Abstract
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.
Keywords: chronic pancreatitis, duodenum-preserving head resection, pancreaticoduodenectomy
Introduction
Chronic pancreatitis is a potentially debilitating disease characterized by recurrent abdominal pain, which leads to an altered quality of life (QoL). Patients with chronic pancreatitis eventually develop exocrine and endocrine insufficiency. Medical management may temporize pain syndromes and improve digestion and nutrition. Unfortunately, a subset of patients eventually require surgical intervention for unremitting abdominal pain. Successful surgical intervention can improve patients' QoL by reducing narcotic dependence and frequent hospitalizations, both of which can limit patients' functional status.
The exact mechanism by which chronic pancreatitis induces pain is not known. However, surgical strategies have focused on the resection of diseased tissue and drainage of the pancreatic duct. Traditionally, in North American centres, the pancreaticoduodenectomy (PD) has been performed for head-predominant chronic pancreatitis, resulting in improved pain control and QoL for many patients.1 In the past several decades, duodenum-preserving head resections (DPHR), first described by Beger and colleagues over 20 years ago, have gained popularity in Europe as an alternative surgical approach to chronic pancreatitis.2 Theoretically, this resection, which is limited to the diseased organ alone, should provide a similar degree of pain relief and less morbidity than PD. This theory has been validated in prospective randomized trials: DPHR operations have achieved superior pain control and improved QoL compared with standard PD procedures and are associated with decreased perioperative morbidity.3–5
Despite this evidence, DPHR procedures have not yet gained widespread popularity in North America, probably as a result of North American surgeons' ongoing familiarity with the PD operation. This study retrospectively evaluated the surgical treatment of chronic pancreatitis at one North American centre and compared traditional PD with DPHR in terms of postoperative morbidity, endocrine and exocrine function, and pain control outcomes. Additionally, the European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire and pancreatic cancer module, both modified to better assess chronic pancreatitis, were utilized to compare QoL outcomes between patients undergoing the two types of operation.
Materials and methods
Treatment algorithm
Patients with chronic pancreatitis are treated by a multidisciplinary pancreas team at our centre. Those with head-predominant disease with debilitating abdominal pain despite maximal medical therapy are discussed as candidates for surgery on a case-by-case basis.
During the early years of the study period (1999–2003), PD operations were performed exclusively for head-predominant chronic pancreatitis. From mid-2003, DPHR operations were preferentially performed. The choice of DPHR operation (Beger, Frey or Bern procedure) was based upon the anatomic characteristics of the patient's disease, such as the length and degree of pancreatic duct stenosis and degree of fibrosis of pancreatic parenchyma, and surgeon preference. Exceptions to this algorithm were patients with bile duct stenosis or portal vein obstruction, who underwent PD. Our technique for performing a PD has been previously described.6 Duodenum-sparing resections of the pancreatic head were performed in a similar fashion to that described earlier.2,7–9 Briefly, the Beger procedure consists of complete resection of the pancreatic head, sparing a rim of tissue adjacent to the duodenum, and the completion of two pancreaticojejunostomy anastamoses. The Frey procedure performed at our institution consists of a coring out of the pancreatic head and lateral pancreatic ductotomy, followed by a single pancreaticojejunostomy. The Bern procedure is identical to the Frey operation, but excludes the lateral pancreatic ductotomy.
Data collection and statistical analysis
Institutional review board (IRB) approval was obtained for this study. Our database was queried to identify patients who had undergone PD or DPHR at the University of Cincinnati Medical Center between September 1999 and August 2006 for the treatment of chronic pancreatitis. Patients whose primary indication for surgery was unremitting abdominal pain despite maximal medical therapy were included in the study.
Patient charts were reviewed to obtain the following data: basic patient characteristics; anatomic characteristics of disease; operative time; estimated blood loss; length of hospital stay; morbidity, and mortality. Delayed gastric emptying and pancreatic leak or fistula were identified using recently described clinical parameters.10,11 Re-operation excluded percutaneous intervention.
Information on QoL was collected by mailed patient questionnaires. As per IRB protocol, patients were promised confidentiality and continuity of current medical care regardless of participation. The EORTC QoL questionnaire (QLQ-C30, Version 3.0) and pancreatic cancer module (QLQ-PAN26) were used in their entirety by permission to create the questionnaire.12 This module has been previously validated for patients with chronic pancreatitis.13 Yes/no questions concerning current narcotic, pancreatic enzyme and insulin usage were also included. Questionnaires were scored by a previously validated procedure.14
sas Version 8.1 was used for statistical analysis (SAS Institute, Inc., Cary, NC, USA). Student's t-test analysis was used to determine significance between operative groups for the following variables: patient age; length of symptoms; length of procedure; estimated blood loss; follow-up time, and for QLQ-C30 and PAN26 items. Fisher's exact test was used to determine significance between operative groups for the following variables: gender; pre- and postoperative medication usage; 30-day morbidity and mortality, and re-operation. Statistical differences in length of stay were analysed using the Wilcoxon two-sample test, and differences in aetiology were determined by chi-square analysis.
Results
Between September 1999 and August 2006, 81 patients underwent pancreatic head resection for chronic pancreatitis. These patients were divided into two groups: 59 underwent a formal pancreaticoduodenectomy (PD group) and the remaining 22 underwent duodenal-sparing head resections (seven Bern, five Beger, 10 Frey procedures; DPHR group). Mean follow-up time was 47 months (range 4–87 months) in the PD group and 14 months (range 5–39 months) in the DPHR group (P < 0.01), reflecting a recent change in our management algorithm for head-predominant chronic pancreatitis.
There were no significant differences between operative groups with respect to age, gender, duration of symptoms, preoperative medication usage, aetiology or preoperatively determined anatomic characteristics, as demonstrated by statistical analysis (Table 1).
Table 1.
Characteristics of study population
| PD group (n= 59) | DPHR group (n= 22) | P-value | |
|---|---|---|---|
| Age, years, mean ± SD | 46.8 ± 11.1 | 44.9 ± 11.1 | NS |
| Gender, male/female | 26/33 | 8/14 | NS |
| History of symptoms, years, mean ± SD | 5.4 ± 6.2a | 6.1 ± 6.1a | NS |
| Preoperative medications, n (% of patients) | |||
| Narcotics | 50 (84%) | 18 (82%) | NS |
| Pancreatic enzymes | 27 (45%) | 8 (36%) | NS |
| Insulin | 4 (7%) | 2 (9%) | NS |
| Aetiology, n (% of patients) | |||
| Ethanol | 26 (44%) | 8 (36%) | NS |
| Idiopathic | 23 (39%) | 8 (36%) | NS |
| Pancreas divisum | 7 (12%) | 5 (23%) | NS |
| Biliary | 3 (5%) | 3 (14%) | NS |
| Anatomic characteristics, n (% of patients) | |||
| Pancreatic duct stenosis | 41 (69%) | 17 (77%) | – |
| Bile duct stenosis | 21 (36%) | 5 (23%) | – |
| Preoperative stent | 15 (25%) | 4 (17%) | – |
| Jaundice | 2 (3%) | 0 (0%) | – |
| Pseudocyst | 9 (15%) | 5 (23%) | – |
| Pancreatic head mass | 4 (7%) | 1 (5%) | – |
| Portal vein thrombosis | 0 (0%) | 0 (0%) | – |
n= 36 in PD group, n= 18 in DPHR group
PD, pancreaticoduodenectomy; DPHR, duodenum-preserving head resection; SD, standard deviation; NS, non-significant
Analysis of operative data revealed higher estimated blood loss (535 ml vs. 214 ml; P < 0.01) and longer procedure time (360 min vs. 246 min; P < 0.01) in the PD group compared with DPHR patients. Duration of stay was also longer for PD patients (12.0 days vs. 9.5 days; P < 0.05). Thirty-day mortality, morbidity and re-operation rates did not differ significantly between the PD and DPHR groups (2/59 patients [3%] vs. 0/22 patients [0%]; 26/59 patients [44%] vs. 12/22 patients [55%]; 1/59 patients [2%] vs. 2/22 patients [9%]). Rates of occurrence of the most common morbidities (delayed gastric emptying, wound infection and pancreatic leak) also did not differ between the PD and DPHR groups (Table 2).
Table 2.
Operative characteristics and postoperative course
| PD group (n= 59) | DPHR group (n= 22) | P-value | |
|---|---|---|---|
| Duration of procedure, min, mean ± SD | 360 ± 119a | 246 ± 72a | P < 0.01 |
| Estimated blood loss, ml, mean ± SD | 535 ± 544 | 214 ± 327 | P < 0.01 |
| Duration of stay, days, median (range) | 12.0 (9.8–14.2) | 9.5 (3.3–15.7) | P < 0.05 |
| 30-day mortality, n (% of patients) | 2 (3%) | 0 (0%) | NS |
| 30-day morbidity, n (% of patients) | 26 (44%) | 12 (55%) | NS |
| Delayed gastric emptying | 9 (15%) | 1 (5%) | NS |
| Wound infection/dehiscence | 6 (10%) | 5 (23%) | NS |
| Pancreatic leak/fistula | 4 (7%) | 3 (14%) | NS |
| 30-day re-operation, n (% of patients) | 1 (2%) | 2 (9%) | NS |
n= 58 in PD group, n= 20 in DPHR group
PD, pancreaticoduodenectomy; DPHR, duodenum-preserving head resection; SD, standard deviation; NS, non-significant
Overall, 39 patients (48% of total) returned questionnaires, including 27 in the PD group (46%) and 12 in the DPHR group (55%). Six patients (7%) were lost to follow-up and another six (7%) were confirmed dead. Of note, two patients in the PD group and one in the DPHR group did not complete the questions regarding medication use.
No significant differences in postoperative medication use were found between the groups. In the PD group, nine of 25 (36%) patients required insulin, compared with two of 11 (18%) patients in the DPHR group (P= NS). Similar rates of pancreatic enzyme and narcotic use were found between the PD and DPHR groups (18/25 patients [73%] vs. 9/11 patients [82%], P= NS; 16/25 patients [65%] vs. 6/11 patients [55%], P= NS) (Table 3).
Table 3.
Comparison of postoperative medications
| PD group (n= 25) | DPHR group (n= 11) | P-value | |
|---|---|---|---|
| Insulin, n (% of patients) | 9 (36%) | 2 (18%) | NS |
| Pancreatic enzymes, n (% of patients) | 18 (73%) | 9 (82%) | NS |
| Narcotics, n (% of patients) | 16 (65%) | 6 (55%) | NS |
| Follow-up time, months | 47 ± 20a | 14 ± 8a | P < 0.01 |
n= 59 in PD group, n= 22 in DPHR group
PD, pancreaticoduodenectomy; DPHR, duodenum-preserving head resections; NS, non-significant
Responses to the QLQ-C30 and QLQ-PAN26 questions were grouped into the pre-defined six functional scales (including global QoL) and 26 symptom scales (including 16 single items). Student's t-test comparing mean values for the operative groups revealed statistically significant differences on only two symptom scales. For both, higher symptomatology was seen in the PD group compared with the DPHR group (diarrhoea: 50.0 vs. 23.2, P < 0.05; dry mouth: 40.7 vs. 18.2, P < 0.05). Although not significant, higher symptomatology was observed in the PD group on 23 of 24 additional symptom scales, and lower QoL was observed in the PD group on five of six functional scales (Table 4).
Table 4.
Postoperative quality of life assessment
| PD group (n= 27) | DPHR group (n= 12) | P-value | |
|---|---|---|---|
| Functional Scales, mean ± SD | |||
| Physical status | 67.5 ± 32.3 | 67.2 ± 34.4 | NS |
| Working ability | 50.6 ± 41.2 | 56.9 ± 41.1 | NS |
| Cognitive functioning | 56.8 ± 32.1 | 68.1 ± 38.6 | NS |
| Emotional functioning | 48.4 ± 32.6 | 62.5 ± 26.7 | NS |
| Social functioning | 50.6 ± 36.5 | 54.2 ± 40.3 | NS |
| Global quality of life | 48.8 ± 29.3 | 52.8 ± 30.8 | NS |
| Symptom Scales, mean ± SD | |||
| Fatigue | 56.8 ± 31.2 | 48.1 ± 36.5 | NS |
| Nausea and vomiting | 43.8 ± 36.7 | 27.8 ± 41.6 | NS |
| Pain | 56.8 ± 38.5 | 54.2 ± 34.2 | NS |
| Dyspnoea | 32.0 ± 37.9 | 22.2 ± 32.8 | NS |
| Insomnia | 58.7 ± 40.0 | 52.8 ± 43.7 | NS |
| Appetite loss | 51.3 ± 39.1 | 33.3 ± 37.6 | NS |
| Constipation | 24.7 ± 32.8 | 16.7 ± 30.2 | NS |
| Diarrhoea | 50.0 ± 36.8 | 23.2 ± 32.8 | P < 0.05 |
| Financial difficulties | 59.3 ± 36.2 | 52.8 ± 43.7 | NS |
| Pancreas-specific pain | 54.0 ± 28.6 | 43.7 ± 31.6 | NS |
| Diet restriction | 62.8 ± 38.3 | 51.4 ± 37.2 | NS |
| Jaundice and pruritus | 16.7 ± 22.2 | 15.2 ± 13.9 | NS |
| Steatorrhoea | 56.2 ± 33.7 | 37.9 ± 32.6 | NS |
| Poor body image | 56.8 ± 44.2 | 34.8 ± 32.9 | NS |
| Sexual dysfunction | 66.0 ± 36.5 | 55.6 ± 40.8 | NS |
| Dissatisfaction with care | 64.1 ± 32.6 | 63.3 ± 32.2 | NS |
| Bloating | 50.7 ± 35.0 | 41.7 ± 37.9 | NS |
| Bad-tasting food | 28.4 ± 34.2 | 30.6 ± 38.8 | NS |
| Indigestion | 40.7 ± 31.1 | 30.0 ± 27.7 | NS |
| Flatulence | 61.7 ± 35.5 | 45.5 ± 37.3 | NS |
| Difficulty gaining weight | 39.5 ± 44.4 | 27.3 ± 41.7 | NS |
| Weakness | 55.6 ± 35.8 | 48.5 ± 43.1 | NS |
| Dry mouth | 40.7 ± 32.5 | 18.2 ± 27.3 | P < 0.05 |
| Treatment side-effects | 59.3 ± 32.5 | 48.5 ± 34.5 | NS |
| Worry about future | 77.5 ± 31.8 | 60.6 ± 29.1 | NS |
| Difficulty planning | 54.3 ± 39.4 | 36.4 ± 43.3 | NS |
PD, pancreaticoduodenectomy; DPHR, duodenum-preserving head resection; SD, standard deviation; NS, non-significant
Discussion
In North America, the PD procedure has remained the standard operation for surgical treatment of chronic pancreatitis. Multiple retrospective reviews have demonstrated this operation to have become increasingly safe, with mortality rates of about 2%.1,15 Because of the chronic debilitating nature of pancreatitis, postoperative complications, most commonly sepsis, delayed gastric emptying, pancreatic fistula and wound infection, are relatively common, occurring in about 33% of patients, and length of hospital stay averages 14–20 days.1,15 However, PD is effective, eliminating or significantly improving pain in 75–100% of patients.1,15,16
Over the past 20 years, DPHR procedures, originally described by Beger and later modified into the Frey and Bern operations, have gradually replaced PD as standard surgical treatment for head-predominant chronic pancreatitis in European centres. A large, single-centre retrospective review of 504 Beger procedures performed over 26 years demonstrated a postoperative mortality of <1%, and the elimination of pain in ∼ 90% of patients at both 2 and 5 years postoperatively; these results indicate the equivalence of the Beger and PD operations in the treatment of chronic pancreatitis.17 Several prospective trials comparing each DPHR operation with PD have produced similar results.3–5,16,18–19 In these trials, the DPHR has been associated with significantly shorter procedure time,4,5 decreased postoperative morbidity4,5 and shorter length of stay5,19 than PD. In trials in which DPHR and PD were compared directly, longterm pain control was significantly better in DPHR patients, compared with PD patients, in three of five studies.3,16,19 Similarly, significantly better weight gain was seen in DPHR patients in three of four trials.3,5,19 Quality of life, measured by the EORTC QoL questionnaire, although improved from baseline at 24 months and 63 months in both groups, was significantly better in DPHR patients at both postoperative time-points.16,19 None of these trials has shown DPHR to be significantly inferior to PD in any of the parameters mentioned, which suggests that DPHR represents a superior operation for chronic pancreatitis.
Despite this evidence, DPHR procedures have not yet gained widespread popularity among US surgeons. In one recent survey of pancreatic surgeons at academic medical centres, only 23 of 59 surgeons operating for chronic pancreatitis stated that they currently performed DPHR operations.13 Further, 76% of pancreas surgeons who had never performed a DPHR cited either inadequate evidence to support the effectiveness of DPHR or the superiority of PD and the Puestow procedure as their reason for not having performed the surgery.13 Only three retrospective studies, including ours, have been performed in North America to assess outcomes following DPHR: Aspelund and colleagues reported decreased morbidity in patients undergoing a Frey procedure compared with those undergoing PD for benign indications, and Varghese and Bell demonstrated significantly improved pain levels and digestive function after DPHR compared with controls with pancreatitis.13,20 We sought to confirm the European results by demonstrating the equivalence of DPHR to PD in terms of both short-term morbidity and mortality and patient QoL.
Our selection criteria for operative intervention were similar to those described in the European prospective trials: severe abdominal pain caused by chronic pancreatitis with preoperative abdominal computed tomography (CT) or endoscopic retrograde cholangiopancreatography (ERCP) diagnostic of head-predominant disease. Interestingly, in all the European trials, pancreatic head enlargement (usually defined as >4 cm) was present in nearly all patients; in some trials, head enlargement was an inclusion criterion.3–5,14–17 This finding was noted specifically by preoperative imaging in <10% of our patients. This disparity probably reflects a difference in diagnostic workups; at our centre, all patients with head masses visualized on initial imaging undergo thin-cut helical CT and endoscopic ultrasound to attempt to distinguish inflammatory from malignant lesions in order to guide operative planning, but this preoperative workup may be less prominent in European algorithms. This difference may also reflect a change in operative management of chronic pancreatitis, in which head enlargement is no longer required as an indication for surgical intervention.
The 30-day morbidity rates did not differ significantly between the PD (44%) and DPHR (55%) groups and are similar to those reported in previous series. Rates of delayed gastric emptying and pancreatic leak also did not differ significantly between groups, or compared with prior studies. Rates of postoperative wound infection have been less frequently reported. However, our wound infection and dehiscence rate in the PD population (10%) is consistent with that reported in one prior study.4 Of note, all of the patients in this group had undergone ERCP with stent placement preoperatively, a known risk factor for the development of wound infection. In the DPHR group, the rate was somewhat higher (23%), although this difference was not statistically significant, probably as a result of the small sample size. Three of the five patients in this group who developed wound infections had undergone prior endoscopic intervention; two of the patients required re-laparotomy for other indications following initial operation and developed wound infections after re-operation.
A total of 36% of patients in the PD group and 18% in the DPHR group required insulin postoperatively; this difference was not significant. In both groups, several patients who had not had diabetes preoperatively required insulin after surgery. Although one prior study demonstrated significantly higher average blood glucose levels in patients following PD surgery, compared with those undergoing DPHR, no other trials have demonstrated higher rates of diabetes in either group.3 The majority of our patients (73% PD, 82% DPHR) continued use of pancreatic enzymes postoperatively; similarly, 60–90% of patients in other trials demonstrated exocrine insufficiency after either procedure.3–5
The EORTC QLQ-C30 and pancreatic cancer module (QLQ-PAN 26) were utilized to evaluate QoL in our patient populations. The QLQ-C30 has been used previously to measure postoperative outcomes in patients with chronic pancreatitis4,18–19; more recently, the QLQ-PAN 26, originally designed for pancreas cancer patients, was also validated as a reliable tool to evaluate the symptoms of chronic pancreatitis.12,21 Previous studies have demonstrated postoperative improvement in QoL after both PD and DPHR operations, compared with preoperative scores.4,18 Our PD patients achieved similar QoL scores postoperatively, with a mean follow-up time of 47 months. By contrast, our DPHR patients had somewhat worse QoL outcomes on both the functional and symptom-based scales compared with patients in prior studies who had undergone these procedures. This may reflect the length of follow-up, which averaged only 13 months in our population, compared with 24–60 months in the prior studies.4,18–19 In one prior study population, significantly better postoperative QoL outcomes were demonstrated following DPHR compared with PD, at both 2- and 5-year follow-up time-points.16,19 Interestingly, our DPHR population demonstrated higher functional scores on five of six scales, and lower symptom scores on 25 of 26 scales, compared with PD patients, even with a significantly shorter follow-up period. Although only two symptom scales were significantly better in DPHR patients, this trend suggests that significant differences may be present and may be more apparent in future studies evaluating larger populations of patients with longer follow-up times.
In this study, we assessed postoperative pain control by questioning patients' narcotic use at the time of questionnaire completion, and as part of the QLQ-C30 and PAN 26 QoL symptom scales. In a few prior studies, DPHR procedures were demonstrated to be superior to PD in achieving relief from pancreatitis-related pain; in most others, the procedures are equivalent.3,19,22 In current series, about 60% of patients are pain-free at longterm follow-up and 20–30% continue to experience occasional to frequent pain.3,19,22 Although we did not directly assess frequency of pain in our population, both our indicators suggest that patients in both our PD and DPHR groups had worse pain outcomes than those previously reported. On the QLQ-C30 scale, our pain symptom scores were 54 and 56 in the DPHR and PD groups, respectively, compared with scores of 19–36 reported in prior studies.16,19 Opioid use has been reported to be about 20% in longterm follow-up after either procedure; 55% and 65% of our patients continued to use narcotics after DPHR and PD, respectively.22 Several reasons may account for or contribute to this disparity. Firstly, a recent retrospective review by Reidiger et al. found both follow-up time <5 years and preoperative duration of symptoms <8 years to be associated with the occurrence of more frequent pain by regression analysis.22 These findings may partially explain our poor results among DPHR patients (mean follow-up time 14 months, preoperative duration of symptoms 6.1 years), although previous trials achieved their superior results with follow-up times similar to ours. Secondly, our study does not assess factors that probably contribute to narcotic use in our patient population, such as the frequency or severity of recurrent attacks of acute pancreatitis, continued ethanol abuse and narcotic dependence or abuse. Our questionnaire also does not establish whether patients have ever achieved pain control without narcotics postoperatively and nor does it inquire about the specific indications for narcotic use. It is likely that more specific questions evaluating these factors might have helped us to better characterize patients' pain experiences and details of their narcotics usage, and to achieve results more similar to those previously reported. Lastly, the relatively small sample size and retrospective nature of our study, compared with the large European prospective trials, may account for the differences in pain outcome we observed.
In conclusion, the DPHR and PD procedures are equally effective in improving QoL and pain relief for patients with chronic pancreatitis. These findings are similar to those demonstrated repeatedly in European trials, but this is the first trial to replicate these results in a North American series. Furthermore, the DPHR outcomes were achieved with significantly shorter operating times and less intraoperative blood loss than PD. Duodenum-preserving head resections should be considered as equivalent alternatives to PD in the surgical treatment of chronic pancreatitis. A multicentre prospective trial in North America may provide more evidence to this end and may help to increase the popularity of these operations on this continent. Regardless, a more widespread adoption of these procedures should be encouraged in North American centres.
Conflicts of interest
None declared.
References
- 1.Russell RC, Theis BA. Pancreatoduodenectomy in the treatment of chronic pancreatitis. World J Surg. 2003;27:1203–1210. doi: 10.1007/s00268-003-7239-6. [DOI] [PubMed] [Google Scholar]
- 2.Beger HG, Krautzberger W, Bittner R, Buchler M. Duodenum-preserving resection of the head of the pancreas in patients with severe chronic pancreatitis. Surgery. 1985;97:467–473. [PubMed] [Google Scholar]
- 3.Buchler MW, Friess H, Muller MW, Wheatley AM, Berger HG. Randomized trial of duodenum-preserving pancreatic head resection versus pylorus-preserving Whipple in chronic pancreatitis. Am J Surg. 1995;169:65–69. doi: 10.1016/s0002-9610(99)80111-1. [DOI] [PubMed] [Google Scholar]
- 4.Izbicki JR, Bloechle C, Broering DC, Knoefel WT, Kuechler T, Broelsch CE. 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. Ann Surg. 1998;22:771–779. doi: 10.1097/00000658-199812000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Farkas G, Leindler L, Daroczi M, Farkas G., Jr. Prospective randomized comparison of organ-preserving pancreatic head resection with pylorus-preserving pancreaticoduodenectomy. Langenbecks Arch Surg. 2006;391:338–342. doi: 10.1007/s00423-006-0051-7. [DOI] [PubMed] [Google Scholar]
- 6.Ahmad SA, Lowy AM, McIntyre BC, Matthews JB. Pancreaticoduodenectomy. J Gastroint Surg. 2005;9:138–43. doi: 10.1016/j.gassur.2004.01.004. [DOI] [PubMed] [Google Scholar]
- 7.Frey CF, Smith GJ. Description and rationale of a new operation for chronic pancreatitis. Pancreas. 1987;2:701–707. doi: 10.1097/00006676-198711000-00014. [DOI] [PubMed] [Google Scholar]
- 8.Gloor B, Friess H, Uhl W, Buchler MW. A modified technique of the Beger and Frey procedure in patients with chronic pancreatitis. Dig Surg. 2001;18:21–25. doi: 10.1159/000050092. [DOI] [PubMed] [Google Scholar]
- 9.Ahmad SA, Wray C, Rilo HLR, Choe KA, Gelrud A, Howington JA, et al. Chronic pancreatitis: recent advances and ongoing challenges. Curr Prob Surg. 2006;43:121–240. doi: 10.1067/j.cpsurg.2005.12.005. [DOI] [PubMed] [Google Scholar]
- 10.Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS) Surgery. 2007;142:761–768. doi: 10.1016/j.surg.2007.05.005. [DOI] [PubMed] [Google Scholar]
- 11.Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138:8–13. doi: 10.1016/j.surg.2005.05.001. [DOI] [PubMed] [Google Scholar]
- 12.Fitzsimmons D, Johnson CD, George S, Payne S, Andren Sandberg A, Bassi C, et al. Development of a disease-specific quality of life (QoL) questionnaire module to supplement the EORTC core cancer QoL questionnaire, the QLQ-C30 in patients with pancreatic cancer. Eur J Cancer. 1999;35:939–941. doi: 10.1016/s0959-8049(99)00047-7. [DOI] [PubMed] [Google Scholar]
- 13.Varghese TK, Bell RH., Jr. Duodenum-preserving head resection for chronic pancreatitis: an institutional experience and national survey of usage. Surgery. 2007;142:588–593. doi: 10.1016/j.surg.2007.08.009. [DOI] [PubMed] [Google Scholar]
- 14.Fayers PM, Aaronson NK, Bjordal K, Groenvold M, Curran D, Bottomley A. The EORTC QLQ-C30 Scoring Manual. 3rd edn. Brussels: European Organization for Research and Treatment of Cancer; 2001. [Google Scholar]
- 15.Traverso LW, Kozarek RA. Pancreatoduodenectomy for chronic pancreatitis: anatomic selection criteria and subsequent longterm outcome analysis. Ann Surg. 1997;226:429–435. doi: 10.1097/00000658-199710000-00004. discussion 435–438. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Mobius C, Max D, Uhlmann D, Gumpp K, Behrbohm J, Horvath K, et al. Five-year follow-up of a prospective non-randomized study comparing duodenum-preserving pancreatic head resection with classic Whipple procedure in the treatment of chronic pancreatitis. Langenbecks Arch Surg. 2007;392:359–364. doi: 10.1007/s00423-007-0175-4. [DOI] [PubMed] [Google Scholar]
- 17.Beger HG, Schlosser W, Friess HM, Büchler MW. Duodenum-preserving head resection in chronic pancreatitis changes the natural course of the disease: a single-centre 26-year experience. Ann Surg. 1999;230:512–519. doi: 10.1097/00000658-199910000-00007. discussion 519–523. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Belina F, Fronek J, Ryska M. Duodenopancreatectomy versus duodenum-preserving pancreatic head excision for chronic pancreatitis. Pancreatology. 2005;5:547–552. doi: 10.1159/000087496. [DOI] [PubMed] [Google Scholar]
- 19.Witzigmann H, Max D, Uhlmann D, Geissler F, Schwarz R, Ludwig S, et al. Outcome after duodenum-preserving pancreatic head resection is improved compared with classic Whipple procedure in the treatment of chronic pancreatitis. Surgery. 2003;134:53–62. doi: 10.1067/msy.2003.170. [DOI] [PubMed] [Google Scholar]
- 20.Aspelund G, Topazian MD, Lee JH, Andersen DK. Improved outcomes for benign disease with limited pancreatic head resection. J Gastrointest Surg. 2005;9:400–409. doi: 10.1016/j.gassur.2004.08.015. [DOI] [PubMed] [Google Scholar]
- 21.Fitzsimmons D, Kahl S, Butturini G, van Wyk M, Bornman P, Bassi C, et al. Symptoms and quality of life in chronic pancreatitis assessed by structured interview and the EORTC QLQ-C30 and QLQ-PAN26. Am J Gastroenterol. 2005;100:918–926. doi: 10.1111/j.1572-0241.2005.40859.x. [DOI] [PubMed] [Google Scholar]
- 22.Riediger H, Adam U, Fischer E, Keck T, Pfeffer F, Hopt UT, et al. Longterm outcome after resection for chronic pancreatitis in 224 patients. J Gastrointest Surg. 2007;11:949–960. doi: 10.1007/s11605-007-0155-6. [DOI] [PubMed] [Google Scholar]