Clinical Experience with Different Techniques of Pancreatic Head Resection for Chronic Pancreatitis / with Invited CommentaryKelemen D. · Horváth Ö.P.
Department of Surgery, Medical Faculty, Pécs University, Pécs, Hungary
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Background/Aims: Recently organ-saving procedures have become popular in the treatment of chronic pancreatitis with head enlargement. The purpose of this study is to compare the results of three different procedures. Methods: Between 1991 and 1998, 32 Beger operations, 13 Frey procedures and 21 pylorus-preserving pancreatoduodenectomies (PPPDs) were performed. The pre-, intra- and postoperative data were detailed. During the follow-up examination the quality of life, body weight, consumption of alcohol and enzymes, as well as the carbohydrate metabolism were checked. Results: Considering the operative and late mortality and reoperation rate, there was no difference between the procedures. The postoperative hospitalization time was the shortest after the duodenum-preserving pancreatic head resections (Beger and Frey). While the rate of early morbidity was higher after PPPDs, there was no difference in late morbidity between the groups. The condition of the patients was better and the development rate of diabetes was lower after the Beger procedure than after PPPDs. Conclusion: Consequently duodenum-preserving pancreatic head resections seem to be more advantageous than PPPD. Nevertheless the latter operation is the only possibility in some situations.
© 2002 S. Karger AG, Basel
W. Schlosser, H.G. Beger
Department of General Surgery, University Hospital of Ulm, Germany
The authors present their monoinstitutional results of pancreatic head resection in chronic pancreatitis patients. They compared two duodenum-preserving pancreatic head resection (DPPHR) procedures (32 Beger procedures, 13 Frey procedures) and the pylorus-preserving pancreaticoduodenectomy (21 PPPD), operated between 1991 and 1998. The study was designed in a prospective but not in randomized fashion. The authors compared clinical outcome and long-term results with regard to pain, endocrine function, enzyme treatment, alcohol consumption and quality of life (QOL) after a mean follow-up period of 20.6 (Frey), 31.1 (PPPD) and 41.5 months (Beger). They found no differences concerning operative mortality in the early and late postoperative course. The hospitalization was shorter in the DPPHRs compared to the PPPD and the postoperative mortality was significantly higher in the PPPD group. Regarding the long-term results the patients operated with the DPPHR had a better preserved endocrine function and a better QOL score compared to the PPPD patients.
Although the study is not randomized, the results are comparable to randomized investigations with regard to a superior early and late outcome for patients operated with the DPPHR technique compared to the PPPD [1–3]. In comparison to major multiorgan resections like the Whipple resection and the PPPD, the DPPHR enables the preservation of the biliary tree, stomach and duodenum. Early and late morbidity after the Whipple procedure are related to the reduced insulin secretion, the occurrence of early and late dumping complaints and attacks of cholangitis. In three prospective clinical investigations the DPPHR has been found to be superior in comparison with the pylorus-preserving pancreatic head resection [1–3]. Compared to the Whipple procedure, the DPPHR revealed a better preserved exocrine function and a better postoperative weight gain after a mean follow-up between 36 and 72 months . In 1985 Beger et al.  published a modification combining a duodenum-preserving head resection with lateral pancreatic duct drainage using the jejunal loop in chronic pancreatitis complicated by pancreatic duct dilatations and stenosis.
Clinical, pathomorphological molecular biologic investigations support the hypothesis that the pancreatic head is the pacemaker in alcoholic chronic pancreatitis. Subtotal resection of the pancreatic head, as performed in the DPPHR, leads to relief of the local complications like common bile duct stenosis, decompression of the duodenum or the portal vein/upper mesenteric vein. The Frey procedure has been introduced primarily as a drainage procedure with an additional minor resection of part of the pancreatic head. In contrast to the DPPHR technique, the Frey procedure is a coring-out of a part of the pancreatic head with an average specimen weight of less than 6 g . The Frey operation is a modified Partington- Rochelle procedure which leaves the major part of the inflammatory mass in the pancreatic head. Consequently this procedure is not effective against cholestasis because the resection is not appropriate to decompress the common bile duct in the intrapancreatic segment. In the subgroup of patients with an inflammatory mass in the pancreatic head, who represent a major part of patients with alcoholic chronic pancreatitis, preservation of the major part of the inflamed pancreatic head results in further attacks of acute pancreatitis and lower pain relief in the long-term follow-up. Even if a prospective trial between DPPHR and the Frey procedure revealed no differences concerning relief of pain, QOL, endocrine and exocrine function, the Frey procedure is not the appropriate type of operation to resolve local complications due to an inflammatory mass in the pancreatic head . The ‘Frey procedure’, as proposed by Izbicki et al. , resulting in subtotal resection of the pancreatic head is similar or rather identical to the principle of DPPHR.
The paper presented here again demonstrates the superiority of the DPPHR over the PPPD in chronic pancreatitis patients. Nevertheless, perhaps due to the significant differences regarding the mean follow-up period of the Beger group (41.5 months) and the Frey group (20.6 months), no difference could be detected in the analysis between both techniques of the DPPHR. To demonstrate the advantages of the Beger procedure, evaluations of the late outcome of an at least 5-year mean follow-up in randomized studies are necessary .
01 Büchler MW, Friess H, Müller MW, et al: Randomized trial of duodenum-preserving pancreatic head resection versus pylorus preserving Whipple in chronic pancreatitis. Am J Surg 1995;169:65–69.
02 Izbicki JR, Bloechle C, Broering D, et al: 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;228:771–779.
03 Klempa I, Spatny M, Menzel J: Pankreasfunktion und Lebensqualität nach Pankreaskopfresektion bei der chronischen Pankreatitis. Chirurg 1995;66:350–359.
04 Beger HG, Krautzberger W, Bittner R, et al: Duodenum-preserving resection of the head of the pancreas in patients with severe chronic pancreatitis. Surgery 1985;97:467–473.
05 Frey CF, Smith GJ: Description and rationale of a new operation for chronic pancreatitis. Pancreas 1987;2:701–707.
06 Beger HG, Schlosser W, Friess HM, Büchler MW: Duodenum-preserving head resection in chronic pancreatitis changes the natural course of the disease. Ann Surg 1999;230:512–523.
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