Surgical treatment of painful chronic pancreatitis: an unresolved problem?

Relief of pain in chronic pancreatitis is the major problem warranting surgical treatment in this disease. The mechanism of pain is largely unknown and several types of operation have been devised for treatment. Side-to-side pancreaticojejunostomy (Partington-Rochelle) and pancreaticoduodenectomy according to Whipple have stood the test of time. Recently, new surgical options have been explored like the operation according to Beger, segmental autotransplantation, and duodenum-preserving total pancreatectomy. Because of the reluctance to refer this type patient for surgery, treatment with analgesic drugs is continued for quite some time and once analgesia addiction has developed clinical judgement in these patients is severely hampered. Surgery can be performed with 70-80% success and with limited morbidity as well as low mortality. For these reasons surgery should be discussed early in the disease if pain becomes a major problem. If these patients are operated prior to analgesia addiction, maybe the long-term prognosis will improve. The diagnostic and surgical approach will be discussed in detail with a plea for considering surgery early in the course of disease.     

Prognostic factors of response to endoscopic treatment in painful chronic pancreatitis

AIM To evaluate the endoscopic treatment efficacy and prognostic factors of long-term response to treatment for painful chronic pancreatitis.METHODS This retrospective analysis identified 168 patients with painful chronic pancreatitis hospitalized during January 2010-January 2015 in a Romanian tertiary referral center. Data on demographics, medical history, alcohol consumption, smoking habit, clinical parameters, type and number of endoscopic procedures and hospital admissions number were collected from the medical charts and analyzed. The absence or substantial reduction of pain(mild pain) at the end of the follow-up associated with the technical success of endotherapy was considered as clinical success. RESULTS Among the 168 patients with painful chronic pancreatitis admitted to our department during the study period, 39(23.21%) had optimal response to the medical therapy. One hundred and twenty-nine patients required endoscopic treatment. The median follow-up period was 15 mo(range, 0-60 mo). Overall, technical success of endotherapy was achieved in 105 patients(81.39%). More than two-thirds of patients(82.78%) had substantial improvement of pain after the endoscopic treatment, including frequency and severity of the pain attacks. Patients younger than 40 years had significantly more successful endoscopic procedures(P = 0.041). Clinical success was higher in non-smoking patients(P = 0.003). The hospital admission rate was higher in patients with recognized alcohol consumption(P = 0.03) and in smokers(P = 0.027). The number and location of pancreatic stones and locations of strictures did not significantly influence the technical success(P 0.05) or the clinical success(P 0.05).CONCLUSION Younger age than 40 years can be considered an important factor positively influencing endoscopic treatment outcome in patients with painful chronic pancreatitis.     

疼痛性慢性胰腺炎死亡风险因素分析

目的 探讨慢性胰腺炎(CP)患者生存率,分析病死原因及病死相关因素.方法 收集1997年至2007年7月首发年龄≥18岁的疼痛性CP患者的资料;寿命表法计算患者累积生存率;建立COX比例风险模型进行逐步回归分析.结果 成功随访346例CP患者(87.2%),男:女=2.4:1,首次住院年龄、首发年龄分别为(47±14)岁和(43±15)岁,随访时间为(34.3±27.1)个月;酒精性CP22.2%,胆源性CP 26.0%;总病死率9.8%(34/346),病死时间为腹痛首发后的(62.5±61.1)个月,病死原因主要为胰腺癌和其他部位癌症;腹痛首发后2、5、10年的CP累积生存率分别为96.3%、93.6%和86.4%.逐步回归分析显示,首发年龄≥51岁、出院后腹痛程度无缓解和腹痛频率增加、未戒烟、无腹泻等因素与病死有关,风险比分别为3.4,3.5、4.2、2.8和17.7.结论 国内CP病死率较国外低,病死原因主要为胰腺癌.对首发年龄大、出院后腹痛程度无缓解和腹痛频率增加、未戒烟及无腹泻CP患者尤应高度警惕.     

Endoscopic treatment of chronic pancreatitis.

Endoscopic therapies, originally utilized for problems in the biliary tree, have been adapted for use in the pancreas. Despite widespread adoption and implementation of these techniques, there are few controlled studies comparing pancreatic endotherapy with either surgery or traditional medical treatment. This review attempts to summarize current endoscopic practice in treating the ductal obstructions and leaks associated with chronic pancreatitis and place these techniques into perspective with respect to alternative management strategies.     

Opioid treatment and hypoalbuminemia are associated with increased hospitalisation rates in chronic pancreatitis outpatients

Background/objectivesChronic pancreatitis (CP) is a complex and debilitating disease with high resource utilisation. Prospective data on hospital admission rates and associated risk factors are scarce. We investigated hospitalisation rates, causes of hospitalisations and associated risk factors in CP outpatients.MethodsThis was a prospective cohort study comprising 170 patients with CP. The primary outcome was time to first pancreatitis related hospitalisation and secondary outcomes were the annual hospitalisation frequency (hospitalisation burden) and causes of hospitalisations. A number of clinical and demographic parameters, including pain pattern and severity, opioid use and parameters related to the nutritional state, were analysed for their association with hospitalisation rates.ResultsOf the 170 patients, 57 (33.5%) were hospitalised during the follow-up period (median 11.4 months [IQR 3.8–26.4]). The cumulative hospitalisation incidence was 7.6% (95% CI; 4.5–12.2) after 30 days and 28.8% (95% CI; 22.2–35.7) after 1 year. Eighteen of the hospitalised patients (32%) had three or more admissions per year. High dose opioid treatment (>100 mg per day) (Hazard Ratio 3.1 [95% CI; 1.1–8.5]; P = 0.03) and hypoalbuminemia (<36 g/l) (Hazard Ratio 3.8 [95% CI; 2.0–7.8]; P < 0.001) were identified as independent risk factors for hospitalisation. The most frequent causes of hospitalisations were pain exacerbation (40%) and common bile duct stenosis (28%).ConclusionsOne-third of CP outpatients account for the majority of hospital admissions and associated risk factors are high dose opioid treatment and hypoalbuminemia. This information should be implemented in outpatient monitoring strategies to identify risk patients and improve treatment.     

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.     

Surgical and interventional treatment of chronic pancreatitis.

The management of patients with chronic pancreatitis (CP) remains a challenging problem. Main indications for surgery are intractable pain, suspicion of malignancy, and involvement of adjacent organs. The main goal of surgical treatment is improvement of patient quality of life. The surgical treatment approach usually involves proximal pancreatic resection, but lateral pancreaticojejunal drainage may be used for large-duct disease. The newer duodenum-preserving head resections of Beger and Frey provide good pain control and preservation of pancreatic function. Thoracoscopic splanchnicectomy and the endoscopic approach await confirmatory trials to confirm their efficiency in the management of CP. Common bile duct obstruction is addressed by distal Roux-en-Y choledochojejunostomy but when combined with dudodenal obstruction must be treated by pancreatic head resection. Pancreatic ascites due to disrupted pancreatic duct should be treated by internal drainage. The approach to CP is multidisciplinary, tailoring the various therapeutic options to meet each individual patient's needs.     

Hypoalgesia to experimental visceral and somatic stimulation in painful chronic pancreatitis

OBJECTIVES: To gain more information of the pain mechanisms in chronic pancreatitis we applied standardized experimental pain stimulation of the duodenum, oesophagus and the skin in 12 healthy controls and 13 patients with chronic pancreatitis and typical pain attacks. METHODS: Using endoscopy a guide wire was positioned into the horizontal part of the duodenum, and a probe with a distal balloon was introduced over the guide wire. Mechanical stimuli were given as tonic (38 ml/min) or phasic (increasing volume steps of 5 ml delivered for 60 s) distensions of the balloon. After stimulation of the duodenum, the distal oesophagus was stimulated with the same protocol. Finally, the skin was stimulated with 'single and repeated burst' electrical stimuli reflecting activation of peripheral and central pain mechanisms. RESULTS: The stimuli reliably evoked both painful and non-painful local and referred sensations. The patients had hyposensitivity to both tonic and phasic mechanical stimuli of the duodenum and the oesophagus (P=0.001). Hypoalgesia was also observed to single and repeated electrical skin stimuli in the patients, most evident for repeated stimuli (P=0.001). The evoked referred pain did not differ between the groups, but the patients used on average more words from the McGill Pain Questionnaire to describe the pain evoked in the duodenum (P=0.02). CONCLUSIONS: Generalized hypoalgesia to experimental visceral and somatic stimulations was found in chronic pancreatitis. The findings suggest that the activation and modulation of central mechanisms is fundamental in pancreatic pain, and future studies should address the effect of analgesics with central effects in the treatment of these patients.     

重视慢性胰腺炎的外科治疗

慢性胰腺炎( chronic pancreatitis,CP)以不可逆的胰腺纤维化、腺体萎缩并进而影响其内外分泌功能为主要病理基础,临床表现有疼痛、体重减轻、内外分泌功能不全等继发症状.由于胰腺纤维化的程度不同,胰腺受累部位及病因各异,致使慢性胰腺炎患者的影像学表现与临床症状有很大差异,治疗方式的选择也较为复杂.     

Interventional treatment of chronic pancreatitis

Endoscopic treatment of chronic pancreatitis is becoming a reality: more and more endoscopy centres are developing the technique, and it is no longer a matter of extreme specialization. Among treatments which have been shown to be feasible, it is possible to distinguish between those approaches that are now considered as efficient with good results and very low risk (e.g. MPD drainage), or are efficient but with risks that seem to be lower than those of surgery (e.g. drainage of cysts), and drainage of the main bile duct, which is easy to perform, but, so far, has not been demonstrated enough as useful.     

Endoscopic treatment of chronic pancreatitis

OBJECTIVES: Endoscopy offers an alternative to surgery for the treatment of ductal complications in patients with chronic pancreatitis. The aim of this study was to evaluate the efficacy of endoscopic treatment on pain, cholestasis and pseudocysts in these patients. PATIENTS AND METHODS: Thirty-nine patients (37 M, 2 F, mean age 44), were included in the study. All patients had at least one of the following criteria demonstrated by imaging tests: dilatation of the main pancreatic duct (MPD) with or without stricture (N = 13), bile duct stricture (N = 12), or pancreatic pseudocyst (N = 14) with pancreatic duct stricture (N = 11) or biliary stricture (N = 3). Pancreatic or biliary sphincterotomy, insertion of pancreatic or biliary stent, pseudocyst drainage with stent placement were performed according to ductal abnormalities. Patients were evaluated early and followed up during the stenting period, and after stent removal. RESULTS: Patients underwent a median of 3.5 endoscopic procedures with an interval of 2.2 months between 2 stenting sessions. A pancreatic or biliary stent was inserted in 25 patients with ductal abnormalities and in 11 patients with pseudocysts. Endoscopic pseudocyst drainage was performed in 6 cases. The mean stenting time was 6 months (range: 3-21). Mean follow-up after stent removal was 9.7 (2-48) months. Complications of endoscopic treatment were encountered in 7% of patients with no deaths. Pain relief was achieved after the first endoscopic procedure and during the overall stenting period in all patients. Recurrence of pain was observed after stent removal in 5/11 patients, requiring surgery in 4. Cholestasis decreased and biochemical values normalized within one month after biliary stenting. Recurrence of cholestasis was observed early after stent removal in 4/9 patients who required complementary surgical treatment. No recurrence of pancreatic pseudocyst was observed after endoscopic drainage and stent removal during the follow-up period. CONCLUSIONS: Endoscopic treatment of pain from pancreatic pseudocysts or ductal strictures is effective in the short-term and in the period of ductal stenting. However, the optimal duration of the latter remains to be determined.     

Surgical treatment of chronic pancreatitis

Debilitating abdominal or back pain remains the most common indication for surgery in patients with chronic pancreatitis. The surgical approach to chronic pancreatitis should be individualized based on pancreatic and ductal anatomy, pain characteristics, baseline exocrine and endocrine function, and medical co‐morbidity. No single approach is ideal for all patients with chronic pancreatitis. Pancreatic ductal drainage with pancreaticojejunostomy targets patients with a dilated pancreatic duct and produces good early postoperative pain relief; however, 30%–50% of patients experience recurrent symptoms at 5 years. Resection for chronic pancreatitis should be considered (1) when the main pancreatic duct is not dilated, (2) when the pancreatic head is enlarged, (3) when there is suspicion of a malignancy, or (4) when previous pancreaticojejunostomy has failed. Re‐sectional strategies include pancreaticoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum‐preserving pancreatic head resection (Beger procedure), or local resection of the pancreatic head with longitudinal pancreaticojejunostomy (Frey procedure). Superior results are obtained when the pancreatic head is resected, either completely (pancreaticoduodenectomy) or partially (Beger or Frey procedure). Although pylorus‐preserving pancreaticoduodenectomy remains the gold standard resection procedure, there is evidence that newer operations, such as the Beger resection, may be as effective in regard to pain relief and better in respect to nutritional repletion and preservation of endocrine and exocrine function.     

Endoscopic treatment of chronic pancreatitis

Treatment of chronic pancreatitis has been exclusively surgical for a long time. Recently, endoscopic therapy has become widely used as a primary therapeutic option. Initially performed for drainage of pancreatic cysts and pseudocysts, endoscopic treatments were adapted to biliary and pancreatic ducts stenosis. Pancreatic sphincterotomy which allows access to pancreatic ducts was firstly reported. Secondly, endoscopic methods of stenting, dilatation, and stones extraction of the bile ducts were applied to pancreatic ducts. Nevertheless, new improvements were necessary： failures of pancreatic stone extraction justified the development of extra-corporeal shock wave lithotripsy; dilatation of pancreatic stenosis was improved by forage with a new device; moreover endosonography allowed guidance for celiac block, gastro-cystostomy, duodeno-cystostomy and pancreatico-gastrostomy. Although endoscopic treatments are more and more frequently accepted, indications are still debated.