Surgical Treatment Of Chronic Pancreatitis Research Articles

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.

Current Surgical Treatment for Chronic Pancreatitis

Chronic pancreatitis (CP) is a painful, yet benign inflammatory process of the pancreas. Surgical management should be individualized because the pain is multifactorial and its mechanisms vary from patient to patient. Two main pathogenetic theories for the mechanisms of pain in CP have been proposed: the neurogenic theory and the theory of increased intraductal/intraparenchymal pressures. The latter theory is strongly supported by the good results of drainage procedures in the surgical management of CP. Other possible contributing factors include pancreatic ischemia; a centrally sensitized pain state; and the development of complications, such as pseudocysts and stenosis of the duodenum or common bile duct. Common indications for surgery include intractable pain, suspicion of neoplasm, and complications that cannot be resolved with radiological or endoscopic treatments. Operative procedures have been historically classified into 4 categories: decompression procedures for diseased and obstructed pancreatic ducts; resection procedures for the proximal, distal, or total pancreas; denervation procedures of the pancreas; and hybrid procedures. Pancreaticoduodenectomy and pylorus-preserving pancreaticoduodenectomy, once the standard operations for patients with CP, have been replaced by hybrid procedures, such as duodenum-preserving pancreatic head resection, the Frey procedure, and their variants. These procedures are safe and effective in providing long-term pain relief and in treating CP-related complications. Hybrid procedures should be the operations of choice for patients with CP.

Ten-Year Experience With Duodenum and Organ-Preserving Pancreatic Head Resection (Büchler-Farkas Modification) in the Surgical Treatment of Chronic Pancreatitis

Chronic pancreatitis, a benign, inflammatory process, can cause enlargement of the pancreatic head, which is accompanied by severe pain and weight loss and often leads to a significant reduction in the quality of life (QoL). Our clinical experience relates to the results attained with duodenum and organ-preserving pancreatic head resection in 160 patients during a 10-year period. The QoL is assessed during the follow-up period by using the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire. Two reoperations were required in consequence of anastomosis bleeding and small bowel obstruction, but no mortality was noted in the postoperative period. The duration of hospitalization ranged between 7 and 12 days. The mean follow-up time was 5.3 years (range, 0.5-10.0 years). The late mortality rate was 6.9%. The QoL improved in 89% of the cases. One hundred thirty-three of the patients became complaint-free, whereas 16 displayed moderate symptoms, and the weight increased by a median of 13.4 kg (range, 4-30 kg). The postoperative endocrine functions remained in almost the same stage as preoperatively. Our 10-year experience clearly demonstrates that this duodenum and organ-preserving pancreatic head resection technique is a safe and effective procedure, which should be preferred in the surgical treatment of the complications of chronic pancreatitis.

Indications for Endoscopic or Surgical Treatment of Chronic Pancreatitis

In patients suffering from chronic pancreatitis, pain as the predominant symptom remains a therapeutic challenge which often cannot be tackled conservatively. Since pancreatic duct obstruction – frequently within the pancreatic head – is an important etiological factor, treatment in these cases aims at decompressing the duct either endoscopically or surgically. Endoscopic drainage includes sphincterotomy, dilation of strictures, removal of stones, and insertion of a stent; it has a success rate of 30–100%. Surgical treatment may be accomplished by drainage or resection procedures. Drainage procedures (such as the longitudinal opening of the pancreatic duct followed by a pancreaticojejunostomy) can be performed with a low rate of postoperative complications (6–30%) and mortality (0–2%), and can achieve long-term pain relief in 65–85% of the cases. Furthermore, there are a variety of resection procedures such as pancreaticoduodenenectomy (Whipple procedure), pylorus-preserving pancreaticoduodenenectomy, different types of the duodenum-preserving pancreatic head resection (i.e. Beger, Frey, or Büchler procedures), segmentectomy, and V-shaped excision of the pancreatic duct. However, the surgical procedure of choice is controversially discussed. While it has been shown that parenchyma-preserving surgery is superior to more extensive resections, it remains unclear which of the modifications of the parenchyma-sparing procedures is suited best for which case. Recently, two randomized controlled trials have demonstrated that surgical treatment is superior to endotherapy in long-term pain reduction, physical health score results, and the number of reinterventions. Thus, in patients with chronic pancreatitis refractory to conservative medical treatment, surgery rather than endotherapy is the standard of care. Parenchyma-preserving resections should preferably be performed because they ensure lower morbidity and mortality, preserve endocrine function, and improve quality of life.

What is the role of endotherapy in chronic pancreatitis?

Chronic pancreatitis (CP) can have debilitating clinical course due to chronic abdominal pain, malnutrition and related complications. Medical, endoscopic and surgical treatment of CP should aim at control of symptoms, prevention of progression of the disease and correction of complications. Endoscopic management plays a specific role in carefully selected patients as primary interventional therapy when medical measures fail or in high-risk surgical candidates. Endotherapy for CP is utilized also as a bridge to surgery or to assess potential response to pancreatic surgery. In this review we address the role of endotherapy for the relief of obstruction of the pancreatic duct (PD) and bile duct, closure of PD leaks and drainage of pseudocysts in the setting of CP. In addition, endotherapy for relief of pancreatic pain by endoscopic ultrasound-guided celiac plexus block for CP is discussed.

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.

Surgical Treatment of Chronic Pancreatitis

Surgical Treatment of Chronic Pancreatitis

Surgical Treatment of Chronic Pancreatitis

We’ve built this digital research platform to provide academics everywhere with fast, stable and secure digital access to our library of over 110,000 scholarly books and 800,000 journal articles. We’ve tested the platform in close cooperation with leading academic institutions. If you have any questions or you notice something doesn’t quite work as it should, please visit our <a href="/publishing/faq?lang=en" class="text-primary">Help/FAQ</a> page and let us know.

M1539 Long Term Follow-Up (7 - 34 Years) After Surgical Treatment of Chronic Pancreatitis

M1539 Long Term Follow-Up (7 - 34 Years) After Surgical Treatment of Chronic Pancreatitis

Tailored resective pancreatic surgery for pediatric patients with chronic pancreatitis

Background Surgical treatment for chronic pancreatitis (CP) in children comprises predominantly nonresective draining procedures. The purpose of this study was to identify indications, techniques, and results of organ-preserving resective pancreatic procedures for pediatric CP at our institution. Patients and Methods A retrospective chart review was performed of all children undergoing pancreatic surgery for CP over a period of 4 years. Results Overall, 6 pediatric patients (3 male, 3 female, ages 7-18 years) underwent a duodenum-preserving pancreatic head resection (3), a middle segmental pancreatic resection (2), or a distal pancreatectomy (1) for CP of different etiologies (idiopathic 2, posttraumatic 2, pancreas divisum 1, situs inversus 1). No mortality or major surgical complication occurred. Mean operative time was 294 min (207-412 min) and intraoperative blood loss was 541 mL (100-1300 mL). Postoperative hospital stay was 13 days (10-18 days). No endocrine or exocrine insufficiency occurred during follow up of 46 months (25-50 m), and pain control was improved in 5 of 6 patients. Conclusions Tailored organ-preserving resective pancreatic surgery can be performed with low morbidity and mortality in pediatric patients with CP and not responding to conservative treatment.

Review article: surgical management of chronic pancreatitis

The therapeutic approach to patients with chronic pancreatitis (CP) is complicated by the fact that patients are presented to the physician at different stages of disease and in the presence of varying clinical symptoms. Generally, an expectant approach is justified for patients with asymptomatic CP. At present, patients with symptoms related to gland destruction are initially treated by endoscopic means, while surgical treatment of CP is usually reserved for intractable abdominal pain, suspicion of cancer, and complications such as persistent pseudocysts. To review the studies currently available evaluating surgical and/or endoscopic management of CP. Improvements in imaging techniques, as well as a better understanding of the pathophysiology of CP and mechanisms causing pain, have led to a more conscious selection of patients for surgery. Type of surgery depends on whether the pancreatic duct is dilated, presence of an inflammatory mass and occurrence of complications (pseudocysts, gastric outlet obstruction). Eventually, after initial endoscopic treatment, a substantial number of patients still need surgery for persistent complaints. For patients with symptomatic CP, a multidisciplinary approach is indicated with low threshold to surgical intervention, since long-term pain relief is accomplished more often after surgical treatment than after endoscopic treatment.

Endoscopic versus Surgical Treatment for Chronic Pancreatitis

Endoscopic versus Surgical Treatment for Chronic Pancreatitis

Surgical treatment of chronic pancreatitis: an overview.

The correct management of chronic pancreatitis remains undecided. The aims of surgical treatment are to relieve pain, treat complications and preserve pancreatic function. The appropriate surgical procedure to achieve these ends must be carefully chosen.

Surgical treatment of chronic pancreatitis with pancreatic main duct dilatation: Long term results after head resection and duct drainage

Tissue and duct hypertension is considered as a major factor in the etiology of pain in patients with chronic pancreatitis (CP). Duct dilatation is a consequence of duct obstruction due to scars or duct stones. Nevertheless, the procedure of choice, drainage or resection, is still under discussion. We present long‐term results of patients operated with duodenum‐preserving pancreatic head resection (DPPHR) combined with a Partington‐Rochelle duct drainage in cases of chronic pancreatitis with multiple stenosis and dilatation of the side ducts. Methods and patientsFrom April 1982 to September 2001, in 55 out of 538 patients with chronic pancreatitis, a DPPHR with additionally Partington‐Rochelle duct drainage was performed (44 male, 11 female, mean age 45.8 years). Ninety‐two percent of the patients suffered from alcoholic pancreatitis. Medical respective pain treatment for chronic pancreatitis was in median 64.5 months prior to surgery. The indications for surgery were in 87% pain, 59% of the patients had an inflammatory mass in the head of the pancreas, 36% a common bile duct stenosis and 5% a severe stenosis of the duodenum. The endocrine function (OGGT) was impaired in 79% of the patients preoperatively. ResultsHospital mortality was 0%, postoperative complications occurred in 11 patients. Follow‐up: All except 2 patients were followed up in the outpatient clinic with the mean follow‐up time of 69.7 months (8–105 months), the late mortality was 9%. Sixty‐eight percent of the patients were completely free of pain, 29% had occasional pain, 3% suffered from a further attack of pancreatitis. Body weight increased in 79%, 58% were professionally rehabilitated. Late postoperative endocrine function was unchanged in 85% (improved in 5%, deteriorated in 10%). ConclusionThe pain control in patients with multiple duct stenosis after duodenum‐preserving pancreatic head resection with duct drainage leads to long‐standing absence of pain and low recurrence rate of attacks of pancreatitis.

Long-term Follow-up of a Randomized Trial Comparing the Beger and Frey Procedures for Patients Suffering From Chronic Pancreatitis

To report on the long-term follow-up of a randomized clinical trial comparing pancreatic head resection according to Beger and limited pancreatic head excision combined with longitudinal pancreatico-jejunostomy according to Frey for surgical treatment of chronic pancreatitis. Resection and drainage are the 2 basic surgical principles in surgical treatment of chronic pancreatitis. They are combined to various degrees by the classic duodenum preserving pancreatic head resection (Beger) and limited pancreatic head excision combined with longitudinal pancreatico-jejunostomy (Frey). These procedures have been evaluated in a randomized controlled trial by our group. Long-term follow up has not been reported so far. Seventy-four patients suffering from chronic pancreatitis were initially allocated to DPHR (n = 38) or LE (n = 36). This postoperative follow-up included the following parameters: mortality, quality of life (QL), pain (validated pain score), and exocrine and endocrine function. Median follow-up was 104 months (72-144). Seven patients were not available for follow-up (Beger = 4; Frey = 3). There was no significant difference in late mortality (31% [8/26] versus 32% [8/25]). No significant differences were found regarding QL (global QL 66.7 [0-100] versus 58.35 [0-100]), pain score (11.25 [0-75] versus 11.25 [0-99.75]), exocrine (88% versus 78%) or endocrine insufficiency (56% versus 60%). After almost 9 years' long-term follow-up, there was no difference regarding mortality, quality of life, pain, or exocrine or endocrine insufficiency within the 2 groups. The decision which procedure to choose should be based on the surgeon's experience.

Extra‐pancreatic end‐to‐side hepaticojejunostomy: a practical modification of the duodenum‐preserving pancreatic head resection (DPPHR) for chronic pancreatitis

Duodenum-preserving pancreatic head resection (DPPHR) is recognised for the surgical treatment of chronic pancreatitis. Approximately 15-20% of patients undergoing DPPHR require a synchronous biliary drainage procedure for stricture. This report describes a technical modification involving the placement of an extra-pancreatic end-to-side Roux hepaticojejunostomy utilising the same jejunal loop employed for pancreaticojejunal anastomosis. Extra-pancreatic end-side hepaticojejunostomy is a simple technical modification of DPPHR. The biliary anastomosis is constructed according to the well-established principles of biliary reconstruction and represents a safe and valuable technical option.

Evidence-based surgery in chronic pancreatitis.

In the past two decades our knowledge of the pathophysiology and surgical treatment options in chronic pancreatitis has improved substantially. Surgical treatment in chronic pancreatitis has evolved from extending to organ-preserving procedures. The classical Whipple resection is no longer a standard procedure in chronic pancreatitis, and is continuously being replaced by operations such as the duodenum-preserving pancreatic head resection and pylorus-preserving Whipple. These procedures allow the preservation of exocrine and endocrine pancreatic function, provides pain relief in up to 90% of patients, and contributes to an improvement in life quality. In addition to presently available results from randomized controlled trials, new studies comparing available surgical approaches in chronic pancreatitis are needed to determine which procedure is the most effective in the treating chronic pancreatitis.

Surgical treatment of chronic pancreatitis.

Debilitating abdominal or back pain remains the most common indication for surgery in patients with chronic pancreatitis. The surgical approach to chronic pancreatitis should be individualized based on pancreatic and ductal anatomy, pain characteristics, baseline exocrine and endocrine function, and medical co-morbidity. No single approach is ideal for all patients with chronic pancreatitis. Pancreatic ductal drainage with pancreaticojejunostomy targets patients with a dilated pancreatic duct and produces good early postoperative pain relief; however, 30%-50% of patients experience recurrent symptoms at 5 years. Resection for chronic pancreatitis should be considered (1) when the main pancreatic duct is not dilated, (2) when the pancreatic head is enlarged, (3) when there is suspicion of a malignancy, or (4) when previous pancreaticojejunostomy has failed. Re-sectional strategies include pancreaticoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum-preserving pancreatic head resection (Beger procedure), or local resection of the pancreatic head with longitudinal pancreaticojejunostomy (Frey procedure). Superior results are obtained when the pancreatic head is resected, either completely (pancreaticoduodenectomy) or partially (Beger or Frey procedure). Although pylorus-preserving pancreaticoduodenectomy remains the gold standard resection procedure, there is evidence that newer operations, such as the Beger resection, may be as effective in regard to pain relief and better in respect to nutritional repletion and preservation of endocrine and exocrine function.

Surgical treatment and long-term follow-up in chronic pancreatitis

In the past two decades our knowledge of the pathophysiology and surgical treatment options in chronic pancreatitis have improved substantially. Surgical treatment in chronic pancreatitis has evolved from radical to organ-preserving procedures. The classic Whipple resection is no longer indicated in chronic pancreatitis, and operations like the duodenum-preserving pancreatic head resection and the pylorus-preserving Whipple have replaced it as surgical standards. These procedures allow the preservation of exocrine and endocrine pancreatic function, provide pain relief in up to 90% of patients, and contribute to an improvement in the quality of life.