Longterm Outcome After Resection for Chronic Panc

Authors: Hartwig Riediger Ulrich Adam Eva Fischer Tobias Keck Frank Pfeffer Ulrich T Hopt Frank Makowiec

Publish Date: 2007/05/30

Volume: 11, Issue: 8, Pages: 949-960

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Abstract

Organ complications like biliary or duodenal stenosis as well as intractable pain are current indications for surgery in patients with chronic pancreatitis CP We present here our experience with pancreatic resection for CP and focus on the longterm outcome after surgery regarding pain exocrine/endocrine pancreatic function and the control of organ complications in 224 patients with a median postoperative followup period of 56 monthsDuring 11 years 272 pancreatic resections were performed in our institution for CP Perioperative mortality was 1 Followup data using at least standardized questionnaires were available in 224 patients The types of resection in these 224 patients were Whipple 9 pyloruspreserving pancreatoduodenectomy PD PPPD 40 duodenumpreserving pancreatic head resection DPPHR 41 50 Frey 42 Beger distal 9 and two central pancreatic resections Eightysix of the patients were part of a randomized study comparing PPPD and DPPHR The perioperative and followup f/up data were prospectively documented Exocrine insufficiency was regarded as the presence of steatorrhea and/or the need for oral enzyme supplementation Multivariate analysis was performed using binary logistic regressionPerioperative surgical morbidity was 28 and did not differ between the types of resection At last f/up 87 of the patients were painfree 60 or had pain less frequently than once per week 27 Thirteen percent had frequent pain at least once per week no difference between the operative procedures A concomitant exocrine insufficiency and former postoperative surgical complications were the strongest independent risk factors for pain and frequent pain at followup At the last f/up 65 had exocrine insufficiency half of them developed it during the postoperative course The presence of regional or generalized portal hypertension a low preoperative body mass index and a longer preoperative duration of CP were independent risk factors for exocrine insufficiency Thirtyseven percent of the patients without preoperative diabetes developed de novo diabetes during f/up no risk factor identified Both exocrine and endocrine insufficiencies were independent of the type of surgery Median weight gain was 2 kg and higher in patients with preoperative malnutrition and in patients without abdominal pain After PPPD 8 of the patients had peptic jejunal ulcers whereas 4 presented with biliary complications after DPPHR Late mortality was analyzed in 233 patients Survival rates after pancreatic resection for CP were 86 after 5 years and 65 after 10 yearsPancreatic resection leads to adequate pain control in the majority of patients with CP Longterm outcome does not depend on the type of surgical procedure but is in part influenced by severe preoperative CP and by postoperative surgical complications regarding pain A few patients develop procedurerelated late complications Late mortality is high probably because of the high comorbidity alcohol smoking in many of these patientsDr W Nealon Galveston TX Dr Kaufman Dr Joseph members and guests The authors from Freiburg have contributed yet another thorough review of their outcomes in the management of chronic pancreatitis They report today their experience with 272 resections including pancreaticoduodenectomy classic Whipple and duodenumpreserving pancreatic head resection either by the Frey or Beger technique and they provide detailed followup data including measures of pain relief functional derangements and nutritional outcomesTheir operative mortality of 1 is striking particularly considering their inclusion of patients with portal vein or splenic vein thrombosis which they have seen in 25 of their resected patients and often this entity raises considerably the risk for hemorrhage in these resections Complete abolition of pain was achieved in 60 and some reduction in pain was achieved in 86 These are superb outcomes Twothirds of the patients had steatorrhea in followup half acquired after surgery 37 developed newonset diabetes Again all these are acceptable rates Notably 86 of patients survived 5 years and 65 10 years reflecting the known chronic nature of this disease and the likely ongoing ravages of alcoholism Nutritional improvements were noted in a high percentage of patients independent of their pancreatic function after operation an observation we have made in the past and a striking one I believeNumber two you don’t mention narcotics use and I must say in my huge experience with these patients this overshadows every bit of patient management I am wondering if you monitor this and whether you have any thoughts on the impact of narcotic dependence on the management of these patients after surgery

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