONIC PANCREATITIS

Currently, surgical treatment of chronic pancreatitis and its complications is performed by surgeons without necessary experience in pancreatic surgery. It is presented case report of successful surgical treatment of the patient who previously underwent non-radical pancreatic intervention without desired result. Moreover, the name of surgery in medical history did not correspond to true nature of the intervention.

Surgical Treatment for Chronic Pancreatitis: Past, Present, and Future.

The pancreas was one of the last explored organs in the human body. The first surgical experiences were made before fully understanding the function of the gland. Surgical procedures remained less successful until the discovery of insulin, blood groups, and finally the possibility of blood donation. Throughout the centuries, the surgical approach went from radical resections to minimal resections or only drainage of the gland in comparison to an adequate resection combined with drainage procedures. Today, the well-known and standardized procedures are considered as safe due to the high experience of operating surgeons, the centering of pancreatic surgery in specialized centers, and optimized perioperative treatment. Although surgical procedures have become safer and more efficient than ever, the overall perioperative morbidity after pancreatic surgery remains high and management of postoperative complications stagnates. Current research focuses on the prevention of complications, optimizing the patient's general condition preoperatively and finding the appropriate timing for surgical treatment.

Efficacy and safety of extracorporeal shock wave lithotripsy for chronic pancreatitis

Introduction: There is still uncertainty regarding the efficacy and optimal modalities of extracorporeal shock wave lithotripsy (ESWL) in the treatment of chronic pancreatitis. The aims of the present study were to assess the safety and the efficacy of ESWL, either alone or followed by therapeutic endoscopic retrograde cholangiopancreatography (adjuvant ERCP) and to determine predictive factors of efficacy, in a real-life setting.Patients and methods: This study included all consecutive patients who underwent an ESWL in a single University Hospital between 2001 and 2012. The indication for ESWL was obstructive stone(s) of the main pancreatic duct resulting in either painful chronic pancreatitis or recurrent acute pancreatitis. Success was defined by resolution of pain, no analgesic treatment, no acute pancreatitis and no surgical treatment for chronic pancreatitis 6 months after the ESWL.Results: One hundred and forty-six patients were studied; 6/146 (4%) had a complication of ESWL. Among the 132 patients in whom follow-up was completed, 91 (69%) had an adjuvant ERCP. After 6 months of follow-up, 100/132 (76%) patients achieved success. In multivariate analysis, the single significant predictive factor of the success of the ESWL treatment was chronic pain (p = 0.03). Patients who had chronic pain and needed opioid treatment had less chance of success than patients without chronic pain (OR 95%CI 0.31 [0.07–1.14]). We found no difference in the success rates between patients who underwent adjuvant ERCP and those who had ESWL only (p = 0.93).Conclusion: This study shows that the ESWL is a safe and effective treatment for patients with chronic pancreatitis and obstructive stones within the main pancreatic duct. Systematic association with therapeutic ERCP appears to provide no additional benefit and is therefore not recommended.

Chronic fibrous-degenerative pancreatitis with involvement of adjacent organs and their dysfunction: contemporary approaches to surgical treatment.

Presently, there is no single opinion concerning the method preferable for surgical treatment of chronic pancreatitis (CP) with dysfunction of adjacent organs. Surgical treatment was applied to 144 patients with CP. In 54 (37.5%) patients, CP was complicated by dysfunction of adjacent organs. Particularly these were biliary hypertension (BH) in 36 (25%) patients and chronic duodenal obstruction (CDO) in 8 (5.5%) patients. In 5 (3.5%) patients, BH was combined with CDO, and another 5 (3.5%) patients had a combination of BH, CDO and venous hypertension (VH) of the portomesenteric area. In 24 patients with BH, we applied intraoperative monitoring of biliary pressure (IOM BP) in the process of performing duodenum-preserving pancreas resections. Frey's procedure was applied in 26 (48.1%) cases, where CP was complicated by the development of CDO, BH or CDO + BH. To correct BH, Frey's procedure was supplemented by application of hepatico-entero anastomosis (HEA) in 10 patients, pancreas lingual was excised; internal biliopancreatic anastomosis was applied in two patients. Beger's procedure was used in 2 (3.7%) patients, in which CP was complicated by BH + CDO + VH. Pancreaticoduodenal resection (PDR) according to Whipple was used in 5 (9.2%) cases. Longitudinal pancreatic-enteric anastomosis (LPEA) supplemented by HEA due to BH was applied to 8 (14.8%) patients. The results of chronic treatment were traced in 23 (42.5%) patients throughout the period of 6 to 36 months. Life quality indicators appeared to be the best among the patients who underwent resection surgeries on the pancreas. The method selected to treat surgically the patients with CP that involves adjacent organs and causes their dysfunction is duodenum-preserving resection surgeries on pancreas head, which in some cases should be supplemented by application of biliodigestive anastomosis or biliopancreatic diversion in the area of pancreas resection to eliminate the BH.

SURGICAL TREATMENT OF CHRONIC CYSTIC PANCREATITIS

Increasing the number of patients with complicated forms of chronic pancreatitis and pancreatic cysts observed in recent decades. Mostly people of working age are susceptible to disease. This makes the issue a social importance.The article presents a modern view of the choice of method of surgical treatment of chronic pancreatitis and cystic optimal terms of therapy, depending on the degree of “maturity” of pancreatic cysts. A detailed analysis of both traditional surgery and advanced minimally invasive treatment for pancreatic cysts is performed in this review of the literature.Emphasis is placed on radical methods of treatment, particularly in the duodenum-preserving operations. Pathogenic study is carried out. The problem of choosing the most radical and at the same time the organ-preserving technique, helping to improve the immediate and long-term results, the quality of life and social and labor rehabilitation, has not lost its relevance. Studies carried out in this area are currently important.

Advances in surgical treatment of chronic pancreatitis.

The incidence of chronic pancreatitis (CP) is between 2 and 200 per 100,000 persons and shows an increasing trend year by year. India has the highest incidence of CP in the world at approximately 114 to 200 per 100,000 persons. The incidence of CP in China is approximately 13 per 100,000 persons. The aim of this review is to assist surgeons in managing patients with CP in surgical treatment. We conducted a PubMed search for “chronic pancreatitis” and “surgical treatment” and reviewed relevant articles. On the basis of our review of the literature, we found that CP cannot be completely cured. The purpose of surgical therapy for CP is to relieve symptoms, especially pain; to improve the patient’s quality of life; and to treat complications. Decompression (drainage), resection, neuroablation and decompression combined with resection are commonly used methods for the surgical treatment of CP. Before developing a surgical regimen, surgeons should comprehensively evaluate the patient’s clinical manifestations, auxiliary examination results and medical history to develop an individualized surgical treatment regimen.Electronic supplementary materialThe online version of this article (doi:10.1186/s12957-014-0430-4) contains supplementary material, which is available to authorized users.

Chronic Pancreatitis: Laser Technologies for Double Balloon Enteroscopy of Pancreatojejunostomy Complications and Reducing the Peripheral Ductal Hypertension

Introduction: Drainage procedures are conventional modifications of surgical treatment for chronic pancreatitis (CP). Nevertheless, the relapse of chronic abdominal pain after the surgery occurs in more than 50% of cases. Aim: To explain the pathogenesis of intractable abdominal pain following the traditional surgery of CP and to propose new laser and double balloon enteroscopy (DBE) technologies for its relief. Materials and methods: Pancreatojejunoanastomosis (PJA) lumen was examined using the videoenteroscope EN-450P5/20 (Fujifilm group, Fujinon Co, Tokio, Japan) for the first time in the world. All 20 patients had had CP and underwent an elective surgery earlier. During 2010-2014, 198 resections were performed, with 159 (80,3%) being laser drainage procedures. Results: DBE revealed strictures of PJA and open common bile duct, residual pancreatoliths in PJA lumen, and PJA leakage. After DBE laser lithotripsy of pancreatoliths in tributary ducts, a free outflow of pancreatic juice from the lumen was obtained. DBE findings were supported by the morphological study of excised pancreatic specimen, CT-scans before the surgery and the staining of PJA lumen. All these data suggest that 17,7% of CP patients along with magistral ductal hypertension had peripheral ductal hypertension (PDH), which seems to be a new cause of severe abdominalgia. The latter arises when pancreatoliths block the orifices of tributary ducts. For reducing the PDH, we have developed a new surgical procedure named «laser cylindric wirsungectomy» (n=26) and proposed our own classification of pancreatic duct stones. Conclusions: DBE has great opportunities for the diagnosis of complications and their mini-invasive treatment after pancreatojejunostomy (PJ). Laser technologies are considered to be a new approach to the effective open and mini-invasive surgical treatment of CP.

Surgical Approaches to Chronic Pancreatitis.

Chronic pancreatitis is a progressive inflammatory disease resulting in permanent structural damage of the pancreas. It is mainly characterized by recurring epigastric pain and pancreatic insufficiency. In addition, progression of the disease might lead to additional complications, such as pseudocyst formation or development of pancreatic cancer. The medical and surgical treatment of chronic pancreatitis has changed significantly in the past decades. With regard to surgical management, pancreatic head resection has been shown to be a mainstay in the treatment of severe chronic pancreatitis because the pancreatic head mass is known to trigger the chronic inflammatory process. Over the years, organ-preserving procedures, such as the duodenum-preserving pancreatic head resection and the pylorus-preserving Whipple, have become the surgical standard and have led to major improvements in pain relief, preservation of pancreatic function, and quality of life of patients.

Clinical efficacy of surgical treatment for chronic pancreatitis with mass in the head of the pancreas

Objective To investigate the clinical efficacy of treatment for chronic pancreatitis and mass in the head of the pancreas.Methods The clinical data of 19 patients with chronic pancreatitis with mass in the head of the pancreas who were admitted to the China-Japan Union Hospital of Jilin University from May 2008 to May 2013 were retrospectively analyzed,including 2 patients with gallstone.Methods of treatment were selected by in traoperative pathological results.All the patients were followed up by outpatient examination and telephone interview till January 2014.Results The operations of the 19 patients were successfully done,including 11 with pancreaticoduodenectomy,5 with exploratory laparotomy and 3 with the laparoscopic cholecystectomy and choledochojejunostomy.The operation time and intraoperative blood loss were (249± 140)minutes (50-390 minutes) and (320 ± 260)mL (50-900 mL).The postoperative mean time of recovery of gastrointestinal function and duration of postoperative hospital stay were 3.0 days (2.0-6.0 days) and 22.6 days (8.0-30.0 days) after the operation.The mean casein-IgG4 of 12 patients was higher (2.64 g/L) after operation.Five patients with operation-related complication were cured after symptomatic treatment,among 2 patients with leakage of the pancreatic fluid,2 with operative incision fat necrosis and liquefaction and 1 with bile leakage.No patients died perioperatively.Nineteen patients were followed up for 11.0 months to 36.0 months with the median time of 28.2 months.The pancreatic head mass of 8 patients with non-pancreaticoduodenectomy were reduced or disappeared by a computed tomography (CT) or magnetic resonance imaging (MRI) rescan,who were treated by the oral prednisone.No complications were detected in the other 11 patients with pancreaticoduodenectomy.Conclusion Method of surgery or medicine treatment for atypical mass in the head of the pancreas is selected according to the pathology results by effective communication with patients and family members,exploratory laparotomy and interpretative aspiration biopsy. Key words: Autoimmune pancreatitis; Mass in the head of the pancreas; Surgical operation

Surgical treatment of chronic pancreatitis in young patients.

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

A single-center analysis of surgical treatment for chronic pancreatitis: relatively rare and unevenly deployed

Background: Management of chronic pancreatitis remains a challenge. Current strategies reserve surgery as a last-available option after medical therapy, lifestyle modifications, and endoscopy have failed. Some clinicians advocate early consideration of surgical treatment to prevent disease progression and reduce the risk of opioid dependency. Aims: The aim of this study was to describe the use of elective surgery for chronic pancreatitis in a high-volume, teaching hospital. Patients & methods: Retrospective analysis of administrative patient data for in-patients with chronic pancreatitis 2003 2013 inclusively. Demographic and clinical information, including number of admissions and costs, was obtained through hospital decision support. Surgery of interest: Frey procedure, pancreaticoduodenectomy, total pancreatectomy, distal pancreatectomy, and Duodenum-Preserving Pancreatic Head Resection. Debridements and emergent pancreatic operations excluded. Results: Of 3,480 patients, 406 (11.7%) received surgery of interest. Both newchronicpancreatitisdiagnosesandproceduresperformedremainedstable throughout this time period. Whipple and other pancreaticoduodenectomies comprised the largestproportionofoperationswith48.8% (n1⁄4198). 22.7%were distal pancreatectomy, and 18.7%were pancreatojejunostomy including Frey’s procedure. There was a non-significant decrease in use of pancreaticoduodenectomy over time. The group receiving surgery was older (mean: 57.8 vs. 54.2 years <0.0001), more likely to be male (21.6% vs. 18.3% p1⁄40.017), white (OR: 1.88 95% CI: 1.4-2.5), married (OR 1.4, 95% CI: 1.1-1.7). Conclusion: Only a minority of patients appear to undergo elective pancreas-directed surgery for chronic pancreatitis. There is heterogeneity in receiving resection across demographic groups. Further investigation with patient risk adjustment comparing clinical outcomes of definitive surgery is warranted. Abstracts / Pancreatol S40

Individualized surgical treatment for chronic pancreatitis

Because of the complex pathogenesis and progressive development,it is difficult to define the optimal surgical time and procedure for chronic pancreatitis.The individualized treatment of chronic pancreatitis should resect the inflammatory mass of the head of the pancreas and preserve the pancreatic parenchyma to postpone the injury of pancreatic function and improve life quality as well as decrease the risk for carcinogenesis of pancreatic cancer.Conservative and endoscopic treatment can be considered in the early stage,while surgical intervention should be applied for chronic pancreatitis with stenosis or obstruction of pancreatic duct and calcification of the pancreatic parenchyma.Frey procedure can be performed on patients only with stone in or dilation of pancreatic duct ; patients with obvious inflammatory mass or calcification of the head of the pancreas should receive Beger procedure to decrease the morbidity of pancreatic cancer. Key words: Chronic pancreatitis ; Individualized treatment; Surgical treatment

Endoscopic versus surgical treatment of chronic pancreatitis: A systematic review

Endoscopic versus surgical treatment of chronic pancreatitis: A systematic review

Surgical treatment for chronic pancreatitis, discussion of drainage and total pancreatectomy with islet autotransplantation

Surgical treatment for chronic pancreatitis, discussion of drainage and total pancreatectomy with islet autotransplantation

Comparative evaluation of the effect of different methods of surgical treatment of chronic pancreatitis on the quality of life of patients

Aim. To conduct a comparative evaluation of the effectiveness of surgical treatment of chronic pancreatitis and define the quality of life of patients depending on the methods of surgical treatment. Methods. The study included 81 of the 165 patients with chronic pancreatitis, who underwent the following operations: endoscopic transmural interventions through the wall of the stomach and duodenum, endoscopic transpapillary surgery, percutaneous interventions for sanitation and drainage of the cystic cavity, laparotomic operations of internal drainage, resection interventions. The quality of life of patients was assessed using the general health questionnaire SF-36. Results. The lowest level of life quality was established in the group of patients after endoscopic transpapillary interventions. Statistically significant differences in the level of physical and psychological health were established when comparing patients after endoscopic transpapillary interventions and after endoscopic transmural surgical interventions, which were carried out through the wall of the stomach and duodenum; differences only in the level of physical health were noted when comparing with the group of resection interventions. Conclusion. The quality of life of patients with chronic pancreatitis depends on the type of surgical intervention, age and sex of the patients.

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.

Tratamento cirúrgico da pancreatite crônica com a técnica de F rey: panorama atual

INTRODUÇÃO: A pancreatite crônica é desordem inflamatória progressiva caracterizada pela destruição irreversível do parênquima pancreático, podendo estar associada à dor crônica incapacitante e perda permanente da função endócrina e exócrina. A principal indicação cirúrgica é a dor abdominal intratável e a escolha da melhor técnica a ser empregada permanece um desafio. A técnica descrita por Frey conseguiu combinar a eficácia no controle da dor das operações de ressecção com as baixas taxas de mortalidade e morbidade das derivativas. OBJETIVO: Comparar e discutir os resultados do tratamento cirúrgico da pancreatite crônica com a técnica de Frey. MÉTODOS: Revisão bibliográfica de 276 artigos científicos disponíveis no Medline/Pubmed e no banco de dados de teses nacionais com os descritores pancreatite crônica, tratamento cirúrgico e cirurgia de Frey. Foram selecionados os 30 artigos de maior importância e que relataram maior experiência com esta opção cirúrgica. CONCLUSÕES: A técnica de Frey demonstra ser opção de alta efetividade no controle da dor abdominal secundária à pancreatite crônica no longo prazo naqueles pacientes com dor abdominal incapacitante e aumento volumétrico da cabeça pancreática, com menores taxas de morbidade e mortalidade. Os estudos demonstraram pequena interferência da técnica na deterioração das funções endócrina e exócrina.

Surgical treatment of chronic pancreatitis using Frey's procedure: a Brazilian 16-year single-centre experience

BackgroundSurgical treatment of chronic pancreatitis is indicated for intractable pain. Frey's procedure is an accepted treatment for this disease. The aim of the present study was to describe a single-centre experience in the treatment of chronic pancreatitis using Frey's procedure. MethodsA retrospective analysis of 73 patients who underwent a Frey's procedure between 1991 to 2007 and had at least 1 year of follow-up. Demographics, indication for surgery, peri-operative complications and late outcomes were analysed. ResultsThe median age was 39.9 years. Seventy out of the 73 (95.8%) patients were male. The median pre-operative body mass index (BMI) was 19.1kg/m2. All patients had abdominal pain, 34 (46.6%) of them daily and 13 (17.8%) weekly, with moderate or severe intensity in 98.6% (n= 72). The aetiology was secondary to alcohol in 70 patients (95.9%), with a median consumption of 278g per day. The surgical morbidity rate was 28.7%; there were no deaths. Median post-operative follow-up was 77.0 months; 64 patients (91.4%) had complete pain relief and post-operative BMI was 22.4kg/m2 (P<0.001). All patients with pre-operative endocrine and exocrine insufficiencies showed no reversal of the situation. New onset insufficiencies appeared late. ConclusionsFrey's procedure was a safe and effective therapeutic option for the surgical treatment of patients with intractable pain caused by chronic pancreatitis.