Christian Bloechle

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.

OBJECTIVE To analyze the efficacy of extended drainage--that is, longitudinal pancreaticojejunostomy combined with local pancreatic head excision (LPJ-LPHE)-and pylorus-preserving pancreatoduodenectomy (PPPD) in terms of pain relief, control of complications arising from adjacent organs, and quality of life. SUMMARY BACKGROUND DATA Based on the hypotheses of pain origin (ductal hypertension and perineural inflammatory infiltration), drainage and resection constitute the main principles of surgery for chronic pancreatitis. METHODS Sixty-one patients were randomly allocated to either LPJ-LPHE (n = 31) or PPPD (n = 30). The interval between symptoms and surgery ranged from 12 months to 10 years (mean 5.1 years). In addition to routine pancreatic diagnostic workup, a multidimensional psychometric quality-of-life questionnaire and a pain score were used. Endocrine and exocrine functions were assessed in terms of oral glucose tolerance and serum concentrations of insulin, C-peptide, and HbA1c, as well as fecal chymotrypsin and pancreolauryl testing. During a median follow-up of 24 months (range 12 to 36), patients were reassessed in the outpatient clinic. RESULTS One patient died of cardiovascular failure in the LPJ-LPHE group (3.2%); there were no deaths in the PPPD group. Overall, the rate of in-hospital complications was 19.4% in the LPJ-LPHE group and 53.3% in the PPPD group, including delayed gastric emptying in 9 of 30 patients (30%; p < 0.05). Complications of adjacent organs were definitively resolved in 93.5% in the LPJ-LPHE group and in 100% in the PPPD group. The pain score decreased by 94% after LPJ-LPHE and by 95% after PPPD. Global quality of life improved by 71% in the LPJ-LPHE group and by 43% in the PPPD group (p < 0.01). CONCLUSIONS Both procedures are equally effective in terms of pain relief and definitive control of complications affecting adjacent organs, but extended drainage by LPJ-LPHE provides a better quality of life.

Duodenum-preserving resection of the head of the pancreas in chronic pancreatitis. A prospective, randomized trial.

ObjectiveTwo techniques of duodenum-preserving resection of the head of the pancreas were compared in a prospective, randomized trial. The technical feasibility and effects on quality of life were assessed. Summary Background DataDrainage and resection are the principles of surgery in chronic pancreatitis. The techniques of duodenum-preserving resection of the head of the pancreas as described by Beger and Frey combine both to different degrees. The efficacy of both procedures has not been compared thus far. MethodsForty-two patients were allocated randomly to either Begers (n = 20) or Freys (n = 22) group. In addition to routine pancreatic diagnostic work-up, a multidimensional psychometric quality-of-life questionnaire and and a pain score were used. Assessment of endocrine and exocrine function included oral glucose tolerance test, serum concentrations of insulin, C-peptide, and HbA1c, as well as fecal chymotrypsin and pancreolauryl test. The interval between symptoms and surgery ranged from 12 months to 12 years, with a mean of 5.7 years. The mean follow-up was 1.5 years. ResultsThere was no mortality. Overall morbidity was 14% (20% Beger, 9% Frey). Complications from adjacent organs were resolved definitively in 94% (90% Beger, 100% Frey). A decrease of 95% and 94% of the pain score after Begers and Freys procedure, respectively, and an increase of 67% of the overall quality-of-life index in both groups were observed. Endocrine and exocrine function did not differ between both groups. ConclusionsBoth techniques of duodenum-preserving resection of the head of the pancreas are equally safe and effective with regard to pain relief, improvement of quality of life, and definitive control of complications affecting adjacent organs. Neither procedure leads to further deterioration of endocrine and exocrine pancreatic function.

Quality of life in chronic pancreatitis-results after duodenum-preserving resection of the head of the pancreas

Studies on chronic pancreatitis have focused predominantly on pain measurement, morbidity, and mortality. In this prospective follow-up study the European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QLQ) was reevaluated for patients suffering from chronic pancreatitis. Pain intensity was quantified using a specially designed pain score. Twenty-five patients with chronic pancreatitis underwent duodenum-preserving pancreatic head resection. The QLQ, Spitzers quality of life index, and the pain score were assessed twice before surgery, before discharge, and 6 and 18 months after surgery. The interscale reliability (Cronbachs coefficient α ≥ 0.70) was confirmed for all multiitem scales except preoperative working ability. Test-retest stability for the QLQ was 94%. The QLQ correlated closely with Spitzers quality of life index (r = 0.985, p < 0.001) and changes in body weight (r = 0.764, p < 0.001). After 18 months physical status, working ability, emotional and social functioning, and global quality of life had improved by 44, 50, 50, 60, and 67%, respectively, showing good responsiveness of the QLQ. The pain score decreased by 95% (p < 0.001). The EORTC quality of life questionnaire represents a reliable and valid measure of quality of life in patients with chronic pancreatitis.

Long-term Follow-up of a Randomized Trial Comparing the Beger and Frey Procedures for Patients Suffering From Chronic Pancreatitis

Objective:To report on the long-term follow-up of a randomized clinical trial comparing pancreatic head resection according to Beger and limited pancreatic head excision combined with longitudinal pancreatico-jejunostomy according to Frey for surgical treatment of chronic pancreatitis. Summary Background Data:Resection and drainage are the 2 basic surgical principles in surgical treatment of chronic pancreatitis. They are combined to various degrees by the classic duodenum preserving pancreatic head resection (Beger) and limited pancreatic head excision combined with longitudinal pancreatico-jejunostomy (Frey). These procedures have been evaluated in a randomized controlled trial by our group. Long-term follow up has not been reported so far. Methods:Seventy-four patients suffering from chronic pancreatitis were initially allocated to DPHR (n = 38) or LE (n = 36). This postoperative follow-up included the following parameters: mortality, quality of life (QL), pain (validated pain score), and exocrine and endocrine function. Results:Median follow-up was 104 months (72-144). Seven patients were not available for follow-up (Beger = 4; Frey = 3). There was no significant difference in late mortality (31% [8/26] versus 32% [8/25]). No significant differences were found regarding QL (global QL 66.7 [0–100] versus 58.35 [0–100]), pain score (11.25 [0–75] versus 11.25 [0–99.75]), exocrine (88% versus 78%) or endocrine insufficiency (56% versus 60%). Conclusions:After almost 9 years’ long-term follow-up, there was no difference regarding mortality, quality of life, pain, or exocrine or endocrine insufficiency within the 2 groups. The decision which procedure to choose should be based on the surgeons experience.

Resection vs drainage in treatment of chronic pancreatitis: long-term results of a randomized trial.

BACKGROUND & AIMS Tailored organ-sparing procedures have been shown to alleviate pain and are potentially superior in terms of preservation of endocrine and exocrine function as compared with standard resection (Whipple) for chronic pancreatitis with inflammatory pancreatic head tumor. Long-term results comparing these 2 procedures have not been published so far. The aim of this study was to report on long-term results of a randomized trial comparing a classical resective procedure (pylorus-preserving Whipple) with an extended drainage procedure (Frey) for chronic pancreatitis. METHODS All patients who participated in a previously published randomized trial on the perioperative course comparing both procedures were contacted with a standardized, validated, quality of life and pain questionnaire. Additionally, patients were seen in the outpatient clinic to assess endocrine and exocrine pancreatic function by an oral glucose tolerance test and fecal chymotrypsin test. RESULTS There were no differences between both groups regarding quality of life, pain control, or other somatic parameters after a median of 7 years postoperatively. Correlations among continuous alcohol consumption, endocrine or exocrine pancreatic function, and pain were not found. CONCLUSIONS Both procedures provide adequate pain relief and quality of life after long-term follow-up with no differences regarding exocrine and endocrine function. However, short-term results favor the organ-sparing procedure.

Longitudinal V-shaped excision of the ventral pancreas for small duct disease in severe chronic pancreatitis: prospective evaluation of a new surgical procedure.

OBJECTIVE The technique of longitudinal V-shaped excision of the ventral pancreas for small duct chronic pancreatitis is presented and its efficacy in terms of pain relief and improvement of quality of life is evaluated. SUMMARY BACKGROUND DATA Small duct chronic pancreatitis has been regarded as a classical indication for more or less extensive resection, in which the therapeutic success of pain relief is offset by the considerable risk of significant perioperative mortality and morbidity and the burden of substantial loss of pancreatic function. METHODS Thirteen patients with severe pain who were diagnosed with small duct pancreatitis (defined as maximal Wirsungian ductal diameter of 2 mm) underwent longitudinal V-shaped excision of the ventral pancreas. In addition to routine pancreatic workup, a multidimensional psychometric quality-of-life questionnaire and a pain score were used. Assessment of exocrine and endocrine function included fecal chymotrypsin and the pancreolauryl test as well as oral glucose tolerance, serum concentrations of insulin, C-peptide, and hemoglobin A1c. The interval between symptoms and surgery ranged from 12 months to 10 years (mean, 5.4 years). Median follow-up was 30 months (range, 12-48 months). RESULTS There were no deaths. Overall morbidity was 15.4%. In 92% of patients, complete relief of symptoms was obtained. Median pain score decreased by 95%. Physical status, working ability, and emotional and social functioning scores improved by 40%, 50%, 67%,, and 75%, respectively. Global quality-of-life index increased by 67%. Occupational rehabilitation was achieved in 69% of patients. Exocrine and endocrine pancreatic function was well preserved. CONCLUSIONS In small duct chronic pancreatitis, longitudinal V-shaped excision of the ventral pancreas is a safe and effective alternative to resection procedures. The new technique provides pain relief and improvement of quality of life, thus offering the benefit of a resection procedure without its burden.

Attenuation of sepsis-related immunoparalysis by continuous veno-venous hemofiltration in experimental porcine pancreatitis.

ObjectivesIn light of evidence suggesting that hemofiltration favorably influences septic diseases by removing sepsis mediators, the impact of different modalities of continuous veno-venous hemofiltration (CVVH) on outcome and immunologic derangements in porcine pancreatogenic sepsis was evaluated. DesignRandomized, controlled intervention trial. SubjectsForty-eight minipigs of either sex. InterventionsPancreatitis was induced by intraductal injection of sodium taurocholate (4%, 1 mL/kg body weight [BW]) and enterokinase (2 U/kg BW). Animals were allocated either to untreated controls—group 1—or to one of three treatment groups—group 2: low-volume CVVH (20 mL/kg BW), no change of hemofilters; group 3: low-volume CVVH, filters changed every 12 hrs; and group 4: high-volume CVVH (100 mL/kg BW), filters changed every 12 hrs. Survival represented the major parameter of the study. Serum cytokine levels, sepsis-related down-regulation of major histocompatibility complex II and CD14 expression on leukocytes, bacterial translocation, and endotoxemia were further parameters evaluated in the study. Measurements and Main Results High-volume CVVH combined with periodic filter change was significantly superior compared with less intensive treatment modalities (low-volume CVVH, no filter change) in sepsis protection. Long-term survival (>60 hrs) was found in 67% of group 4 and 33% of group 3 animals (p < .05), whereas in controls and group 2 no animal survived. CVVH ameliorated the initial serum tumor necrosis factor-&agr; response and prevented sepsis-induced in vitro endotoxin hyporesponsiveness. Down-regulation of major histocompatibility complex II and CD14 expression on monocytes was significantly improved by CVVH. Improved oxidative burst and phagocytosis capacity in polymorphonuclear leukocytes suggested that leukocyte function was stabilized by CVVH. Also, CVVH significantly reduced bacterial translocation and endotoxemia. ConclusionsHemofiltration reversed sepsis-induced immunoparalysis in a porcine model of bile acid–induced pancreatitis. Implications for human pancreatitis must be validated in prospective, clinical protocols.

Drainage versus Resektion in der chirurgischen Therapie der chronischen Kopfpankreatitis: eine randomisierte Studie

Summary. Drainage and resection are the principles of surgery in chronic pancreatitis. The techniques of duodenum-preserving resection of the head of the pancreas as described by Beger and Frey combine both to different degrees. In a prospective randomized trial both procedures were compared: 74 patients were randomly allocated to either Begers (n = 38) or Freys (n = 36) group. In addition to routine pancreatic diagnostic work-up a multidimensional psychometric quality-of-life questionnaire and a pain score were used. Assessment of endocrine and exocrine function included oral glucose tolerance test, serum concentrations of insulin, C-peptide, and HbA1c, as well as fecal chymotrypsin and pancreolauryl test. The mean interval between symptoms and surgery was 5.1 years (1–12 years). The median follow-up was 30 months. There was no mortality. Overall morbidity was 27 % (32 % Beger, 22 % Frey). Complications from adjacent organs were definitively resolved in 91 % (92 % Beger, 91 % Frey). A decrease in pain score of 95 % and 93 % after Begers and Freys procedure, respectively, and an increase of 67 % in the overall quality-of-life index in both groups were observed. Endocrine and exocrine function did not differ between the two groups. Both techniques of duodenum-preserving resection of the head of the pancreas are equally safe and effective with regard to pain relief, improvement of quality of life, and control of complications affecting adjacent organs. Neither procedure leads to further deterioration of endocrine and exocrine pancreatic function.Zusammenfassung. Drainage und Resektion sind die Grundprinzipien in der chirurgischen Therapie der chronischen Pankreatitis. Die von Beger und Frey beschriebenen Techniken der duodenumerhaltenden Pankreaskopfresektion betonen diese in unterschiedlichem Ausmaß. In einer prospektiv randomisierten Studie wurden beide Verfahren verglichen; 74 Patienten wurden zufällig entweder der Beger- (n = 38) oder der Frey-Gruppe (n = 36) zugeteilt. Zusätzlich zur Routinediagnostik wurde ein multidimensionaler psychometrischer Lebensqualitätsfragebogen erhoben und das Schmerzempfinden anhand eines definierten Schmerzscores quantifiziert. Die endokrine und exokrine Pankreasfunktion wurde mit Hilfe des oralen Glucosetoleranztest, der Serumkonzentrationen von Insulin, C-Peptid und HbA1c sowie der Chymotrypsinkonzentration im Stuhl und des Pankreolauryltests untersucht. Das mittlere Intervall zwischen Symptombeginn und Operation betrug 5,1 (1–12) Jahre. Die mediane Nachbeobachtungszeit betrug 30 Monate. Die Krankenhausletalität war null. Die Gesamtmorbiditätsrate betrug 27 % (Beger-Gruppe: 32 %, Frey-Gruppe: 22 %). Assoziierte Komplikationen benachbarter Organe wurden bei 91 % der Patienten beherrscht (Beger-Gruppe: 92 %, Frey-Gruppe: 91 %). Der Schmerzscore nahm um 95 % in der Beger- und 93 % in der Frey-Gruppe ab, während die globale Lebensqualität in beiden Gruppen um 67 % anstieg. Die endokrinen und exokrinen Funktionsparameter unterschieden sich nicht signifikant zwischen den beiden Gruppen. Beide Techniken der duodenumerhaltenden Pankreaskopfresektion sind gleichermaßen sicher und effektiv in bezug auf Schmerzfreiheit und Verbesserung der Lebensqualität, ohne die endokrine und exokrine Pankreasfunktion zu verschlechtern. Assoziierte Komplikationen benachbarter Organe können mit beiden Verfahren beherrscht werden.

Extended resections are beneficial for patients with locally advanced colorectal cancer

PURPOSE: Locally advanced colorectal cancer often requires extended resection to radically remove all tumor. This is the only chance for cure in these patients, but a higher complication rate would be expected. To evaluate the overall benefit for the patient, this study assesses morbidity and mortality as well as long-term survival of patients who underwent extended resection for a T3–T4 carcinoma. METHODS: Two hundred twenty patients with locally advanced adenocarcinoma of the colorectum were included. One hundred fifty presented with a T3 and 70 with a T4 tumor. Eighty-three patients underwent extended resection. In 38 patients extendeden blocresection was performed because of inflammatory adherence mimicking infiltration. Thirty-three patients who underwent extended resections were over 70 years of age. There were no significant differences between the groups that underwent extended or nonextended resections in age, sex, stage, or grading. RESULTS: pT4 lesions were significantly more frequent in the extended resection group than in the nonextended resection group. Mean survival was 44 months after extended resections and 45 months after nonextended resections. In the extended resection group there was no significant difference in mean survival between pT3 and pT4 stage patients within 46 and 38 months, respectively. In patients who underwent nonextended resections, however, there was a significant difference in mean survival within 48 months for pT3 and 28 for pT4 patients (P< 0.05). Postoperative morbidity and mortality were comparable between the extended resection group and the non-extended resection group. The presence of residual tumor influenced prognosis of patients significantly; RO resections fared significantly better than patients who underwent R1 or R2 resections (55 and 51 to 14/12 and 23/8 months) (P< 0.01). Nodal stage and International Union Against Cancer stage were also significant determinants of prognosis. After extended resections mean survival morbidity and 30-day mortality in patients more than 70 years was similar to those less than 70 years. CONCLUSION: Because extended resections can achieve comparable results in locally more advanced colorectal cancer as nonextended resections in less advanced cancer, an aggressive surgical approach is warranted.

Effect of a pneumoperitoneum on the extent and severity of peritonitis induced by gastric ulcer perforation in the rat

Laparoscopic surgical repair of perforated gastroduodenal ulcer is technically feasible. To study the effect of a pneumoperitoneum on the extent and severity of peritonitis this animal study was devised. In rats gastric ulceration was induced by instillation of ethanol (50%, 2 ml) and followed by gastrotomy to simulate perforation. Animals were randomly allocated to pneumoperitoneum (PP) and control groups. In PP groups CO2 was insufflated intraperitoneally 6, 9, 12, and 24 h after gastrotomy. In controls the abdomen was only punctured. Animals were sacrificed 5 h after the end of PP or abdominal puncture. Blood cultures and intraabdominal swabs were assessed. A peritonitis severity score (PSS) based on histologies from peritoneum, liver, left kidney, spleen, and first jejunal loop was estimated. Six and 9 h after gastrotomy no significant differences between the PP and control groups were observed; 12 h after gastrotomy cultures of blood samples and abdominal swabs were positive in 67% and 75% in the PP group compared to 42% (P<0.05), and 42% (P<0.05) in controls. The mean PSS was 20.8 (standard deviation [SD] 2.2) in the PP group compared to 11.3 (1.5) (P<0.01) in controls; 24 h after gastrotomy cultures of blood samples and abdominal swabs were positive in 83% and 100% in the PP group compared to 42% (P<0.05) and 50% (P<0.01) in controls. The mean PSS was 22.1 (1.5) in the PP group compared to 11.8 (2.4) (P<0.01) in the controls. In rats a pneumoperitoneum aggravates the extent and severity of peritonitis, when the interval between gastric ulcer perforation and pneumoperitoneum lasts 12 h or longer.