Surgical management of chronic pancreatitis

BACKGROUND: Treatment of chronic pancreatitis (CP) is a challenging condition for surgeons. During the last decades, increasing knowledge about pathophysiology of CP, improved results of major pancreatic resections, and integration of sophisticated diagnostic methods in clinical practice have resulted in significant changes in surgery for CP. DATA SOURCES: To detail the indications for CP surgery, the surgical procedures, and outcome, a Pubmed database search was performed. The abstracts of searched articles about surgical management of CP were reviewed. The articles could be identified and further scrutinized. Further references were extracted by cross-referencing. RESULTS: Main indications of CP for surgery are intractable pain, suspicion of malignancy, and involvement of adjacent organs. The goal of surgical treatment is to improve the quality of life of patients. The surgical approach to CP should be individualized according to pancreatic anatomy, pain characteristics, baseline exocrine and endocrine function, and medical co-morbidity. The approach usually involves pancreatic duct drainage and resection including longitudinal pancreatojejunostomy, pancreatoduodenectomy (Whipple's procedure), pylorus-preserving pancreatoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum- preserving pancreatic head resection (Beger's procedure), and local resection of the pancreatic head with longitudinal pancreatojejunostomy (Frey's procedure). Non-pancreatic and endoscopic management of pain has also been advocated. CONCLUSIONS: Surgical procedures provide long-term pain relief, a good postoperative quality of life withpreservation of endocrine and exocrine pancreatic function, and are associated with low early and late mortality and morbidity. In addition to available results from randomized controlled trials, new studies are needed to determine which procedure is the most effective for the management of patients with CP.     

A comparison of pancreaticoduodenectomy and duodenum-preserving head resection for the treatment of chronic pancreatitis

Background:

For chronic pancreatitis, European prospective trials have concluded that duodenum-preserving head resections (DPHR) are associated with less morbidity and similar pain relief and quality of life (QoL) outcomes compared with pancreaticoduodenectomy (PD). However, DPHR procedures are seldom performed in North America.

Methods:

Patients undergoing PD or DPHR for unremitting pain secondary to chronic pancreatitis were retrospectively identified. Quality of life was assessed cross-sectionally using the European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life Questionnaire (QLQ-C30) and pancreatic cancer-specific supplemental module (QLQ-PAN26).

Results:

Eighty-one patients underwent either a Whipple PD (n= 59) or a DPHR (Bern, Beger or Frey procedure, n= 22) for the treatment of pain caused by chronic pancreatitis over a 5-year period. The characteristics of patients undergoing DPHR and PD procedures were similar. Duration of procedure (360 min vs. 245 min), duration of hospital stay (12.0 days vs. 9.5 days) and estimated blood loss (535 ml vs. 214 ml) were all significantly less for DPHR patients (P < 0.05). Thirty-day morbidity and mortality, postoperative pain relief and QoL scores did not differ significantly between groups.

Conclusions:

Duodenum-preserving head resection is equally as effective as PD in relieving pain and improving QoL in chronic pancreatitis patients, and involves a shorter hospital stay and less blood loss.     

Role of original and modified Frey's procedures in chronic pancreatitis

AIM To retrospectively review patients with chronic pancreatitis(CP) treated with Frey's procedures between January 2009 and January 2014.METHODS A retrospective review was performed of patients with CP treated with Frey's procedures between January 2009 and January 2014 in the Department of Pancreatic Surgery. A cross-sectional study of postoperative pain relief, quality of life(Qo L), and alcohol and nicotine abuse was performed by clinical interview, letters and telephone interview in January 2016. Qo L of patients was evaluated with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire(EORTC QLQ-C30) version 3.0. The patients were requested to fill in the questionnaires by themselves via correspondence or clinical interview.RESULTS A total of 80 patients were enrolled for analysis, including 44 who underwent the original Frey's procedure and 36 who underwent a modified Frey's procedure. The mean age was 46 years in the original group and 48 years in the modified group. Thirtyfive male patients(80%) were in the original group and 33(92%) in the modified group. There were no differences in the operating time, blood loss, and postoperative morbidity and mortality between the two groups. The mean follow-up was 50.3 mo in the original group and 48.7 mo in the modified group. There were no differences in endocrine and exocrine function preservation between the two groups. The original Frey's procedure resulted in significantly betterpain relief, as shown by 5-year follow-up(P = 0.032), better emotional status(P = 0.047) and fewer fatigue symptoms(P = 0.028). When stratifying these patients by the M-ANNHEIM severity index, no impact was found on pain relief after the two types of surgery.CONCLUSION The original Frey's procedure is as safe as the modified procedure, but the former yields better pain relief. The severity of CP does not affect postoperative pain relief.     

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

Background/objectivesChronic 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.MethodsAn 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.ResultsStrong 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.ConclusionsThis 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.     

Pain severity reduces life quality in chronic pancreatitis: Implications for design of future outcome trials

Background/objectivesChronic pancreatitis (CP) is a disabling disease characterised by abdominal pain, and various pancreatic and extra-pancreatic complications. We investigated the interactions between pain characteristics (i.e. pain severity and its pattern in time), complications, and quality of life (QOL) in patients with CP.MethodsThis was a cross-sectional study of 106 patients with CP conducted at two North European tertiary medical centres. Detailed information on clinical patient characteristics was obtained from interviews and through review of the individual patient records. Pain severity scores and pain pattern time profiles were extracted from the modified brief pain inventory short form and correlated to QOL as assessed by the EORTC QLQ-C30 questionnaire. Interactions with exocrine and endocrine pancreatic insufficiency, as well as pancreatic and extra-pancreatic complications were analysed using regression models.ResultsPain was the most prominent symptom in our cohort and its severity was significantly correlated with EORTC global health status (r = −0.46; P < 0.001) and most functional and symptom subscales. In contrast the patterns of pain in time were not associated with any of the life quality subscales. When controlling for interactions from exocrine and endocrine pancreatic insufficiency no effect modifications were evident (P = 0.72 and P = 0.85 respectively), while the presence of pancreatic and extra-pancreatic complications was associated with an almost 15% decrease in life quality (P = 0.004).ConclusionsPain severity and disease related complications significantly reduce life quality in patients with CP. This information is important in order to design more accurate and clinical meaningful endpoints in future outcome trials.     

Which is a Less Invasive Pancreatic Head Resection: PD, PPPD, or DPPHR?

Less invasive pancreatic head resection, such as pylorus preserving pancreatoduodenectomy (PPPD) and duodenum preserving pancreatic head resection (DPPHR) has been introduced for the treatment of pancreatoduodenal lesions, especially for benign conditions, in consideration of postoperative quality of life. Surgical stress and exocrine and endocrine function of the residual pancreas were examined in 44 patients with PPPD, 10 with conventional pancreatoduodenectomy (PD) and six with DPPHR. Clinical findings including serum levels of C reactive protein (CRP), fasting blood sugar, a 120-min value of the 75-g oral glucose tolerance test (OGTT), N-benzol-l-tyrosyl-p-aminobenzoic acid (BT-PABA) excretion value (a pancreatic exocrine function test), and volume of postoperative pancreatic juice drainage were compared among the three different variants of pancreatectomy. Operation time and operative blood loss in PD were largest of the three, followed by PPPD and DPPHR. Postoperative elevation of serum CRP on postoperative day (POD) 2 or 3 was similar among the three different types of operation. Fasting blood sugar concentrations were not different among the three groups at short- and long-term after the operation, while the 120-min value of the GTT showed a marked elevation at long-term only after PPPD. The volume of pancreatic juice drainage increased up to POD 4 and became constant thereafter. The total amount of pancreatic juice drainage from POD 4 to 13 was smallest in PD (637 ml) followed by PPPD (1255 ml) and DPPHR (1431 ml). The BT-PABA value declined after PD (–20.3%, P = 0.0437) and PPPD (–20.2%, P = 0.0239) at short term, but not after DPPHR (8.2%). These findings suggest that the early impairment of the pancreatic exocrine function after PD and PPPD but not after DPPHR may indicate that the invasiveness of pancreatic head resection to the pancreatic functions is greater in PD and PPPD than in DPPHR.     

Pylorus-preserving pancreaticoduodenectomy with combined resection of the portal vein and gastrointestinal reconstruction by imanaga procedure for ductal cancer of the head of the pancreas

Twenty-six patients who underwent pyloruspreserving pancreaticoduodenectomy (PPPD) for ductal cancer of the head of the pancreas between 1983 and 1993 were reviewed. Gastrointestinal continuity was restored by the methods of Imanaga (n=21) and Traverso (n=5). Combined resection of the portal vein and/or superior mesenteric vein was performed in 13 patients. Surgical complications occurred in 5 patients, but there were no postoperative deaths. Delayed gastric emptying was observed in 42% of patients. The median survival time for all 26 patients was 13 months. Three patients survived for more than 3 years, and one of them is currently alive without recurrence at 10 years. Differences in survival rates were not apparent between patients who underwent PPPD with and without portal vein resection. Survival rate after PPPD was compared with that after pancreaticoduodenectomy (PD) performed between 1974 and 1992; the difference was not significant. Patients who underwent noncurative PPPD had a significantly better survival rate than those who underwent noncurative PD (P<0.05). PPPD has improved the quality of life of the resected patients, without reducing survival rate. At present, PPPD by the Imanaga procedure could be the best choice for management of cancer of the pancreatic head.     

Proximal pancreatectomy in the surgical management of chronic pancreatitis.

During the past three decades, important advances in our understanding of the pathophysiology of chronic pancreatitis (CP), improved results of major pancreatic resections (including pancreatoduodenectomy), and integration of sophisticated diagnostic methods in clinical practice resulted in significant changes in our surgical approach to CP. Proximal pancreatectomy (including the pancreatoduodenectomy and the newer duodenum-preserving and common bile duct-preserving Beger and Frey procedures) achieved good results concerning pain relief (>80%) and quality of life in selected patients with head-dominant CP. Beger and Frey procedures were associated with lower early and late mortality and morbidity. However, when there is strong suspicion of an underlying malignancy, a pancreatoduodenectomy should be considered in surgically fit patients, as this is an adequate procedure for both CP and pancreatic cancer.     

Symptoms and quality of life in chronic pancreatitis assessed by structured interview and the EORTC QLQ-C30 and QLQ-PAN26

BACKGROUND AND AIMS: Chronic pancreatitis (CP) produces disabling symptoms and requires major clinical interventions over a number of years. There is consensus that quality-of-life (QoL) assessment should be part of assessing the treatment and outcome of CP. These symptoms and treatments resemble those of pancreatic cancer, for which there are validated QoL assessment instruments. The aim of our study was to assess the appropriateness of using the EORTC QoL assessment system for pancreatic cancer (the EORTC QLQ-C30 and QLQ-PAN26) for patients with CP, and to document important issues that affect QoL in these patients. METHODS: A structured literature review was undertaken to determine current approaches to QoL in pancreatic disease. Sixty-six patients with newly diagnosed or treated CP were asked to complete the EORTC QLQ-C30 and QLQ-PAN26 in four countries (Germany, Italy, South Africa, and United Kingdom). Patients were asked to review the appropriateness of the content and structure of the instruments, during a directed interview. Standard psychometric tests were used to assess the reliability and validity of the instruments. Peer review was undertaken to review findings and adapt the QLQ-PAN26 on the basis of the responses obtained. RESULTS: The literature review highlighted the potential value of the EORTC QLQ-C30 and identified the lack of a CP-specific instrument, which had been appropriately developed. There was overwhelming consensus among experts that the EORTC assessment system appeared suitable for use in CP patients. This was endorsed by all patients. Patients identified additional issues related to guilt about the use of alcohol and the burden of trying to abstain. All but one scale (jaundice) exhibited adequate internal consistency (r > 0.70) Construct validity of the QLQ-C30 and QLQ-PAN26 showed strong associations between conceptually related scales (r > 0.6, p < 0.001) and significantly discriminated between patients on the basis of performance status and requirement for opiate analgesia. Significant issues affecting QoL in CP patients, in addition to recognized symptoms of the disease, were fear of future health problems, difficulty sleeping, and fatigue. CONCLUSION: The EORTC QLQ-C30 and QLQ-PAN26 appear to be an appropriate assessment system for CP, with the addition of items to cover guilt about alcohol consumption, and the burden of abstention. Patients' QoL is adversely affected by the fear of future health problems, difficulty sleeping, and fatigue.     

Surgical management of pancreatic cancer]

Pancreatic cancer is a major problematic concern among all forms of gastrointestinal malignancies because of its poor prognosis. Although significant progress has been made in the surgical treatment in terms of increased resection rate and decreased treatment-related morbidity and mortality, the true survival rate still remains below 5% today. Surgical options for pancreatic cancer are based on the its unique anatomy and physiology, catastrophic tumor biology, experience of surgeon, and status of patients. Four main options exist for the surgical treatment of pancreatic cancer. These include standard "Whipple" pancreaticoduodenectomy (PD), pylorus preserving PD (PPPD), distal pancreatectomy (left-side pancreatectomy), and total pancreatectomy according to the location of tumor. Portal vein involvement by tumor is regarded as an anatomical extension of disease, and en bloc resection of portal vein with tumor is recommended if technically feasible, which is stated in 2002 AJCC tumor staging for pancreatic cancer. In comparison of the survival rates between standard and extended resection of pancreatic head cancer, no significant survival benefit was demonstrated from the prospective reports. PPPD may be superior to standard PD in respect to nutrition and quality of life without any deleterious effect upon long term survival or tumor recurrence. New surgical treatment modalities including modified extended pancreatectomy, neoadjuvant chemotherapy, and radical antegrade modular distal pancreatectomy have been tried to improve the patients' survival. However, early diagnosis and treatment remain as key factors for the cure of pancreatic cancer irrespective of various surgical trials.     

The natural history of pain in alcoholic chronic pancreatitis

BACKGROUND & AIMS: The pain pattern of chronic pancreatitis (CP) and its surgical implications are discussed. The aim of this study was to (1) define typical pain patterns, (2) correlate pain patterns with the presumptive causes of the pain, and (3) compare the natural history of patients treated conservatively or surgically with respect to pain relief, pancreatic dysfunction, and clinical outcome. METHODS: A cohort in this prospective long-term study included 207 patients with alcoholic CP (91 without and 116 with surgery for pain relief). A clinically based staging system was applied to characterize pain in the evolution from onset to end-stage CP. RESULTS: Average duration of CP was 17 years. In early-stage CP, episodes of recurrent (acute) pancreatitis predominated. Chronic pain was typically associated with local complications (mainly pseudocysts, 84 of 155; 54%), relieved definitely by a single (drainage) procedure in approximately two thirds of patients. Additional surgery was required for late pain recurrence in 39 patients (34%), primarily symptomatic cholestasis (18 of 39; 46%). All patients achieved complete pain relief in advanced CP. CONCLUSIONS: In our experience, relief of chronic pain regularly follows selective surgery tailored to the presumptive pain cause or occurs spontaneously in uncomplicated advanced CP.     

Prognosis and feasibility of en-bloc vascular resection in stage Ⅱ pancreatic adenocarcinoma

AIM:To establish the prognosis and feasibility of en-bloc vascular resection of stage pancreatic adenocarcinoma of the head and uncinate process.METHODS:We retrospectively analyzed 87 patients with stage pancreatic adenocarcinoma,who were subjected to pancreaticoduodenectomy (PD) and pylo-rus-preserving PD (PPPD) between 1996 and 2006 in Chang Gung Memorial Hospital,Taiwan. Twelve and 75 patients underwent PD/PPPD with and without resection of portal vein/superior mesenteric vein (PV/SMV),respectively.RESUL...     

Limited pancreatectomy: significance of postoperative maintenance of pancreatic exocrine function

This study attempted to clarify whether limited pancreatectomy (duodenum-preserving total pancreatic head resection [DPTPHR], or medial pancreatectomy [MP], maintain pancreatic exocrine function more than conventional pancreaticoduodenectomy (Whipple) or pylorus-preserving pancreaticoduodenectomy (PPPD). A total of 125 patients (18 with Whipple, 71 with PPPD, 13 with DPTPHR, and 23 with MP) were studied. Fecal chymotrypsin and p-type amylase, and pancreatic function diagnostant (PFD) tests were used for evaluation. There were no differences in preoperative background. Pancreatic function was seen to be significantly lower after surgery than before surgery in patients who underwent the Whipple procedure and PPPD (P < 0.05), but there was no difference between pre- and postoperative pancreatic function in patients who underwent DPTPHR and MP. Postoperative pancreatic function was shown to be significantly worse in Whipple procedure and PPPD patients than in those with DPTPHR and MP (P < 0.05). Patients who underwent the Whipple procedure and PPPD showed significantly lower pancreatic function than patients who underwent DPTPHR and MP (P < 0.05). There was no difference in pancreatic function between patients who underwent DPTPHR and those with MP. DPTPHR and MP, both of which preserve the entire duodenum, maintain pancreatic function more than the Whipple procedure and PPPD.     

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.     

Appraisal of the Imaizumi modification of the Beger procedure: the TWMU experience

Background/purpose

We developed the Imaizumi modification of the Beger procedure, a duodenum-preserving pancreatic head resection. The Imaizumi modification allows for removal of more of the subtotal pancreatic head than in the conventional Beger procedure, including the intrapancreatic bile duct, for chronic pancreatitis with common bile duct stenosis. A retrospective study was performed to evaluate the efficacy of the Imaizumi modification compared to a pylorus-preserving pancreaticoduodenectomy (PPPD), based on the early and late postoperative results.

Methods

A group of 14 patients who underwent the Beger procedure with the Imaizumi modification to treat chronic pancreatitis from November 1997 to December 2005 was investigated retrospectively. This group was compared to a group of 21 patients who underwent PPPD from November 1997 to December 2003. The median follow-up period was 3.6 years (range 3.1–5.7 years) for the Imaizumi modification group and 4.0 years (range 3.0–8.3 years) for the PPPD group.

Results

A pancreatic fistula formed in 7% of the Imaizumi modification patients (PPPD 5%), pain relief was achieved in 92% (PPPD 94%), complete professional rehabilitation was achieved in 71% (PPPD 67%), insulin-dependent diabetes mellitus was present in 43 versus 36% before the procedure (PPPD 62 versus 38% before the procedure), and body weight improved in 79% (PPPD 48%). No significant differences were found between the two groups for the early postoperative complications and the late postoperative outcome 3 years after the procedure. However, the Imaizumi modification group exhibited an encouraging tendency to have a lower rate of new-onset exocrine and endocrine insufficiency than the PPPD group.

Conclusions

Our Imaizumi modification of the Beger procedure, including intrapancreatic bile duct resection, represents a useful alternative for the treatment of chronic pancreatitis with an inflammatory mass and bile duct stenosis in the pancreatic head.     

Prognosis and feasibility of en-bloc vascular resection in stage II pancreatic adenocarcinoma

AIM: To establish the prognosis and feasibility of en-bloc vascular resection of stage n pancreatic adenocarcinoma of the head and uncinate process.METHODS: We retrospectively analyzed 87 patients with stage Ⅱ pancreatic adenocarcinoma, who were subjected to pancreaticoduodenectomy (PD) and pylorus-preserving PD (PPPD) between 1996 and 2006 in Chang Gung Memorial Hospital, Taiwan. Twelve and 75 patients underwent PD/PPPD with and without resection of portal vein/superior mesenteric vein (PV/SMV), respectively.RESULTS: The overall 1- and 3-year survival rates of patients undergoing PD/PPPD with and without vascular resection were 50.0% and 16.7%, and 44.4% and 12.2%, respectively. Morbidity and mortality rates in the PV/SMV resection vs non-resection group were 50.0% and 0.0%, and 40.0% and 2.7%, respectively. In multivariate analysis, serum bilirubin, histologicaldifferentiation and adjuvant chemotherapy were independent prognostic factors that influenced survival.CONCLUSION: In stage Ⅱ adenocarcinoma of the pancreatic head and uncinate process, serum bilirubin, histological differentiation and adjuvant chemotherapy were independent prognostic factors, and en-bloc vascular resection is a feasible option in carefully selected patients.     

Long-term results after surgery for chronic pancreatitis.

AIM: To determine the early and late morbidity and mortality after surgical treatment of chronic pancreatitis. METHODS: We determined long-term outcome and early and late morbidity and mortality, respectively, in 484 consecutive patients undergoing surgery for chronic pancreatitis from 1976 through 1997. Sixty-five percent of the patients had small duct disease (main pancreatic duct <7 mm), whereas 35% had large duct disease. Indications for operation were pain (95%), suspicion of malignancy (28%), and complications involving adjacent organs (35%). Pseudocysts were present in 27% of patients. Hospital morbidity (8 vs 23%, p = 0.0002) and mortality (0 vs 1.9%, p = 0.12) were less after drainage procedures (n = 162) than after pancreatic resections (n = 286). Among resectional procedures, total pancreatectomy had the highest 30-d operative mortality (5%) and morbidity rates (47%), followed by pancreatoduodenectomy (3 and 32%, respectively). The best results with pain relief occurred after proximal pancreatic resection (89% after mean follow-up of 6.5 yr). The number of patients able to function normally after surgical treatment increased from 39 to 79% (p < 0.001). Long-term survival of our patients was lower than expected rates based on Minnesota life tables analysis (p < 0.0001) especially in alcoholics. Patients undergoing a ductal drainage procedure had the longest survival, whereas those after total pancreatectomy had the shortest survival (p = 0.06). Pancreatic insufficiency, peptic ulcer, and/or anastomotic ulcers caused significant morbidity after total pancreatectomy and pancreatoduodenectomy. A small percentage (3%) developed pancreatic cancer. CONCLUSIONS: Operative treatment of chronic pancreatitis, when indicated, can be performed safely with good results in terms of pain relief and quality of life. Resectional procedures (especially total pancreatectomy) are associated with higher early and late morbidity, greater perioperative mortality, and lower survival rates compared with drainage procedures. Abstinence from alcohol is associated with longer survival rates, which, however, still remain lower than expected rates.     

Surgical strategies for chronic pancreatitis in a 1,327- patient Scandinavian Baltic pancreatic Club (SBPC) register

BackgroundChronic pancreatitis (CP) may cause intermittent or continuous pain and complications requiring invasive interventions. No specific recommendations for surgical interventions have been presented. Our aim was to determine the surgical treatment strategies for the treatment of CP in the Scandinavian and Baltic countries.MethodsThis multi-centre cross sectional study included 1327 CP patients from eight centres. The data was gathered from the Scandinavian Baltic Pancreatic Club (SBPC) database. Patients who underwent pancreatic surgery were analysed. The baseline CP population from the eight centres was used as a reference. The information registered included comorbidities, pancreatic function, previous interventions, time and type of surgery and the EORTC-30 quality of life (QOL) questionnaire.ResultsOverall, 95/1327 (7%) patients underwent pancreatic surgery. Fifty-one (54%) of these underwent pancreatic surgery for chronic pain (PSCP) and formed the final study group. Median follow-up time was two (range 0–8) years after surgery and seven (1–46) years after diagnosis. The most common surgical procedures were pancreatic resection combined with drainage (54%) followed by pancreatic resections (32%) and drainage procedures (14%). Postoperatively, 47% of the patients were pain free with or without pain medication while 16% had chronic pain episodes, this did not differ from the base CP population. In QOL questionnaires, PSCP patients reported the same QOL but worse social functioning and more symptoms compared to the CP population.ConclusionsPancreatic surgery for CP is rare: surgical procedures were performed on only 7% of the CP patients in the SBPC database. In half of the patients the indication was pain. Most of these patients underwent endoscopic procedures before surgery. Half of the patients reported being pain-free after surgery.     

The impact of pylorus-preserving pancreatoduodenectomy on surgical treatment for cancer of the pancreatic head

Pylorus‐preserving pancreatoduodenectomy (PPPD) was reintroduced in 1978. This pylorus‐preserving modification was designed to minimize complications related to gastric resection, such as early satiety, marginal ulceration, and bile reflux gastritis, as well as diarrhea and dumping. Since 1978, PPPD has been performed preferentially for benign and malignant diseases of the periampullary region and pancreatic head. Some groups have argued against PPPD for cancer of the pancreatic head, because the pylorus‐preserving procedure is likely to compromise the field of resection and does not allow lymph node dissection of the peripyloric and perigastric groups. However, comparative survival rates after PPPD have been the same as, or better than, those with classic pancreatoduodenectomy, showing the rationale for PPPD as a radical resection procedure for cancer of the pancreatic head. PPPD can be performed with low mortality. Delayed gastric emptying, which is the most common complication in the immediate postoperative period after PPPD, is always transient. Many investigators have shown that body weight and the majority of nutritional parameters are better than after PD. PPPD does not appear to cause any negative outcomes. We conclude that PPPD is the surgical procedure of choice for cancer of the head of the pancreas.     

Clinical,Emotional and Social Factors Associated with Quality of Life in Chronic Pancreatitis

Background: In chronic pancreatitis (CP), a debilitating, progressive and incurable disease, patients' wellbeing is considerably impaired, butthedifferentfactorsaffecting quality of life (QoL), have not been identified yet. Methods: 69 patients with CP were evaluated (M/F 55/14; mean age 46.6 ± 10.05 years). Different degrees of pancreatic damage were defined using the Cambridge classification; pain intensity and frequency were assessed using pain index. QoL was measured using EORTC QLQ-C30 and the PAN26 questionnaire. Although developed for pancreatic cancer, the C30/PAN26 has been validated for chronic pancreatitis. Results: Digestive symptoms, financial difficulties, fear of future health and general pain scales showed considerable effects of CP on QoL. We observed significant negative correlation between mean QoL scores and pain index in almost all domains (p< 0.001, p<0.05). Pain intensity affects QoL scales more often than pain frequency. BMI correlated positively with QoL in global health status, altered bowel habits, body image and satisfaction with health care domains (p<0.01, p<0.05). Conclusion: Pain index, BMI, Cambridge classification and disease duration are the most important factors adversely affecting QoL in CP. Measurement of QoL is essential in the disease management and improves the knowledge of psychosocial functioning of these patients.