Local Resection of the Head of the Pancreas Combined with Longitudinal Pancreaticojejunostomy in the Management of Patients with Chronic Pancreatitis

Abstract

OperationLocal resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy of the body and tail of the pancreas (LR-LPJ) was designed to improve decompression of the head of the pancreas, which often was not drained well by standard longitudinal pancreaticojejunostomy. This was achieved by excising the head of the pancreas overlying the ducts of Wirsung and Santorini, and duct to the uncinate, along with their tributary ducts. Patient MaterialThe operation has been performed on 50 patients. There were five late deaths among the 50 patients; two at 6 months, and one each at 24, 26, and 91 months. Eighty percent of the patients were alcoholics, 50% had pseudocysts, and 80% had calcification. AssessmentPain was assessed on a scale of 1 to 10, with 10 being most severe. Narcotic intake was considered minimal-Vicodin equivalent (hydrocodone bitartate, 5 mg, acetaminophen, 500 mg; Vicodin, Knoll Pharmaceuticals, Whippany, NJ) once or twice/month; moderate-Vicodin weekly, daily; and major-meperidine hydrochloride (Demerol, Winthrop Pharmaceuticals, New York, NY) weekly or daily. ResultsPain relief in 47 patients was excellent (74.5%), improved in 12.75%, and unimproved in 12.75%. Endocrine status in 45 patients was as follows: 69% were not diabetic, and 20% were diabetic preoperatively and postoperatively. Postoperatively, 1 1% had progression of their diabetes. Exocrine function was not worsened and may have been improved in some patients. Sixty-four percent of 39 patients gained an average of 15.3 pounds. Fifty-nine percent of patients were not working preoperatively or postoperatively. ConclusionsThe LR-LPJ provides good pain relief with a modest increase in endocrine and exocrine insufficiency and a significant increase in weight. Even when relieved of pain, patients seldom return to the work force. 492

Tratamento cirúrgico da pancreatite crônica com a técnica de F rey: panorama atual

“…Both endocrine and exocrine pancreatic dysfunction seem to have less influence on late mortality of patients with CP than the continued use of alcohol, narcotics, liver failure, suicide, accidents and recurrent pancreatitis 11 . However, this does not diminish the goal to preserve pancreatic function because they greatly influence the quality of life.…”

“…In addition, articles began to appear showing that despite a remission rate of pain about 80% in three years, approximately 30% of patients had recurrent pain with this technique after this period 7 . Later, it was well established that the main cause of failure of the Partington-Rochelle procedure is the absence of adequate decompression of the proximal main pancreatic duct, and uncinate process and secondary ducts of pancreas 11 . Given to these observations, the partial or total resection of the pancreas appeared to be an attractive solution for the definitive resolution of the pain caused by the disease, since even if the pain was caused by an inflammatory process that affects the nerves, for ductal hypertension or chronic ischemia, surgical removal of pancreatic injured tissue would heal it.…”

“…The technique also proved to be easier to perform and with less morbidity than Beger's technique with similar results with regard to pain management in long follow-up 17 . The rate of postoperative complications reported in international literature varies from 0% to 42%; comprehensive national study presented by Gestic had postoperative morbidity of 28.7% 10,11,13,15,16,17,22,23 . Most of these complications are due to infectious complications, mainly pneumonia 23 .…”

“…The operative mortality ranges from 0% to 3.2% and the causes are more often assigned is sepsis (abdominal and lung) and bleeding 10,11,13,15,16,17,22,23 . Several papers of reference centers for surgical treatment of CP reported rates of postoperative bleeding less than 3%, grouping all the techniques employed.…”

Surgery for Chronic Pancreatitis

“…Frey (G) introduced a prototype procedure that consists of coring the head of pancreas combined with LPJ as described by Partington and Rochelle, and the procedure avoids transection of the neck above the portal vein [14,15]. Being simple to perform, it has been accepted widely and has been modified with varying extent of resection of the head of the pancreas along with the uncinate process known as Hamburg's modification.…”