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Ball CG, Biffl WL, Vogt K, Hameed SM, Parry NG, Kirkpatrick AW, Kaminsky M. Does drainage or resection predict subsequent interventions and long-term quality of life in patients with Grade IV pancreatic injuries: A population-based analysis. J Trauma Acute Care Surg 2021; 91:708-715. [PMID: 34559164 DOI: 10.1097/ta.0000000000003313] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Clinical equipoise remains significant for the treatment of Grade IV pancreatic injuries in stable patients (i.e., drainage vs. resection). The literature is poor in regards to experience, confirmed main pancreatic ductal injury, nuanced multidisciplinary treatment, and long-term patient quality of life (QOL). The primary aim was to evaluate the management and outcomes (including long-term QOL) associated with Grade IV pancreatic injuries. METHODS All severely injured adult patients with pancreatic trauma (1995-2020) were evaluated (Grade IV injuries compared). Concordance of perioperative imaging, intraoperative exploration, and pathological reporting with a main pancreatic ductal injury was required. Patients with resection of Grade IV injuries were compared with drainage alone. Long-term QOL was evaluated (Standard Short Form-36). RESULTS Of 475 pancreatic injuries, 36(8%) were confirmed as Grade IV. Twenty-four (67%) underwent a pancreatic resection (29% pancreatoduodenectomy; 71% extended distal pancreatectomy [EDP]). Patient, injury and procedure demographics were similar between resection and drainage groups (p > 0.05). Pancreas-specific complications in the drainage group included 92% pancreatic leaks, 8% pseudocyst, and 8% walled-off pancreatic necrosis. Among patients with controlled pancreatic fistulas beyond 90 days, 67% required subsequent pancreatic operations (fistulo-jejunostomy or EDP). Among patients whose fistulas closed, 75% suffered from recurrent pancreatitis (67% eventually undergoing a Frey or EDP). All patients in the resection group had fistula closure by 64 days after injury. The median number of pancreas-related health care encounters following discharge was higher in the drainage group (9 vs. 5; p = 0.012). Long-term (median follow-up = 9 years) total QOL, mental and physical health scores were higher in the initial resection group (p = 0.031, 0.022 and 0.017 respectively). CONCLUSION The immediate, intermediate and long-term experiences for patients who sustain Grade IV pancreatic injuries indicate that resection is the preferred option, when possible. The majority of drainage patients will require additional, delayed pancreas-targeted surgical interventions and report poorer long-term QOL. LEVEL OF EVIDENCE Epidemiology/Prognostic, Level III.
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Affiliation(s)
- Chad G Ball
- From the Department of Surgery (C.G.B., A.W.K.), University of Calgary, Calgary, Alberta, Canada; Department of Surgery (W.L.B.), Scripps Clinic Medical Group, La Jolla, California; Department of Surgery (S.M.H.), University of British Columbia, Vancouver, BC, Canada; Department of Surgery (K.V., N.G.P.), Western University, London, Ontario, Canada; and Department of Surgery (M.K.), Cook County Hospital, Chicago, Illinois
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Assessment of pain associated with chronic pancreatitis: An international consensus guideline. Pancreatology 2021; 21:1256-1284. [PMID: 34391675 DOI: 10.1016/j.pan.2021.07.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 07/16/2021] [Accepted: 07/16/2021] [Indexed: 12/11/2022]
Abstract
Pain is the most common symptom in chronic pancreatitis (CP) with a major impact on quality of life. Few validated questionnaires to assess pain in CP exist, and the lack of consensus negatively impacts clinical management, research and meta-analysis. This guideline aims to review generic pain questionnaires for their usability in CP, to outline how pain assessment can be modified by confounding factors and pain types, to assess the value of additional measures such as quality of life, mental health and quantitative sensory testing, and finally to review pain assessment questionnaires used specifically in CP. A systematic review was done to answer 27 questions that followed the PICO (Population; Intervention; Comparator; Outcome) template. Quality of evidence of the statements was judged by Grades of Recommendation, Assessment, Development and Evaluation (GRADE) criteria. The manuscript was sent for review to 36 experts from various disciplines and continents in a multi-stage Delphi process, and finally reviewed by patient representatives. Main findings were that generic pain instruments are valid in most settings, but aspects of pain are specific for CP (including in children), and instruments have to account for the wide phenotypic variability and development of sensitization of the central nervous system. Side effects to treatment and placebo effects shall also be considered. Some multidimensional questionnaires are validated for CP and are recommended together with assessment of quality of life and psychiatric co-morbidities. This guideline will result in more homogeneous and comprehensive pain assessment to potentially improve management of painful CP.
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Jiang L, Ning D, Cheng Q, Chen XP. Endoscopic versus surgical drainage treatment of calcific chronic pancreatitis. Int J Surg 2018; 54:242-247. [DOI: 10.1016/j.ijsu.2018.04.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 03/22/2018] [Accepted: 04/13/2018] [Indexed: 01/10/2023]
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Teo K, Johnson MH, Truter S, Pandanaboyana S, Windsor JA. Pain assessment in chronic pancreatitis: A comparative review of methods. Pancreatology 2016; 16:931-939. [PMID: 27693097 DOI: 10.1016/j.pan.2016.09.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 09/10/2016] [Accepted: 09/14/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with chronic pancreatitis (CP) frequently report chronic abdominal pain that adversely impacts their quality of life. Assessment of pain in CP is required for clinical management and clinical studies. International consensus guidelines recognized a lack of specific and validated pain assessment tools for CP. Therefore, the aim of this systematic review is to identify and compare all clinical studies that assessed pain in the context of a treatment for pain in CP. METHODS A systematic literature search was performed in PubMed, Cochrane Library and Ovid MEDLINE. The search identified all intervention studies for pain in CP and the pain assessment tools used based on pre-defined inclusion and exclusion criteria. RESULTS Of 341 articles identified, 137 studies were included. Pain assessment tools were both general and CP-specific. The latter were used in only 22 (16%) studies. Despite recommendations the aspects of pain assessed were limited and variable between tools. Validation of these tools in CP patients was limited to quality of life measures. None of the pain assessment tools evaluated duration of pain and postprandial pain. CONCLUSIONS There are no published pain assessment tools for CP that includes all relevant aspects of pain. There is the need to develop a comprehensive and validated pain assessment tool for patients with CP to standardised pain assessment, identify likely underlying pain mechanisms, help select appropriate treatments, report outcomes from interventions, improve clinical communication and aid the allocation of patients to clinical trials.
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Affiliation(s)
- K Teo
- Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - M H Johnson
- Department of Psychological Medicine, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - S Truter
- Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - S Pandanaboyana
- Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - J A Windsor
- Department of Surgery, School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, New Zealand.
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Fischer TD, Gutman DS, Warner EA, Trevino JG, Hughes SJ, Behrns KE. Local pancreatic head resection: the search for optimal indications through quality of life assessments. Am J Surg 2015; 210:417-23. [PMID: 26003202 DOI: 10.1016/j.amjsurg.2014.12.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 12/10/2014] [Accepted: 12/23/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Local pancreatic head resection (LPHR) for chronic pancreatitis has had limited adoption in the United States perhaps because of sparse outcomes and quality of life data. METHODS Forty-four patients underwent LPHR and retrospective evaluation of patient outcomes and quality of life assessment was performed. RESULTS The mean age was 49 ± 11 years (50% men) with chronic alcohol use as the etiology in 79% of patients. One patient (2%) died within 90 days. The intensive care unit stay was 1.8 ± 3.1 days and postoperative length of stay was 12.6 ± 9.4 days with 96% of patients discharged home. Ten (22%) patients had major perioperative complications. Biliary stricture was the most common late complication (14%). Quality of life assessment results showed that global status (47/100) and physical (66/100), cognitive (68/100), and social (52/100) functions were acceptable. Prevalent postoperative symptoms were pain (52/100), insomnia (56/100), and digestive disturbance (60/100). CONCLUSIONS LPHR is safe and effective for a substantial proportion of patients with chronic pancreatitis. Further refinement in the selection of patients most likely to benefit from this operation is warranted.
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Affiliation(s)
- Trevan D Fischer
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Daniel S Gutman
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | | | - Jose G Trevino
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Steven J Hughes
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Kevin E Behrns
- Department of Surgery, University of Florida, Gainesville, FL, USA.
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Dasari BV, Farid S, Roberts K, Morris-Stiff G. Overview of pancreatic resections: indications and procedures. Br J Hosp Med (Lond) 2015; 76:C34-7. [PMID: 25761816 DOI: 10.12968/hmed.2015.76.3.c34] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Bobby Vm Dasari
- Specialty Registrar in the Department of Hepatobiliary and Pancreatic Surgery, Mater Hospital, Belfast Health and Social Care Trust, Belfast BT14 6AB
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Pothula Rajendra VK, Sivanpillay Mahadevan S, Parvathareddy SR, Nara BK, Gorlagunta Ramachandra M, Tripuraneni Venkata AC, Bathalapalli JMR, Gudi VPR, Sampath T. Frey’s Pancreaticojejunostomy in Tropical Pancreatitis: Assessment of Quality of Life. A Prospective Study. World J Surg 2014; 38:3235-47. [DOI: 10.1007/s00268-014-2732-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Bouwense SA, Ahmed Ali U, ten Broek RP, Issa Y, van Eijck CH, Wilder-Smith OH, van Goor H. Altered central pain processing after pancreatic surgery for chronic pancreatitis. Br J Surg 2014; 100:1797-804. [PMID: 24227367 DOI: 10.1002/bjs.9322] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic abdominal pain is common in chronic pancreatitis (CP) and may involve altered central pain processing. This study evaluated the relationship between pain processing and pain outcome after pancreatic duct decompression and/or pancreatic resection in patients with CP. METHODS Patients with CP underwent quantitative sensory testing. Pain processing was measured via electrical pain detection (ePDT) and electrical pain tolerance (ePTT) thresholds in dermatomes C5 and L4. Inhibitory descending pain control mechanisms were assessed using the conditioned pain modulation (CPM) paradigm. Healthy controls and patients with CP were compared, and patients with CP and a poor pain outcome (visual analogue scale (VAS) score greater than 30) were compared with those with a good pain outcome (VAS score 30 or less). RESULTS Forty-eight patients with CP had lower ePDT, ePTT and CPM responses compared with values in 15 healthy controls (P < 0·030). The sum of ePDT values was lower in patients with a poor pain outcome than in those with a good outcome (median 7·1 versus 11·2 mA; P = 0·008). There was a correlation with the VAS score and the sum of ePDT values (rs = -0·45, P = 0·016) and ePTT values (rs = -0·46, P = 0·011), and CPM response (rs = -0·43, P = 0·006) in patients with CP. CONCLUSION After pain-relieving pancreatic surgery, patients with CP exhibit altered central pain processing compared with that in healthy controls. Poor pain outcomes are associated with more central sensitization and more pronociceptive descending pain modulation, and this should be considered when managing persistent pain after pain-relieving surgery for CP.
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Affiliation(s)
- S A Bouwense
- Department of Surgery, Rotterdam, The Netherlands
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Belyaev O, Herzog T, Chromik AM, Meurer K, Uhl W. Early and late postoperative changes in the quality of life after pancreatic surgery. Langenbecks Arch Surg 2013; 398:547-55. [DOI: 10.1007/s00423-013-1076-3] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 02/28/2013] [Indexed: 01/29/2023]
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Walsh RM, Saavedra JRA, Lentz G, Guerron AD, Scheman J, Stevens T, Trucco M, Bottino R, Hatipoglu B. Improved quality of life following total pancreatectomy and auto-islet transplantation for chronic pancreatitis. J Gastrointest Surg 2012; 16:1469-77. [PMID: 22673773 DOI: 10.1007/s11605-012-1914-6] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2011] [Accepted: 05/15/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Total pancreatectomy (TP) with auto-islet transplant (AIT) is an extreme treatment for chronic pancreatitis, and we reviewed our experience to assess the impact on quality of life (QOL). METHODS A prospective cohort study from 2007 through 2010 with pre- and postoperative assessments of the Depression Anxiety Stress Scale, Pain Disability Index, and visual analogue pain scale was performed. RESULTS Twenty patients underwent TP-AIT with a median follow-up of 12 months (6.75-24 months). All patients reported moderate (45 %) to severe (55 %) pain prior to surgery. TP-AIT resulted in significant decreases in abdominal pain (p < 0.001), 80 % reporting no or mild pain. Despite pain improvement, only 30 % discontinued narcotics. Improvements in all PDI QOL domains improved from 79 to 90 % (p = 0.002), with greatest improvements seen in those without prior pancreatic surgery, younger patients, and in those with higher levels of preoperative pain. Patients were less affected by depression and anxiety prior to surgery, but 60 and 70 % did show improvement in depression and anxiety, respectively (p = 0.033). Sixteen patients (80 %) required exogenous insulin at last follow-up (mean total dose of insulin 11.6 U/day). CONCLUSIONS TP-AIT significantly improves pain and QOL measures in appropriately selected patients with CP.
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Affiliation(s)
- R M Walsh
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA.
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Abstract
OBJECTIVE We measured a comprehensive set of outcome measures after different surgical procedures for painful chronic pancreatitis (CP) at long-term follow-up. BACKGROUND Pain caused by CP can be alleviated through operative intervention with type of procedure depending on anatomical abnormalities. Outcome measures include functional (pain relief, quality of life [QoL]), medical (endo- and exocrine function), and clinical (reoperation) results reported by patient. METHODS A cross-sectional cohort of 223 consecutive patients who underwent surgical drainage, head resection, or left-sided pancreas resection, depending on anatomical abnormalities, was analyzed. Participating patients were reassessed during a prospectively scheduled outpatient clinic visit. RESULTS At follow-up, 44 patients had died; 146 of 179 living patients consented to participate in the study. After 63 months (range: 14-268), 68% reported no or little pain, 19% reported intermediate pain, and 12% reported severe pain. Preoperative daily opioid use (OR: 3.04; 95% confidence interval [CI]: 1.09-8.49) and high numbers of preceding endoscopic procedures (OR [odds ratio]: 3.89; 95% CI: 1.01-14.9) were associated with persistent severe pain. Compared with the general population, physical more than mental QoL remained impaired (P < 0.05). At follow-up, endocrine insufficiency was present in 57% of patients and exocrine insufficiency was present in 77%. Independently, a head resection and a reoperation for any cause were moderately associated with new-onset diabetes (P < 0.1). Compared with patients who underwent left-sided resection, the risk of developing exocrine insufficiency after surgery was higher after drainage or head resection. After 20 months (interquartile range: 10-51) after surgery, 26 (12%) of 223 patients underwent 1 or more elective reoperations. CONCLUSIONS Operative intervention for painful CP, tailored to anatomical abnormalities, results in excellent to fair long-term pain relief, but approximately 10% of patients do not respond. QoL scores remained slightly compromised. High preoperative pain levels, suggested through daily opioid use and high numbers of endoscopic procedures, are associated with less favorable outcome.
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Abstract
OBJECTIVES There are limited data on health-related quality of life (HRQOL) in pediatric patients with long-standing pancreatitis (including acute relapsing and chronic pancreatitis) using age-appropriate measurement instruments. METHODS We evaluated HRQOL in children with long-standing pancreatitis using the PedsQL 4.0 Generic Core Scales by patient self-report as well as parent proxy report. Additionally, patient self-reports and parent proxy reports were completed for the PedsQL Multidimensional Fatigue Scale. RESULTS Across all of the dimensions, significantly impaired HRQOL and higher fatigue were noted for both pediatric patient self-report and parent proxy report in comparison with the matched healthy children samples. Higher fatigue was associated with lower HRQOL. There was moderate to good agreement between patient self-reports and parent proxy reports. CONCLUSIONS Given the impaired HRQOL and fatigue documented in the present study, future studies are needed to determine whether specific factors can modify HRQOL and fatigue in this patient population.
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Perwaiz A, Singh A, Chaudhary A. Surgery for chronic pancreatitis. Indian J Surg 2011; 74:47-54. [PMID: 23372307 DOI: 10.1007/s12262-011-0374-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 11/10/2011] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Azhar Perwaiz
- Department of GI Surgery, GI Oncology and Bariatric Surgery, Room No-10, 11th floor, OPD block, Medanta, The Medicity, Sector-38, 12001 Gurgaon, Haryana India
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Jongsma MLA, Postma SAE, Souren P, Arns M, Gordon E, Vissers K, Wilder-Smith O, van Rijn CM, van Goor H. Neurodegenerative properties of chronic pain: cognitive decline in patients with chronic pancreatitis. PLoS One 2011; 6:e23363. [PMID: 21876748 PMCID: PMC3158076 DOI: 10.1371/journal.pone.0023363] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 07/13/2011] [Indexed: 12/20/2022] Open
Abstract
Chronic pain has been associated with impaired cognitive function. We examined cognitive performance in patients with severe chronic pancreatitis pain. We explored the following factors for their contribution to observed cognitive deficits: pain duration, comorbidity (depression, sleep disturbance), use of opioids, and premorbid alcohol abuse. The cognitive profiles of 16 patients with severe pain due to chronic pancreatitis were determined using an extensive neuropsychological test battery. Data from three cognitive domains (psychomotor performance, memory, executive functions) were compared to data from healthy controls matched for age, gender and education. Multivariate multilevel analysis of the data showed decreased test scores in patients with chronic pancreatitis pain in different cognitive domains. Psychomotor performance and executive functions showed the most prominent decline. Interestingly, pain duration appeared to be the strongest predictor for observed cognitive decline. Depressive symptoms, sleep disturbance, opioid use and history of alcohol abuse provided additional explanations for the observed cognitive decline in some of the tests, but to a lesser extent than pain duration. The negative effect of pain duration on cognitive performance is compatible with the theory of neurodegenerative properties of chronic pain. Therefore, early and effective therapeutic interventions might reduce or prevent decline in cognitive performance, thereby improving outcomes and quality of life in these patients.
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Affiliation(s)
- Marijtje L. A. Jongsma
- Donders Centre for Cognition, Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen, Nijmegen, The Netherlands
- Department of Learning and Development, Behavioral Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Simone A. E. Postma
- Donders Centre for Cognition, Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Pierre Souren
- Research Technical Support Group (RTOG), Department of Social Psychology, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Martijn Arns
- Research Institute Brainclinics, Nijmegen, The Netherlands
| | - Evian Gordon
- The Brain Resource International Database and the Brain Resource Company, Ultimo, Australia
| | - Kris Vissers
- Pain and Nociception Neuroscience Research Group, Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Oliver Wilder-Smith
- Pain and Nociception Neuroscience Research Group, Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Clementina M. van Rijn
- Donders Centre for Cognition, Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen, Nijmegen, The Netherlands
- * E-mail:
| | - Harry van Goor
- Pain and Nociception Neuroscience Research Group, Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Imrie CW. Long-term quality of life after surgery for chronic pancreatitis ( Br J Surg 2010; 97: 1079–1086) Pain relief after Frey's procedure for chronic pancreatitis ( Br J Surg 2010; 97: 1087–1095). Br J Surg 2010. [DOI: 10.1002/bjs.7117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- C W Imrie
- Lister Department of Surgery, Glasgow Royal Infirmary, Alexandra Parade, Glasgow G31 2ER, UK
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