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Kunovský L, Dítě P, Jabandžiev P, Eid M, Poredská K, Vaculová J, Sochorová D, Janeček P, Tesaříková P, Blaho M, Trna J, Hlavsa J, Kala Z. Causes of Exocrine Pancreatic Insufficiency Other Than Chronic Pancreatitis. J Clin Med 2021; 10:jcm10245779. [PMID: 34945075 PMCID: PMC8708123 DOI: 10.3390/jcm10245779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/30/2021] [Accepted: 12/02/2021] [Indexed: 12/12/2022] Open
Abstract
Exocrine pancreatic insufficiency (EPI), an important cause of maldigestion and malnutrition, results from primary pancreatic disease or is secondary to impaired exocrine pancreatic function. Although chronic pancreatitis is the most common cause of EPI, several additional causes exist. These include pancreatic tumors, pancreatic resection procedures, and cystic fibrosis. Other diseases and conditions, such as diabetes mellitus, celiac disease, inflammatory bowel disease, and advanced patient age, have also been shown to be associated with EPI, but the exact etiology of EPI has not been clearly elucidated in these cases. The causes of EPI can be divided into loss of pancreatic parenchyma, inhibition or inactivation of pancreatic secretion, and postcibal pancreatic asynchrony. Pancreatic enzyme replacement therapy (PERT) is indicated for the conditions described above presenting with clinically clear steatorrhea, weight loss, or symptoms related to maldigestion and malabsorption. This review summarizes the current literature concerning those etiologies of EPI less common than chronic pancreatitis, the pathophysiology of the mechanisms of EPI associated with each diagnosis, and treatment recommendations.
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Affiliation(s)
- Lumír Kunovský
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
| | - Petr Dítě
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
- Department of Gastroenterology and Internal Medicine, University Hospital Ostrava, Faculty of Medicine, University of Ostrava, 70852 Ostrava, Czech Republic;
| | - Petr Jabandžiev
- Department of Pediatrics, University Hospital Brno, Faculty of Medicine, Masaryk University, 61300 Brno, Czech Republic;
- Central European Institute of Technology, Masaryk University, 62500 Brno, Czech Republic
| | - Michal Eid
- Department of Hematology, Oncology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic;
| | - Karolina Poredská
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
| | - Jitka Vaculová
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
| | - Dana Sochorová
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
| | - Pavel Janeček
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
| | - Pavla Tesaříková
- Department of Internal Medicine, Hospital Boskovice, 68001 Boskovice, Czech Republic;
| | - Martin Blaho
- Department of Gastroenterology and Internal Medicine, University Hospital Ostrava, Faculty of Medicine, University of Ostrava, 70852 Ostrava, Czech Republic;
| | - Jan Trna
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (L.K.); (P.D.); (K.P.); (J.V.)
- Department of Internal Medicine, Hospital Boskovice, 68001 Boskovice, Czech Republic;
- Department of Gastroenterology and Digestive Endoscopy, Masaryk Memorial Cancer Institute Brno, 60200 Brno, Czech Republic
- Correspondence: (J.T.); (J.H.)
| | - Jan Hlavsa
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
- Correspondence: (J.T.); (J.H.)
| | - Zdeněk Kala
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, 62500 Brno, Czech Republic; (D.S.); (P.J.); (Z.K.)
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Kozlov IA, Baydarova MD, Shevchenko TV, Ikramov RZ, Zharikov YO. Duodenum-preserving total pancreatic head resection. Early postoperative outcomes. ACTA ACUST UNITED AC 2020. [DOI: 10.16931/1995-5464.20204107-117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Aim. To study the early postoperative outcomes of duodenum-preserving total pancreatic head resections in benign, premalignant tumors of the pancreatic head and chronic pancreatitis complicated by duodenal dystrophy in comparison with the results of pylorus-preserving pancreaticoduodenectomy. Materials and methods. From 2006 to 2019, 54 patients underwent duodenum-preserving total pancreatic head resection for chronic pancreatitis complicated by duodenal dystrophy, benign or premalignant tumors of the pancreatic head. At the same time, in 25 cases, the operation was performed in an isolated version, in 29 – with a resection of the duodenum. As a comparison group, we used data from 89 patients who underwent pyloruspreserving pancreaticoduodenectomy during the same period. Results. Compared to pancreaticoduodenectomy, duodenum-preserving total pancreatic head resection exhibits significantly longer times for surgery (420 and 310 minutes, respectively). There was no statistically significant difference in the volume of intraoperative blood loss. There are no differences between groups in hospital morbidity (the frequency of pancreatic fistulas, delayed gastric emptying, bile leakage and post-resection bleeding). The frequency of postoperative complications for Clavien-Dindo III and higher did not differ significantly in the groups. There is no hospital mortality after duodenum-preserving total pancreatic head resection; three patients died after pancreatoduodenectomy. Conclusion. Early postoperative outcomes following duodenum-preserving total pancreatic head resection and pylorus-preserving pancreaticoduodenectomy are comparable. However, to develop a full-fledged concept of surgical treatment of pancreatic head benign, premalignant neoplasms and chronic pancreatitis with duodenal dystrophy, it is necessary to analyze the long-term outcomes of treatment.
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Affiliation(s)
- I. A. Kozlov
- Vishnevsky National Medical Scientific Centre of Surgery, Ministry of Health of the Russian Federation
| | - M. D. Baydarova
- Vishnevsky National Medical Scientific Centre of Surgery, Ministry of Health of the Russian Federation
| | - T. V. Shevchenko
- Vishnevsky National Medical Scientific Centre of Surgery, Ministry of Health of the Russian Federation
| | - R. Z. Ikramov
- Vishnevsky National Medical Scientific Centre of Surgery, Ministry of Health of the Russian Federation
| | - Yu. O. Zharikov
- Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University)
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Chen S, Gao P, Cai H, Cai Y, Wang X, Peng B. Indocyanine Green-Enhanced Fluorescence in Laparoscopic Duodenum-Preserving Pancreatic Head Resection: Technique with Video. Ann Surg Oncol 2020; 27:3926-3927. [PMID: 32266569 DOI: 10.1245/s10434-020-08360-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND In 1972, Beger et al.1 first described duodenum-preserving pancreatic head resection (DPPHR) for patients with severe chronic pancreatitis. Then DPPHR also was proved capable of providing comparable long-term oncologic outcomes in the setting of benign or low-grade malignant tumors.2 As an organ-preserving procedure, DPPHR preserves the integrity of the digestive tract and improves the patient's quality of life compared with pancreaticoduodenectomy (PD),3 although DPPHR is more technically challenging, especially in protecting the bile duct and the pancreaticoduodenal vascular arch.4,5 The indocyanine green (ICG)-enhanced fluorescence imaging system in laparoscopic surgery can identify the biliary and vascular anatomy clearly to ensure a safe cholecystectomy and an adequate vascular supply for colectomy or nephrectomy.6 Nevertheless, to date, no report has described ICG-enhanced fluorescence in laparoscopic duodenum-preserving pancreatic head resection (LDPPHR). This article describes the technique of LDPPHR using a video of a real-time ICG fluorescence imaging system. METHODS A 29-year-old woman received a diagnosis of chronic pancreatitis and an inflammatory mass in the head of the pancreas. A computed tomography (CT) scan showed atrophy of the pancreas, dilation of the main pancreatic duct, and heterogeneous enhancement of the pancreatic head parenchyma (Fig. 1). Her other preoperative examination results were normal except for high blood sugar. To avoid an extended PD for this young patient, LDPPHR was performed. The patient was placed in supine position with her two legs apart. The observing trocar (10 mm) was located at the inferior umbilicus. Four trocars (two 5-mm trocars and two 12-mm trocars) were distributed symmetrically at the midclavicular line and anterior axillary line. Another 5-mm trocar located at the subxiphoid was used for traction of the stomach with a rubber band. Before the operation, ICG (5 mg) was injected intravenously from the elbow vein. The gastrocolic ligament was opened, and the hepatic flexure of the colon was taken down to explore the head of the pancreas without making a Kocher's maneuver. After hanging of the distal stomach with a rubber band, both the right gastroepiploic vein and Henle's trunk were dissected. The number 8a lymph node was dissected for intraoperative rapid frozen pathology. A post-pancreatic neck tunnel was built, and the pancreatic neck was transected with an ultrasonic scalpel. The main pancreatic duct was identified and transected with cold scissors. The superior mesenteric vein (SMV) was hung with another rubber band and retracted to the left. The uncinate process of the pancreas was retracted to the right, and subcapsular dissection was performed, with particular attention paid to protection of the anterior inferior pancreaticoduodenal artery (AIPDA), the posterior inferior pancreaticoduodenal artery (PIPDA), and their branches that go into the duodenum. Then the gastroduodenal artery (GDA) was identified, and the anterosuperior pancreatic duodenal artery (ASPDA) was dissected. The upper part of the pancreatic head was separated to expose the common bile duct (CBD) with the help of real-time ICG fluorescence imaging (Fig. 2). The pancreas was dissected from the left edge of the duodenum and the right and ventral edges of the CBD. The posterosuperior pancreatic duodenal artery (PSPDA) was identified at the dorsal edge of the CBD. The PSPDA and its branches going into the distal CBD as well as the ampulla of Vater were carefully preserved. The proximal side of the main and accessory pancreatic duct was identified and sutured. Pancreatic anastomosis was performed using the technique of Bing's anastomosis.7 Fig. 1 Enhanced computed tomography (CT) scan showing atrophy of the pancreas, dilatation of the main pancreatic duct, and heterogeneous enhancement of the pancreatic head parenchyma Fig. 2 The common bile duct was separated and exposed from the head to the tail by the assistance of the real-time indocyanine green (ICG)-enhanced fluorescence imaging system RESULTS: The operation time was 251 min, and the estimated blood loss was 150 ml. The postoperative course was uneventful, with a hospital stay of 13 days. From February 2019 to November 2019, LDPPHR was used by the authors to manage 24 cases, including chronic pancreatitis (6 cases), pancreatic intraductal papillary mucinous tumors (6 cases), pancreatic neuroendocrine tumors (4 cases), pancreatic solid pseudopapillary tumors (4 cases), serous cystadenoma (3 cases), and mucinous cystadenoma (1 case). CONCLUSIONS Indocyanine green-enhanced fluorescence in laparoscopic duodenum-preserving pancreatic head resection was safe and may offer a benefit for maintaining the integrity of the biliary system.
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Affiliation(s)
- Sirui Chen
- Department of Hepatobiliary Surgery, Mianyang Central Hosptial, Mianyang, China
| | - Pan Gao
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hosptial, Chengdu, China.,Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - He Cai
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hosptial, Chengdu, China.,Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yunqiang Cai
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hosptial, Chengdu, China.,Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xin Wang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Bing Peng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China.
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