Improved outcomes for benign disease with limited pancreatic head resection

Duodenum-Preserving Pancreatic Head Resection for Benign and Premalignant Tumors-a Systematic Review and Meta-analysis of Surgery-Associated Morbidity

BACKGROUND

Pancreatic benign, cystic, and neuroendocrine neoplasms are increasingly detected and recommended for surgical treatment. In multiorgan resection pancreatoduodenectomy or parenchyma-sparing, local extirpation is a challenge for decision-making regarding surgery-related early and late postoperative morbidity.

METHODS

PubMed, Embase, and Cochrane Libraries were searched for studies reporting early surgery-related complications following pancreatoduodenectomy (PD) and duodenum-preserving total (DPPHRt) or partial (DPPHRp) pancreatic head resection for benign tumors. Thirty-four cohort studies comprising data from 1099 patients were analyzed. In total, 654 patients underwent DPPHR and 445 patients PD for benign tumors. This review and meta-analysis does not need ethical approval.

RESULTS

Comparing DPPHRt and PD, the need for blood transfusion (OR 0.20, 95% CI 0.10-0.41, p<0.01), re-intervention for serious surgery-related complications (OR 0.48, 95% CI 0.31-0.73, p<0.001), and re-operation for severe complications (OR 0.50, 95% CI 0.26-0.95, p=0.04) were significantly less frequent following DPPHRt. Pancreatic fistula B+C (19.0 to 15.3%, p=0.99) and biliary fistula (6.3 to 4.3%; p=0.33) were in the same range following PD and DPPHRt. In-hospital mortality after DPPHRt was one of 350 patients (0.28%) and after PD eight of 445 patients (1.79%) (OR 0.32, 95% CI 0.10-1.09, p=0.07). Following DPPHRp, there was no mortality among the 192 patients.

CONCLUSION

DPPHR for benign pancreatic tumors is associated with significantly fewer surgery-related, serious, and severe postoperative complications and lower in-hospital mortality compared to PD. Tailored use of DPPHRt or DPPHRp contributes to a reduction of surgery-related complications. DPPHR has the potential to replace PD for benign tumors and premalignant cystic and neuroendocrine neoplasms of the pancreatic head.

Surgical Outcomes and Trends for Chronic Pancreatitis: An Observational Cohort Study from a High-Volume Centre

Surgery for chronic pancreatitis (CP) is considered as a last resort treatment. The present study aims to determine the short- and medium-term outcomes of surgical treatment for CP with a comparison between duodenum-preserving pancreatic head resection (DPPHR) and pancreatoduodenectomy (PD). The trends in surgical procedures were also examined. This was a retrospective cohort study of patients who underwent surgery for CP between 2000 and 2019 at the Karolinska University Hospital. One hundred and sixty-two patients were included. Surgery performed included drainage procedures (n = 2), DPPHR (n = 35), resections (n = 114, of these PD in n = 65) and other procedures (n = 11). Morbidity occurred in 17%, and the 90-day mortality was 1%. Complete or partial pain relief was achieved in 65% of patients. No significant difference in morbidity was observed between the DPPHR and PD groups: 17% vs. 20% (p = 0.728). Pain relief did not differ between the groups (62% for DPPHR vs. 73% for PD, p = 0.142). The frequency of performed DPPHR decreased, whereas the rate of PD remained unaltered. Surgical treatment for CP is safe and effective. DPPHR and PD are comparable regarding post-operative morbidity and are equally effective in achieving pain relief. Trends over time revealed PD as more commonly performed compared to DPPHR.

Long-term Metabolic Morbidity and Steatohepatosis Following Standard Pancreatic Resections and Parenchyma-sparing, Local Extirpations for Benign Tumor: A Systematic Review and Meta-analysis

OBJECTIVE

To assess metabolic dysfunctions and steatohepatosis after standard and local pancreatic resections for benign and premalignant neoplasms.

SUMMARY OF BACKGROUND DATA

Duodenopancreatectomy, hemipancreatectomy, and parenchyma-sparing, limited pancreatic resections are currently in use for nonmalignant tumors.

METHODS

Medline, Embase, and Cochrane libraries were searched for studies reporting measured data of metabolic functions following PD, pancreatic left resection (PLR), duodenum-sparing pancreatic head resection (DPPHR), pancreatic middle segment resection (PMSR), and tumor enucleation (TEN). Forty cohort studies comprising data of 2729 patients were eligible.

RESULTS

PD for benign tumor was associated in 46 of 327 patients (14.1%) with postoperative new onset of diabetes mellitus (pNODM) and in 109 of 243 patients (44.9%) with postoperative new onset of pancreatic exocrine insufficiency measured after a mean follow-up of 32 months. The meta-analysis displayed pNODM following PD in 32 of 204 patients (15.7%) and in 10 of 200 patients (5%) after DPPHR [P < 0.01; OR: 0.33; (95%-CI: 0.15-0.22)]. PEI was found in 77 of 174 patients following PD (44.3%) and in 7 of 104 patients (6.7%) following DPPHR (P < 0.01;OR: 0.15; 95%-CI: 0.07-0.32). pNODM following PLR was reported in 107 of 459 patients (23.3%) and following PMSR 23 of 412 patients (5.6%) (P < 0.01; OR: 0.20; 95%-CI: 0.12-0.32). Postoperative new onset of pancreatic exocrine insufficiency was found in 17% following PLR and in 8% following PMSR (P < 0.01). pNODM following PPPD and tumor enucleation was observed in 19.7% and 5.7% (P < 0.03) of patients, respectively. Following PD/PPPD, 145 of 608 patients (23.8%) developed a nonalcoholic fatty liver disease after a mean follow-up of 30.4 months. Steatohepatosis following DPPHR developed in 2 of 66 (3%) significantly lower than following PPPD (P < 0.01).

CONCLUSION

Standard pancreatic resections for benign tumor carry a considerable high risk for a new onset of diabetes, pancreatic exocrine insufficiency and following PD for steatohepatosis. Parenchyma-sparing, local resections are associated with low grade metabolic dysfunctions.

Reporting of longitudinal pancreatojejunostomy with partial pancreatic head resection (the Frey procedure) for chronic pancreatitis: A systematic review

BACKGROUND

Longitudinal pancreatojejunostomy with partial pancreatic head resection (the Frey procedure) is accepted for surgical treatment of painful chronic pancreatitis. However, conduct and reporting are not standardized and thus, making comparisons difficult. This study assesses the reporting standards of this procedure.

DATA SOURCES

A systematic literature review was performed between January 1987 and January 2020. The keyword and Medical Subject Heading "chronic pancreatitis" was used together with the individual operation term "Frey pancreatojejunostomy". Reports were included if they provided original information on conduct and outcome. Thirty-three papers providing information on 1205 patients constituted the study population. Risk of bias in included reports was assessed.

RESULTS

Etiology of chronic pancreatitis (alcohol) was reported in 26 of 28 (93%) studies, duration of symptoms prior to surgery in 19 (58%) studies and pre-operative opiate use in 12 (36%) studies. In terms of morphology, pancreatic duct diameter was reported in 17 (52%) studies and diameter of the pancreatic head in 13 (39%) studies. In terms of technique, three (9%) studies reported weight of excised parenchyma. There were 9 (0.7%) procedure-related deaths. Post-operative follow-up ranged from 6 to 82.5 months. No studies reported post-operative portal hypertension.

CONCLUSIONS

There is substantial heterogeneity between studies in reporting of clinical baseline, morphology of the diseased pancreas, operative detail and outcome after longitudinal pancreatojejunostomy with partial pancreatic head resection. This critically compromises the comparison between centers and between surgeons. Structured reporting is necessary for clinicians to assess choice of procedure and for patients to make informed choices when seeking treatment for painful chronic pancreatitis.

Resection of the duodenum causes long-term endocrine and exocrine dysfunction after Whipple procedure for benign tumors - Results of a systematic review and meta-analysis

BACKGROUND

Metabolic dysfunctions after pancreatoduodenectomy (PD) need to be considered when pancreatic head resection is likely to lead to long-term survival.

METHODS

Medline, Embase and Cochrane Library were searched for studies reporting measured data of metabolic function after PD and duodenum-sparing total pancreatic head resection (DPPHR). Data from 23 cohort studies comprising 1019 patients were eligible; 594 and 910 patients were involved in systematic review and meta-analysis, respectively.

RESULTS

The cumulative incidence of postoperative new onset of diabetes mellitus (pNODM) after PD for benign tumors was 46 of 321 patients (14%) measured after follow-up of in mean 36 months postoperatively. New onset of postoperative exocrine insufficiency (PEI) was exhibited by 91 of 209 patients (44%) after PD for benign tumors measured in mean 23 months postoperatively. The meta-analysis indicated pNODM after PD for benign tumor in 32 of 208 patients (15%) and in 10 of 178 patients (6%) after DPPHR (p = 0.007; OR 3.01; (95%CI:1.39-6.49)). PEI was exhibited by 80 of 178 patients (45%) after PD and by 6 of 88 patients (7%) after DPPHR (p < 0.001). GI hormones measured in 194 patients revealed postoperatively a significant impairment of integrated responses of gastrin, motilin, insulin, secretin, PP and GIP (p < 0.050-0.001) after PD. Fasting and stimulated levels of GLP-1 and glucagon levels displayed a significant increase (p < 0.020/p < 0.030). Following DPPHR, responses of gastrin, motilin, secretin and CCK displayed no change compared to preoperative levels.

CONCLUSIONS

After PD, duodenectomy, rather than pancreatic head resection is the main cause for long-term persisting, postoperative new onset of DM and PEI.

Geographical variance in reporting of elective surgery for chronic pancreatitis

The selection of optimum surgical procedure from the range of reported operations for chronic pancreatitis (CP) can be difficult. The aim of this study is to explore geographical variation in reporting of elective surgery for CP. A systematic search of the literature was performed using the Scopus database for reports of five selected procedures for CP: duodenum-preserving pancreatic head resection, total pancreatectomy with islet autotransplantation (TPIAT), Frey pancreaticojejunostomy, thoracoscopic splanchnotomy and the Izbicki V-shaped resection. The keyword and MESH heading 'chronic pancreatitis' was used. Overall, 144 papers met inclusion criteria and were utilized for data extraction. There were 33 reports of duodenum-preserving pancreatic head resection. Twenty-one (64%) were from Germany. There were 60 reports of TPIAT, 53 (88%) from the USA. There are only two reports of TPIAT from outwith the USA and UK. The 34 reports of the Frey pancreaticojejunostomy originate from 12 countries. There were 20 reports of thoracoscopic splanchnotomy originating from nine countries. All three reports of the Izbicki 'V' procedure are from Germany. There is geographical variation in reporting of surgery for CP. There is a need for greater standardization in the selection and reporting of surgery for patients with painful CP.

Parenchyma-sparing, local pancreatic head resection for premalignant and low-malignant neoplasms - A systematic review and meta-analysis

BACKGROUND

Parenchyma-sparing, local pancreatic head resection, but not pancreaticoduodenectomy (PD) preserves tissue and maintains the pancreatic metabolic functions.

METHODS

PubMed/Medline, Embase, and Cochrane library collections were systematically searched. Twenty-six cohort studies with 523 cumulative patients, who underwent duodenum-sparing pancreatic head resection (DPPHR), were retrieved. The meta-analysis was based on 14 controlled studies.

RESULTS

In total, 338 patients suffered cystic neoplasms and 59 PNETs, IPMN-174, MCN-43 and SPN-23 patients. Eighty-one patients (15.5%) histo-pathologically displayed a low-malignant tumor, of which 27 were carcinoma in-situ. Tumor recurrence was observed after a mean follow-up of 47.1 months in 11 patients. In-hospital and late mortality after DPPHR was 0.6% and 1.7%, respectively. The meta-analysis was based on 318 DPPHR compared to 404 PD patients. DPPHR was performed for premalignant neoplasm and PNET in 164 and 46 patients, and PD in 181 and 46 patients, respectively. Events of recurrence displayed no statistically significant difference between the DPPHR and PD groups.

CONCLUSION

DPPHR is associated with oncologically complete tumor resection for patients suffering premalignant IPMN, MCN, or SPN and for low-risk cancer.

New-onset diabetes after pancreatoduodenectomy: A systematic review and meta-analysis

BACKGROUND

Pancreatoduodenectomy may lead to new-onset diabetes mellitus, also known as type 3c diabetes, but the exact risk of this complication is unknown. The aim of this review was to assess the risk of new-onset diabetes mellitus after pancreatoduodenectomy.

METHODS

A literature search was performed in PubMed, Embase (Ovid), and the Cochrane Library for English articles published from March 1993 until March 2017 (PROSPERO registry number: CRD42016039784). Studies reporting on the risk of new-onset diabetes mellitus after pancreatoduodenectomy were included. For meta-analysis, studies were pooled using the random-effects model. All studies were appraised according to the Newcastle-Ottawa Scale.

RESULTS

After screening 1,523 studies, 22 studies involving 1,121 patients were eligible. The mean weighted overall proportion of new-onset diabetes mellitus after pancreatoduodenectomy was 16% (95% confidence interval, 12%-20%). We found no significant difference in risk of new-onset diabetes mellitus when pancreatoduodenectomy was performed for nonmalignant disease after excluding patients with chronic pancreatitis (19% risk; 95% confidence interval, 7%-43%; 6 studies) or for malignant disease (22% risk; 95% confidence interval, 14%-32%; 11 studies), P = .71. Among all patients, 6% (95% confidence interval, 4%-10%) developed insulin-dependent new-onset diabetes mellitus.

CONCLUSION

This systematic review identified a clinically relevant risk of new-onset diabetes mellitus after pancreatoduodenectomy of which patients should be informed preoperatively.

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.

Mini-Review on the Glucose Metabolism Modifications after Pancreatic Resection

Pancreatic cancer is one of the most severe malignant disease, with an extreme degree of lethality, considering that the survival rate at 5 years is up to 4%. In addition, a major disadvantage of this disease is the fact that the diagnosis is determined very late in the evolution of the disorder, despite the development of new technologies. In this way, the main symptoms are occurring later on, when the tumour is already locally advanced and unresectable. Up to now surgery is the only modality that can provide a greater chance of survival, but unfortunately the pancreatic resection has many unknowns and controversies around it. Moreover, the studies on endocrine pancreatic function after resection are very few and somehow controversial. In this way, in the present mini-review we will describe the most relevant experimental data regarding the post-resection pancreatogenic diabetes, the pancreatic polypeptide PP and the pancreatic glucose metabolism after resection or the glucose metabolism after partial or total pancreatectomy.

Mini-Review on the Glucose Metabolism Modifications after Pancreatic Resection

Pancreatic cancer is one of the most severe malignant disease, with an extreme degree of lethality, considering that the survival rate at 5 years is up to 4%. In addition, a major disadvantage of this disease is the fact that the diagnosis is determined very late in the evolution of the disorder, despite the development of new technologies. In this way, the main symptoms are occurring later on, when the tumour is already locally advanced and unresectable. Up to now surgery is the only modality that can provide a greater chance of survival, but unfortunately the pancreatic resection has many unknowns and controversies around it. Moreover, the studies on endocrine pancreatic function after resection are very few and somehow controversial. In this way, in the present mini-review we will describe the most relevant experimental data regarding the post-resection pancreatogenic diabetes, the pancreatic polypeptide PP and the pancreatic glucose metabolism after resection or the glucose metabolism after partial or total pancreatectomy.

Chronic Pancreatitis and Diabetes Mellitus

OPINION STATEMENT

Patients with chronic pancreatitis should be screening at least annually for diabetes. Lifestyle modifications remain to be an important part of treatment for diabetic control. Unless contraindicated or not tolerated, metformin can be initiated and continued concurrently with other anti-diabetic agents or insulin. All anti-diabetic agents should be used based on their physiology and adverse effect profiles, along with the metabolic status of patients. Insulin therapy should be initiated without delay for any of the following: symptomatic or overt hyperglycemia, catabolic state secondary to uncontrolled diabetes, history of diabetic ketoacidosis, hospitalization or acute exacerbation of pancreatitis, or hyperglycemia that cannot be otherwise controlled. Dose adjustment should be done conservatively as these patients are more likely to be insulin sensitive and have loss of counter regulatory hormones. Insulin pump and continuous glucose monitoring should be considered early during therapy in selected patients. For patients undergoing total pancreatectomy or extensive partial pancreatectomy, evaluations to determine the eligibilities for islet cell autotransplantation should be considered.

Frey procedure for chronic pancreatitis: Evidence-based assessment of short- and long-term results in comparison to pancreatoduodenectomy and Beger procedure: A meta-analysis

BACKGROUND AND OBJECTIVE

Patients with chronic pancreatitis often require surgical treatment. The aim of this study was to evaluate the published evidence for Frey procedure in patients with chronic pancreatitis.

METHODS

Literature search was undertaken to identify eligible studies until February 2015. Using meta-analytical techniques, Frey procedure was compared with pancreatoduodenectomy or Beger procedure, and the short- and long-term outcomes were analysed.

RESULTS

Twenty-three studies comprising a total of 800 patients were reviewed. The postoperative morbidity and mortality were 23.2% and 0.4% respectively. The percentage of postoperative pain-relief patients was 89.4%. New onset of diabetes and exocrine insufficiency was present in 17.3% and 30.7% of patients, respectively. Compared with pancreatoduodenectomy, Frey procedure had favorable outcomes in terms of operation time, blood transfusion, overall morbidity, length of hospital and intensive care unit stay, pancreatic function and quality of life. Compared with Beger procedure, Frey procedure had shorter operation time and lower morbidity.

CONCLUSIONS

Frey procedure is a safe and effective surgical procedure for chronic pancreatitis with dilated duct in the absence of neoplasia.

Incidence and severity of pancreatogenic diabetes after pancreatic resection

BACKGROUND

While many patients experience prolonged survival after pancreatic resection for benign or malignant disease, the long-term risk of pancreatogenic diabetes mellitus (DM) remains poorly characterized.

METHODS

One thousand one hundred seven patients underwent pancreatectomy at Thomas Jefferson University between 2006 and 2013. Attempts were made to contact all living patients by telephone and a DM-focused questionnaire was administered.

RESULTS

Two hundred fifty-nine of 691 (37 %) surviving patients completed the survey, including 179 pancreaticoduodenectomies (PD), 78 distal pancreatectomies (DP), and 2 total pancreatectomies. In the PD group, 44 (25 %) patients reported having DM prior to resection. Of these, 5 (12 %) had improved glucose control after resection and 21 (48 %) reported escalated DM medication requirements post-resection. Of 135 PD patients without preoperative DM, 24 (18 %) had new-onset DM postoperatively. In the DP group, 23 patients (29 %) had DM preoperatively. None had improved glucose control after resection, while six (26 %) had worse control after resection. Seventeen of 55 DP patients (31 %) without preoperative DM developed new-onset DM postoperatively (p = 0.04 vs. PD). Preoperative HgbA1C >6.0 %, glucose >124 mg/dL, and insulin use >2 units per day were associated with an increased risk of new-onset postoperative DM.

CONCLUSIONS

The development or worsening of DM after pancreatic resection is extremely common, with different types of resections conveying different risks for disease progression. DP places patients at a greater risk for the development of new-onset postoperative diabetes when compared to PD. In contrast, patients with preoperative diabetes are more likely to experience worsening of their disease after PD as compared to DP. Patients should be screened prospectively, particularly those at highest risk, and informed of and educated about the potential for post-resection DM.

Short- and long-term outcomes of pancreatectomy with or without biliary tract and duodenum preservation for benign and borderline neoplasms

OBJECTIVES

The aim of this study was to compare short- and long-term outcomes of biliary tract and duodenum-preserving pancreatectomy (BT-DPP) versus non-conservative pancreatectomy (NCP).

PATIENTS AND METHODS

From 2008 to 2012, 39 of 259 patients underwent pancreatectomy for benign or borderline neoplasms. Patients were classified as BT-DPP (n = 15) or NCP (n = 24). Data were prospectively collected and retrospectively analyzed on an intention-to-treat basis.

RESULTS

Both groups were comparable regarding demography, intra- and postoperative data (operative time, blood loss) and length of hospital stay. Overall complications occurred in 10 and 19 (p = 0.31), postpancreatectomy fistula in 2 and 4 (p = 0.6), biliary fistula in 3 and 1 (p = 0.15), and postpancreatectomy hemorrhage in 3 and 7 (p = 0.4) patients in the BT-DPP and NCP groups, respectively. One patient in the NCP group died. The median follow-up was 27 (4.4-56.5) and 23.4 (0.3-53) months in the BT-DPP and NCP groups, respectively. One BT-DPP patient had biliary stenosis treated endoscopically and 1 patient in the NCP group required surgery. The incidence of diabetes was equal.

CONCLUSION

Our study shows that BT-DPP is feasible without an increase in morbidity compared with NCP. In the long term, BT-DPP was not associated with higher morbidity.

Chronic pancreatitis: A surgical disease? Role of the Frey procedure

Although medical treatment and endoscopic interventions are primarily offered to patients with chronic pancreatitis, approximately 40% to 75% will ultimately require surgery during the course of their disease. Although pancreaticoduodenectomy has been considered the standard surgical procedure because of its favorable results on pain control, its high postoperative complication and pancreatic exocrine or/and endocrine dysfunction rates have led to a growing enthusiasm for duodenal preserving pancreatic head resection. The aim of this review is to better understand the rationale underlying of the Frey procedure in chronic pancreatitis and to analyze its outcome. Because of its hybrid nature, combining both resection and drainage, the Frey procedure has been conceptualized based on the pathophysiology of chronic pancreatitis. The short and long-term outcome, especially pain relief and quality of life, are better after the Frey procedure than after any other surgical procedure performed for chronic pancreatitis.

A sharable cloud-based pancreaticoduodenectomy collaborative database for physicians: emphasis on security and clinical rule supporting

BACKGROUND

Pancreaticoduodenectomy (PD) is a major operation with high complication rate. Thereafter, patients may develop morbidity because of the complex reconstruction and loss of pancreatic parenchyma. A well-designed database is very important to address both the short-term and long-term outcomes after PD.

OBJECTIVE

The objective of this research was to build an international PD database implemented with security and clinical rule supporting functions, which made the data-sharing easier and improve the accuracy of data.

METHODS

The proposed system is a cloud-based application. To fulfill its requirements, the system comprises four subsystems: a data management subsystem, a clinical rule supporting subsystem, a short message notification subsystem, and an information security subsystem. After completing the surgery, the physicians input the data retrospectively, which are analyzed to study factors associated with post-PD common complications (delayed gastric emptying and pancreatic fistula) to validate the clinical value of this system.

RESULTS

Currently, this database contains data from nearly 500 subjects. Five medical centers in Taiwan and two cancer centers in Mongolia are participating in this study. A data mining model of the decision tree analysis showed that elderly patients (>76 years) with pylorus-preserving PD (PPPD) have higher proportion of delayed gastric emptying. About the pancreatic fistula, the data mining model of the decision tree analysis revealed that cases with non-pancreaticogastrostomy (PG) reconstruction - body mass index (BMI)>29.65 or PG reconstruction - BMI>23.7 - non-classic PD have higher proportion of pancreatic fistula after PD.

CONCLUSIONS

The proposed system allows medical staff to collect and store clinical data in a cloud, sharing the data with other physicians in a secure manner to achieve collaboration in research.

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.

Pancreatogenic diabetes: special considerations for management

BACKGROUND/AIMS

Pancreatogenic, or type 3c, diabetes (T3cDM) occurs due to inherited or acquired pancreatic disease or resection. Although similar to the more prevalent type 1 and type 2 diabetes, pancreatogenic diabetes has a unique pattern of hormonal and metabolic characteristics and a high incidence of pancreatic carcinoma in the majority of patients with T3cDM. Despite these differences, no guidelines for therapy have been described.

METHODS

Published studies on the prevalence, pathophysiology, and cancer associations of T3cDM were reviewed. The recent studies on the protective role and mechanism of metformin therapy as both an anti-diabetic and anti-neoplastic agent were reviewed, and studies on the cancer risk of other anti-diabetic drugs were surveyed.

RESULTS

T3cDM accounts for 5-10% of Western diabetic populations and is associated with mild to severe disease. Hepatic insulin resistance is characteristic of T3cDM and is caused by deficiencies of both insulin and pancreatic polypeptide. 75% of T3cDM is due to chronic pancreatitis, which carries a high risk for pancreatic carcinoma. Insulin and insulin secretagogue treatment increases the risk of malignancy, whereas metformin therapy reduces it. Pancreatic exocrine insufficiency associated with T3cDM contributes to nutritional deficiencies and the development of metabolic bone disease.

CONCLUSIONS

Until consensus recommendations are reached, the glycemic treatment of T3cDM should avoid insulin and insulin secretagogues if possible. Metformin should be the first line of therapy, and continued if insulin treatment must be added for adequate glucose control. Pancreatic enzyme therapy should be added to prevent secondary nutritional and metabolic complications. and IAP.

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.

Parenchyma-sparing pancreatectomies for benign or border-line tumors of the pancreas

Standard pancreatic resections, such as pancreaticoduodenectomy, distal pancreatectomy, or total pancreatectomy, result in an important loss of normal pancreatic parenchyma and may cause impairment of exocrine and endocrine function. Whilst these procedures are mandatory for malignant tumors, they seem to be too extensive for benign or border-line tumors, especially in patients with a long life expectancy. In recent years, there has been a growing interest in parenchyma-sparing pancreatic surgery with the aim of achieving better functional results without compromising oncological radicality in patients with benign, border-line or low-grade malignant tumors. Several limited resections have been introduced for isolated or multiple pancreatic lesions, depending on the location of the tumor: central pancreatectomy, duodenum-preserving pancreatic head resection with or without segmental duodenectomy, inferior head resection, dorsal pancreatectomy, excavation of the pancreatic head, middle-preserving pancreatectomy, and other multiple segmental resections. All these procedures are technically feasible in experienced hands, with very low mortality, although with high morbidity rate when compared to standard procedures. Pancreatic endocrine and exocrine function is better preserved with good quality of life in most of the patients, and tumor recurrence is uncommon. Careful patient selection and expertise in pancreatic surgery are crucial to achieve the best results.

Organ-preserving surgery for benign lesions and low-grade malignancies of the pancreatic head: a matched case-control study

PURPOSE

To compare the postoperative results of various preservative surgery (PS) techniques with those of two types of pancreatoduodenectomy (PD).

METHODS

The subjects of this study were 65 patients treated surgically for chronic pancreatitis, or benign or borderline tumors. We defined PS as any of the following: duodenum-preserving pancreatic head resection (DPPHR), uncinatectomy (UC), and cystic tumor enucleation (EN). The two types of PD were Whipple pancreatoduodenectomy (WPD) and pylorus-preserving pancreatoduodenectomy (PPPD).

RESULTS

Benign lesions were treated with PD in 41 patients and PS in 24 patients. Whipple pancreatoduodenectomy was performed in 17 patients, PPPD in 24, DPPHR in 20, EN in 3, and UC in 1. The main indication for surgery was chronic pancreatitis (66%). Delayed gastric emptying (DGE) was seen in 41% of patients in the PD group but none in the PS group (P = 0.04). However, there were no differences between the two groups in the incidence of pancreatic fistulas or other complications. Reoperation was required in five of the PD patients, but none of the PS patients.

CONCLUSION

Surgical techniques for preserving pancreatic tissue are effective for carefully selected patients with benign pancreatic disorders.

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.

A comparison of pancreaticoduodenectomy and duodenum-preserving head resection for the treatment of chronic pancreatitis

BACKGROUND

For chronic pancreatitis, European prospective trials have concluded that duodenum-preserving head resections (DPHR) are associated with less morbidity and similar pain relief and quality of life (QoL) outcomes compared with pancreaticoduodenectomy (PD). However, DPHR procedures are seldom performed in North America.

METHODS

Patients undergoing PD or DPHR for unremitting pain secondary to chronic pancreatitis were retrospectively identified. Quality of life was assessed cross-sectionally using the European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life Questionnaire (QLQ-C30) and pancreatic cancer-specific supplemental module (QLQ-PAN26).

RESULTS

Eighty-one patients underwent either a Whipple PD (n= 59) or a DPHR (Bern, Beger or Frey procedure, n= 22) for the treatment of pain caused by chronic pancreatitis over a 5-year period. The characteristics of patients undergoing DPHR and PD procedures were similar. Duration of procedure (360 min vs. 245 min), duration of hospital stay (12.0 days vs. 9.5 days) and estimated blood loss (535 ml vs. 214 ml) were all significantly less for DPHR patients (P < 0.05). Thirty-day morbidity and mortality, postoperative pain relief and QoL scores did not differ significantly between groups.

CONCLUSIONS

Duodenum-preserving head resection is equally as effective as PD in relieving pain and improving QoL in chronic pancreatitis patients, and involves a shorter hospital stay and less blood loss.

Interactions between the endocrine and exocrine pancreas and their clinical relevance

In consequence of the close anatomical and functional links between the exocrine and endocrine pancreas, any disease affecting one of these parts will inevitably affect the other. Pancreatic conditions which might cause diabetes mellitus include acute and chronic pancreatitis, pancreatic surgery, cystic fibrosis and pancreatic cancer. The development of diabetes greatly influences the prognosis and quality of life of patients with exocrine pancreatic diseases. It may cause life-threatening complications, such as hypoglycemia, due to the lack of glucagon and the impaired absorption of nutrients, or the micro- and macrovascular complications may impair the organ functions. Diabetes mellitus is an independent risk factor of mortality in those with exocrine pancreatic diseases. The treatment of pancreatic diabetes, a distinct metabolic and clinical form of diabetes, requires special knowledge. Diet and pancreatic enzyme replacement therapy may be sufficient in the early stages. Oral antidiabetic drugs are not recommended. If the diet proves inadequate to reach the glycemic goals, insulin treatment with multiple injections is required. Impairments of the exocrine pancreatic function and morphology in diabetic patients are frequent and well known. Atrophy of the exocrine tissue may be caused by the lack of trophic insulin, whereas pancreatic fibrosis can result from activation of stellate cells by hyperglycemia, or from microangiopathy and neuropathy. The regulation of the exocrine pancreatic function is also damaged because of the impaired effect of islet hormones. In the event of a proven impairment of the pancreatic exocrine function in diabetes mellitus, pancreatic enzyme replacement therapy is indicated. This may improve the nutritional condition of the patient and decrease the metabolic instability.

[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.

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.

Mechanisms and emerging treatments of the metabolic complications of chronic pancreatitis

OBJECTIVES

Exocrine and endocrine abnormalities in chronic pancreatitis contribute to the morbidity and mortality risks of the disease. Complications of exocrine insufficiency include malabsorption, vitamin deficiency syndromes, and weight loss. Oral enzyme replacement therapy is usually effective if attention is paid to factors that affect the bioavailability of enzyme preparations. Complications of endocrine insufficiency can be more difficult to treat due in part to an incomplete knowledge of their etiology.

METHODS

This review focuses on the endocrine aspects of chronic pancreatitis and highlights the observations of our laboratory on the pathogenesis of the metabolic complications of the disease.

RESULTS

In addition to decreased insulin secretory capacity, pancreatogenic (or apancreatic) diabetes is characterized by decreased or absent glucagon and pancreatic polypeptide (PP) secretion, a loss of hepatic insulin receptor (IR) expression/availability, and an impairment in hepatic IR function (phosphorylation and endocytosis). Diminished hepatic IR expression in chronic pancreatitis appears to be because of PP deficiency; laboratory animals and patients with PP deficiency demonstrate decreased hepatic IR availability that is reversed by prolonged (8-hour) PP administration. The impairment in hepatic IR function appears independent of PP deficiency but is reversed by prolonged (28-day) treatment with the insulinotropic/insulinomimetic hormone glucagon-like peptide 1. The endocytosis of hepatic IR is linked to the endocytosis of the glucose transporter 2 from the hepatocyte plasma membrane, and studies suggest that the 2 plasma membrane-bound proteins are complexed noncovalently to function and translocate as a unit after insulin binding to the hepatic IR. The process appears vigorous and sensitive enough to account for a significant reduction in hepatic glucose output and may represent a major mechanism for insulin regulation of hepatic glucose production.

CONCLUSIONS

The regulatory mechanisms of PP-mediated hepatic IR expression and combined IR and GLUT2 endocytosis after insulin binding are defective in chronic pancreatitis and contribute to the apancreatic diabetes, which characterizes this disease.