Functional and medical outcomes after tailored surgery for pain due to chronic pancreatitis. Ann Surg. 2012;255:763-770. [PMID: 22418009 DOI: 10.1097/sla.0b013e31824b7697]

Surgery for chronic pancreatitis across Europe (ESCOPA): prospective multicentre study

BACKGROUND

Randomized trials have demonstrated the superiority of surgery over endoscopy in patients with symptomatic chronic pancreatitis. However, large international studies quantifying the impact of surgery on chronic pancreatitis are lacking. The aim of this study was to evaluate current practice across Europe regarding indications, surgical techniques, and outcomes of surgery for chronic pancreatitis.

METHODS

A prospective multicentre study of consecutive patients undergoing surgery for symptomatic chronic pancreatitis from 22 centres in 13 countries from 1 June 2021 to 30 November 2022 was conducted. The outcome of interest in patients with pain as an indication was the Izbicki pain score at 6-month follow-up, with complete pain relief defined as an Izbicki pain score ≤10 and partial pain relief defined as an Izbicki pain score >10, but with a >50% decrease compared with the baseline score. Quality of life was assessed using Pancreatitis Quality of Life Instrument (PANQOLI) and 12-Item Short-Form (SF-12) surveys. Predictors of pain relief were analysed using multivariable analysis.

RESULTS

Overall, 207 patients underwent surgery (24.6% underwent surgical drainage procedures, 29.5% underwent duodenum-preserving head resections, and 45.9% underwent formal pancreatic resections). Before surgery, 48.8% used opioids and 51.2% had undergone prior endoscopic treatment. Major morbidity occurred in 14.0% and the 90-day mortality rate was 1.4%. Among 113 patients operated on for pain, the median Izbicki pain score decreased from 61.3 to 19.0 at 6 months (P < 0.001). Pain relief was achieved in 72.6% (43 patients reported complete pain relief and 39 patients reported partial pain relief). PANQOLI and SF-12 Physical Component Summary scores improved significantly (P < 0.001). Longer symptom duration (OR 0.95 (95% c.i. 0.90 to 1.00), P = 0.045) and use of opioids before surgery (OR 3.16 (95% c.i. 1.04 to 9.64), P = 0.043) predicted less pain relief.

CONCLUSION

Surgery for chronic pancreatitis across Europe was performed with low morbidity. Patients reported good pain relief and improvements in quality-of-life scores. Multidisciplinary consultation is recommended for all patients with chronic pancreatitis before undergoing any intervention.

Surgical management of chronic pancreatitis: A narrative review

Chronic pancreatitis is a severe disabling disease with persistent pain as the most prominent symptom often leading to significant quality of life (QoL) reduction. Current international guidelines propagate a step-up approach in which surgery should only be considered as a last resort in patients with failure of both medical and endoscopic interventions. Accumulating evidence, however, suggests that surgery is superior to endoscopic therapy and that early surgical intervention is beneficial in terms of pain relief, pancreatic function and QoL. Several surgical procedures are available with low morbidity and mortality rates, providing excellent long-term results. The purpose of this review was to present an overview of the surgical treatment options for chronic pancreatitis with a focus on the timing of surgery.

Pancreatic extracorporeal shock wave lithotripsy: a key technology truly improves treatment model for pancreatic stones

Chronic pancreatitis (CP) is characterized by irreversible destruction of pancreatic parenchyma, inflammatory cell infiltration and progressive fibrosis of pancreatic tissue. Obstruction of pancreatic duct by pancreatic stone is the common pathological change in the course of CP with the incidence of over 50 % at the diagnosis of CP. These ductal stones would cause pancreatic parenchymal hypertension and local ischemia, which was eventually followed by recurrent episodes of painful pancreatitis or other manifestations of pancreatic exocrine and endocrine insufficiency. Removing pancreatic stones has been confirmed as the core to reduce pressure, improve drainage and lessen pain. Surgical therapy achieves satisfying pain relief with more complications, higher cost and less repeatability compared with endoscopic therapy. Endoscopic retrograde cholangiopancreatography, which used to be the standard endoscopic therapy for pancreatic stones, would fail if these stones are large or complex, while pancreatic extracorporeal shock wave lithotripsy (P-ESWL), which has been applied since 1987, could overcome this problem. Up to now, a large number of guidelines have recommended the P-ESWL as the first-line treatment strategy for radiopaque obstructive main pancreatic duct stones larger than 5 mm located in the head/body of the pancreas, and P-ESWL had completely changed the traditional treatment model for CP patients with pancreatic stones. In this article, we will focus on the technical progress, efficacy, safety and potential research areas of P-ESWL, we also give us suggestions for lithotripters improvement.

Quality of life instruments in acute and chronic pancreatitis: a consensus-based standards for the selection of health measurement instruments (COSMIN) approach

BACKGROUND

Pancreatitis is a common surgical emergency, associated with pain and poor quality of life for patients. However, assessment of patient-reported outcome measures in these patients is unclear. This study aimed to identify and evaluate the methodological quality of the health-related quality of life instruments used for patients with acute or chronic pancreatitis.

METHODS

Prospective studies that evaluated health-related quality of life in acute or chronic pancreatitis were identified from systematic review of MEDLINE, EMBASE, and Web of Science until 28th June 2023 (PROSPERO: CRD42021274743). Instrument characteristics were extracted, and methodological quality assessed using COSMIN (COnsensus-based Standards for the selection of health status Measurement Instruments) guidelines and GRADE approach. Narrative synthesis was conducted, with recommendations for use based on COSMIN criteria, evaluated according to World Health Organisation (WHO) quality of life domains.

RESULTS

From 3850 records screened, 41 quality of life instruments were identified across 138 studies included. The majority (69.8%, n = 26) were designed to assess general health-related quality of life, whereas the remainder were abdominal-specific (n = 5) or pancreas-specific (n = 10). Only ten instruments (24.3%) demonstrated sufficient content validity, incorporating items in ≥5 WHO quality of life domains. However, only nine instruments (21.9%) incorporated public and patient involvement. Only the Gastrointestinal Quality of Life Index and PAN-PROMISE met the criteria to be recommended for use based on COSMIN methodological assessment.

CONCLUSION

There is significant heterogeneity in instruments used to assess quality of life after pancreatitis, with almost all instruments considered insufficient. Robust, validated, and relevant instruments are needed to better understand and determine appropriate interventions to improve quality of life for these patients.

Surgical Treatment for Chronic Pancreatitis With a Normal-Sized Pancreatic Head and a Dilated Duct: Frey or Extended Partington Procedure?

BACKGROUND

Surgical drainage for chronic pancreatitis patients with a normal-sized pancreatic head remains controversial. Both Frey and extended Partington procedures could be used, but the level of evidence is weak.

METHOD

The object of this prospective cohort study was to assess the mid-term results concerning pain, quality of life, and pancreatic function of surgical drainage (Frey or extended Partington procedure) in patients with painful chronic pancreatitis and a normal-sized pancreatic head.

RESULTS

Fifty-nine patients (Frey procedure: 14 cases; extended Partington procedure: 45 cases) were enrolled in the study with a median length of follow-up of 16 months. The effective and complete pain relief rate was 85% and 58%, respectively. The Izbicki score decreased from 53.4 preoperatively to 8.8 postoperatively. The general 12-Item Short Form Health Survey (SF-12) score increased from 45.2 to 75.4. The pancreatic insufficiency did not change significantly postoperatively. At three months after surgery, the complete pain relief and Izbicki score were more favorable in the Frey group than in the extended Partington group.

CONCLUSION

Both Frey and extended Partington procedures resulted in excellent pain relief and quality of life improvement and did not worsen pancreatic function. The Frey procedure could yield a more favorable result in the early postoperative period.

Mapping global new-onset, worsening, and resolution of diabetes following partial pancreatectomy: a systematic review and meta-analysis

BACKGROUND AND AIMS

Partial pancreatectomy, commonly used for chronic pancreatitis, or pancreatic lesions, has diverse impacts on endocrine and metabolism system. The study aims to determine the global prevalence of new-onset, worsening, and resolution of diabetes following partial pancreatectomy.

METHODS

The authors searched PubMed, Embase, Web of Science, and Cochrane Library from inception to October, 2023. DerSimonian-Laird random-effects model with Logit transformation was used. Sensitivity analysis, meta-regression, and subgroup analysis were employed to investigate determinants of the prevalence of new-onset diabetes.

RESULTS

A total of 82 studies involving 13 257 patients were included. The overall prevalence of new-onset diabetes after partial pancreatectomy was 17.1%. Univariate meta-regression indicated that study size was the cause of heterogeneity. Multivariable analysis suggested that income of country or area had the highest predictor importance (49.7%). For subgroup analysis, the prevalence of new-onset diabetes varied from 7.6% (France, 95% CI: 4.3-13.0) to 38.0% (UK, 95% CI: 28.2-48.8, P <0.01) across different countries. Patients with surgical indications for chronic pancreatitis exhibited a higher prevalence (30.7%, 95% CI: 21.8-41.3) than those with pancreatic lesions (16.4%, 95% CI: 14.3-18.7, P <0.01). The type of surgical procedure also influenced the prevalence, with distal pancreatectomy having the highest prevalence (23.7%, 95% CI: 22.2-25.3, P <0.01). Moreover, the prevalence of worsening and resolution of preoperative diabetes was 41.1 and 25.8%, respectively.

CONCLUSIONS

Postoperative diabetes has a relatively high prevalence in patients undergoing partial pancreatectomy, which calls for attention and dedicated action from primary care physicians, specialists, and health policy makers alike.

Patient reported outcomes of duodenum-preserving pancreatic head resection in chronic pancreatitis: high effectivity is impaired by prolonged non-surgical management

BACKGROUND

Chronic pancreatitis (CP) causes suffering and socioeconomic burden. This study evaluated perioperative results and patient-reported outcomes (PRO) in CP patients treated with duodenum-preserving pancreatic head resection (DPPHR).

METHODS

Data were analyzed of CP patients undergoing DPPHR between 01/2001-10/2014. PROs were measured using a specifically designed questionnaire and the EORTC QLQ-C30/PAN26. Associations between treatment variables and PROs were examined.

RESULTS

Of 332 patients who received DPPHR, most (n = 251, 75.6%) underwent the Berne modification. Surgical morbidity was 21.5% (n = 71) and 90-day mortality 1.5% (n = 5). Median follow-up was 79.9 months, 5-year survival 90.5%, and 1.8% of patients developed pancreatic cancer. Of 283 patients alive, 178 (62.9%) returned questionnaires. Referral for surgery was self-initiated (38.0% of cases), by gastroenterologists (27.5%) and by general practitioners (21.1%). QoL improved in 78.7% of patients, remained stable in 12.1%, and worsened in 9.1%. Median Izbicki scores decreased from 90 to 5 points after surgery (p < 0.0001). Time from diagnosis to DPPHR was an independent, proportional predictor of a higher postoperative Izbicki score (p = 0.04).

CONCLUSION

DPPHR is an effective, safe treatment for CP. A delay in surgery decreases surgical effectivity, hence CP patients should be referred to surgery early to ensure satisfactory outcomes.

An update on improving long-term outcomes for patients with chronic pancreatitis post-surgery

INTRODUCTION

Chronic pancreatitis is a common inflammatory disease that severely impairs patients' quality of life, mainly due to abdominal pain which is the most frequent symptom. Current guidelines suggest medical therapy as the first line intervention based on a stepwise use of analgesics (i.e. NSAIDs followed by weak opioids and later by strong oppioids), which is rarely effective in improving pain and often leads to opioid addiction. Interventional procedures are therefore frequently needed. Endoscopic therapy is suggested as the second line of intervention, aiming at decompressing the main pancreatic duct via structure dilatation and ductal stone removal. Endoscopic therapy is usually effective in reducing pain in the short term, but its effects frequently decrease with time and multiple procedures are often required. Surgery is usually reserved as a last resource when medical and endoscopic therapy have failed. Pancreatic surgery is burdened with non negligible morbidity and mortality but is effective in reducing pain and improving quality of life in chronic pancratitis with long lasting effects.

AREAS COVERED

Surgical treatment of chronic pancreatitis is based on resection of inflammatory head mass or decompression of the ductal system, alone or in combination, which can be performed using different techniques. In this paper we reviewed the current evidence on the long-term outcomes of this type of surgery in terms of pain relief, quality of life, exocrine end endocrine function, and long-term mortality.

EXPERT OPINION

Quality of current evidence on this field is on average poor; a consensus to define clinically significant outcomes is needed in order to correctly design prospective studies that will enable gastroenterologists to understand which patients, and when, will benefit most from surgery and should therefore be referred to surgeons.

The Role of Surgery in Chronic Pancreatitis

Chronic pancreatitis is an inflammatory disease characterized by the progressive replacement of the functional pancreatic parenchyma with fibrotic tissue. This leads to exocrine and endocrine insufficiency. A typical clinical feature is recurrent, severe upper abdominal pain, which negatively affects the patient's quality of life. Conservative treatment as the method of first choice does not prevent irreversible changes in the pancreatic tissue. While endoscopic drainage can have some benefits in the early stages of the disease, it is generally unsuccessful in the long term. Based on recent studies, surgical intervention appears to be the most suitable treatment option for improving the patient's quality of life. It currently includes a wide range of effective, proven drainage and resection procedures. Advances in surgical techniques and postsurgical intensive care have increased the frequency of pancreatic surgeries, while improvements in diagnostic methods have increased the number of patients who meet the indications for such surgery, including elderly and chronically ill patients. However, despite mortality rates decreasing, high morbidity rates remain a problem. Currently, in patients with an inflammatory mass in the head of the pancreas, pyloric and duodenal-preserving resection offers the best results. Different variants of these techniques appear to produce similar results. Various techniques have shown similar outcomes in terms of mortality, morbidity, pain relief, life expectancy and improved quality of life. The optimal timing of surgery has been addressed by several studies and most surgeons now favor early surgical intervention in order to prevent extensive destruction of pancreatic tissue.

Outcomes of total pancreatectomy with islet autotransplantation: A systematic review and meta-analysis

BACKGROUND

Despite the increased use of total pancreatectomy with islet autotransplantation (TPIAT), systematic evidence of its outcomes remains limited.

AIM

To evaluate the outcomes of TPIAT.

METHODS

We searched PubMed, EMBASE, and Cochrane databases from inception through March 2019 for studies on TPIAT outcomes. Data were extracted and analyzed using comprehensive meta-analysis software. The random-effects model was used for all variables. Heterogeneity was assessed using the I² measure and Cochrane Q-statistic. Publication bias was assessed using Egger’s test.

RESULTS

Twenty-one studies published between 1980 and 2017 examining 1011 patients were included. Eighteen studies were of adults, while three studied pediatric populations. Narcotic independence was achieved in 53.5% [95% Confidence Interval (CI): 45-62, P < 0.05, I² = 81%] of adults compared to 51.9% (95%CI: 17-85, P < 0.05, I² = 84%) of children. Insulin-independence post-procedure was achieved in 31.8% (95%CI: 26-38, P < 0.05, I² = 64%) of adults with considerable heterogeneity compared to 47.7% (95%CI: 20-77, P < 0.05, I² = 82%) in children. Glycated hemoglobin (HbA_1C) 12 mo post-surgery was reported in four studies with a pooled value of 6.76% (P = 0.27). Neither stratification by age of the studied population nor meta-regression analysis considering both the study publication date and the islet-cell-equivalent/kg weight explained the marked heterogeneity between studies.

CONCLUSION

These results indicate acceptable success for TPIAT. Future studies should evaluate the discussed measures before and after surgery for comparison.

Frey procedure for chronic pancreatitis: A narrative review

Chronic pancreatitis is (CP) is a progressive inflammatory disease of the pancreas associated with disabling abdominal pain and gradual deterioration of exocrine and endocrine function. Up to 50% of patients with CP may require surgery during the course of the disease. The main indication for surgery is intractable abdominal pain not amenable to medical and endoscopic therapy. The type of surgery depends on pancreatic ductal diameter and associated parenchymal pathology like inflammatory head mass. Frey procedure (FP) is an effective method for control of pain in patients with enlarged pancreatic head. FP can be performed with a very low mortality and an acceptable morbidity. Compared with pancreaticoduodenectomy (PD), FP has favourable outcomes in terms of operation time, blood loss, morbidity, post-operative hospital stay, intensive care unit stay, and quality of life. FP has shorter operation time and lower morbidity in comparison to Beger procedure. But, long-term pain control and exocrine and endocrine dysfunctions are comparable between PD, Beger and FP. FP is technically easier than PD and Beger procedure. FP is thus a widely acceptable procedure for CP with enlarged pancreatic head in absence of a neoplasia.

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.

Pancreatitis After Pancreaticojejunostomy Procedure? A Tale Involving the Tail of the Pancreas

Recurrent acute pancreatitis (RAP) involving the tail of the pancreas after pancreaticojejunosotomy (PJP) is rare, has very challenging management, and there is minimal literature. We describe a case of idiopathic RAP, complicated with chronic pancreatitis that failed medical and endoscopic management and required PJP. Unfortunately, RAP recurred after PJP, and we describe his clinical course and management.

The in situ near-total pancreatectomy (LIVOCADO procedure) for end-staged chronic pancreatitis

PURPOSE

Total pancreatectomy for severe pain in end-stage chronic pancreatitis may be the only option, but with vascular involvement, this is usually too high risk and/or technically not feasible. The purpose of the study was to present the clinical outcomes of a novel procedure in severe chronic pancreatitis complicated by uncontrollable pain and vascular involvement.

METHODS

We describe an in situ near-total pancreatectomy that avoids peripancreatic vascular dissection (Livocado procedure) and report on surgical and clinical outcomes.

RESULTS

The Livocado procedure was carried out on 18 (3.9%) of 465 patients undergoing surgery for chronic pancreatitis. There were 13 men and 5 women with a median (IQR) age of 48.5 (42.4-57) years and weight of 60.7 (58.0-75.0) kg. All had severe pain and vascular involvement; 17 had pancreatic parenchymal calcification; the median (IQR) oral morphine equivalent dose requirement was 86 (33-195) mg/day. The median (IQR) maximal pain scores were 9 (9-10); the average pain score was 6 (IQR 4-7). There was no peri-operative or 90-day mortality. At a median (IQR) follow-up of 32.5 (21-45.75) months, both maximal and average pain scores were significantly improved post-operatively, and at 12 months, two-thirds of patients were completely pain free. Six (33%) patients had employment pre-operatively versus 13 (72%) post-operatively (p = 0.01).

CONCLUSIONS

The Livocado procedure was safe and carried out successfully in patients with chronic pancreatitis with vascular involvement where other procedures would be contraindicated. Perioperative outcomes, post-operative pain scores, and employment rehabilitation were comparable with other procedures carried out in patients without vascular involvement.

Long-term survival, risk factors and causes of mortality in surgically treated chronic pancreatitis

BACKGROUND/OBJECTIVES

Chronic pancreatitis (CP) is a complex disease with a high complications rate, poor quality of life and considerable mortality. Prospective investigations on long-term outcomes in chronic pancreatitis are scarce. Thus, we aimed to assess long-term survival, causes of death and impact of risk factors on survival in a cohort of surgically managed patients with chronic pancreatitis.

METHODS

After IRB approval, a prospective longitudinal cohort study with long-term follow-up (up to 19.6 years) was conducted. All consecutive single center patients operated between 1997 and 2019 were included. Data on health and social status, risk behavior, history of CP, indications for surgery, comorbidities and causes of death were collected. Survival analysis was performed using Kaplan-Meier analysis. Cox proportional multivariate hazard regression was used to assess the impact of risk factors on mortality. The results are reported as the hazard ratio (HR) with the 95% confidence interval (CI). The log-rank test was used to test for differences in survival between groups.

RESULTS

A total of 161 patients with CP were subjected to operative management due to chronic pain or local complications of CP. Forty-eight patients (29.8%) died during the follow-up period. Mortality rate was 32.8 per 1000 patient-years (PY) since the diagnosis of CP. Standardized mortality ratio (SMR) was 1.8 (2.7 for the subgroup of continuous alcohol users). Median survival after surgical treatment was 13.3 years. Univariate analysis revealed the following risk factors on survival: preoperative and postoperative continuous moderate or heavy alcohol consumption, heavy smoking, age ≥50 years, Charlson's comorbidity index (CCI) ≥4 and 2-3, unemployment, disability, insulin-dependent diabetes, pancreatic exocrine insufficiency (PEI), and low body mass index (BMI). In multivariate regression analysis lower survival was associated with continuous moderate/heavy alcohol consumption (hazard ratio (HR) 2.27), history of heavy smoking (HR 4.40), unemployment (HR 2.49), CCI 2-3 and ≥4 (HR 2.53 and HR 3.16, respectively), and BMI <18.5 (HR 4.01). Behavioral risk factors accounted for the vast majority of deaths due to chronic alcoholic liver disease (21 cases, 43.7%), smoking-related diseases (15 cases, 31.3%). CP-related mortality was 4.2%.

CONCLUSIONS

Long-term outcomes of surgically treated chronic pancreatitis was associated with low CP-related mortality. Alcohol-related and smoking-related diseases caused the vast majority of deaths. Thus, surgery provides the best results in patients, preventing postsurgical relapse of original behavioral risks. For achieving this, ongoing postoperative support would be highly beneficial.

International consensus guidelines on interventional endoscopy in chronic pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with the International Association of Pancreatology, the American Pancreatic Association, the Japan Pancreas Society, and European Pancreatic Club

BACKGROUND/OBJECTIVES

This paper is part of the international consensus guidelines on chronic pancreatitis, presenting for interventional endoscopy.

METHODS

An international working group with experts on interventional endoscopy evaluated 26 statements generated from evidence on 9 clinically relevant questions. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to evaluate the level of evidence. To determine the level of agreement, a nine-point Likert scale was used for voting on the statements.

RESULTS

Strong consensus was obtained for 15 statements relating to nine questions including the recommendation that endoscopic intervention should be offered to patients with persistent severe pain but not to those without pain. Endoscopic decompression of the pancreatic duct could be used for immediate pain relief, and then offered surgery if this fails or needs repeated endoscopy. Endoscopic drainage is preferred for portal-splenic vein thrombosis and pancreatic fistula. A plastic stent should be placed and replaced 2-3 months later after insertion. Endoscopic extraction is indicated for stone fragments remaining after ESWL. Interventional treatment should be performed for symptomatic/complicated pancreatic pseudocysts. Endoscopic treatment is recommended for bile duct obstruction and afterwards surgery if this fails or needs repeated endoscopy. Surgery may be offered if there is significant calcification and/or mass of the pancreatic head. Percutaneous endovascular treatment is preferred for hemosuccus pancreaticus. Surgical treatment is recommended for duodenal stenosis due to chronic pancreatitis.

CONCLUSIONS

This international expert consensus guideline provides evidenced-based statements concerning indications and key aspects for interventional endoscopy in the management of patients with chronic pancreatitis.

Short- and long-term outcome of surgery for chronic pancreatitis in children: a single surgeon experience

OBJECTIVE

The aim of this study was to report on the short-and long-term outcomes of surgery for chronic pancreatitis (CP) in children.

METHODS

All the children, who underwent surgery for CP between August 2007 and July 2019 in the Department of Surgical gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, India were retrospectively reviewed.

RESULTS

Of the total 54 patients, 33 (61%) were girls. The median age at operation was 16.5 years. The median duration between onset of pain and surgery was 36 months. 26% of patients were referred after failure of endotherapy. The most common indication for surgery was pain (94%). Surgery performed included modified Puestow (n = 26), Frey (n = 25), and Izbicki procedures. Twelve postoperative complications developed in ten (18.5%) patients. Most common complication was wound infection. Pancreatic leak developed in four (7.4%) patients (type A = 3, type B = 1). Median postoperative hospital stay was 8 days. There was no in-hospital mortality. Over a median follow-up of 48 months, 83% of patients had complete pain control. Weight gain was achieved in 77% of patients. New-onset diabetes and exocrine insufficiency developed in 4 and 14% of patients, respectively.

CONCLUSIONS

Surgery is safe with fairly acceptable perioperative complications and good long-term pain control.

Surgical treatment for chronic pancreatitis: A single-center retrospective study in Japan

BACKGROUND/PURPOSE

To determine the short- and long-term results of surgical treatments for chronic pancreatitis (CP) at a high-volume center in Japan.

METHODS

The records of 151 consecutive patients undergoing surgery for CP were retrospectively reviewed. Selection of surgical procedures used had been according to the Japanese Clinical Practice Guidelines for CP 2015. Long-term (≥1 year) follow-up was performed in 100 patients (median of 37 months).

RESULTS

Surgical drainage procedures were performed in 107 patients (Frey operation in 81, longitudinal pancreaticojejunostomy in 26), pancreatic resection in 37 (subtotal stomach-preserving pancreaticoduodenectomy in 11, distal pancreatectomy in 26), and other procedures in six. The rates of postoperative mortality and morbidity were 1% and 26%, respectively. The rates of complete and partial pain relief were 62% and 37%. The frequency of occurrence of severe morbidity was significantly higher after pancreatic resection than in patients receiving drainage procedures (13% vs 2%, P = .019). The rate of new-onset diabetes was also significantly higher after resection than drainage (60% vs 25%, P = .017).

CONCLUSIONS

Surgical treatment for painful chronic pancreatitis can be safe and effective. An optimal procedure should guarantee pain relief and preserve a maximum of pancreatic function.

Preoperative opioid use is associated with increased length of stay after pancreaticoduodenectomy

BACKGROUND

Preoperative opioid use in patients undergoing low complexity operations has been associated with increased complications, but its relationship to procedures of greater complexity is unclear. We aimed to assess this impact on outcomes following pancreaticoduodenectomy (PD).

METHODS

A single institution, retrospective cohort of adults undergoing elective PD for cancer (1/2009-9/2015). Preoperative opioid users were defined as patients documented as taking opioids up to 90 days preoperatively. Discharge prescriptions were converted into Oral Morphine Equivalents (OME) and ten-point pain scores were abstracted. Univariate and multivariable analyses compared outcomes of naïve and preoperative opioid users overall and for laparoscopic vs open surgery.

RESULTS

Of 661 PD patients, 131 (19.8%) were preoperative opioid users. These patients had greater mean pain scores over the first three days after surgery (3.4 ± 1.6, vs 2.8 ± 1.4, p < 0.001), max pain (7.9 ± 1.9 vs 7.2 ± 2.0, p < 0.001), and discharge pain (2.3 ± 1.9 vs 1.8 ± 1.6, p = 0.01) than naïve patients. Preoperative opioid users received more opioids at discharge (mean 496 ± 764 OME) than naïve (320 ± 489 OME, p = 0.03). Thirty-day refill rates were 12.6% (19.1% preoperative vs 10.9% naïve, p = 0.02). After controlling for tumor type, pancreas texture, and duct size, naïve patients had similar odds of clinically significant post-operative pancreatic fistulas (grade B or C) (OR 1.13, p = 0.68) and delayed gastric emptying (OR 1.05, p = 0.87). After controlling for age and complications, preoperative opioid use was associated with increased odds of LOS ≥9 days (OR 1.59, p = 0.04).

CONCLUSION

Following PD, preoperative opioid users had worse pain scores, received more opioids at discharge, refilled prescriptions more frequently, and were more likely to have prolonged LOS. As most opioid utilization research has been focused on low complexity surgery, additional work aimed at optimizing opioid use in complex oncologic operations is warranted.

New-Onset Diabetes Mellitus After Distal Pancreatectomy: A Systematic Review and Meta-Analysis

Background and Objective: Endocrine insufficiency must be considered following distal pancreatectomy (DP), because diabetes mellitus can impose a long-term burden on patients. This systematic review and meta-analysis aimed to identify the incidence and severity of new-onset diabetes mellitus (NODM) after DP for benign and malignant tumors, and other indications. Methods: Articles reporting NODM after DP from PubMed, Embase, Cochrane Library, and Google Scholar were analyzed. The quality of the studies was assessed using the Newcastle-Ottawa Scale or MOGA scale. Inverse variance analysis calculated the overall NODM incidence, and 95% confidence intervals (CIs) and P values were determined. Subgroup analyses considered pre-existing pancreatic diseases. Results: The quantitative analysis involved 18 articles that described 2356 patients with pancreatic neoplasms or inflammatory lesions. The overall incidence of NODM after DP was 29% (95% CI 25-33). The NODM rates were 23% (95% CI 17-30) and 38% (95% CI 30-45) for patients with pancreatic neoplasms and chronic pancreatitis, respectively. Pre-existing chronic pancreatitis and being male were risks associated with NODM. Conclusion: NODM is fairly common after DP. Surgeons and patients should be aware of postoperative treatment-dependent endocrine dysfunction. Larger cohort studies are required to clarify the risk factors for NODM after DP.

Laparoscopic Beger procedure for the treatment of chronic pancreatitis: a single-centre first experience

Background

The Beger procedure is a common surgical option in the management of the unremitting abdominal pain of chronic pancreatitis (CP). As an organ-sparing surgery, it might be a better choice than pancreatoduodenectomy (PD). However, it is rather challenging for surgeons to perform the Beger procedure laparoscopically, especially for patients with CP; indeed, it has rarely reported. Here, we describe the technique and results of our early experience in laparoscopic Beger procedure for the treatment of CP.

Case presentation

Five patients (1 male) with CP (alcohol induced, n = 3; idiopathic, n = 2) who underwent laparoscopic Beger procedure from May to October 2019 in West China Hospital were included in this study. The median pancreatic duct diameter was 6.8 (4 to 12) mm. The median operating time was 275 (150 to 305) minutes without conversion. Only one patient (20%) developed a grade B pancreatic fistula. One patient required re-operation for jejunal anastomotic bleeding on the first post-operative day. The median hospital stay was 11 (9 to 34) days. No patient experienced biliary fistula, gastroparesis, duodenal necrosis, or abdominal bleeding. The 90-day mortality rate was 0%. All the patients were pain free in the two months after the operation.

Conclusion

The laparoscopic Beger procedure is feasible and safe with good short-term results and some potential benefits in selected patients with chronic pancreatitis. Further study and longer follow-up are required.

International consensus guidelines for surgery and the timing of intervention in chronic pancreatitis

BACKGROUND/OBJECTIVES

Chronic pancreatitis (CP) is a complex inflammatory disease with pain as the predominant symptom. Pain relief can be achieved using invasive interventions such as endoscopy and surgery. This paper is part of the international consensus guidelines on CP and presents the consensus guideline for surgery and timing of intervention in CP.

METHODS

An international working group with 15 experts on CP surgery from the major pancreas societies (IAP, APA, JPS, and EPC) evaluated 20 statements generated from evidence on 5 questions deemed to be the most clinically relevant in CP. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to evaluate the level of evidence available for each statement. To determine the level of agreement, the working group voted on the 20 statements for strength of agreement, using a nine-point Likert scale in order to calculate Cronbach's alpha reliability coefficient.

RESULTS

Strong consensus was obtained for the following statements: Surgery in CP is indicated as treatment of intractable pain and local complications of adjacent organs, and in case of suspicion of malignant (cystic) lesion; Early surgery is favored over surgery in a more advanced stage of disease to achieve optimal long-term pain relief; In patients with an enlarged pancreatic head, a combined drainage and resection procedure, such as the Frey, Beger, and Berne procedure, may be the treatment of choice; Pancreaticoduodenectomy is the most suitable surgical option for patients with groove pancreatitis; The risk of pancreatic carcinoma in patients with CP is too low (2% in 10 year) to recommend active screening or prophylactic surgery; Patients with hereditary CP have such a high risk of pancreatic cancer that prophylactic resection can be considered (lifetime risk of 40-55%). Weak agreement for procedure choice in patients with dilated duct and normal size pancreatic head: both the extended lateral pancreaticojejunostomy and Frey procedure seems to provide equivalent pain control in patients.

CONCLUSIONS

This international expert consensus guideline provides evidenced-based statements concerning key aspects in surgery and timing of intervention in CP. It is meant to guide clinical practitioners and surgeons in the treatment of patients with CP.

The Liverpool duodenum-and spleen-preserving near-total pancreatectomy can provide long-term pain relief in patients with end-stage chronic pancreatitis

PURPOSE

Total pancreatectomy may improve symptoms in patients with severe end-stage chronic pancreatitis. This might be achieved whilst preserving both the duodenum- and spleen-(DPSPTP). Mature clinical outcomes of this approach are presented.

METHODS

Single-centre prospective cohort study performed between September 1996 and May 2016. Demographic, clinical details, pain scores and employment status were prospectively recorded during clinic attendance.

RESULTS

Fifty-one patients (33 men, 18 women) with a median (interquartile range) age of 40.8 (35.3-49.4) years, a median weight of 69.8 (61.0-81.5) Kg and a median body mass index of 23.8 (21.5-27.8), underwent intended duodenum-and spleen-preserving near-total pancreatectomy for end-stage chronic pancreatitis. Aetiology was excess alcohol in 25, idiopathic (no mutation) in 15, idiopathic (SPINK-1/CFTR mutations) in two, hereditary (PRSS1 mutation) in seven and one each post-necrotising pancreatitis and obstructive pancreatic duct divisum in 1. The main indication for surgery was severe pain. Findings included parenchymal calcification in 79% and ductal calculi in 24%, a dilated main pancreatic duct in 57% and a dilated main bile duct in 17%, major vascular involvement in 27% and pancreato-peritoneal fistula in 2%. Postoperative complications occurred in 20 patients with two deaths. Median pain scores were 8 (7-8) preoperatively and 3 (0.25-5.75) at 5 years (p = 0.013). Opiate analgesic use was significantly reduced postoperatively (p = 0.048). Following surgery, 22 (63%) of 38 patients of working age re-entered employment compared with 12 (33%) working preoperatively (p = 0.016).

CONCLUSION

Duodenum-and spleen-preserving near-total pancreatectomy provided long-term relief in adult patients with intractable chronic pancreatitis pain, with improved employment prospects.

Surgery in Chronic Pancreatitis: Indication, Timing and Procedures

Chronic pancreatitis is a chronic inflammation of the pancreas with pain as its severest symptom and often an impaired quality of life. Surgical intervention plays an important role in the management of pain but is generally kept as a last resort when conservative measures and endoscopy have failed. However, in the last few years multiple studies suggested the superiority of (early) surgical treatment in chronic pancreatitis for multiple end points, including pain relief. In this paper we highlight the most recent high-quality evidence on surgical therapy in chronic pancreatitis and the rationale for early (surgical) intervention.

Recent advances in the diagnosis and management of chronic pancreatitis

Chronic pancreatitis is a chronic condition characterized by pancreatic inflammation that causes fibrosis and the destruction of exocrine and endocrine tissues. Chronic pancreatitis is a progressive disease, and no physiological treatment is available to reverse its course. However, with advances in medical technology, the existing diagnostic and treatment methods for chronic pancreatitis are evolving. Managing patients with chronic pancreatitis is challenging and necessitates a multidisciplinary approach. In this review, we discuss the recent advances in the diagnosis and management of chronic pancreatitis and introduce future alternative modalities.

Earlier surgery improves outcomes from painful chronic pancreatitis

The timing of surgery for painful chronic pancreatitis (CP) may affect outcomes.Clinical course, Izbicki pain scores, and pancreatic function were retrospectively compared and analyzed between patients undergoing either early or late surgery (< 3 or ≥ 3 years from diagnosis) for painful CP in a single center from 2007 to 2012.The early surgery group (n = 98) more frequently than the late group (n = 199) had abdominal pain with jaundice (22.4% vs 9.5%, P = .002) and pancreatic mass +/- ductal dilatation (47% vs 27%, P < .001), but less frequently abdominal pain alone (73.5% vs 85.9%, P = .009), ductal dilatation alone (31% vs 71%, P < .001), parenchymal calcification (91.8% vs 100%, P < .001) or exocrine insufficiency (60% vs 72%, P = .034); there were no other significant differences. The early group had longer hospital stay (14.4 vs 12.2 days, P = .009), but no difference in complications. Significantly greater pain relief followed early surgery (complete 69% vs 47%, partial 22% vs 37%, none 8% vs 16%, P = .01) with lower rates of exocrine (60% vs 80%, P = .005) and endocrine insufficiency (36% vs 53%, P = .033).Our data indicate that early surgery results in higher rates of pain relief and pancreatic sufficiency than late surgery for chronic pancreatitis patients. Frey and Berne procedures showed better results than other surgical procedures.

Extracorporeal Shock Wave Lithotripsy for Chronic Pancreatitis Patients With Stones After Pancreatic Surgery

OBJECTIVES

The objective of this study was to evaluate the safety and efficacy of pancreatic extracorporeal shock wave lithotripsy (P-ESWL) in chronic pancreatitis (CP) patients with pancreatic stones after previous pancreatic surgery.

METHODS

This is a single-center study prospectively conducted in pained CP patients undergoing P-ESWL. Patients with a pancreatic surgery history (PSH) were included in the PSH group, and patients without a PSH during the same period were assigned to the control group. The primary outcomes included complications associated with P-ESWL and pain relief. Secondary outcomes included stone clearance and improved quality-of-life scores.

RESULTS

From March 2011 to October 2014, P-ESWLs were performed on 1017 patients (50 in the PSH group, 967 in the control group). No significant difference was observed in the frequency of occurrence of P-ESWL complications between the PSH group and control group (14.0% vs 13.2%, P = 0.877). At follow-up (2.6 years; range, 1.0-4.5 years), pain relief was achieved in 36 patients (75.0%), and 37 patients (77.1%) experienced complete stone clearance. No significant differences were observed between these patients and the matched controls.

CONCLUSIONS

For CP patients who develop painful stones after pancreatic surgery, P-ESWL safely achieves significant pain relief and stone clearance, preventing the need for a repeat surgery.

Chronic pancreatitis

Chronic pancreatitis is defined as a pathological fibro-inflammatory syndrome of the pancreas in individuals with genetic, environmental and/or other risk factors who develop persistent pathological responses to parenchymal injury or stress. Potential causes can include toxic factors (such as alcohol or smoking), metabolic abnormalities, idiopathic mechanisms, genetics, autoimmune responses and obstructive mechanisms. The pathophysiology of chronic pancreatitis is fairly complex and includes acinar cell injury, acinar stress responses, duct dysfunction, persistent or altered inflammation, and/or neuro-immune crosstalk, but these mechanisms are not completely understood. Chronic pancreatitis is characterized by ongoing inflammation of the pancreas that results in progressive loss of the endocrine and exocrine compartment owing to atrophy and/or replacement with fibrotic tissue. Functional consequences include recurrent or constant abdominal pain, diabetes mellitus (endocrine insufficiency) and maldigestion (exocrine insufficiency). Diagnosing early-stage chronic pancreatitis is challenging as changes are subtle, ill-defined and overlap those of other disorders. Later stages are characterized by variable fibrosis and calcification of the pancreatic parenchyma; dilatation, distortion and stricturing of the pancreatic ducts; pseudocysts; intrapancreatic bile duct stricturing; narrowing of the duodenum; and superior mesenteric, portal and/or splenic vein thrombosis. Treatment options comprise medical, radiological, endoscopic and surgical interventions, but evidence-based approaches are limited. This Primer highlights the major progress that has been made in understanding the pathophysiology, presentation, prevalence and management of chronic pancreatitis and its complications.

A comprehensive pain assessment tool (COMPAT) for chronic pancreatitis: Development, face validation and pilot evaluation

BACKGROUND/OBJECTIVES

Chronic pancreatitis (CP) pain is challenging to treat. Treatment selection is hampered by there being no validated pain assessment tool that accounts for the complexity of CP pain and its underlying mechanisms. This study aims to develop a comprehensive pain assessment tool (COMPAT) specific for CP, evaluate its face validity with experts and patients and test it with a pilot cohort of patients.

METHODS

COMPAT was developed from existing pain assessment tools and a literature review. Face validity was conducted by pancreatologists and CP patients using an item-content validity index for importance, relevance and clarity. Subsequent revisions were made to COMPAT. A pilot cohort of CP patients tested COMPAT.

RESULTS

COMPAT was developed and covered all important aspects of CP pain. Experts and CP patients reported that 70% of questions were important and relevant to CP pain. Most experts were willing to use COMPAT in clinic, ward/hospital and research settings. The most common location of pain was the epigastrium and food was the most important trigger. Pain Pattern C (constant background pain with pain attacks), had significantly higher frequency of pain attacks, higher opioid use, and affective descriptors of pain than Pattern A (pain attacks with no background pain).

CONCLUSIONS

COMPAT has high face validity and met with high acceptance. CP patients successfully self-reported their pain with COMPAT. The results reveal many differences in the CP pain within the pilot cohort, which may reflect different mechanisms of pain. A larger prospective cohort study is planned to further validate COMPAT.

The impact of surgical strategies on outcomes for pediatric chronic pancreatitis

PURPOSE

To review our institutional experience in the surgical treatment of pediatric chronic pancreatitis (CP) and evaluate predictors of long-term pain relief.

METHODS

Outcomes of patients ≤21 years surgically treated for CP in a single institution from 1995 to 2014 were evaluated.

RESULTS

Twenty patients underwent surgery for CP at a median of 16.6 years (IQR 10.7-20.6 years). The most common etiology was pancreas divisum (n = 7; 35%). Therapeutic endoscopy was the first-line treatment in 17 cases (85%). Surgical procedures included: longitudinal pancreaticojejunostomy (n = 4, 20%), pancreatectomy (n = 9, 45%), total pancreatectomy with islet autotransplantation (n = 2; 10%), sphincteroplasty (n = 2, 10%) and pseudocyst drainage (n = 3, 15%). At a median follow-up of 5.3 years (IQR 4.2-5.3), twelve patients (63.2%) were pain free and five (26.3%) were insulin dependent. In univariate analysis, previous surgical procedure or >5 endoscopic treatments were associated with a lower likelihood of pain relief (OR 0.06; 95% CI 0.006-0.57; OR 0.07; 95%, CI 0.01-0.89). However, these associations were not present in multivariate analysis.

CONCLUSION

In children with CP, the step-up practice including a limited trial of endoscopic interventions followed by surgery tailored to anatomical abnormalities and gene mutation status is effective in ensuring long-term pain relief and preserving pancreatic function.

Evidence-based Guidelines for the Management of Exocrine Pancreatic Insufficiency After Pancreatic Surgery

OBJECTIVE

To provide evidence-based recommendations for the management of exocrine pancreatic insufficiency (EPI) after pancreatic surgery.

BACKGROUND

EPI is a common complication after pancreatic surgery but there is certain confusion about its frequency, optimal methods of diagnosis, and when and how to treat these patients.

METHODS

Eighteen multidisciplinary reviewers performed a systematic review on 10 predefined questions following the GRADE methodology. Six external expert referees reviewed the retrieved information. Members from Spanish Association of Pancreatology were invited to suggest modifications and voted for the quantification of agreement.

RESULTS

These guidelines analyze the definition of EPI after pancreatic surgery, (one question), its frequency after specific techniques and underlying disease (four questions), its clinical consequences (one question), diagnosis (one question), when and how to treat postsurgical EPI (two questions) and its impact on the quality of life (one question). Eleven statements answering those 10 questions were provided: one (9.1%) was rated as a strong recommendation according to GRADE, three (27.3%) as moderate and seven (63.6%) as weak. All statements had strong agreement.

CONCLUSIONS

EPI is a frequent but under-recognized complication of pancreatic surgery. These guidelines provide evidence-based recommendations for the definition, diagnosis, and management of EPI after pancreatic surgery.

Chronic pancreatitis

Chronic pancreatitis describes a wide spectrum of fibro-inflammatory disorders of the exocrine pancreas that includes calcifying, obstructive, and steroid-responsive forms. Use of the term chronic pancreatitis without qualification generally refers to calcifying chronic pancreatitis. Epidemiology is poorly defined, but incidence worldwide seems to be on the rise. Smoking, drinking alcohol, and genetic predisposition are the major risk factors for chronic calcifying pancreatitis. In this Seminar, we discuss the clinical features, diagnosis, and management of chronic calcifying pancreatitis, focusing on pain management, the role of endoscopic and surgical intervention, and the use of pancreatic enzyme-replacement therapy. Management of patients is often challenging and necessitates a multidisciplinary approach.

Trends in the Use of Endoscopic Retrograde Cholangiopancreatography for the Management of Chronic Pancreatitis in the United States

GOALS

The aim of this study was to characterize current trends in the use of endoscopic retrograde cholangiopancreatography (ERCP) in the United States for patients hospitalized with chronic pancreatitis.

BACKGROUND

Historically, ERCP was the primary tool for diagnostic and therapeutic management of chronic pancreatitis. With increased availability of magnetic resonance imaging and endoscopic ultrasound, indications for ERCP are being redefined.

STUDY

We performed a retrospective cohort study using the Nationwide Inpatient Sample from 1998 to 2010. We identified patients with a primary discharge diagnosis of chronic pancreatitis who underwent ERCP. We excluded patients diagnosed with biliary, gallbladder, or pancreatic neoplasm and patients who underwent gallbladder or pancreatic operation during the same admission. We analyzed patient and hospital characteristics, length of stay, and in-hospital mortality, and adjusted for weighted sample schema.

RESULTS

During the study period, 29,318 patients with chronic pancreatitis (mean age 52 y, 57.2% female) underwent ERCP during their hospitalization. The majority of patients were white (56.1%). The majority of procedures were performed at large (72.4%), urban (95.2%), and academic (69.0%) hospitals. Mean hospital charges were $32,929 (SE= $1605). Mean length of stay was 6 days (SE=0.3), with in-hospital mortality of 0.76%. Over the study period, the number of procedures has decreased significantly (P<0.001).

CONCLUSIONS

In the United States, ERCP has been an important diagnostic and therapeutic tool for chronic pancreatitis. Over the last decade, ERCP has become an uncommon inpatient procedure for chronic pancreatitis.

Risk Factors for Diabetes Mellitus in Chronic Pancreatitis: A Cohort of 2,011 Patients

Diabetes mellitus (DM) is a common complication of chronic pancreatitis (CP) and increases the mortality. The identification of risk factors for DM development may contribute to the early detection and potential risk reduction of DM in patients with CP.Patients with CP admitted to Changhai Hospital (Shanghai, China) from January 2000 to December 2013 were enrolled. Cumulative rates of DM after the onset of CP were calculated by Kaplan-Meier method. Risk factors for DM development after the diagnosis of CP were identified by Cox proportional hazards regression model.A total of 2011 patients with CP were enrolled. During follow-up (median duration, 22.0 years), 564 patients developed DM. Cumulative rates of DM 20 and 50 years after the onset of CP were 45.8% (95% confidence interval [CI], 41.8%-50.0%) and 90.0% (95% CI, 75.4%-97.7%), respectively. Five risk factors for DM development after the diagnosis of CP were identified: male sex (hazard ratio [HR], 1.51; 95% CI, 1.08-2.11), alcohol abuse (HR, 2.00; 95% CI, 1.43-2.79), steatorrhea (HR, 1.46; 95% CI, 1.01-2.11), biliary stricture (HR, 2.25; 95% CI, 1.43-3.52), and distal pancreatectomy (HR, 3.41; 95% CI, 1.80-6.44).In conclusion, the risk of developing DM in patients with CP is not only influenced by the development of biliary stricture and steatorrhea indicating disease progression, and inherent nature of study subjects such as male sex, but also by modifiable factors including alcohol abuse and distal pancreatectomy.

Surgical Management of Chronic Pancreatitis

Advances over the past decade have indicated that a complex interplay between environmental factors, genetic predisposition, alcohol abuse, and smoking lead towards the development of chronic pancreatitis. Chronic pancreatitis is a complex disorder that causes significant and chronic incapacity in patients and a substantial burden on the society. Major advances have been made in the etiology and pathogenesis of this disease and the role of genetic predisposition is increasingly coming to the fore. Advances in noninvasive diagnostic modalities now allow for better diagnosis of chronic pancreatitis at an early stage of the disease. The impact of these advances on surgical treatment is beginning to emerge, for example, patients with certain genetic predispositions may be better treated with total pancreatectomy versus lesser procedures. Considerable controversy remains with respect to the surgical management of chronic pancreatitis. Modern understanding of the neurobiology of pain in chronic pancreatitis suggests that a window of opportunity exists for effective treatment of the intractable pain after which central sensitization can lead to an irreversible pain syndrome in patients with chronic pancreatitis. Effective surgical procedures exist for chronic pancreatitis; however, the timing of surgery is unclear. For optimal treatment of patients with chronic pancreatitis, close collaboration between a multidisciplinary team including gastroenterologists, surgeons, and pain management physicians is needed.

Surgical management of chronic pancreatitis: current utilization in the United States

BACKGROUND

Surgical intervention is uncommon in chronic pancreatitis. Literature largely describes single institution or international experiences. This study describes US-based chronic pancreatitis surgical management.

METHODS

Retrospective analysis of chronic pancreatitis patients in the Healthcare Cost and Utilization Project Florida State Inpatient Database 2007-2011. Patients with malignancy or congenital abnormalities were excluded. Univariate analysis using the chi-square test. The number of readmissions, inpatient length of stay and cost using Wilcoxon's signed-rank test. Multivariate analysis of surgery by logistic regression.

RESULTS

Twenty-one thousand four hundred and forty-five patients with chronic pancreatitis. 10.8% (2 307) underwent surgery including 1652 cholecystectomies, 564 drainage procedures and 498 pancreatectomies. Procedures decreased from 12.1% to 8.3% over time (P < 0.001), but intervention within 3 months increased (7.2% to 8.4%; P = 0.017). 15.3% (3 278) had pancreatic cysts/pseudocysts and 43.4% (9 312) had diabetes. The median numbers of admissions were 2 [interquartile range (IQR) 1,5] and 3 (IQR 2,7) among non-surgical and surgical patients, respectively (P < 0.001). Predictors of surgery were fewer co-morbidities, private insurance, and either diabetes mellitus or pancreatic cyst/pseudocyst.

CONCLUSION

Chronic pancreatitis leads to numerous inpatient readmissions, but surgical intervention only occurs in a minority of cases. Complicated patients are more likely to undergo surgery. The complexities of chronic pancreatitis management warrant early multidisciplinary evaluation and ongoing consideration of surgical and non-surgical options.

New-onset diabetes after distal pancreatectomy: a systematic review

OBJECTIVE

The true rate of new-onset diabetes (NODM) after distal pancreatectomy (DP) is not known. This systematic review was carried out to obtain exact percentages regarding the incidence of NODM after DP for different indications.

BACKGROUND

Distal pancreatectomy is the standard procedure for removal of benign or (potentially) malignant lesions from the pancreatic body or tail and increasingly used for removal of often benign lesions. It is associated with low mortality rates, though postoperative diabetes remains a serious problem.

METHODS

Embase, PubMed, Medline, Web of Science, the Cochrane Library, and Google Scholar were searched for articles reporting incidence of NODM after DP. Methodological quality of the included studies was assessed by means of the Newcastle-Ottawa scale for cohort studies and the Moga scale for case series. Mean weighted overall percentages of NODM after DP for different indications were calculated with 95% confidence intervals (CI) and corresponding P values.

RESULTS

Twenty-six studies were included, comprising 1.731 patients undergoing DP. The average cumulative incidence of NODM after DP performed for chronic pancreatitis was 39% and for benign or (potentially) malignant lesions it was 14%. Comparing the proportions of these 2 groups showed a significant difference (95% CI: 0.351-0.434 and 0.110-0.172, respectively, P < 0.000). The average percentage of insulin-dependent diabetes among patients with NODM after DP was 77%.

CONCLUSIONS

This review is the largest of its kind to assess the cumulative incidence of NODM after DP and shows that NODM is a frequently occurring complication, with incidence depending on the preexisting disease and follow-up time. Because NODM can affect quality of life, patients undergoing DP should be preoperatively provided with this information as specific as possible.

Local pancreatic head resection: the search for optimal indications through quality of life assessments

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.

Systematic review of early surgery for chronic pancreatitis: impact on pain, pancreatic function, and re-intervention

BACKGROUND

Surgical intervention has traditionally been reserved as the last management option for pain in chronic pancreatitis. Recently, there has been a call for surgery to be offered earlier in the disease process. The objectives of this review were to evaluate the effect of early surgery on postoperative pain, pancreatic function, and re-intervention rates in chronic pancreatitis.

METHODS

A systematic literature search through EMBASE, Cochrane Review, and PubMed from January 1950 to January 2014 was conducted. Citations found in relevant papers are hand-searched. Data which could be pooled were analyzed using Revman (v5.2). Risk of bias analysis was conducted.

RESULTS

Of the 2,886 potentially eligible studies identified, 11 studies met the inclusion criteria. There was large heterogeneity in the study designs, and studies were conducted over a lengthy time span. Seven studies examined pain, three studies examined pancreatic function, and three studies examined rates of re-intervention. Meta-analysis of the three studies with comparative raw data regarding complete pain relief showed that early surgery was associated with an increased likelihood of complete postoperative pain relief (RR = 1.67, 95% CI 1.09-2.56, p = 0.02). Early surgery was also associated with reduced risk of pancreatic insufficiency and low re-intervention rates.

CONCLUSIONS

Data from this study supports considering early surgery for pain management in patients with chronic pancreatitis, with the potential of a reduced risk of pancreatic insufficiency and the need for further intervention. Further prospective randomized studies are warranted comparing early surgery against conservative step-up approaches.

How severe is diabetes after total pancreatectomy? A case-matched analysis

OBJECTIVES

Total pancreatectomy (TP) is associated with significant morbidity and mortality. The severity of postoperative diabetes and existence of 'brittle diabetes' are unclear. This study sought to identify quality of life (QoL) and diabetes-specific outcomes after TP.

METHODS

Patients who underwent TP were matched for age, sex and duration of diabetes with patients with type 1 diabetes. General QoL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) core quality of life questionnaire QLQ-C30 and the PAN26 tool. Diabetes-specific outcomes were assessed using the Problem Areas in Diabetes (PAID) tool and an assessment of diabetes-specific complications and outcomes.

RESULTS

A total of 123 patients underwent TP; 88 died (none of diabetic complications) and two were lost to follow-up. Of the remaining 33 patients, 28 returned questionnaires. Fourteen general and pancreas-specific QoL measurements were all significantly worse amongst the TP cohort (QLQ-C30 + PAN26). However, when diabetes-specific outcomes were compared using the PAID tool, only one of 20 was significantly worse. HbA1c values were comparable (P = 0.299), as were diabetes-related complications such as hypoglycaemic attacks and organ dysfunction.

CONCLUSIONS

Total pancreatectomy is associated with impaired QoL on general measures compared with that in type 1 diabetes patients. Importantly, however, there was almost no significant difference in diabetes-specific outcomes as assessed by a diabetes-specific questionnaire, or in diabetes control. This study does not support the existence of 'brittle diabetes' after TP.

Treatment options for chronic pancreatitis

This Review covers the latest developments in the treatment options for chronic pancreatitis. Pain is the most frequent and dominant symptom in patients with chronic pancreatitis, which ranges from severe disabling continuous pain to mild pain attacks and pain-free periods. Conventional treatment strategies and recent changes in the treatment of pain in patients with chronic pancreatitis are outlined. The different treatment options for pain consist of medical therapy, endoscopy or surgery. Their related merits and drawbacks are discussed. Finally, novel insights in the field of genetics and microbiota are summarized, and future perspectives are discussed.

Treatment options in painful chronic pancreatitis: a systematic review

BACKGROUND

Longlasting and unbearable pain is the most common and striking symptom of chronic pancreatitis. Accordingly, pain relief and improvement in patients' quality of life are the primary goals in the treatment of this disease. This systematic review aims to summarize the available data on treatment options.

METHODS

A systematic search of MEDLINE/PubMed and the Cochrane Library was performed according to the PRISMA statement for reporting systematic reviews and meta-analysis. The search was limited to randomized controlled trials and meta-analyses. Reference lists were then hand-searched for additional relevant titles. The results obtained were examined individually by two independent investigators for further selection and data extraction.

RESULTS

A total of 416 abstracts were reviewed, of which 367 were excluded because they were obviously irrelevant or represented overlapping studies. Consequently, 49 full-text articles were systematically reviewed.

CONCLUSIONS

First-line medical options include the provision of pain medication, adjunctive agents and pancreatic enzymes, and abstinence from alcohol and tobacco. If medical treatment fails, endoscopic treatment offers pain relief in the majority of patients in the short term. However, current data suggest that surgical treatment seems to be superior to endoscopic intervention because it is significantly more effective and, especially, lasts longer.

Transient receptor potential ion channels: powerful regulators of cell function

OBJECTIVE

This article reviews the current understanding of transient receptor potential ion channels (TRP channels) in health and disease.

BACKGROUND

Transient receptor potential ion channels are a group of 27 channels that are expressed in all tissues. These channels play important roles in surgically important problems, such as chronic pain, susceptibility to infection, hypothermia, and some cancers.

METHODS

A literature search was performed. This review focuses on the role of TRP channels in a few surgically important disease processes, such as pain, inflammation, airway diseases, and malignant melanomas. In addition, we discuss some of the structural properties that are important for the activation of TRP channels.

RESULTS

TRPA1 and TRPV1 are expressed on pain fibers and play an important role in the development of chronic pain, such as chemotherapy-related neuropathic pain. Deletion of TRPA1 and TRPV1 suppresses the development of chronic pain, and blockers of TRPA1 and TRPV1 show promise as a new class of painkillers. Furthermore, several TRP channels are expressed on immune cells. Macrophages express at least 3 different TRP channels, and the properly balanced activation of all these channels together allows normal macrophage function. Deletion of any of these channels results in impaired macrophage function and increased susceptibility to infection. Because several of these TRP channels on macrophages are temperature sensitive, they may comprise the link for hypothermia-related infectious complications in trauma, and to a lesser degree, in elective surgical patients.

CONCLUSIONS

Transient receptor potential ion channels are involved in several surgically important disease processes. Activation or blockade of these channels offers new therapeutic opportunities. Pharmacologic activation or blockade of TRP channels may offer new treatment options in surgical patients for the management of pain and infections.

Insulin dependence and pancreatic enzyme replacement therapy are independent prognostic factors for long-term survival after operation for chronic pancreatitis

BACKGROUND

This retrospective, single-center, observational study on postoperative long-term results aims to define yet unknown factors for long-term outcome after operation for chronic pancreatitis.

PATIENTS AND METHODS

We analyzed 147 consecutive patients operated for chronic pancreatitis from 2000 to 2011. Mean follow-up was 5.3 years (range, 1 month to 12.7 years). Complete long-term survival data were provided by the German citizen registration authorities for all patients. A quality-of-life questionnaire was sent to surviving patients after a mean follow-up of 5.7 years.

RESULTS

Surgical principles were resection (n = 86; 59%), decompression (n = 29; 20%), and hybrid procedures (n = 32; 21%). No significant influences of different surgical principles and operative procedures on survival, long-term quality of life and pain control could be detected. Overall 30-day mortality was 2.7%, 1-year survival 95.9%, and 3-year survival 90.8%. Multivariate Cox regression analysis revealed that only postoperative insulin dependence at the time of hospital discharge (P = .027; Exp(B) = 2.111; 95% confidence interval [CI], 1.089-4.090) and the absence of pancreas enzyme replacement therapy at the time of hospital discharge (P = .039; Exp(B) = 2.102; 95% CI, 1.037-4.262) were significant, independent risk factors for survival with significant hazard ratios for long-term survival. Long-term improvement in quality of life was reported by 55 of 76 long-term survivors (73%).

CONCLUSION

Pancreatic enzyme replacement should be standard treatment after surgery for chronic pancreatitis at the time of hospital discharge, even when no clinical signs of exocrine pancreatic failure exist. This study underlines the potential importance of early operative intervention in chronic pancreatitis before irreversible endocrine dysfunction is present.