Organ-preserving pancreatic head resection in chronic pancreatitis

Surgical Interventions in Chronic Pancreatitis: A Systematic Review of Their Impact on Quality of Life

This systematic review evaluates the efficacy of surgical interventions in improving the quality of life for patients with chronic pancreatitis (CP). A thorough literature search, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identified 11 studies that focused on patient-reported outcomes after surgical treatments, including pancreatic resections, drainage procedures, and duodenum-preserving head resections. The findings indicate that organ-preserving procedures, notably the Frey and Beger operations, significantly enhance pain control and overall quality of life while reducing analgesic dependency. This review provides crucial insights into the long-term efficacy and comparative benefits of different surgical approaches, highlighting the need for personalized surgical strategies in CP management. It emphasizes the necessity for standardized outcome measures and further comparative research to refine CP treatment protocols.

Hasnyálmirigy-sebészet

Közleményünk célja bemutatni az új sebészi technikát és módszereket, amelyeket 1986 óta alkalmazunk az inficiálódott necrotizáló pancreatitis, a krónikus pancratitis gyógyításakor, illetve a szigetsejt-transzplantáció alkalmával.

Az inficiálódott necrotizáló pancreatitis (INP) az akut pancreatitis legsúlyosabb formája, amely az esetek többségében felelős a pancreatitishez kapcsolódó morbiditásért és magas halálozásért. 1986 óta 224 beteget gyógyítottunk INP miatt. A sebészi terápia magában foglalta a kiterjesztett necrosectomiát, a többszörös drenázst, amely biztosította a folyamatos öblítést. A sebészi beavatkozást követően supportiv kezelést alkalmaztunk. A globális kórházi mortalitás 7,7% volt. Tapasztalataink szerint, az INP komplex terápiája, amely magában foglalja az adequat sebészi beavatkozást, a folyamatos, hosszan tartó, többszörös öblítést és a supportiv kezelést, biztosíthatja a sikeres gyógyítást.

A krónikus pancreatitisben szenvedő betegek egyharmadában az inflammatoricus folyamat a pancreasfej gyulladásos tumorát idézi elő, amely a vezetékrendszerek obstructioját, alkalmasint a duodenum kompresszióját idézi elő, fájdalmat és fogyást okozva. Minthogy egy benignus elváltozással állunk szemben, egy biztonságos szervmegtartó pancreasfej-resectiót (OPPHR) dolgoztunk ki, amely magában foglalja a pancreasfejben kialakult gyulladásos tumor széles resectióját, anélkül, hogy a pancreast a v. portae felett izolálnánk, illetve átvágnánk. Napjainkig 196 esetben végeztünk szervmegtartó pancreasfej-resectiót mortalitás nélkül. A műtét után a betegek életminősége 89%-ban javult. A 10 éves klinikai megfigyelés és a prospektiv randomizált összehasonlító vizsgálat egyértelműen alátámasztotta, hogy az OPPHR-műtét egy biztonságos és hatásos beavatkozás, amely hosszú távon javítja a betegek életminőségét.

A distalis pancreas resectio leggyakoribb szövődménye a pancreas fistula, amelynek kivédésére számos műtéti megoldást alkalmaznak, változó sikerrel. Az irodalmi adatok alapján a fistula kialakulása 6–30% -ra tehető distalis resectio után. Műtéti gyakorlatunkban 1994-ben alkalmaztuk először a pancreas resectios felszínének zárására a Premium PolysorbR (abszorbeálodó laktomer) kapocssort. Napjainkig e módszert 187 distalis resectiós műtétnél alkalmaztuk. A postoperativ időszakban két esetben jelentkezett pancreas fistula, amelyek konzervatív kezelésre szanálódtak. Így a postoperativ fistula incidenciája 0,9% volt.

A hasnyálmirigy-szigetsejt beültetésének egyik potenciális és egyben ígéretes forrása az embrionális hasnyálmirigy. Az embrionális pancreas endokrin szövet tartama csaknem 90%. Az izolált szigetek megfelelő feltételek mellett hosszabb ideig mesterséges körülmények között tenyészthetők, és ez alatt jelentős mértékű sejtosztódás, illetve differenciálódás jön létre. Előnynek tekinthető, hogy a tenyésztett szövetkultúra mélyfagyasztásos tárolása is megoldott, mely ún. szövetbank kialakítását teszi lehetővé. Az első embrionális szigetsejt klinikai transzplantációnk 1982-ben történt. Az ezt követő 25 esetben, köztük egy kombinált vese- és szigetsejt-beültetés, bár inzulinmentességet nem sikerül elérni, de az inzulinszükséglet szignifikáns csökkenése mellett, a cukoranyagcsere normalizálódott, és az 5–10 évig működő szigetsejtapparátus hatására a még nem visszafordíthatatlan másodlagos diabeteszes szövődmények (retinopathia, nephropathia, neuropathia) progressziója megállt, sőt az esetek egy részében javulást is eredményezett.

Pancreatic head excavation for tissue diagnosis may reduce unnecessary pancreaticoduodenectomies in the setting of chronic pancreatitis

BACKGROUND

The necessity to obtain a tissue diagnosis of cancer prior to pancreatic surgery still remains an open debate. In fact, a non-negligible percentage of patients undergoing pancreaticoduodenectomy (PD) for suspected cancer has a benign lesion at final histology. We describe an approach for patients with diagnostic uncertainty between cancer and chronic pancreatitis, with the aim of minimizing the incidence of PD for suspicious malignancy finally diagnosed as benign disease.

METHODS

Eighty-eight patients (85.4%) with a clinicoradiological picture highly suggestive for malignancy received formal PD (group 1). Fifteen patients (14.6%) in whom preoperative diagnosis was uncertain between pancreatic cancer and chronic pancreatitis underwent pancreatic head excavation (PHEX) for intraoperative tissue diagnosis (group 2): those diagnosed as having cancer received PD, whereas those with chronic pancreatitis received pancreaticojejunostomy (PJ).

RESULTS

No patient received PD for benign disease. All patients in group 1 had adenocarcinoma on final histology. Eight patients of group 2 (53.3%) received PD after intraoperative diagnosis of cancer, whereas 7 (46.7%) received PJ because no malignancy was found at introperative frozen sections. No signs of cancer were encountered in patients receiving PHEX and PJ after a median follow-up of 42 months. Overall survival did not differ between patients receiving PD for cancer in the group 1 and those receiving PD for cancer after PHEX in the group 2 (P=0.509).

CONCLUSION

Although the described technique has been used in a very selected group of patients, our results suggest that PHEX for tissue diagnosis may reduce rates of unnecessary PD, when the preoperative diagnosis is uncertain between cancer and chronic pancreatitis.

Surgery remains the best option for the management of pain in patients with chronic pancreatitis: A systematic review and meta-analysis

Controversy related to endoscopic or surgical management of pain in patients with chronic pancreatitis remains. Despite improvement in endoscopic treatments, surgery remains the best option for pain management in these patients.

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.

Surgery for chronic pancreatitis

Chronic pancreatitis (CP) is progressive inflammatory process of the pancreas. Abdominal pain remains the most debilitating symptom affecting quality of life, apart from diabetes mellitus, steatorrhoea and weight loss. The treatment options have evolved over the past decades and are aimed to provide durable relief in pain with possible attempt to support or improve the failing endocrine and exocrine functions. Surgical treatment options have shown the potentials to provide superior long term results compared to the pharmacological and endoscopic modalities and are broadly divided in to drainage, resection and combination hybrid procedures. The choice is based on the morphology of the main pancreatic duct, presence of head mass and associated complication of CP. Knowing the basic nature of the disease, total pancreatectomy seems a curative option but not without significant morbidities. There is recent paradigm shift towards organ sparing surgical procedures with reasonable success. Despite recent advancement in the treatment modalities for CP the overall quality of life remains moderate which need further addressal.

The complex exocrine-endocrine relationship and secondary diabetes in exocrine pancreatic disorders

The pancreas is a dual organ with exocrine and endocrine functions. The interrelationship of the endocrine-exocrine parts of the pancreas is a complex one, but recent clinical and experimental studies have expanded our knowledge. Many disorders primarily of the exocrine pancreas, often solely in the clinical realm of gastroenterologists are associated with diabetes mellitus (DM). Although, the DM becoming disorders are often grouped with type 2 diabetes, the pathogenesis, clinical manifestations and management differ. We review here data on the association of exocrine-endocrine pancreas, the many hormones of the pancreas and their possible effects on the exocrine functions followed by data on the epidemiology, pathogenesis, and management of DM in chronic pancreatitis, cystic fibrosis, pancreatic cancer, and clinical states after pancreatic surgery.

Ten-year experience with duodenum and organ-preserving pancreatic head resection (Büchler-Farkas modification) in the surgical treatment of chronic pancreatitis

OBJECTIVES

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).

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Long-term outcome after 92 duodenum-preserving pancreatic head resections for chronic pancreatitis: comparison of Beger and Frey procedures

INTRODUCTION

Duodenum-preserving pancreatic head resection may be an alternative to pancreatoduodenectomy or drainage procedures for chronic pancreatitis. There are few studies directly comparing the long-term outcome after the operations described by Beger and Frey.

METHODS

One hundred thirteen patients underwent duodenum-preserving pancreatic head resection for complications of chronic pancreatitis. Follow-up was obtained in 92 patients (42 Beger, 50 Frey, median follow-up almost 5 years).

RESULTS

Overall/surgery-related perioperative morbidity was 30%/20% (Frey) and 40%/31% (Beger). In long-term follow-up (Frey vs Beger), 62% vs 50% were completely free of pain, but 6% vs 19% had pain at least once per week or daily, and 32% vs 31% experienced pain attacks at least once per year (n.s.). Diabetes mellitus occurred in 60% vs 57% (de novo 34% vs 17%). Rates of exocrine insufficiency were 76% vs. 74% (de novo 34% vs. 33%). Median gain in body weight was 2.5 vs 1.5 kg (n.s.), respectively. Four patients had clinically relevant biliary complications during follow-up requiring reintervention.

CONCLUSIONS

Our (nonrandomized) comparison of the long-term outcome after Frey and Beger procedures for chronic pancreatitis reveals a tendency for better pain control with the Frey operation. The functional outcomes were almost identical.

The evolution of the surgical treatment of chronic pancreatitis

OBJECTIVE

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.

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

Local resection of the pancreatic head appears to offer best outcomes and lowest risk for the management of the pain of chronic pancreatitis.

Beger's operation and the Berne modification: origin and current results

BACKGROUND/PURPOSE

The purpose of this paper is to illuminate the origin and current results of the duodenum-preserving pancreatic head resection (DPPHR) developed by Beger in the 1970s, as well as its simplified Berne modification, for patients suffering from chronic pancreatitis (CP). Indications for the procedures and their results are presented on the basis of available data.

METHODS

A selected review was made of the available data on the DPPHR developed by Beger and its modifications.

RESULTS

The organ-sparing DPPHR developed by Beger, and its modifications, provide better pain relief, better preservation of exocrine and endocrine pancreatic function, and a superior quality of life compared with the more radical pancreaticoduodenectomy (PD, with or without pylorus-preservation), once the standard treatment for patients with CP. Recently published data on the long-term follow-up of studies comparing PD to DPPHR indicate that the initial benefits of DPPHR over PD might be less pronounced in the long-run.

CONCLUSIONS

The organ-preserving DPPHR developed by Beger, and its modifications, have become established and well-evaluated surgical treatment options for patients with CP.

Surgical therapy of chronic pancreatitis: indications, techniques and results

In chronic pancreatitis (CP) a benign inflammatory process in the pancreas results in progressive structural changes with replacement of functional exocrine and endocrine parenchyma by a fibrotic and inflammatory tissue, often evident as an inflammatory mass. The consequences are diabetes mellitus, exocrine insufficiency, and severe recurrent upper abdominal pain, often resulting in a significant reduction in the quality of life. The inflammatory process or the formation of pseudocysts can cause local complications such as obstruction of the pancreatic duct, bile duct or the duodenum. In spite of intensive research there is still no specific therapy for CP. Medical pharmacologic treatment is the basis of therapy in CP and aims at pain relief and treatment of exocrine and endocrine insufficiency. However, many patients require additional therapy for effective pain relief or treatment of local complications. Whereas a lot of these patients undergo repetitive endoscopic interventions, surgical drainage results in better long-term outcome. In patients with an inflammatory mass of the pancreatic head, surgical resection procedures provide good short and long-term results, especially in terms of pain relief. This article summarizes indications and potential of endoscopic/interventional and surgical therapy and gives an overview of surgical techniques with special focus on organ-sparing procedures such as the duodenum-preserving pancreatic head resection and its variants. Whereas exocrine and endocrine insufficiency may progress, adequate surgical therapy can provide effective long-term pain relieve and improvement in the quality of life in patients with CP.

Long-term follow-up of a randomized clinical trial comparing Beger with pylorus-preserving Whipple procedure for chronic pancreatitis

BACKGROUND

Duodenum-preserving pancreatic head resection according to Beger and the pylorus-preserving Whipple (ppWhipple) procedure were compared in patients with chronic pancreatitis (CP) in a randomized clinical trial. Perioperative data and short-term outcome have been reported previously. The present study evaluated long-term follow-up.

METHODS

Forty patients were enrolled originally, 20 in each group. Long-term follow-up included mortality, morbidity, pain status, occupational rehabilitation, quality of life (QoL), and endocrine and exocrine function at median follow-up of 7 and 14 years.

RESULTS

One patient who had a ppWhipple procedure was lost to follow-up. There were five late deaths in each group. No differences were noted in pain status and exocrine pancreatic function. Loss of appetite was significantly worse in the ppWhipple group at 14 years' follow-up, but there were no other differences in QoL parameters examined. After 14 years, diabetes mellitus was present in seven of 15 patients who had the Beger procedure and 11 of 14 patients after ppWhipple resection (P = 0.128).

CONCLUSION

After long-term follow-up of up to 14 years early advantages of the Beger procedure were no longer present.

Duodenum-preserving pancreatic head resection--a randomized controlled trial comparing the original Beger procedure with the Berne modification (ISRCTN No. 50638764)

OBJECTIVE

A prospective, randomized study was performed to evaluate two variations of the duodenum-preserving pancreatic head resection (DPPHR), either with (Beger procedure) or without (Berne modification) the division of the pancreas anterior to the portal vein, in patients with chronic pancreatitis.

METHODS

Randomized, controlled, patient-blinded trial of patients with inflammatory pancreatic head tumors. The primary endpoint was the duration of surgery. Other a priori-ordered endpoints were length of ICU stay, postoperative complication, length of hospital stay, and quality of life after 24 months.

RESULTS

Sixty-five patients were randomized to the Berne or Beger procedures. The Berne modification could be performed faster (46 minutes difference, P < .05). The median length of stay on the ICU was one day in both groups (P = .97) but the median hospital stay was shorter in the Berne group (11 (8-39) versus 15 (8-47); P = .015). The quality of life two years after surgery did not differ significantly between the two groups (EORTC-QLQ-C30, Beger 65.6% vs. Berne 71.3%, P = .371). Three patients who had received the Berne procedure were reoperated on during the follow-up period due to ongoing pancreatitis and bile duct obstruction (P = .22).

CONCLUSION

The Berne technique is technically simpler compared with the original Beger procedure, reflected in its significantly shorter operation times and hospital stays. The quality of life is similar after both procedures. The Berne modification of DPPHR adds to our panel of surgical procedures that can be applied with effective early and late outcomes.

[Long-term follow-up after organ-preserving pancreatic head resection in patients with chronic pancreatitis: an 8-year clinical experience]

In one-third of the patients with chronic pancreatitis (CP), enlargement of the pancreatic head develops as a result of inflammatory alterations. A safe procedure has been developed for organ-preserving pancreatic head resection (OPPHR). This report relates to the results attained with OPPHR in 150 patients in an 8-year period. The surgical procedure consists of a wide resection of the inflammatory mass in the region of the pancreatic head, without division and cutting of the pancreas over the portal vein. Reconstruction, with drainage of the secretion from the remaining pancreas into the intestinal tract, is carried out by a jejunal Roux-en-Y loop. Two reoperations were required as a result of anastomotic bleeding and small bowel obstruction, but no mortality was detected in the postoperative period. The length of hospitalization ranged between 7 and 12 days. The mean follow-up period was 4.5 years (range 0.5-8.0). Late mortality rate was 4%. Quality of life, measured by the EORTC Quality-of-Life Questionnaire during follow-up, improved in 89% of the patients. The 8-year experience clearly reveals that this OPPHR technique is a safe and effective procedure for definitive control of the complications of CP and should be regarded as a recommended procedure in the treatment of CP.

Surgical approaches to chronic pancreatitis

Chronic pancreatitis (CP), a benign, inflammatory process of the pancreas, can cause severe pain, diabetes mellitus, steatorrhoea, and weight loss and often leads to a significant reduction in the quality of life. In the past decade our knowledge of the pathophysiology of CP has increased together with the number and quality of treatment options available for this disease. In addition to pharmacological and endoscopic treatment modalities, surgical drainage and resection procedures have become increasingly important since they have the potential to provide superior long-term results in patients with CP. The classical and pylorus-preserving pancreaticoduodenectomy, once the standard operations for patients with CP, have been replaced by organ-sparing procedures like the duodenum preserving pancreatic head resection and its variants. The latter allow better preservation of the exocrine and endocrine pancreatic function, and provide adequate pain relieve and improvement in the quality of life of CP patients.

Long-term follow-up after organ-preserving pancreatic head resection in patients with chronic pancreatitis

In chronic pancreatitis (CP), enlargement of the pancreatic head develops as a result of inflammatory alterations. This report relates to the results attained with an organ-preserving pancreatic head resection (OPPHR) in 135 patients in a 7-year period. The surgical procedure consists of a wide excision of the inflammatory tumor in the region of the pancreatic head, without division and cutting of the pancreas over the portal vein. Reconstruction, with drainage of the secretion from the remaining pancreas into the intestinal tract, takes place through a jejunal Roux-en-Y loop. Only one reoperation was required in consequence to anastomosis bleeding, but no mortality occurred in the postoperative period. The duration of hospitalization ranged between 7 and 12 days. The mean follow-up period was 4.1 years (range, 0.5-7.0). The late mortality rate was 3.7%. The quality of life, measured during the follow-up by using EORTC Quality-of-Life Questionnaire, improved in 89% of the patients. One hundred sixteen patients became complaint-free, while 14 patients had moderate symptoms; the weight increased by a median of 11.3 kg (range, 4-28). The 7-year experience clearly reveals that this OPPHR technique is a safe and effective procedure for definitive control of the complications of CP.

Frey procedure in the treatment of chronic pancreatitis: short-term results

OBJECTIVE

The aim of this multicenter study was to report the short-term results of the Frey procedure in the treatment of chronic pancreatitis.

METHODS

For the period between September 2000 and January 2005, 34 Frey procedures were performed for chronic pancreatitis in 4 university hospitals. This study includes 31 men (91%) and 3 women (9%), with a mean age of 48 +/- 6 years (range, 32-58 years). The etiology of chronic pancreatitis was chronic alcohol ingestion in 32 patients (94%) and hereditary chronic pancreatitis in 2 patients. The indications of surgery were abdominal pain in all patients, requiring opiates in 59% (n = 20) and associated with a weight loss in 79% (n = 27).

RESULTS

There was no mortality. Eleven postoperative surgical complications occurred in 7 patients (20%). Three patients had a single complication, and 4 patients had 2 complications. Pancreatic fistula occurred in 4 patients and healed under conservative management in all cases. One patient had massive bleeding from the stump of gastroduodenal artery requiring reoperation. The mean hospital stay was 16 +/- 8 days (range, 9-40 days). The mean follow-up was 15 +/- 12 months (range, 3-37 months). At the time of the last follow-up visit, the examiner judged that 19 patients (56%) have complete pain relief and 11 patients (32%) have substantial pain relief. No patient used narcotic analgesics postoperatively. Seven patients developed diabetes mellitus, requiring insulin (n = 1), oral hypoglycemic agents (n = 5), and diet adjustment (n = 1). Four patients developed exocrine insufficiency. Weight increases with a mean of 4.8 +/- 5.4 kg (range, 1-24 kg) in 27 patients (79%).

CONCLUSIONS

Frey procedure appears as a safe technique with low mortality and morbidity rates and allows effective pain relief in about 90% of patients.

A new model of chronic pancreatitis in rats

This study was designed to examine whether continuous pancreatic ductal hypertension (PDH) plays an important role in the onset and development of chronic pancreatitis (CP). Pancreatic, biliary, and duodenal cannulas were implanted in male Wistar rats. PDH was induced by vertically raising the free end of the pancreatic duct cannula to exert a hydrostatic pressure and maintained for 2 wk. PDH was gradually increased, but when the pancreatic juice (PJ) flow was interrupted, PDH was decreased to restore PJ flow. The induction of PDH resulted in a marked reduction of amylase activity in PJ and an increase in serum amylase activity. At 2 wk after persistent PDH, pancreatic exocrine function was markedly decreased in response to a bolus injection of secretin (100 pmol/kg) compared with the control group. Histological examination revealed interlobular as well as intralobular fibrosis in the form of nodular pancreatitis at 2 wk after the induction of PDH. Immunohistochemistry revealed the expression of fibronectin and collagen types I and III. Quantitative real-time RT-PCR showed an increase in transforming growth factor-beta(1) mRNA expression in the pancreas during PDH. The present results suggest that PDH plays an important role in the onset and development of CP. Furthermore, our animal model seems useful for investigating the mechanisms of CP in rats.

Prospective randomised comparison of organ-preserving pancreatic head resection with pylorus-preserving pancreaticoduodenectomy

BACKGROUND AND AIMS

In a prospective, randomised, control trial organ-preserving pancreatic head resection (OPPHR) was compared with pylorus-preserving pancreaticoduodenectomy (PPPD) to assess the advantages and disadvantages of each type of operation.

PATIENTS AND METHODS

Forty patients were allocated randomly to either the OPPHR (n=20) or the PPPD (n=20) group. The surgical data, postoperative complications, induction of diabetes mellitus, postoperative pain and quality of life 1 year, postoperatively, were considered.

RESULTS

The two study groups of 20 patients were well balanced with regard to sex, age, chronic pancreatitis history and indication for surgery. The duration of the operation for OPPHR and PPPD was 142.5+/-4.9 and 278+/-6.9 min, respectively (P<0.05). The postoperative mortality in each group was zero. After OPPHR and PPPD, the morbidity was 0 and 40%, respectively (P<0.05). The duration of hospital stay was also significantly different: 8.05+/-0.9 vs 13.8+/-3.9 days (P<0.05). After 1 year the pain relief was effective in both groups, but three patients acquired diabetes mellitus after PPPD; the body weight had increased by 7.8+/-0.9 and 3.2+/-0.3 kg after OPPHR and PPPD, respectively (P<0.05).

CONCLUSION

The two procedures are equally safe and effective with regard to pain relief, but OPPHR is superior to PPPD not only in the operation data and morbidity, but also in the quality of life 1 year postoperatively. OPPHR should be regarded as a recommended procedure in the treatment of chronic pancreatitis.

Endocrine pancreatic insufficiency in chronic pancreatitis

Chronic pancreatitis (CP) is considered to be a rare cause of diabetes mellitus. However, in both the developed and developing world, there is an increasing number of patients suffering from pancreatitis probably due to lifestyle changes, which is partially associated with both social factors and the poor health status of immigrants. Owing to these circumstances, CP has evolved with one of the possible causes of diabetes in a selected group of patients and should be included in the differential diagnosis of diabetes. Several studies have shown that the long-term rate of diabetic complications in patients with CP and insulin-dependent diabetes is similar to that in patients with type 1 diabetes of equal duration. The hypothesis that early diagnosis of CP should result in better prognosis is not validated and may complicate the issue, since the risk of diabetes has been shown to increase significantly only once pancreatic calcification has developed. Accumulative evidence suggests that the risk of diabetes is not influenced by elective pancreatic surgical procedures other than distal pancreatectomy. The lack of contemporary data points to the urgent need for large prospective studies in order to accurately evaluate the special characteristics of disorders in glucose homeostasis in patients with CP.

Surgical and interventional treatment of chronic pancreatitis

The management of patients with chronic pancreatitis (CP) remains a challenging problem. Main indications for surgery are intractable pain, suspicion of malignancy, and involvement of adjacent organs. The main goal of surgical treatment is improvement of patient quality of life. The surgical treatment approach usually involves proximal pancreatic resection, but lateral pancreaticojejunal drainage may be used for large-duct disease. The newer duodenum-preserving head resections of Beger and Frey provide good pain control and preservation of pancreatic function. Thoracoscopic splanchnicectomy and the endoscopic approach await confirmatory trials to confirm their efficiency in the management of CP. Common bile duct obstruction is addressed by distal Roux-en-Y choledochojejunostomy but when combined with dudodenal obstruction must be treated by pancreatic head resection. Pancreatic ascites due to disrupted pancreatic duct should be treated by internal drainage. The approach to CP is multidisciplinary, tailoring the various therapeutic options to meet each individual patient's needs.