Which Surgeries Are the Best Choice for Chronic Pancreatitis: A Network Meta-Analysis of Randomized Controlled Trials

Simplified technique in total pancreatectomy with islet cell autotransplantation after Frey's procedure: a case report

BACKGROUND

The selection of the surgical approach for chronic pancreatitis (CP) is determined by various factors including inflammatory location, presence of pancreatic duct dilatation, or possibility of cancer. Total pancreatectomy (TP), with or without islet cell autotransplantation, is considered for patients with refractory CP after the failure of other surgical treatments. Considering the increasing incidence of CP requiring surgical treatment, the number of cases in which TP is performed after previous surgical treatment is expected to increase.

CASE PRESENTATION

We reported a case of TPIAT in a patient with alcoholic CP who had previously undergone Frey's procedure. During the operation, the sufficient length of the elevated jejunal loop for pancreaticojejunostomy in Frey's procedure allowed it to be used directly for biliary jejunostomy during TP. In addition, jejunojejunostomy from the previous operation could be used, and these methods contributed to simplifying the operative procedure. We need open hemostasis on post-operative day (POD) 1and a percutaneous drainage tube replacement for an intraperitoneal abscess on POD 24. The patient was discharged from the hospital on POD 37 with normal serum C-peptide level, which suggests favorable insulin secretion from transplanted islets, and the epigastric pain that suffered her preoperatively resulted in a dramatic improvement.

CONCLUSIONS

When performing the Frey's procedure, the elevated jejunal loop and Y-anastomosis jejunal loop with sufficient length allow them to be used directly for the reconstructions in the possible subsequent TP.

Post-surgical exocrine pancreatic insufficiency

Being an underdiagnosed and under or insufficiently treated condition, surgical pancreatic exocrine insufficiency (PSP) is the condition in which pancreatic enzymes are insufficient for digestion because of gastrointestinal (GI) surgery involving the upper GI tract, biliary ducts, or the pancreas, and and leading to potential malnutrition and deterioration in quality of life. Age, obesity, history of tobacco use, family history of diabetes, surgery due to a malignant tumor, presence of steatorrhea, jaundice, weight loss, and intraoperative findings of hard pancreatic texture have been associated with a higher risk of PSP. Pancreatoduodectomy (PD) has demonstrated an increased risk of developing PSP, with a prevalence between 19-100%. Distal pancreatectomy (DP) and central pancreatectomy (CenP) are associated with less risk of PSP, with a prevalence of 0-82% and 3.66-8.7%, respectively. In patients with chronic pancreatitis (CP), PSP was associated with 80% in Partington-Rochelle procedure, 86% in Frey procedure, 80% in duodenum preserving pancreatic head procedure, >60% in PD and 27.5-63% in DP. Fecal elastase-1 (FE-1) is a generally accepted tool for diagnosis. Treatment is recommended to start as soon as a diagnosis is achieved, or clinical suspicion is high. Pancreatic enzyme replacement therapy improves symptoms of malabsorption, facilitates weight gain, and ultimately improves patients' quality of life. Starting dosage is between 10,000-50,000 units in snacks and 50,000-75,000 units in main meals, administered throughout food intake, though further data specifically on PSP are needed. Follow-up in PSP is recommended on an on-demand basis, where malnutrition should be assessed.

Outcomes after Frey's procedure for chronic pancreatitis: a 8-year single-center experience in Colombia

BACKGROUND

Chronic pancreatitis is an inflammatory disease characterized by irreversible morphological changes due to chronic pancreatic fibrosis. The treatment goals are to relieve pain, preserve function, and prevent further pathological consequences. Endoscopic treatment, surgery, or both are options for untreatable pain or suspected malignancy. Frey procedure is a reasonable surgical intervention because of its hybrid character, combining resection and drainage. Unfortunately, there is limited information about the outcomes of this procedure in Latin America, and few cases described in Colombia. This study aims to describe the experience of a pancreatic surgery reference center in the management of patients undergoing Frey's surgery for chronic pancreatitis.

METHODS

A retrospective review of a prospectively collected database of patients who underwent a Frey procedure due to chronic pancreatitis between January 2014 to February 2022 in a hospital in Bogotá, Colombia, was made. A demographic, clinical, and postoperative outcome description was performed. Mann-Whitney Willcoxon test was performed between operative variables and long-term outcomes.

RESULTS

Eighteen patients met the inclusion criteria. 55.5% of patients were male. Chronic pancreatitis etiology in most cases (83.3% n = 15) was idiopathic. The median duration of symptoms and chronic pancreatitis diagnosis before surgery was 6.15 months (IQR 5;97). Overall morbidity was 38.88%. One patient died at 30 days of follow-up. The median follow-up time was 42.5 (IQR 19;65 months). The median pain reduction was 3 points according to the visual analog score. Six patients were diagnosed with malignant conditions after surgery (mean 27.8 ± 7.5 months). Wirsung's duct size was statistically related with malignancy presentation after Frey's procedure (Z = 2.54; P = 0.01).

CONCLUSION

According to our data, Frey's procedure remains safe and feasible, with acceptable outcomes in terms of pain relief and pancreatic function. The study confirms the importance of a longstanding follow-up due to an inherent risk of pancreatic malignancy. Our data suggest that pancreatic duct size could be related with the malignancy diagnosis after Frey's procedure; however, further prospective studies with a larger sample size would be helpful to confirm these results.