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de Castro SMM, de Nes LCF, Nio CY, Velseboer DC, Kate FJWT, Busch ORC, van Gulik TM, Gouma DJ. Incidence and characteristics of chronic and lymphoplasmacytic sclerosing pancreatitis in patients scheduled to undergo a pancreatoduodenectomy. HPB (Oxford) 2010; 12:15-21. [PMID: 20495640 PMCID: PMC2814399 DOI: 10.1111/j.1477-2574.2009.00112.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Accepted: 07/09/2009] [Indexed: 12/12/2022]
Abstract
BACKGROUND The determination of the exact nature of a pancreatic head mass in a patient scheduled to undergo a pancreatoduodenectomy can be very difficult. This is important as patients who suffer from benign disease such as pancreatitis do not always require surgery. The aim of the present study was to analyse the incidence of pancreatitis and the signs and symptoms associated with these tumours mistaken for pancreatic cancer and the diagnostic procedures performed. METHODS A consecutive group of patients who underwent a pancreatoduodenectomy between 1992 and 2005 with histopathologically proven pancreatic adenocarcinoma (PCA) and pancreatitis were analysed. RESULTS The incidence of pancreatitis after pancreatoduodenectomy is 63 out of 639 patients who underwent a pancreaticoduodenectomy (9.9%). Of these patients, 24 patients (38%) had lymphoplasmacytic sclerosing pancreatitis (LPSP) and 31 patients (49%) had focal chronic pancreatitis. Eight patients (13%) had an intermediate form with characteristics of both. Pancreatic adenocarcinoma occurred in 227 patients (36%). The presence of pancreatitis without a discrete mass on endoscopic ultrasonography (EUS) seemed to have clinical relevance with a positive likelihood ratio of 5.1. Mortality after resection was nil in both groups. CONCLUSION The incidence of pancreatitis is 9.9% for patients scheduled to undergo a pancreatoduodenectomy. Of these patients, 38% had LPSP, 13% had a intermediate form and 49% had focal chronic pancreatitis. The determination of the exact nature of a pancreatic head mass remains difficult.
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Affiliation(s)
- Steve MM de Castro
- Departments of Surgery, Academic Medical CenterAmsterdam, the Netherlands
| | - Lindsey CF de Nes
- Departments of Surgery, Academic Medical CenterAmsterdam, the Netherlands
| | - C Yung Nio
- Departments of Radiology, Academic Medical CenterAmsterdam, the Netherlands
| | - Daan C Velseboer
- Departments of Pathology, Academic Medical CenterAmsterdam, the Netherlands
| | - Fiebo JW Ten Kate
- Departments of Pathology, Academic Medical CenterAmsterdam, the Netherlands
| | - Olivier RC Busch
- Departments of Surgery, Academic Medical CenterAmsterdam, the Netherlands
| | - Thomas M van Gulik
- Departments of Surgery, Academic Medical CenterAmsterdam, the Netherlands
| | - Dirk Jan Gouma
- Departments of Surgery, Academic Medical CenterAmsterdam, the Netherlands
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van der Gaag NA, de Castro SMM, Rauws EAJ, Bruno MJ, van Eijck CHJ, Kuipers EJ, Gerritsen JJGM, Rutten JP, Greve JW, Hesselink EJ, Klinkenbijl JHG, Rinkes IHMB, Boerma D, Bonsing BA, van Laarhoven CJ, Kubben FJGM, van der Harst E, Sosef MN, Bosscha K, de Hingh IHJT, Th de Wit L, van Delden OM, Busch ORC, van Gulik TM, Bossuyt PMM, Gouma DJ. Preoperative biliary drainage for periampullary tumors causing obstructive jaundice; DRainage vs. (direct) OPeration (DROP-trial). BMC Surg 2007; 7:3. [PMID: 17352805 PMCID: PMC1828149 DOI: 10.1186/1471-2482-7-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2007] [Accepted: 03/12/2007] [Indexed: 01/11/2023] Open
Abstract
Background Surgery in patients with obstructive jaundice caused by a periampullary (pancreas, papilla, distal bile duct) tumor is associated with a higher risk of postoperative complications than in non-jaundiced patients. Preoperative biliary drainage was introduced in an attempt to improve the general condition and thus reduce postoperative morbidity and mortality. Early studies showed a reduction in morbidity. However, more recently the focus has shifted towards the negative effects of drainage, such as an increase of infectious complications. Whether biliary drainage should always be performed in jaundiced patients remains controversial. The randomized controlled multicenter DROP-trial (DRainage vs. Operation) was conceived to compare the outcome of a 'preoperative biliary drainage strategy' (standard strategy) with that of an 'early-surgery' strategy, with respect to the incidence of severe complications (primary-outcome measure), hospital stay, number of invasive diagnostic tests, costs, and quality of life. Methods/design Patients with obstructive jaundice due to a periampullary tumor, eligible for exploration after staging with CT scan, and scheduled to undergo a "curative" resection, will be randomized to either "early surgical treatment" (within one week) or "preoperative biliary drainage" (for 4 weeks) and subsequent surgical treatment (standard treatment). Primary outcome measure is the percentage of severe complications up to 90 days after surgery. The sample size calculation is based on the equivalence design for the primary outcome measure. If equivalence is found, the comparison of the secondary outcomes will be essential in selecting the preferred strategy. Based on a 40% complication rate for early surgical treatment and 48% for preoperative drainage, equivalence is taken to be demonstrated if the percentage of severe complications with early surgical treatment is not more than 10% higher compared to standard treatment: preoperative biliary drainage. Accounting for a 10% dropout, 105 patients are needed in each arm resulting in a study population of 210 (alpha = 0.95, beta = 0.8). Discussion The DROP-trial is a randomized controlled multicenter trial that will provide evidence whether or not preoperative biliary drainage is to be performed in patients with obstructive jaundice due to a periampullary tumor.
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Affiliation(s)
| | - Steve MM de Castro
- Department of Surgery, Academic Medical Center Amsterdam, the Netherlands
| | - Erik AJ Rauws
- Department of Gastroenterology, Amsterdam, the Netherlands
| | - Marco J Bruno
- Department of Gastroenterology, Amsterdam, the Netherlands
| | | | - Ernst J Kuipers
- Department of Gastroenterology, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Jan-Paul Rutten
- Department of Surgery, University Hospital Maastricht, Maastricht, the Netherlands
| | - Jan Willem Greve
- Department of Surgery, University Hospital Maastricht, Maastricht, the Netherlands
| | - Erik J Hesselink
- Department of Surgery, Gelre Hospital, Apeldoorn, the Netherlands
| | | | | | - Djamila Boerma
- Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, the Netherlands
| | | | - Frank JGM Kubben
- Department of Gastroenterology, Medical Center Rijnmond Zuid, Rotterdam, the Netherlands
| | - Erwin van der Harst
- Department of Surgery, Medical Center Rijnmond Zuid, Rotterdam, the Netherlands
| | - Meindert N Sosef
- Department of Surgery, Atrium Medical Center, Heerlen, the Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's Hertogenbosch, the Netherlands
| | | | - Laurens Th de Wit
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Otto M van Delden
- Department of Radiology, Academic Medical Center Amsterdam, The Netherlands
| | - Olivier RC Busch
- Department of Surgery, Academic Medical Center Amsterdam, the Netherlands
| | - Thomas M van Gulik
- Department of Surgery, Academic Medical Center Amsterdam, the Netherlands
| | - Patrick MM Bossuyt
- Department of clinical epidemiology and biostatistics, Academic Medical Center Amsterdam, the Netherlands
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center Amsterdam, the Netherlands
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