Duodenum-Preserving Resection of the Head of the Pancreas in Chronic Pancreatitis A Prospective, Randomized Trial

Abstract

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 Beger's (n = 20) or Frey's (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 Beger's and Frey's 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.

Italian consensus guidelines for chronic pancreatitis

“…Consensus Levels of Agreement: A+ 67.3%; A 24.5%; A− 6.1%; D− 2%; D 0%; D+ 0% Some RCTs have analyzed the results of the mixed procedures. Two RCTs [284,285] compared LR-LPJ vs. DPHR and showed similar short-term and long-term results for pain relief, pancreatic function, mortality rates and quality of life. LR-LPJ is technically easier to perform than DPHR because it does not require the section of the neck of the pancreas [286].…”

“…However, LPJ has not been evaluated in RCTs, even if it is widely used. A recent meta-analysis [283], some RCTs [228,232,284] and a recent review [266] have demonstrated the effectiveness of such procedures. DPHR, LR-LPJ and Berne operation are indicated when an inflammatory enlargement of the pancreatic head has been found with or without dilation of the ductal system.…”

Surgery for Chronic Pancreatitis

“…Endocrine and exocrine functions of the pancreas were not different between the two groups. There was a tendency for lower overall morbidity for Frey procedure (Frey: 9-22% vs Beger: 20-32%, respectively) [16,40]. Although long-term results seem to indicate that both approaches might be equally effective [52], neither procedure can be favoured over the other based on the current report..…”

“…Comparing Beger procedure with Frey procedure (RCT) [16,40,52], the pain relief (ranging between 93% and 95%), control of complications to adjacent organs (91% Frey, 92% Beger) and improvement in the QOL (58-67% increase in the overall QOL index) were similar. Endocrine and exocrine functions of the pancreas were not different between the two groups.…”

“…The longterm results in CP, however, are poor. Postoperative morbidities range between 30% and 50% [33][34][35][36] with disappointing endocrine and exocrine functions as compared with other resection procedures [16,32,33,[35][36][37][38][39][40]. Thus, PD is no longer a preferred choice in patients with CP.…”