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. 1998 Dec;228(6):771–779. doi: 10.1097/00000658-199812000-00008

Extended drainage versus resection in surgery for chronic pancreatitis: a prospective randomized trial comparing the longitudinal pancreaticojejunostomy combined with local pancreatic head excision with the pylorus-preserving pancreatoduodenectomy.

J R Izbicki 1, C Bloechle 1, D C Broering 1, W T Knoefel 1, T Kuechler 1, C E Broelsch 1
PMCID: PMC1191595  PMID: 9860476

Abstract

OBJECTIVE: To analyze the efficacy of extended drainage--that is, longitudinal pancreaticojejunostomy combined with local pancreatic head excision (LPJ-LPHE)-and pylorus-preserving pancreatoduodenectomy (PPPD) in terms of pain relief, control of complications arising from adjacent organs, and quality of life. SUMMARY BACKGROUND DATA: Based on the hypotheses of pain origin (ductal hypertension and perineural inflammatory infiltration), drainage and resection constitute the main principles of surgery for chronic pancreatitis. METHODS: Sixty-one patients were randomly allocated to either LPJ-LPHE (n = 31) or PPPD (n = 30). The interval between symptoms and surgery ranged from 12 months to 10 years (mean 5.1 years). In addition to routine pancreatic diagnostic workup, a multidimensional psychometric quality-of-life questionnaire and a pain score were used. Endocrine and exocrine functions were assessed in terms of oral glucose tolerance and serum concentrations of insulin, C-peptide, and HbA1c, as well as fecal chymotrypsin and pancreolauryl testing. During a median follow-up of 24 months (range 12 to 36), patients were reassessed in the outpatient clinic. RESULTS: One patient died of cardiovascular failure in the LPJ-LPHE group (3.2%); there were no deaths in the PPPD group. Overall, the rate of in-hospital complications was 19.4% in the LPJ-LPHE group and 53.3% in the PPPD group, including delayed gastric emptying in 9 of 30 patients (30%; p < 0.05). Complications of adjacent organs were definitively resolved in 93.5% in the LPJ-LPHE group and in 100% in the PPPD group. The pain score decreased by 94% after LPJ-LPHE and by 95% after PPPD. Global quality of life improved by 71% in the LPJ-LPHE group and by 43% in the PPPD group (p < 0.01). CONCLUSIONS: Both procedures are equally effective in terms of pain relief and definitive control of complications affecting adjacent organs, but extended drainage by LPJ-LPHE provides a better quality of life.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Aaronson N. K., Ahmedzai S., Bergman B., Bullinger M., Cull A., Duez N. J., Filiberti A., Flechtner H., Fleishman S. B., de Haes J. C. The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst. 1993 Mar 3;85(5):365–376. doi: 10.1093/jnci/85.5.365. [DOI] [PubMed] [Google Scholar]
  2. Adams D. B., Ford M. C., Anderson M. C. Outcome after lateral pancreaticojejunostomy for chronic pancreatitis. Ann Surg. 1994 May;219(5):481–489. doi: 10.1097/00000658-199405000-00006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Ammann R. W., Akovbiantz A., Largiader F., Schueler G. Course and outcome of chronic pancreatitis. Longitudinal study of a mixed medical-surgical series of 245 patients. Gastroenterology. 1984 May;86(5 Pt 1):820–828. [PubMed] [Google Scholar]
  4. Axon A. T., Classen M., Cotton P. B., Cremer M., Freeny P. C., Lees W. R. Pancreatography in chronic pancreatitis: international definitions. Gut. 1984 Oct;25(10):1107–1112. doi: 10.1136/gut.25.10.1107. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Barry R. E., Barry R., Ene M. D., Parker G. Fluorescein dilaurate--tubeless test for pancreatic exocrine failure. Lancet. 1982 Oct 2;2(8301):742–744. doi: 10.1016/s0140-6736(82)90924-2. [DOI] [PubMed] [Google Scholar]
  6. Beger H. G., Krautzberger W., Bittner R., Büchler M., Limmer J. Duodenum-preserving resection of the head of the pancreas in patients with severe chronic pancreatitis. Surgery. 1985 Apr;97(4):467–473. [PubMed] [Google Scholar]
  7. Bloechle C., Busch C., Tesch C., Nicolas V., Binmoeller K. F., Soehendra N., Izbicki J. R. Prospective randomized study of drainage and resection on non-occlusive segmental portal hypertension in chronic pancreatitis. Br J Surg. 1997 Apr;84(4):477–482. [PubMed] [Google Scholar]
  8. Bloechle C., Izbicki J. R., Knoefel W. T., Kuechler T., Broelsch C. E. Quality of life in chronic pancreatitis--results after duodenum-preserving resection of the head of the pancreas. Pancreas. 1995 Jul;11(1):77–85. doi: 10.1097/00006676-199507000-00008. [DOI] [PubMed] [Google Scholar]
  9. Bockman D. E., Buchler M., Malfertheiner P., Beger H. G. Analysis of nerves in chronic pancreatitis. Gastroenterology. 1988 Jun;94(6):1459–1469. doi: 10.1016/0016-5085(88)90687-7. [DOI] [PubMed] [Google Scholar]
  10. Braasch J. W., Vito L., Nugent F. W. Total pancreatectomy of end-stage chronic pancreatitis. Ann Surg. 1978 Sep;188(3):317–322. doi: 10.1097/00000658-197809000-00006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Büchler M. W., Baer H. U., Seiler C., Reber P. U., Sadowski C., Friess H. Die duodenumerhaltende Pankreaskopfresektion: ein Standardverfahren bei chronischer Pankreatitis. Chirurg. 1997 Apr;68(4):364–368. doi: 10.1007/s001040050199. [DOI] [PubMed] [Google Scholar]
  12. Büchler M. W., Friess H., Bittner R., Roscher R., Krautzberger W., Müller M. W., Malfertheiner P., Beger H. G. Duodenum-preserving pancreatic head resection: Long-term results. J Gastrointest Surg. 1997 Jan-Feb;1(1):13–19. doi: 10.1007/s11605-006-0004-z. [DOI] [PubMed] [Google Scholar]
  13. Büchler M. W., Friess H., Müller M. W., Wheatley A. M., Beger H. G. Randomized trial of duodenum-preserving pancreatic head resection versus pylorus-preserving Whipple in chronic pancreatitis. Am J Surg. 1995 Jan;169(1):65–70. doi: 10.1016/s0002-9610(99)80111-1. [DOI] [PubMed] [Google Scholar]
  14. Dresler C. M., Fortner J. G., McDermott K., Bajorunas D. R. Metabolic consequences of (regional) total pancreatectomy. Ann Surg. 1991 Aug;214(2):131–140. doi: 10.1097/00000658-199108000-00007. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Ebbehøj N., Svendsen L. B., Madsen P. Pancreatic tissue pressure: techniques and pathophysiological aspects. Scand J Gastroenterol. 1984 Nov;19(8):1066–1068. [PubMed] [Google Scholar]
  16. Frey C. F., Amikura K. Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy in the management of patients with chronic pancreatitis. Ann Surg. 1994 Oct;220(4):492–507. doi: 10.1007/BF02348284. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Frey C. F., Child C. G., Fry W. Pancreatectomy for chronic pancreatitis. Ann Surg. 1976 Oct;184(4):403–413. doi: 10.1097/00000658-197610000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Frey C. F., Pitt H. A., Yeo C. J., Prinz R. A. A plea for uniform reporting of patient outcome in chronic pancreatitis. Arch Surg. 1996 Mar;131(3):233–234. doi: 10.1001/archsurg.1996.01430150011001. [DOI] [PubMed] [Google Scholar]
  19. Frey C. F., Smith G. J. Description and rationale of a new operation for chronic pancreatitis. Pancreas. 1987;2(6):701–707. doi: 10.1097/00006676-198711000-00014. [DOI] [PubMed] [Google Scholar]
  20. Frey C. F., Suzuki M., Isaji S. Treatment of chronic pancreatitis complicated by obstruction of the common bile duct or duodenum. World J Surg. 1990 Jan-Feb;14(1):59–69. doi: 10.1007/BF01670547. [DOI] [PubMed] [Google Scholar]
  21. Greenlee H. B., Prinz R. A., Aranha G. V. Long-term results of side-to-side pancreaticojejunostomy. World J Surg. 1990 Jan-Feb;14(1):70–76. doi: 10.1007/BF01670548. [DOI] [PubMed] [Google Scholar]
  22. Izbicki J. R., Bloechle C. Die Drainageoperation als Therapieprinzip der chirurgischen organerhaltenden Behandlung der chronischen Pankreatitis. Chirurg. 1997 Sep;68(9):865–873. doi: 10.1007/s001040050286. [DOI] [PubMed] [Google Scholar]
  23. Izbicki J. R., Bloechle C., Knoefel W. T., Kuechler T., Binmoeller K. F., Broelsch C. E. Duodenum-preserving resection of the head of the pancreas in chronic pancreatitis. A prospective, randomized trial. Ann Surg. 1995 Apr;221(4):350–358. doi: 10.1097/00000658-199504000-00004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Karanjia N. D., Widdison A. L., Leung F., Alvarez C., Lutrin F. J., Reber H. A. Compartment syndrome in experimental chronic obstructive pancreatitis: effect of decompressing the main pancreatic duct. Br J Surg. 1994 Feb;81(2):259–264. doi: 10.1002/bjs.1800810236. [DOI] [PubMed] [Google Scholar]
  25. Keith R. G., Keshavjee S. H., Kerenyi N. R. Neuropathology of chronic pancreatitis in humans. Can J Surg. 1985 May;28(3):207–211. [PubMed] [Google Scholar]
  26. Klempa I., Spatny M., Menzel J., Baca I., Nustede R., Stöckmann F., Arnold W. Pankreasfunktion und Lebensqualität nach Pankreaskopfresektion bei der chronischen Pankreatitis. Eine prospektive, randomisierte Vergleichsstudie nach duodenumerhaltender Pankreaskopfresektion versus Whipple'scher Operation. Chirurg. 1995 Apr;66(4):350–359. [PubMed] [Google Scholar]
  27. Lankisch P. G., Löhr-Happe A., Otto J., Creutzfeldt W. Natural course in chronic pancreatitis. Pain, exocrine and endocrine pancreatic insufficiency and prognosis of the disease. Digestion. 1993;54(3):148–155. doi: 10.1159/000201029. [DOI] [PubMed] [Google Scholar]
  28. Markowitz J. S., Rattner D. W., Warshaw A. L. Failure of symptomatic relief after pancreaticojejunal decompression for chronic pancreatitis. Strategies for salvage. Arch Surg. 1994 Apr;129(4):374–380. doi: 10.1001/archsurg.1994.01420280044006. [DOI] [PubMed] [Google Scholar]
  29. PARTINGTON P. F., ROCHELLE R. E. Modified Puestow procedure for retrograde drainage of the pancreatic duct. Ann Surg. 1960 Dec;152:1037–1043. doi: 10.1097/00000658-196012000-00015. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Stapleton G. N., Williamson R. C. Proximal pancreatoduodenectomy for chronic pancreatitis. Br J Surg. 1996 Oct;83(10):1433–1440. doi: 10.1002/bjs.1800831035. [DOI] [PubMed] [Google Scholar]
  31. Traverso L. W., Longmire W. P., Jr Preservation of the pylorus in pancreaticoduodenectomy. Surg Gynecol Obstet. 1978 Jun;146(6):959–962. [PubMed] [Google Scholar]
  32. Warshaw A. L. Pain in chronic pancreatitis. Patients, patience, and the impatient surgeon. Gastroenterology. 1984 May;86(5 Pt 1):987–989. [PubMed] [Google Scholar]
  33. Warshaw A. L., Torchiana D. L. Delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy. Surg Gynecol Obstet. 1985 Jan;160(1):1–4. [PubMed] [Google Scholar]
  34. Whipple A. O. Radical Surgery for Certain Cases of Pancreatic Fibrosis associated with Calcareous Deposits. Ann Surg. 1946 Dec;124(6):991–1006. [PMC free article] [PubMed] [Google Scholar]

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