chronic pancreatitis - adhy

7/28/2019 Chronic Pancreatitis - Adhy

1/8

Surgery of chronic pancreatitis

Charles F. Frey, M.D. a , Dana K. Andersen, M.D. b, *a University of California Davis, Rescue, CA, USA

b Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, MD 21224, USA

Abstract

Chronic pancreatitis is a progressive disease of multiple etiologies. Surgery is frequently indicated forrelief of debilitating pain as well as to address other complications, and three operations have proveneffective. The pancreatico-duodenectomy (Whipple) procedure results in excellent long-term pain relief,but is associated with a low mortality rate and a persistent risk of early and late complications. Theduodenum-preserving pancreatic head resection (DPPHR) introduced by Beger et al, and the local

resection of the pancreatic head with longitudinal pancreatico-jejunostomy (LR-LPJ) devised by Frey,achieve the same high rate of pain relief long term but are associated with lower rates of perioperativecomplications and a decreased incidence of diabetes long term. All 3 operations address the head of thepancreas as the nidus of persistent inammation, and all 3 achieve success with both dilated and nondilatedduct disease. The LR-LPJ has a lower risk of perioperative problems and may be easier to perform. 2007Excerpta Medica Inc. All rights reserved.

Keywords: Chronic pancreatitis; Duodenum-preserving pancreatic head resection; Beger procedure; Local resectionof the pancreatic head with longitudinal pancreatico-jejunostomy; Frey procedure; Whipple procedure

Chronic pancreatitis is a progressive, debilitating disease of multiple etiologies. Although alcohol abuse accounts for the

majority of cases in North American and some Europeanseries, biliary stone disease, tropical brocalcic pancreati-tis, post ERCP and post-traumatic pancreatitis, congenital orhereditary pancreatitis, ductal anomalies such as pancreasdivisum, and idiopathic causes also have been reported.Symptoms include chronic relapsing pain, obstruction of adjacent structures due to peri-pancreatic inammation, andthe manifestations of exocrine and endocrine insufciency.Although chronic pain is the most common indication forsurgical treatment, complications of chronic pancreatitissuch as pseudocyst formation, strictures of pancreatic andbiliary ductal systems, and suspected neoplasm also result insurgery. For a complete review of the causes, manifesta-

tions, and treatment approaches to chronic pancreatitis, seeFisher et al [1].Until recently, surgery was considered the last resort

after medical management of chronic pancreatitis hadfailed. Lankisch et al reported that pain may decrease ordisappear over a period of several years, although this isaccompanied by worsening exocrine and e ndocrine dys-function, narcotic addiction, and disability [2]. Although

increased ductal pressure is thou ght to be a cause for pain inchronic obstructive pancreatitis [3], the role of chronic in-

ammation and prog ressive perineural disease is also heldas a cause of pain [4]. Nealon and Matin analyzed thevarious pain syndromes associated with chronic pancreatitisand proposed a meth od to predict the responses to varioussurgical approaches [5]. Pain that is found in associationwith pancreatic ductal hypertension is most readily relievedby surgical drainage, and a trial of endoscopic decompres-sion may predict those patients who will benet from sur-gical decompression. In a prospective randomized trial,Nealon and Thompson found that decompression of anobstructed pancr eatic duct prevents or delays the progres-sion of disease [6], so that surgical intervention is nowdictated by the anatomy of the disease and the need to

restore patients to full activity.

The Evolution of Surgical TreatmentThree operative approaches to relieve the pain and

address the major complications of chronic pancreatitishave proven to be efcacious: pancreatico-duodenectomy(Whipple procedure), duodenal-preserving pancreatichead resection (DPPHR or Beger procedure), and localresection of the pancreatic head with extended longitu-dinal pancreatico-jejunostomy (LR-LPJ or Frey proce-dure). Each procedure addresses disease in the proximalpancreas by removing all or part of the head of the

* Corresponding author. Tel.: 1-410-550-2821; fax: 1-410-550-0154.

E-mail address: [email protected]

The American Journal of Surgery 194 (Suppl to October 2007) S53S60

0002-9610/00/$ see front matter 2007 Excerpta Medica Inc. All rights reserved.doi:10.1016/j.amjsurg.2007.05.026


2/8

pancreas, so that the ducts of Santorini and Wirsung areexcised, and the uncinate duct is excised or decom-pressed. Therefore, whether the cause of pain in chronicpancreatitis is due to perineural inammation or ductalhypertension, all 3 procedures remove the source of chronic inammatory changes and provide drainage for

the distal ductal system. Other frequent complications of chronic pancreatitis resulting from brosis and obstruc-tion, such as pseudocysts and common bile duct andduodenal obstruction, can usually be managed by modi-cations of these 3 procedures. Occasionally, a patientwith chronic inammatory changes localized to the bodyor tail of the gland will benet from distal pancreatec-tomy alone.

A variety of surgical procedures advocated in the pasthave lost favor because of serious drawbacks associatedwith their use. In 1947, Cattell described a Roux-en-Y,side-to-end, pancreatico-jejunostomy as effective palliationfor obstructive pancreatopathy secondary to malignancy [7],

and in 1954, Duval described the caudal, end-to-end, pan-creatico -jejunostomy as a drainage procedure for chronicpancreatitis [8]. These efforts at duct drainage failed as aresult of recurrent or progressive segmental stenosis of thepancreatic duct, which was described by Puestow andGillesby as a chain-of-lakes appearance of the duct [9].They reported good results with a longitudinal decompres-sion of the body and tail of the pancreas into a Roux limb of jejunum. Four of Puestow and Gillesbys 21 initial caseswere constructed as side-to-side anastomoses, and 2 yearslater, in 1960, Partington and Rochell described in detail theside-to-side longitudinal pancreatico-jejunostomy that be-came known as the Puestow procedure [10]. Althoughthis procedure became the standard drainage procedure forclose to 30 years, it was evident that not all patients withchronic pancreatitis had dilated ductal disease. Moreover,despite early postoperative pain relief observed in 80% of patients, recurrent pain developed within 3 to 5 years in upto 30% of patients after the Puestow procedure [1113] . Therecurrence of pain was often attributed to persistent orrecurrent disease in the head of the pancreas [14] (Fig. 1).

Whipple described the proximal pancreatico-duodenec-tomy (and total pancreatectomy) for the treatment of chronic pancreatitis in 1946 [15] , but early experience dem-onstrated that this was a daunting approach in that era. The95% distal pancreatectomy (Child procedure) was describedin 1965 [16] as an alternative to total or proximal pancrea-tectomy, and as an approach that would spare the duodenumand biliary tree from resection. The rst duodenal-preserv-ing head resection was effective in achieving long lastingpain relief in 80% o f patients studied after an averagefollow-up of 6 years [17] but was abandoned due to themetabolic consequences of the operation. It became appar-ent that the remnant of pancreatic tissue left along the inneraspect of the duodenum was insufcient to prevent exocrineand endocrine insufciency post operatively, and the result-ing brittle diabetes was particularly difcult to manage insome patients. Gall et al reported that in a series of morethan 100 total pancreatectomies performed for chronic pan-creatitis, half of all the late deaths were due to fatal hypo-glycemia [18] . Most recently, total pancreatectomy has been

combined with islet autotransplantation to afford both ahigh likelihood of pain relief, as well as improved metaboliccontrol [19,20] . However, the still limited availability of this technique prevents its widespread adoption.

Proximal Pancreatico-DuodenectomyMany reports have conrmed pancreatico-duodenectomy

to be an effective means of man aging pa in and the compli-cations of chronic pancreatitis [2126] . In the 3 largestmodern (circa 2000) series of the treatment of chronicpancreatitis by the Whipple procedure, pain relief 4 to 6years after operation ranged from 71% to 89% of patients[2426] . However, in spite of the long history and extensiveexperience with the operation, pancreatico-duodenectomyremains a work in progress due to many technical issues.

While the mortality rate of the operation has been re-duced to less than 5% in high-vo lume centers, the morbiditystubbornly remains at about 40% [2427] . The introduction of the pylorus-preserving pancreatico-duodenectom y (PPPD) inchronic pancreatitis by Traverso and Longmire [28] was en-thusiastically received because of presumed nutritional andphysiol ogic benets associated with retention of the pylorus[23,28] , but these benets have never been well substanti-ated, and some studies have shown no signic ant nutritionaldifferences between the 2 procedures [29,30] . Most studieshave documented an improved quality of life after the PPPD[3134] , but others support the use of the standard technique[21,22,29] .

Pancreatic anastomotic leak is a major cause of pro-longed hospital stay and intra-abdominal infection. Theincidence in series that include both malignancy and chronicpancreatitis varies fro m 6% to 28%, and is dependent on thedenition of a leak [3537] . Although pancreatic anasto-motic leaks are less likely to occur in chronic pancreatitisbecause of the rmer consistency of the gland, the main ductcan be 2 to 3 mm or less in a gland with diffuse sclerosis,and difculties with the anastomosis can occur. A variety of techniques have been employed, and the duct-to-mucosa

Fig. 1. Head-of-pancreas mass after Puestow procedure. The computedtomographic appearance of an inammatory mass occupying the head of the pancreas, which developed 2 years after Puestow-type decompressionof the body and tail of the pancreas. Reprinted with permission [1].

S54 C.F. Frey and D.K. Andersen / The American Journal of Surgery 194 (Suppl to October 2007) S53S60


3/8

anastomosis leak rate has been reported to be as low as .9%[38], considerably less than th e 12% leak rate observed withthe invagination anastomosis [39] . Prospective, randomizedtrials of the use of octreotide admi nistered postope rativelyto prevent leak have both supported [40] and refuted [39,41]its value, and the use of brin glue appears ineffective toprevent leak [42,43] .

Pancreatico-gastrostomy has been advocated as safer andeasier to perform than the pancreatico-jejunostomy anasto-mosis [44] . Randomized, controlled trials are contradictory

as to whether the leak ra te or the operating time differsbetween these techniques [45,46] , and Jang et al found nofunctional differences between the 2 anastomoses in pa-tients with pancreatic cancer 1 year after pancreatico-duo-denectomy [47]. The use of either internalized or external-ized pancreatic duct stents to ensure patency of theanastomosis has been advocated, but complications havebeen reported, including migration and alterations of thepancre atic duct anatomy when stents are left for months orlonger [48,49] .

Fig. 2. Duodenum-preserving pancreatic head resection (DPPHR) or Beger procedure. The neck of the pancreas is transected, and most of the head anduncinate process is excised, leaving a rim of pancreatic tissue and the exposed intra-pancreatic portion of the distal common bile duct. Reprinted withpermission from Bell RH. Atlas of pancreatic surgery. In: Bell RH, Rikkers LF, Mulholland MW, editors. Digestive Tract Surgery: A Text and Atlas .Philadelphia, PA: Lippincott-Raven; 1996:1014.

Fig. 3. Reconstruction of the DPPHR or Beger procedure. An end-to-end pancreatico-jejunostomy to the body of the pancreas, and an end-to-sidepancreatico-jejunostomy to the same Roux-en-Y limb of jejunum is constructed. A separate chole-dochojejunostomy can be fashioned if needed, orthe exposed intra-pancreatic common bile duct can be incorporated into the proximal anastomosis. Reprinted with permission from Bell RH. Atlas of pancreatic surgery. In: Bell RH, Rikkers LF, Mulholland MW, editors. Digestive Tract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott-Raven;1996:10145.

S55C.F. Frey and D.K. Andersen / The American Journal of Surgery 194 (Suppl to October 2007) S53S60


4/8

Life-threatening postoperative complications that occurrarely include the development of necrotizing pancreatitis inthe remaining pancreas, which may require completion pan-createctomy, and intraluminal bleeding from a pancreaticartery or from erosion by the gastroduodenal artery into theRoux limb. Such complications are more commonly asso-

ciated with operation performed for neoplasms.Long-term complications of the panceatico-duodenec-tomy include stricturing of the anastomoses with loss of exocrine and endocrine function in the remaining pancreas[5052] ; the late incidence of both exocrine and endocrinedysfunction is about 50%. Delayed gastric emptying hasbeen reported as an early postoperative complication, whichusually resolves spontaneously, or as a late complicationassociated with a r etro-coli c, as opposed to an ante-colic,gastro-jejunostomy [5356] . The incidence of delayed gas-tric emptying has been reported to be higher in patients inwhom the pylorus was preserved than with the standar doperation or duodenal-preserving head resection [5763] .

The Duodenum-Preserving Pancreatic Head Resectionof Hans Beger

The genius of Hans Begers duodenal-preserving pa ncre-atic head resection (DPPHR), rst reported in 1980 [64],and what distinguished it from the 95% distal pancreatec-tomy, was that the pancreatic resection was limited to thehead of the g land wit h preservation of the body and tail of the pancreas ( Figs. 2 and 3). Experience with the operationhas been extensive and pain relief of 80 % to 85% has beenwell maintained for 5 years or more [65]. Exocrine andendocrine insufciency after DPPHR progresses as a func-tion of the underlying chronic pancreatitis a nd its courseappears minimally altered by the operation [65,66] . Theincidence of new diabetes after DPPHR ranges from 8% to21%, and some patients show an improvement in glucosemetabolism after the procedure [65] . This appears to be dueto preservation of in sulin and pancreatic polypeptide secre-tion postoperatively [52] .

Key steps in the performance of the DPPHR includeidentifying and preserving the posterior branch of the gas-troduodenal artery, which provides blood ow to the duo-denum, intrapancreatic common bile duct, and pancreatico-duodenal groove. The neck of the pancreas overlying theportal and superior mesenteric vein is divided, and all but asmall amount of pancreatic tissue along the inner aspect of the duodenum is resected. The common bile duct is decom-pressed, if necessary, either by choledocho-pancreatostomyto the rim of surrounding pancreas, or by choledocho-jeju-nostomy to the Roux limb of jejunum that is used to formthe pancreatico-jejunostomy with the pancreatic body andtail. Reconstruction consists of an end-to-end pancreatico- jejunostomy to the distal pancreas, and end-to-side pancre-atico-jejunostomy to the remnant of pancreatic tissue on theinner aspect of the duodenum.

The body and tail of the pancreas can be drained with alongitudinal pancreatico-jejunostomy if the main duct in thebody and tail of the pancreas is obstructed. Beger decom-presses the common duct in about 50% of his patients andemploys the longitudinal pancreaticojejunostomy in 10% to15% [65].

Complications of the DPPHR procedure include the risk of ischemia of the duodenum due to inadequate perfusion of the posterior branch of the gastroduodenal artery, the risk of leak from either of the 2 pancreatico-jejunal anatomoses,and the risks of delayed gastric emptying, ileus, and intra-abdominal problems similar to the Whipple procedure. In a

prospective study in which 40 patients were randomized toeither DPPHR or the pylorus-preserving Whipple proce-dure, Buchler et al reported that postoperative morbidity(15% to 20%) and length of stay (13 to 14 days) weresimilar [67]. Aspelund et als retrospective study of DPPHR, LR-LPJ, and Whipple procedures performed con-secutively at Yale revealed a major complication rate afterWhipple procedures of 40%, compared to 25% after theDPPH R, with the rates of leak being 10% and 25%, respec-tively [68].

Local Resection of the Head of the Pancreas with

Longitudinal Pancreatico-JejeunostomyIn 1987 the local resection of the head of the pancreascombined with longitudinal pancreatico -jejunostomy (LR-LPJ) was described by Frey and Smith [69] (Fig. 4). Theoperation combined features of Childs 95% distal pancre-atectomy in the head of the pancreas (with whom Freyworked while at the University of Michigan) and the lon-gitudinal pancreatico-jejunostomy of Puestow. In 1994, af-ter an average follow-up of 3 years, the results of 50 caseswere reported [70] . Pain was relieved in 80% of the patientsand exocrine and endocrine insufciency followed the nat-ural history of chronic pancreatitis and did not seem to beaffected by the operation.

The operation was designed to remove most of the headof the pancreas (the so-called pacemaker of the disease)while preserving the body and tail of the pancreas, thestomach, and duodenum to minimize morbidity. Althoughdrainage of the main pancreatic duct in the body and tail of the gland is usually performed because of the presence of post-stenotic dilatation and ductal stones, it may not be anessential part of the procedure if the main duct in the bodyand tail is open and uninammed throughout its length. Thiscoring of the pancreatic head with preservation of theposterior capsule is the essential feature of the LR-LPJoperation. It can be pe rformed saf ely using the ultrasonicdissector and aspirator [71] (Fig. 5), or with a combinationof suture plication and cautery. As with the DPPHR, it isimportant to recognize and preserve the intrapancreaticcommon bile duct.

The DPPHR described by Beger has similarities to theLR-LPJ. Both are directed primarily at the disease in thehead of the pancreas and both preserve gastrointestinalcontinuity. Not surprisingly, the results of both opera-tions in terms of pain relief and quality of life appear tobe similar. These 2 operations also have signicant dif-ferences. The posterior capsule of the pancreas is pre-served in the LR-LPJ, which allows the excavated head(and dorsal duct) to be drained into a single, side-to-sidepancreatico-jejunostomy. The DPPHR does not preservethe posterior capsule, which mandates 2 anastomoses.The Beger operation requires that the pancreas be dividedat its neck overlying the superior mesenteric and portal



5/8

vein. In the event of portal hypertension and associatedinammatory changes, this may be technically difcult,but is avoided in the LR-LPJ.

Comparisons of the Three Operative Procedures:Pancreatico-Duodenectomy, DPPHR, and LR-LPJ

There has been considerable interest particularly in Eu-ropean centers to apply evidence-based methods to the

study of the 3 operations currently advocated for the treat-ment of chronic pancreatitis. Reports of results of a single

operative procedure from a single institution are difcult tocompare with those of another operative procedure fromanother institution, as patient selection, patient populations,measurements of pain and quality of life may vary, as do themethods and details of follow-up. The best studies, or level1 data by the Strength of Recommendation Taxonomy(SORT), are prospective, randomized controlled trials com-paring 2 or more operations from a single or multi-institu-tional study. Retrospective, cohort-based studies are re-garded as level 2 data by the SORT criteria.

To date, 5 published level 1 studies have examinedvarious comparisons between these 3 operations, and 1 level2 study has examined all 3 procedures at a single instit ution.In the level 1 study of 43 patients by Klempa et al [72],DPPHR patients had a shorter hospital stay, greater weightgain, less postoperative diabetes, and exocrine dysfunctionthan PPPD over a 3- to 5-year follow-up. Pain control wassimilar between the 2 procedures. This was c onrmed in alevel 1 study of 40 patients by Buchler et al [67] in whichDPPHR patients reported better pain relief, glucose toler-ance, and weight gain; however, the follow-up averaged lessthan 1 year.

In a level 1 study of 61 patients randomized to PPPD orLR-LPJ, Izbicki et al [73] found a lower postoperativecomplication rate associated with the Frey procedure (19%)compared to the PPPD group (53%), and better globalquality of life scores (71% vs 43%, respectively). Bothoperations were equally effective in controlling pain over a

Fig. 4. Local resection of the pancreatic head with longitudinal pancreatico-jejunostomy (LR-LPJ) or Frey procedure. The extended longitudinal Roux-en-Ypancreatico-jejunostomy with excavation of the pancreatic head provides complete decompression of the distal ductal system as well as removal of the nidusof chronic inammation. Reprinted with permission from Bell RH. Atlas of pancreatic surgery. In: Bell RH, Rikkers LF, Mulholland MW, editorss. DigestiveTract Surgery: A Text and Atlas. Philadelphia, PA: Lippincott-Raven; 1996:1024.

Fig. 5. Operative photograph of a completed excavation of the pancreatichead using the ultrasonic aspirator and dissector. Note the complete re-moval of the proximal ductal systems with preservation of the posteriorpancreatic capsule. The longitudinal pancreatotemy reveals chronic inam-mation of the ductal mucosa in the body and tail, consistent with recurrentinammation due to chronic pancreatitis. Reprinted with permission [71].



6/8

2-year follow-up. More recently, a level 1 study by Farkaset al [74] examined 40 patients randomized to PPPD or whatwas described as an organ-preserving pancreatic head re-section (OPPHR), which appears essentially identical tothe Frey procedure. The authors found that OPPHR wasassociated with a shorter operating time, less postoperative

morbidity, shorter hospital stay, and better quality of lifethan PPPD, and the degree of pain relief was equal over a1- to 3-year follow-up.

In 1995, Izbicki and colleagues began a level 1 stu dy of 42 patients randomized to receive DPPHR or LR-L PJ [75].The study was continued and updated in 1997 [76] toinclude 74 patients. In 2005 the long-term results of these 74patients with an average follow-up of 8.5 years was reported[77]. There were no signicant differences between thegroups with regard to global quality of life, pain scores, latemortality, and exocrine or endocrine insufciency. Theseresults were echoed in the level 2 study by Aspelund et al,which demonstrated fewer complications with both the

DPPHR and LR-LPJ procedures compared to pancreatico-duodenectomy, and a lower incidence of new diabetes (8%)for both DPPHR and LR-LPJ compared to the Whippleprocedure (25%), but no signicant difference s in outcomesor pain relief between DPPHR and LR-LPJ [68] . Finally,level 2 data support the efcacy of both DPPHR and LR-LPJ in patients with dilated as well as nondilated ducts[78,79] .

CommentsThe operative procedures that provide the least postop-

erative morbidity and mortality and the best quality of life inpatients who require pain relief due to chronic pancreatitisare the DPPHR of Beger and the LR-LPJ of Frey. The Freyprocedure may be easier to perform, particularly in situa-tions when portal hypertension and inammation make di-vision of the neck of the pancreas difcult, and it has alower incidence of pancreatic leak. However, long-termresults of these 2 operations are virtually identical. Both theBeger and Frey operations are improvements over the stan-dard or PPPD in terms of operative morbidity and mortality,length of hospital stay, weight gain, nutrition and quality of life. Therefore PPPD should be reserved for those patientsin whom there is suspicion for the presence of carcinoma.Pain relief after pancreatico-duodenectomy, DPPHR, orLR-LPJ is similarly good, although the risk of new diabetes

is less with both the Beger and Frey procedures.

AcknowledgmentThe authors are indebted to Louisa L. Petrosillo and

Robyn Hinke for assistance with the manuscript.

References[1] Fisher WE, Andersen DK, Bell RH Jr, et al, Pancreas. In: Brunicardi FC,

Andersen DK, Billiar TR, et al, editors. Schwartzs Principles of Surgery. 8th ed. New York, NY: McGraw-Hill; 2005:124074 (al soavailable at: http://www.accesssurgery.com/content.aspx?aid 16220 ).

[2] Lankisch PG, Lohr-Happe A, Otto J, et al. Natural course in chronicpancreatitis: pain, exocrine and endocrine pancreatic insufciency

and prognosis of the disease. Digestion 1993;54:14857.[3] Bradley EL III. Pancreatic duct pressure in chronic pancreatitis. Am JSurg 1982;144:3136.

[4] Bockman DE, Buchler MW. Pain mechanisms. In: Beger HG, War-shaw AL, Buchler MW, et al, editors. The Pancreas. London, UK:Blackwell-Science; 1998:698702.

[5] Nealon WH, Matin S. Analysis of surgical success in preventingrecurrent acute exacerbations in chronic pancreatitis. Ann Surg 2001;233:793800.

[6] Nealon WH, Thompson JC. Progressive loss of pancreatic function inchronic pancreatitis is delayed by main pancreatic duct decompres-sion. A longitudinal prospective analysis of the modied Puestowprocedure. Ann Surg 1993;217:45864.

[7] Cattell RB. Anastomosis of the duct of Wirsung in palliative opera-tion for carcinoma of the head of the pancreas. Surg Clin North Am1947;27:63753.

[8] Duval MK Jr. Caudal pancreatico-jejunostomy for chronic relapsingpancreatitis. Ann Surg 1954;140:77581.

[9] Puestow CB, Gillesby WJ. Retrograde surgical drainage of pancreasfor chronic relapsing pancreatitis. Arch Surg 1958;76:898904.

[10] Partington PF, Rochelle REL. Modied Puestow procedure forretrograde drainage of the pancreatic duct. Ann Surg 1960;152:103744.

[11] Bradley EL. Long term results of pancreaticojejunostomy in patientswith chronic pancreatitis. Am J Surg 1987;153:20713.

[12] Mannell A, Adson MA, McIlrath DC, et al. Surgical management of

chronic pancreatitis: long term results in 141 patients. Br J Surg1988;75:46772.[13] Taylor RH, Bagley FH, Braasch JW, et al. Ductal drainage or resec-

tion for chronic pancreatitis. Am J Surg 1981;141:2833.[14] Beger HG, Buchler M, Ditschnuneit H. Malfertheiner. Berlin, Ger-

many: Springer-Verlag; 1990:418.[15] Whipple AO. Radical surgery for certain cases of pancreatic brosis

associated with calcareous deposits. Ann Surg 1946;124:9911006.[16] Fry WJ, Child CG. Ninety-ve percent distal pancreatectomy for

chronic pancreatitis. Ann Surg 1965;162:5439.[17] Frey CF, Child CG, Fry WJ. Pancreatectomy for chronic pancreatitis.

Ann Surg 1976;184:40314.[18] Gall FP, Muhe E, Gebhardt C. Results of partial and total pancrea-

tectomy in 117 patients with chronic pancreatitis. World J Surg1981;5:26975.

[19] Robertson RP, Lanz KJ, Sutherland DER. Prevention of diabetes for

up to 13 years by autoislet transplantation after pancreatectomy forchronic pancreatitis. Diabetes 2001;50:4750.

[20] Rodriquez Rilo HL, Ahmad SA, DAlessio D, et al. Total pancrea-tectomy and autologous islet cell transplantation as a means to treatsevere chronic pancreatitis. J Gastrointest Surg 2003;7:97889.

[21] Sakorafas G, Sarr MG. Changing trends in operations for chronicpancreatitis: a 22 year experience. Eur J Surg 2000;166:6337.

[22] Schmidt CM, Powell ES, Yiannoutsos CT, et al. Pancreaticoduode-nectomy: a 20year experience in 516 Patients. Arch Surg 2004;139:71825.

[23] Vickers SM, Chan C, Heslin MJ, et al. The role of pancreaticoduo-denectomy in the treatment of severe pancreatitis. Am Surg 1999;65:110811.

[24] Jiminez RE, Fernandez-Del Castillo C, Rattner DW, et al. Pyloruspreserving pancreaticoduodenectomy in the treatment of chronic pan-creatitis. World J Surg 2003;27:12116.

[25] Russell RC, Theis BA. Pancreaticoduodenectomy in the treatment of chronic pancreatitis. World J Surg 2003;27:120310.

[26] Sakorafas GH, Farnell MB, Nagorney DM. Pancreatico-duodenec-tomy for chronic pancreatitis. Long term results in 1105 patients.Arch Surg 2000;135:51723.

[27] Huang JJ, Yeo CJ, Sohn TA, et al. Quality of life and outcomes afterpancreaticoduodenectomy. Ann Surg 2000;231:8907.

[28] Traverso LW, Longmire WP. Preservation of the pylorus duringpancreaticoduodenectomy. Surg Gynecol Obstet 1978;146:95962.

[29] Balcon JH 4th, Rattner DW, Warshaw AL, et al. Ten year expe-rience with 733 pancreatic resections: changing indications, olderpatients, and decreasing length of hospitalization. Arch Surg 2001;136:3918.

[30] Mcleod RS, Taylor BR, OConnor BI, et al. Quality of life, nutritionalstatus, and gastrointestinal hormone prole following the Whipple

procedure. Am J Surg 1995;169:179 85.[31] Traverso LW. The pylorus preserving Whipple procedure for thetreatment of chronic pancreatitis. Swiss Surg 2000;6:25963.

http://www.accesssurgery.com/content.aspx?aid=16220http://www.accesssurgery.com/content.aspx?aid=16220http://www.accesssurgery.com/content.aspx?aid=16220http://www.accesssurgery.com/content.aspx?aid=16220http://www.accesssurgery.com/content.aspx?aid=16220http://www.accesssurgery.com/content.aspx?aid=16220


7/8

[32] Hartel M, Tempia-Callera AA, Wente MN, et al. Evidence-basedsurgery in chronic pancreatitis. Langenbecks Arch Surg 2003;388:1329.

[33] Slavin J, Ghaneh P, Sutton R, et al. Pylorus-preserving Kausch-Whipple resection: the successor of the classical Kausch-Whipple inchronic pancreatitis. Ann Ital Chir 2000;71:5764.

[34] Ohtsuka T, Yamaguchi K, Ohuchida J, et al. Comparison of quality of life after pylorus-preserving pancreticodenectomy and Whipple re-section. Hepatogastroenterology 2003;50:84650.

[35] Ohwada S, Ogawa T, Kawate S, et al. Results of duct to mucosapancreaticojejunostomy for pancreaticoduodenectomy Billroth I typereconstruction in 100 consecutive patients. J Am Coll Surg 2001;193:2935.

[36] Hsu JT, Yeh CN, Hwang TL, et al. Outcome of pancreaticoduode-nectomy for chronic pancreatitis. J Formosa Med Assoc 2005;104:8115.

[37] Yang YM, Tian XD, Zhuang Y, et al. Risk factors of pancreaticleakage after pancreaticoduodenectomy. World J Gastroenerol 2005;11:245661.

[38] Shyr YM, Chen TH, Su CH, et al. Non-stented pancreaticogastros-tomy for 111 patients undergoing pylorus-preserving pancreaticoduo-denectomy. Hepatogatroenterology 2005;52:2537.

[39] Yeo CJ, Cameron JL, Lillemoe KD, et al. Does prophylactic ocre-otide decrease the rates of pancreatic stula and other complicationsafter pancreaticoduodenectomy? Results of a prospective randomizedplacebo-controlled trial. Ann Surg 2000;232:41929.

[40] Buchler MW, Friess H, Klempa I, et al. Role of octreotide in theprevention of post-operative complications following pancreatic re-section. Am J Surg 1992;163;12531.

[41] Shan YS, Sy ED, Tsai ML, et al. Effects of somatostatin prophylaxisafter pylorus preserving pancreatico-duodenectomy: increased de-layed gastric emptying and reduced plasma motilin. World J Surg2005;29:131924.

[42] Lillemoe KD, Cameron JL, Kim MP, et al. Does brin glue sealantdecrease the rate of Pancreatic stula after pancreaticoduodenec-tomy? Results of a prospective randomized trial. J Gastrointest Surg2004;8:76672.

[43] Adam U, Makowiec F, Riediger H, et al. [Pancreatic leakage afterpancreas resection. An analysis of 345 operated patients.] Chirug2002;73:46673.

[44] Standop J, Overhaus M, Schaefer N, et al. Pancreatogastrostomy afterpancreatoduodenectomy: a safe, feasible reconstruction method?World J Surg 2005;29:50512.

[45] Bassi C, Falconi M, Molinari E, et al. Reconstruction by pancreati-cojejunostomy following pancreaticoduodenectomy: results of a com-parative study. Ann Surg 2005;242:76771.

[46] Duffas JP, Suc B, Msika S, et al. A controlled randomized multicentertrial of pancreatogastrostomy or pancreatojejunostomy after pancre-atoduodenectomy. Amer J Surg 2005;189:7209.

[47] Jang JY, Kim SW, Park SJ, et al. Comparison of the functionaloutcome after pylorus-preserving pancreatoduodenectomy: pancrea-togastrostomy and pancreatojejunostomy. World J Surg 2002;26:36671.

[48] Ammori BJ, White CM. Proximal migration of transanastomoticpancreatic stents following pancreaticoduodenectomy and pancreatic

jejunostomy. Int J Pancreatol 1999;25:2115.[49] Schnelldorfer T, Lewin DN, Adams DB. Do preoperative pancreaticstents increase operative morbidity for chronic pancreatitis? Hepato-gastroenterology 2005;66:187882.

[50] Telford GL, Mason GR. Improved technique for pancreaticojejunos-tomy after pancreaticoduodenectomy. Am J Surg 1981;142:3867.

[51] Amano H, Takada T, Ammori BJ, et al. Pancreatic duct patency afterpancreaticogastrostomy: long-term follow-up study. Hepatogastroen-terology 1998;45:23827.

[52] Slezak LA, Andersen DK. Pancreatic resection. Effects on glucosemetabolism. World J Surg 2001;25:45260.

[53] Tani M, Terasawa H, Kawai M, et al. Improvement of delayedgastric emptying in pylorus-preserving pancreaticoduodenectomy:results of a prospective, randomized, controlled trial. Ann Surg2006;243:31620.

[54] Butler TJ, Vair DB, Colohan S, et al. Multivariate analysis of tech-

nical variables in pancreaticoduodenectomy: the effect of Pyloruspreservation and retro-mesenteric jejunal position on early outcome.Can J Surg 2004;47:3337.

[55] Park YC, Kim SW, Jang JY, et al. Factors inuencing delayed gastricemptying after pylorus-preserving pancreatoduodenectomy. J AmColl Surg 2003;196:85965.

[56] Kurosaki I, Hatakeyama K. Clinical and surgical factors inuencingdelayed gastric emptying after pyloric-preserving pancreaticoduode-nectomy. Hepatogastroenterology 2005;52:1438.

[57] Fischer CP, Hong JC. Method of pyloric reconstruction and impactupon delayed gastric emptying and hospital stay after pylorus-preserving pancreaticoduodenectomy. J Gastrointest Surg 2006;10:2159.

[58] Muller MW, Friess H, Beger HG, et al. Gastric emptying followingpylorus-preserving Whipple and duodenum-preserving pancreatichead resection in patients with chronic pancreatitis. Amer J Surg1997;173:25763.

[59] Shan YS, Tsai ML, Chiu NT, et al. Reconsideration of delayedgastric emptying in pancreaticoduodenectomy. World J Surg 2005;29:8739.

[60] Takahata S, Ohtsuka T, Nabae T, et al. Comparison of recovery of gastric phase III motility and gastric juice output after different typesof gastrointestinal reconstruction following pylorus-preserving pan-creatoduodenectomy. J Gastroenterol 2002;37:596603.

[61] Shan YS, Hsieh YH, Sy ED, et al. Delayed gastric emptying afterpylorus-preserving pancreaticoduodenectomy. J Formosa Med Assoc2004;103:76772.

[62] Strommer L, Raty S, Hennig R, et al. Delayed gastric emptying andintestinal hormones following pancreatoduodenectomy. Pancreatol-ogy 2005;5:53744.

[63] Riediger H, Makowiec F, Schareck WD, et al. Delayed gastric emp-tying after pylorus-preserving pancreatoduodenectomy is stronglyrelated to other postoperative complications. J Gastroenterol Surg2003;7:75865.

[64] Beger HG, Witte C, Krautzberger W, et al. Experience with duode-num-sparing pancreas head resection in chronic pancreatitis. Chirurg1980;51:3037.

[65] Beger HG, Schlosser W, Freiss HM, et al. Duodenum-preservinghead resection in chronic pancreatitis changes the natural course of the disease: a single-center 26 year experience. Ann Surg 1999;230:5129.

[66] Malka D, Hammel P, Sauvanet A, et al. Risk factors for diabe-tes mellitus in chronic pancreatitis. Gastroenterology 2000;119:132432.

[67] Buechler M, Friess H, Mueller MW, et al. Randomized trial of duodenum preserving pancreatic head resection versus pylorus pre-serving Whipple in chronic pancreatitis. Am J Surg 1995;169:65.

[68] Apelund G, Topazian MD, Lee JH, et al. Improved outcomes forbenign disease with limited pancreatic head resection. J GastrointestSurg 2005;9:4009.

[69] Frey CF, Smith GJ. Description and rationale of a new operation forchronic pancreatitis. Pancreas 1987;2:7017.

[70] Frey CF, Amikura K. Local resection of the head of the pancreascombined with longitudinal pancreaticojejunostomy in the manage-ment of patients with chronic pancreatitis. Arch Surg 1994;220:492507.

[71] Andersen DK, Topazian MD. Excavation of the pancreatic head: avariation on the theme of duodenum-preserving pancreatic head re-section. Arch Surg 2004;139:3759.

[72] Klempa I, Spatny M, Menzel J, et al. Pankreasfunktion und Kebens-qualitat nach Pankreaskopfresektion bei der chronischen Pankreatitis.Chirurg 1995;66:3509.

[73] Izbicki JR, Bloechle C, Broering DC, et al. Extended drainage versusresection in surgery for chronic pancreatitis prospective randomizedtrail comparing the longitudinal pancreatico-jejunostomy combinedwith local pancreatic head excision with pylorus preserving pancre-aticoduodenectomy. Ann Surg 1998;228:7719.

[74] Farkas G, Leindler L, Daroczi M, et al. Prospective randomizedcomparison of organpreserving pancreatic head resection with py-lorus-preserving pancreaticoduodenectomy. Langenbecks Arch Surg2006;391:33842.

[75] Izbicki JR, Bloechle C, Knoefel WT, et al. Duodenum preservinghead resections of the head of the pancreas in chronic pancreatitis: aprospective randomized trial. Ann Surg 1995;221:3508.



8/8

[76] Izbicki JR, Bloechle C, Knoefel WT, et al. Drainage versus resectionin surgical therapy of chronic pancreatitis of the head of the pancreas:a randomized study. Chirurg 1997;68:36977.

[77] Strate T, Taherpour Z, Bloechle C, et al. Long term follow-up of arandomized trial comparing the Beger and Frey procedures for pa-tients suffering from chronic pancreatitis. Ann Surg 2005;241:5918.

[78] Ramesh H, Jacob G, Lekha V, et al. Ductal drainage with head coringin chronic pancreatitis with small-duct disease. J Hepatobiliary Pan-creat Surg 2003;10;36672.

[79] Shrikhande SV, Kleef J, Friess H, et al. Management of painin small duct chronic pancreatitis. J Gastrointest Surg 2006;10:22733.


chronic pancreatitis - adhy

Documents