Long-term metabolic results after pancreatic resection for severe chronic pancreatitis

HYPOTHESIS: Type and extent of pancreatic resection have little effect on long-term development of diabetes in patients with chronic pancreatitis (CP) considering the distinctive relentless progression of the disease. DESIGN: A case series of consecutive patients included over a 10-year period. Median duration of follow-up was 6.3 years. Follow-up of survivors was at least 5 years (median, 7.7 years). SETTING: A referral center in a university hospital. PATIENTS: All 68 patients (57 men and 11 women) who underwent pancreatic resection for CP during the study period were included. Median age of patients was 44 years. Complete follow-up was obtained for all patients. INTERVENTIONS: Resection procedures included 35 proximal pancreatoduodenectomies (51%), 31 distal pancreatectomies (46%), and 2 total pancreatoduodenectomies (3%). Four patients (6%) received autologous intraportal islet transplants. MAIN OUTCOME MEASURES: Time from surgery to introduction of insulin therapy or death, perioperative morbidity and mortality, and pain control. RESULTS: Fifty-one patients (75%) had experienced acute episodes of CP 5 months to 13 years before resection. Perioperative mortality and morbidity were 1.5% and 21.0%, respectively. Satisfactory long-term pain control was achieved in 61 patients (90%). Actuarial survival was 54% at 10 years and was significantly worse for patients with alcoholic CP (48% vs 78%; P =.04). Diabetes-free survival was 26% at 10 years, with no difference according to type or extent of pancreatic resection. CONCLUSIONS: Pancreatic resection for severe CP is safe and has good long-term results on pain control but is performed late in the course of disease. Earlier resection and islet of Langerhans autotransplantation should be considered for patients who are inexorably heading toward diabetes, regardless of type and extent of resection performed.     

Long-term results of distal pancreatectomy for chronic pancreatitis in 90 patients

OBJECTIVE: To determine the indications for distal pancreatectomy for chronic pancreatitis and to evaluate the risks, functional loss, and outcome of the procedure. SUMMARY BACKGROUND DATA: Chronic pancreatitis is generally associated with continued pain, parenchymal and ductal hypertension. and progressive pancreatic dysfunction, and it is a cause of premature death in patients who receive conservative treatment. Good results have recently been reported by the authors and others for resection of the pancreatic head in this disease, but distal pancreatectomy is a less popular option attended by variable success rates. It remains a logical approach for patients with predominantly left-sided pancreatic disease, however. METHODS: A personal series of 90 patients undergoing distal pancreatectomy for chronic pancreatitis over the last 20 years has been reviewed, with a mean postoperative follow-up of 34 months (range 1-247). Pancreatic function was measured before and after operation in many patients. RESULTS: Forty-eight of 84 patients available for follow-up had a successful outcome in terms of zero or minimal, intermittent pain. There was one perioperative death, but complications developed in 29 patients, with six early reexplorations. Morbidity was unaffected by associated splenectomy or right-to-left dissection. Late mortality rate over the follow-up period was 10%; most of these late deaths occurred because of failure to abstain from alcohol. Preoperative exocrine function was abnormal in two thirds of those tested and was unchanged at follow-up. Diabetic curves were seen in 10% of patients preoperatively, while there was an additional diabetic morbidity rate of 23% related to the procedure and late onset of diabetes (median duration 27 months) in another 23%. Diabetic onset was related to percentage parenchymal resection as well as splenectomy. Outcome was not clearly dependent on the etiology of pancreatitis or on disease characteristics as assessed by preoperative imaging. However, patients with pseudocyst disease alone did better than other groups. Twenty-one of 36 patients who failed to respond to distal pancreatectomy required further intervention, including completion pancreatectomy, neurolysis, and sphincteroplasty. Thirteen of these 21 patients achieved long-term pain relief after their second procedure. CONCLUSIONS: Distal pancreatectomy for chronic pancreatitis from any etiology can be performed with low mortality and a good outcome in terms of pain relief and return to work in approximately 60% of patients. Little effect is seen on exocrine function of the pancreas, but there is a diabetic risk of 46% over 2 years. Pseudocyst disease is associated with the best outcome, but other manifestations of this disease, including strictures, calcification, and limited concomitant disease in the head of the pancreas, can still be associated with a good outcome.     

Pancreatic resection for chronic pancreatitis

Patients with chronic pancreatitis needing operative management include those with severe pain, those with complications of pancreatitis, or those in whom it is not possible to distinguish cancer of the pancreas from chronic pancreatitis. The use of endoscopic retrograde cholangiopancreatography, CT, and angiography to define the structural abnormalities has increased the surgeon's ability to select an operation matched to the patient's needs. A longitudinal pancreaticojejunostomy should be performed in patients whose ducts are dilated. When the head of the pancreas is enlarged and thickened, pancreaticoduodenectomy has been the traditional operation of choice. However, local resection with pyloric and duodenal preservation should now be considered an alternative that has a lower mortality rate and less likelihood of creating diabetes or exocrine insufficiency. Patients whose ducts are of insufficient caliber to permit longitudinal pancreaticojejunostomy are candidates for resection of the proximal or distal pancreas, depending on the site of disease or, alternatively, for the Beger or Warren procedure. Pain relief is achieved with surgery in about 80 per cent of patients with chronic pancreatitis. Many of the late deaths following operation for chronic pancreatitis are attributable, not to the operation, but to the effects of alcoholism. There is a need for surgeons to improve their observations and assessment of operative results.     

Duodenum-preserving pancreatic head resection (DPPHR) in chronic pancreatitis: its rationale and results

Persistent, uncontrolled pain is the most common indication for surgery in chronic pancreatitis. In the presence of an inflammatory mass in the pancreatic head or in pancreatic head-related complications of chronic pancreatitis, resection procedures are inevitable. The Whipple procedure, originally introduced for malignat lesions of the periampullary region, is commonly employed, although it represents surgical over-treatment in a benign pancreatic disorder. In this article, we discuss our long experience with duodenum-preserving pancreatic head resection (Beger procedure) for chronic pancreatitis. Prospective, randomized controlled trials suggest that this organ- and function-preserving procedure should be the gold standard for the surgical treatment of pancreatic head-related complications of chronic pancreatitis. Received: July 3, 2000 / Accepted: August 8, 2000     

Duodenum-preserving head resection in chronic pancreatitis

A duodenum-preserving head resection was performed in 295 patients with chronic pancreatitis and an inflammatory mass in the head of the pancreas. Ninety-four percent of patients suffered severe pain syndrome, 48% had a common bile duct stenosis, 17% a vascular obstruction in the portal vein and splenic vein branches, and 6% had a severe stenosis of the duodenum. Surgical resection of the inflammatory mass in the head of the pancreas was indicated after a medical treatment of 4.1 years (median). Subtotal resection of the head of the pancreas, including the inflammatory mass, resulted in decompression of the narrowed common bile duct segment, decompression of the pancreatic main duct, and the relief of duodenum stenosis, as well as a relief of portal hypertension. The mean hospitalization time was 13 days, frequency of re-operation 5.8%, and hospital mortality 1.02%. Seventy-nine percent of patients experienced long-lasting pain relief and 11% reported a significant and long-lasting reduction of pain; late morbidity proved to be low. In comparison to the Whipple procedure the duodenum-preserving head resection has the advantage of preserving the stomach, duodenum and biliary tract.     

Organ-preserving pancreatic head resection in chronic pancreatitis

BACKGROUND: Twenty to thirty per cent of patients with chronic pancreatitis develop inflammatory enlargement of the head of the pancreas. A safe procedure has been developed for duodenum-preserving pancreatic head resection; this report describes the preliminary results achieved. METHODS: Thirty patients, 27 men and three women of mean age 44 years, underwent surgical resection following the development of an inflammatory mass in the pancreatic head. All patients had weight loss and frequent abdominal pain. Jaundice was present in three and diabetes mellitus in ten patients. The diagnosis of chronic pancreatitis was made by a combination of endoscopic retrograde cholangiopancreatography, sonography and computed tomography. Pancreatic function was assessed by amylum tolerance test (ATT), oral glucose tolerance test and stool elastase measurement. The surgical procedure involved wide local resection of the inflammatory tumour in the pancreatic head, without division of the pancreas over the portal vein. Reconstruction involved drainage via a jejunal Roux-en-Y loop. In three icteric cases, prepapillary bile duct anastomosis was also performed using the same jejunal loop. RESULTS: There were no hospital deaths or major complications. After a median follow-up of 10 (range 6-14) months, all patients were symptom free. The mean increase in body-weight was 8.9 (range 4-20) kg. The ATT and stool elastase level demonstrated improved exocrine function but there was no change in endocrine function. CONCLUSION: This type of pancreatic head resection is a safe procedure that provides good short-term relief of symptoms associated with inflammatory changes in the head of the pancreas in chronic pancreatitis.     

Surgical treatment of chronic pancreatitis by distal pancreatectomy

No consensus exists on the best surgical treatment for chronic pancreatitis. In a retrospective study on 29 patients it was found that pain caused by chronic pancreatitis can be treated effectively by a 95% DP or a 40-80% DP. However, after a 40-80% DP the incidence of endocrine and exocrine pancreatic insufficiency is less frequent than after a 95% DP. Therefore, distal pancreatectomy can be advised as a treatment of pain, caused by chronic pancreatitis. In order to minimize the chance of pancreatic insufficiency resection should be done as conservatively as possible.     

Ductal drainage or resection for chronic pancreatitis

We report a 10 year review comparing the results of pain relief after three procedures for chronic pancreatitis: Whipple pancreatoduodenectomy, modified Puestow side-to-side longitudinal pancreaticojejunostomy and distal pancreatic resection. Results of follow-up review at 6 months, 2 years and 5 years were tabulated. Five year follow-up data were available on more than 80 percent of patients. The proportion of good results for pain relief decreased with the passage of time regardless of the procedure performed. Although equally good results are obtained after either pancreatoduodenectomy or pancreaticojejunostomy, we conclude that in the presence of a dilated duct, the procedure of choice is pancreaticojejunostomy. If the duct is not dilated, we then favor pancreatoduodenectomy, after which the pain relief is significantly better (p = 0.05) than after distal resection. Our data show that, for all factors evaluated, the poorest pain relief was obtained after distal resection. Therefore that procedure has limited value when used specifically for relief of pain in chronic pancreatitis, except in the uncommon circumstance when the disease is confined to the distal part of the gland. Our study also shows that patients who have more radical distal resection have no better pain relief than those who have 50 percent distal resection.     

Osteolysis of the distal clavicle: Long-term results of arthroscopic resection

Purpose: The purpose of this study was to evaluate the outcome of arthroscopic distal clavicle resection by the direct superior approach for treatment of isolated osteolysis of the distal clavicle. Type of Study: Case series. Materials and Methods: Forty-one shoulders in 37 patients underwent arthroscopic resection of the distal clavicle. Thirty-three patients were male and 4 female, with an average age of 39 years. All patients complained of pain localized to the acromioclavicular joint region. Symptoms began after a traumatic event in 18 shoulders and were associated with repetitive stressful activity in 23 shoulders. Results: At an average follow-up of 6.2 years, 22 shoulders had excellent results, 16 had good results, and 3 were failures. All 3 failures occurred in patients with a traumatic etiology. Conclusions: Arthroscopic resection for osteolysis of the distal clavicle has results comparable to open excision with low morbidity. Patients with a traumatic etiology had slightly worse results compared with patients with a microtraumatic etiology.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 6 (September), 2000: pp 600–605     

Subtotal resection of the head of the pancreas combined with ductal obliteration of the distal pancreas in chronic pancreatitis.

Subtotal resection of the head of the pancreas combined with duct obliteration of the distal pancreas by prolamine was performed in 12 selected patients who had chronic alcohol-induced pancreatitis with most destruction in the proximal pancreas. The main indication for operation was intractable pain. There was no postoperative mortality but morbidity was high when no pancreaticojejunostomy was constructed. After a follow-up period of 32 months, lasting pain relief was obtained in 10 patients; pseudocyst formation occurred in three patients; calcification of the distal pancreas, absent before operation, was demonstrated in four of six patients; six of 11 nondiabetic patients became hyperglycemic either abruptly (1 patient) or progressively (5 patients); quality of life improved in most patients. This procedure preserves the stomach, duodenum, spleen, distal pancreas and common bile duct if possible. However, pancreatic ductal obliteration with prolamine does not prevent relapses of chronic pancreatitis.     

Long-term results of pancreatojejunostomy in patients with chronic pancreatitis

During a 10 year period, 69 patients with pancreatic duct dilation of 7 mm or more and intractable pain from chronic pancreatitis underwent Roux-Y drainage either as a lateral pancreatojejunostomy on 48 occasions or as a caudal pancreatojejunostomy in 21 cases. Nine patients (three with caudal pancreatojejunostomy and six with lateral pancreatojejunostomy) were lost to follow-up within the first postoperative year. The residual 60 patients undergoing 64 procedures were followed for an average of 69.3 months (range 10 to 144 months). Four patients with recurrent pain after caudal pancreatojejunostomy were converted to a lateral pancreatojejunostomy, with resolution of pain. Long-term pain relief occurred significantly more often in patients undergoing lateral pancreatojejunostomy than in those who received a caudal pancreatojejunostomy (66 versus 34 percent, p less than 0.01). Accordingly, caudal pancreatojejunostomy has little place in the surgical management of these patients. Since no differences existed in the two surgical populations, long-term pain relief in chronic pancreatitis appears more favorably influenced by the choice of an appropriate surgical procedure, rather than resulting solely from progressive destruction of the gland, as has been claimed. Although successful results in patients with lateral pancreatojejunostomy could not be correlated with anastomotic suture technique (one layer versus two layers or capsule versus mucosa-to-mucosa, p greater than 0.05), the creation of a pancreatojejunal anastomosis of more than 6 cm was found to be critical for success (p less than 0.001). Restoration of either exocrine or endocrine function should not be anticipated after otherwise successful lateral pancreatojejunostomy. However, if ductal dilatation can be demonstrated, recurrent pain after lateral pancreatojejunostomy is best managed by repeat lateral pancreatojejunostomy rather than resection.     

Treatment of chronic alcoholic pancreatitis by pancreatic resection

Forty-one patients with chronic pancreatitis caused by alcoholism were selected for resective surgery on the basis of clinical criteria and findings on pancreatography. Five patients had Whipple resections, 32 had 80 percent resections, and 7 had total pancreatectomies (3 previously had subtotal pancreatectomies). One perioperative and three late deaths accounted for the overall mortality of 10 percent. Complete freedom from pain on long-term follow-up was achieved in all of the patients who had total pancreatectomy, in half of the patients who had 80 percent resection, and in only one of five patients who had Whipple resection. Diabetes occurred in only one patient after Whipple resection, in nearly half of the patients after 80 percent pancreatectomy, in a gradually accelerating manner, up to 5 years, and in all patients after total resection, where it was frequently complicated by recurrent alcoholism. Jaundice was a rare complication of disease progression in the overall treatment group; none of these patients presented with cholestasis preoperatively. Recurrent alcoholism was reported in 32 percent of the patients and contributed to two deaths.     

Organ-preserving surgery in chronic pancreatitis: the duodenum-preserving pancreatic head resection

Chronic pancreatitis is a inhomogeneous disease of multifactorial genesis and a variable clinical course. Upper abdominal pain is the leading clinical symptom of the majority of the patients. The primary treatment of these patients is conservative, but if the treatment fails in pain relief or organ complications occur surgical treatment is indicated. The most common organ complications due to chronic pancreatitis are stenosis of the common bile duct and the pancreatic duct, duodenal stenosis, stenosis of the portal vein with portal hypertension, pancreatic pseudocysts and the development of pancreatic fistula. Due to the pathophysiological concept of an elevated duct pressure as a source of pain, duct decompression by drainage procedures is the favored surgical procedure by many surgeons. Nevertheless, even in patients with a dilated pancreatic main duct, only half of the patients will benefit from drainage operations. Long-term severe upper abdominal pain and complications of the neighboring organs due to an inflammatory mass in the head of the pancreas should be indicative for resective procedures which should be organ-preserving as much as possible and take into account the endocrine function of the pancreatic gland. Simultaneous multiple organ resections like pylorus-preserving partial duodenopancreatectomy or total pancreatectomy are not necessary for a benign disease and should be only performed in patients with proven malignancy. The aim of the surgical procedure is to reduce pain and frequency of relapsing pancreatitis without impairing the endocrine function of the pancreatic gland.     

Long-term results after pancreas resection for acute necrotizing pancreatitis

This study was designed to investigate the long-term effects of early pancreatic resection for acute necrotizing pancreatitis. During 1973-1978 40 resections were performed in our clinic. Eleven patients died initially (28 per cent). None of the four further deaths was due to pancreatitis or associated disorders. Twenty-four patients were re-examined 5-11 years after resection--one patient refused to participate. Five had not been able to return to work because of severe polyneuropathy; one more had retired because of chronic pancreatitis in the pancreatic remnant. Polyneuropathy was found in five further patients. The reason for this high incidence of polyneuropathy (42 per cent) remains unknown. Eight patients still drank excessive alcohol; three of them had had recurrent pancreatitis and dyspepsia, and insulin requiring diabetes. All but 2 (92 per cent) had diabetes, 14 needing insulin--half of them at 6 months to 6 years after the resection. Moreover, 11 patients (46 per cent) suffered from dyspeptic symptoms. The results suggest that because of the high frequency of late complications, in addition to the early complications, early resection of pancreas should be critically re-evaluated as the treatment for acute necrotizing pancreatitis. If resection is used in patients with extreme pancreatic necrosis, careful and continuous postoperative follow-up will be needed.     

Long-term results of arthroscopic resection of the distal clavicle with concomitant subacromial decompression

Purpose: The goal of the study was to evaluate the long-term outcome of combined arthroscopic distal clavicle excision and subacromial decompression. Type of Study: Retrospective, long-term cohort evaluation. Methods: Twenty patients with an average follow-up of 6 years (range, 3.9 to 9 years) were reviewed. All patients had ipsilateral impingement syndrome and acromioclavicular joint disease at the time of surgery and underwent arthroscopic subacromial decompression combined with arthroscopic distal clavicle excision. All patients returned for evaluation in person, in addition to filling out a questionnaire incorporating the University of California, Los Angeles (UCLA), and Constant scoring systems. Preoperative and postoperative radiographs were available for all patients. Results: Postoperatively, all patients had pain relief and were satisfied with the result. The average postoperative UCLA Shoulder score was 29.8 ± 0.6, compared with 17.5 ± 3.0 before surgery (P = .001). The Constant Shoulder score averaged 98.5 ± 2.1 postoperatively, compared with 70.5 ± 11.2 preoperatively (P = .001). There was 100% good to excellent results using both scoring systems. Individual components of the UCLA scoring system (pain, function, and power) all showed significant postoperative improvement (P = .001). Constant categories of pain, activities of daily living, range of motion, and power also improved. Follow-up radiographs showed maintenance of the resected distal clavicle in 19 patients. Five patients (25%) had radiographic evidence of calcific density distal to the resected clavicle but were asymptomatic. Conclusions: The long-term results of arthroscopic resection of the distal clavicle with concomitant subacromial decompression are uniformly good or excellent. Impingement and acromioclavicular joint disease frequently coexist and should be identified and treated concurrently.     

改良保留十二指肠胰头切除术治疗慢性胰腺炎的疗效分析

目的:观察改良保留十二指肠的胰头切除术(改良Beger手术)对伴胰头炎性肿块的慢性胰腺炎病人的治疗效果。方法:回顾性分析自2004年1月至2010年12月,在我院胰腺外科接受改良Beger手术治疗的51例伴胰头炎性肿块的慢性胰腺炎病人的临床资料,并对病人术后疼痛症状、生活质量及内分泌功能等进行随访。结果:无手术死亡病例,术后并发症发生率为15.7%,其中胰漏3例,胆漏2例,十二指肠漏1例,腹腔出血1例,切口裂开1例。术后6个月,病人疼痛得到明显缓解,EORTC QLQ-C30疼痛评分由(64.3±5.8)降至(12.5±3.7)(P<0.01),生活质量获显著提高,GLQI生活质量评分由(70.1±5.8)增至(86.4±6.6)(P<0.01);病人内分泌功能未受影响,无新增糖尿病病例。结论:采用改良Beger手术治疗伴胰头炎性肿块的慢性胰腺炎是安全、有效的。