Total pancreatectomy for chronic pancreatitis.

Abstract

SUMMARY The operation of total pancreatectomy is performed rarely. Its role in the management of patients with chronic pancreatitis remains to be elucidated. We have reviewed our series of 29 total pancreatectomies for benign disease [14 women median age 39 years; 15 men median age 34 years]. Twelve underwent standard total pancreatectomy, in 17 duodenum preserving total pancreatectomy (DPTP) was performed. There was one death (mortality 3.4%). In no patient was the total pancreatectomy the first operative procedure. The patients were compared with age and sex matched diabetic control subjects selected on a best fit basis from the diabetic clinic database. The aetliology of the pancreatitis was idiopathic nine, pancreas divisum nine, alcohol eight and other causes three. The indication for surgery was pain 27, acute pancreatitis one and cholangitis with pancreatitis one. The complications of the procedures were mainly caused by infection [wound three, chest six and central line sepsis four] and in two there was a leak from the duodenum; no patient required re-operation. The postoperative stay [standard total, median 21 days (range 13-98) DPTP median 31 days (range 17-49)] has lengthened over the period due to greater attention to analgesic, diabetic and enzyme deficiency control before discharge. In standard total pancreatectomy there were five major hypoglycaemic episodes with only two in 17 DPTP patients. The per cent ideal body weight, the insulin requirement and the HbAl compared less well in standard total pancreatectomy group compared with controls than did DPTP. With both groups large doses of enzyme replacement were required, and this proved of importance in diabetic control. Our experience with total pancreatectomy suggests that pain will be improved in over 80% of patients and that the results of surgery will improve with prolonged follow up provided attention is given to analgesic abuse, enzyme deficiency and diabetes.The role of surgery in the management of chronic pancreatitis is a subject of debate.' Most would agree that the place for surgery is clear when there is a complication of chronic pancreatitis amenable to surgical intervention. Unfortunately the problem often facing the clinician is that of a patient with chronic pain, on an increasing dosage and strength of analgesia, whose quality of life is destroyed by the effects of both pain and analgesia. There is a group of patients who fail to respond to, or who relapse after, non-surgical procedures such as nerve blocks and endoscopic sphincterotomies: of these, there are some whose symptoms are not relieved by pancreatic

Pancreatogenic Diabetes after Pancreatic Resection

“…The keen observations of Linehan et al [52] in 1988 from a series of total pancreatectomies revealed that the correct dose of pancreatic enzymes can produce optimal glycemic control and increase insulin demand, although these observations were not backed up by specific data. They proposed that rapid intestinal transit due to pancreatic insufficiency results in unpredictable glucose absorption and different levels of glucose uptake for every meal thus putting patients at risk of iatrogenic hypoglycemic attack.…”

Organ-preserving surgery for benign lesions and low-grade malignancies of the pancreatic head: A matched case-control study

“…4 Subsequent studies compared both techniques until fi nally the latter technique became established as the technical option for periampullary tumors. 5 During the 1970s and 1980s, patients needing surgery for chronic pancreatitis were subjected to aggressive pancreatectomies, [6][7][8][9] although some teams were critical of the postsurgical results. 9 To spare pancreatic tissue in these patients, Beger et al described cephalic pancreatectomy preserving the duodenum, namely, duodenum-preserving pancreatic head resection (DPPHR).…”

“…5 During the 1970s and 1980s, patients needing surgery for chronic pancreatitis were subjected to aggressive pancreatectomies, [6][7][8][9] although some teams were critical of the postsurgical results. 9 To spare pancreatic tissue in these patients, Beger et al described cephalic pancreatectomy preserving the duodenum, namely, duodenum-preserving pancreatic head resection (DPPHR). 10,11 When the outcomes of PPPD and DPPHR were compared, it was clear that pain control was similar but that DPPHR resulted in better postoperative quality of life (QOL).…”

Strategies in Preventing Diabetes after Pancreatectomy Using Islet Auto- and Allo-Transplantation

“…Several published works in the late 1970s demonstrated the effectiveness of Total Pancreatectomy (TP) for the amelioration of intractable pain experienced by those with chronic pancreatitis [17,29,30]. It has since been accepted as the best treatment option for patients who have exhausted or are not amenable to more conservative medical or surgical therapies.…”