Der Chirurg

, Volume 84, Issue 2, pp 112–116

Chirurgisches Vorgehen bei chronischer Pankreatitis

Drainierende und resezierende Verfahren
Leitthema

Zusammenfassung

Die chirurgische Therapie der chronischen Pankreatitis (CP) umfasst als wichtigste Ziele die Schmerzfreiheit und gute langfristige Lebensqualität bei gleichzeitigem größtmöglichem Erhalt der endo- und exokrinen Organfunktion. Vom chirurgischen Ansatz stehen dabei die Entlastung des gestauten Pankreas- (und Gallen-)gangs sowie die Resektion von fibrotischem und kalzifiziertem Gewebe im Mittelpunkt. Die reinen Drainageverfahren kommen bei Pseudozysten (Zystojejunostomie) sowie selten als laterale Pankreatikojejunostomie nach Partington bei Gangdilatation ohne weitere entzündliche Organauftreibung zur Anwendung. Beim größten Teil der Patienten besteht ein entzündlicher Tumor des Pankreaskopfes mit konsekutivem Gangaufstau. Hier können bevorzugt die verschiedenen Modifikationen der duodenumerhaltenden Pankreaskopfresektion (Beger, Bern) eingesetzt werden, eine partielle Duodenopankreatektomie ist ebenfalls möglich, kann jedoch v. a. bei entzündlicher Beteiligung der Pfortader und ausgeprägten venösen Kollateralkreisläufen schwieriger durchzuführen sein. Die Pankreassegmentresektion und die V-shaped-Exzision bleiben Sonderindikationen vorbehalten (segmentale Fibrose bzw. „small-duct disease“) und werden bezogen auf das chirurgische Gesamtkollektiv selten (ca. 5%) durchgeführt. Bei Verdacht auf das Vorliegen eines Malignoms auf dem Boden der CP muss immer eine formale Resektion (partielle, distale oder totale Pankreatikoduodenektomie) nach onkologischen Kriterien erfolgen.

Schlüsselwörter

Chronische Pankreatitis Drainageoperation Duodenumerhaltende Pankreaskopfresektion Schmerz Lebensqualität 

Surgical approach to chronic pancreatitis

Draining and resection procedure

Abstract

The major aims of surgical therapy in chronic pancreatitis (CP) are pain relief and good long-term quality of life with preservation of endocrine and exocrine organ function. The surgical approach is therefore focused on drainage of the congested pancreatic (and bile) duct as well as resection of fibrotic and calcified tissue. Draining procedures alone are adequate for drainage of pseudocysts (cystojejunostomy) and the pancreatic duct (Partington) if no inflammatory tumor is present in the organ. Most CP patients present with unclear head mass and subsequent duct dilation. In these patients the different modifications of duodenum-preserving pancreatic head resections (e.g. Beger, Bern) offer a preferable option. Partial duodenopancreatectomy is an alternative but may be difficult to perform due to inflammatory changes around the portal vein and venous collaterals. Segmental resection and V-shaped excision may be appropriate in special situations (segmental fibrosis, small duct disease) and are performed less frequently (approximately 5 %) in the entire surgical CP population. In cases of suspected CP-related malignancy, formal resections (partial, distal or total pancreaticoduodenectomy) must be the surgical procedures of choice and be performed according to oncological principles.

Keywords

Chronic pancreatitis Drainage operation Duodenum-preserving pancreatic head resection Pain Quality of life 

Literatur

  1. 1.
    Hunger RE, Mueller C, Z’graggen K et al (1997) Cytotoxic cells are activated in cellular infiltrates of alcoholic chronic pancreatitis. Gastroenterology 112:1656–1663PubMedCrossRefGoogle Scholar
  2. 2.
    Di Sebastiano P, Mola FF di, Bockman DE et al (2003) Chronic pancreatitis: the perspective of pain generation by neuroimmune interaction. Gut 52:907–911CrossRefGoogle Scholar
  3. 3.
    Di Sebastiano P, Fink T, Weihe E et al (1997) Immune cell infiltration and growth-associated protein 43 expression correlate with pain in chronic pancreatitis. Gastroenterology 112:1648–1655CrossRefGoogle Scholar
  4. 4.
    Friess H, Zhu ZW, Mola FF di et al (1999) Nerve growth factor and its high-affinity receptor in chronic pancreatitis. Ann Surg 230:615–624PubMedCrossRefGoogle Scholar
  5. 5.
    Ceyhan GO, Bergmann F, Kadihasanoglu M et al (2009) Pancreatic neuropathy and neuropathic pain: a comprehensive pathomorphological study of 546 cases. Gastroenterology 136:177–186PubMedCrossRefGoogle Scholar
  6. 6.
    Bachmann K, Izbicki JR, Yekebas EF (2011) Chronic pancreatitis: modern surgical management. Langenbecks Arch Surg 396:139–149PubMedCrossRefGoogle Scholar
  7. 7.
    Raimondi S, Lowenfels AB, Morselli-Labate AM et al (2010) Pancreatic cancer in chronic pancreatitis; aetiology, incidence, and early detection. Best Pract Res Clin Gastroenterol 24:349–358PubMedCrossRefGoogle Scholar
  8. 8.
    Lerch MM, Stier A, Wahnschaffe U et al (2009) Pancreatic pseudocysts: observation, endoscopic drainage, or resection? Dtsch Arztebl Int 106:614–621PubMedGoogle Scholar
  9. 9.
    Behrns KE, Ben-David K (2008) Surgical therapy of pancreatic pseudocysts. J Gastrointest Surg 12:2231–2239PubMedCrossRefGoogle Scholar
  10. 10.
    Schneider CG, Cataldegirmen G, Mann O et al (2009) Lateral anastomosis techniques: Partington-Rochelle and V-shaped excision. Chirurg 80:28–33PubMedCrossRefGoogle Scholar
  11. 11.
    Hoffmeister A, Mayerle J, Beglinger C et al und die Mitglieder der Leitlinienkommission (2012) S3-Consensus guidelines on definition, etiology, diagnosis and medical, endoscopic and surgical management of chronic pancreatitis German Society of Digestive and Metabolic Diseases (DGVS). Z Gastroenterologie 50:1176–1224CrossRefGoogle Scholar
  12. 12.
    Sakorafas GH, Farnell MB, Nagorney DM et al (2000) Pancreatoduodenectomy for chronic pancreatitis: long-term results in 105 patients. Arch Surg 135:517–523PubMedCrossRefGoogle Scholar
  13. 13.
    Cataldegirmen G, Bogoevski D, Mann O et al (2008) Late morbidity after duodenum-preserving pancreatic head resection with bile duct reinsertion into the resection cavity. Br J Surg 95:447–452PubMedCrossRefGoogle Scholar
  14. 14.
    Morgan KA, Fontenot BB, Harvey NR et al (2010) Revision of anastomotic stenosis after pancreatic head resection for chronic pancreatitis: is it futile? HPB (Oxford) 12:211–216Google Scholar
  15. 15.
    Hackert T, Tjaden C, Lutz S et al (2011) Redo-operations in chronic pancreatitis: indications, procedures and outcome. Pancreas 40:1324–1324Google Scholar
  16. 16.
    Müller MW, Friess H, Kleeff J et al (2007) Is there still a role for total pancreatectomy? Ann Surg 246:966–975PubMedCrossRefGoogle Scholar
  17. 17.
    White SA, Sutton CD, Weymss-Holden S et al (2000) The feasibility of spleen-preserving pancreatectomy for end-stage chronic pancreatitis. Am J Surg 179:294–297PubMedCrossRefGoogle Scholar
  18. 18.
    Billings BJ, Christein JD, Harmsen WS et al (2005) Quality-of-life after total pancreatectomy: is it really that bad on long-term follow-up? J Gastrointest Surg 9:1059–1067PubMedCrossRefGoogle Scholar
  19. 19.
    Bramis K, Gordon-Weeks AN, Friend PJ et al (2012) Systematic review of total pancreatectomy and islet autotransplantation for chronic pancreatitis. Br J Surg 99:761–766. DOI 10.1002/bjs.8713PubMedCrossRefGoogle Scholar
  20. 20.
    Beger HG, Buchler M, Bittner RR et al (1989) Duodenum-preserving resection of the head of the pancreas in severe chronic pancreatitis. Early and late results. Ann Surg 209:273–278PubMedCrossRefGoogle Scholar
  21. 21.
    Bockhorn M, Gebauer F, Bogoevski D et al (2011) Chronic pancreatitis complicated by cavernous transformation of the portal vein: contraindication to surgery? Surgery 149:321–328PubMedCrossRefGoogle Scholar
  22. 22.
    Frey CF, Amikura K (1994) Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy in the management of patients with chronic pancreatitis. Ann Surg 220:492–507PubMedCrossRefGoogle Scholar
  23. 23.
    Keck T, Marjanovic G, Fernandez-del Castillo C et al (2009) The inflammatory pancreatic head mass: significant differences in the anatomic pathology of German and American patients with chronic pancreatitis determine very different surgical strategies. Ann Surg 249:105–110PubMedCrossRefGoogle Scholar
  24. 24.
    Gloor B, Friess H, Uhl W et al (2001) A modified technique of the Beger and Frey procedure in patients with chronic pancreatitis. Dig Surg 18:21–25PubMedCrossRefGoogle Scholar
  25. 25.
    Müller MW, Friess H, Leitzbach S et al (2008) Perioperative and follow-up results after central pancreatic head resection (Berne technique) in a consecutive series of patients with chronic pancreatitis. Am J Surg 196:364–372PubMedCrossRefGoogle Scholar
  26. 26.
    Köninger J, Seiler CM, Sauerland S et al (2008) Duodenum-preserving pancreatic head resection: a randomized controlled trial comparing the original Beger procedure with the Berne modification (ISRCTN No. 50638764). Surgery 143:490–498PubMedCrossRefGoogle Scholar
  27. 27.
    Büchler MW, Friess H, Muller MW et al (1995) Randomized trial of duodenumpreserving pancreatic head resection versus pylorus-preserving Whipple in chronic pancreatitis. Am J Surg 169:65–69PubMedCrossRefGoogle Scholar
  28. 28.
    Klempa I, Spatny M, Menzel J et al (1995) Pancreatic function and quality of life after resection of the head of the pancreas in chronic pancreatitis. A prospective, randomized comparative study after duodenum preserving resection of the head of the pancreas versus Whipple’s operation. Chirurg 66:350–359PubMedGoogle Scholar
  29. 29.
    Müller MW, Friess H, Martin DJ et al (2008) Long-term follow-up of a randomized clinical trial comparing Beger with pylorus-preserving Whipple procedure for chronic pancreatitis. Br J Surg 95:350–356PubMedCrossRefGoogle Scholar
  30. 30.
    Keck T, Adam U, Makowiec F et al (2012) Short- and long-term results of duodenum preservation versus resection for the management of chronic pancreatitis: a prospective, randomized study. Surgery 152(Suppl 1):95–102. DOI 10.1016/j.surg.2012.05.016CrossRefGoogle Scholar
  31. 31.
    Strate T, Bachmann K, Busch P et al (2008) Resection vs drainage in treatment of chronic pancreatitis: long-term results of a randomized trial. Gastroenterology 134:1406–1411PubMedCrossRefGoogle Scholar
  32. 32.
    Diener MK, Rahbari NN, Fischer L et al (2008) Duodenum-preserving pancreatic head resection versus pancreatoduodenectomy for surgical treatment of chronic pancreatitis: a systematic review and meta-analysis. Ann Surg 247:950–961PubMedCrossRefGoogle Scholar
  33. 33.
    Diener MK, Bruckner T, Contin P et al (2010) ChroPac-trial: duodenum-preserving pancreatic head resection versus pancreatoduodenectomy for chronic pancreatitis. Trial protocol of a randomised controlled multicentre trial. Trials 11:47PubMedCrossRefGoogle Scholar
  34. 34.
    Müller MW, Friess H, Kleeff J et al (2006) Middle segmental pancreatic resection: an option to treat benign pancreatic body lesions. Ann Surg 244:909–920PubMedCrossRefGoogle Scholar
  35. 35.
    Kutup A, Vashist Y, Kaifi JT et al (2010) For which type of chronic pancreatitis is the „Hamburg procedure“ indicated? J Hepatobiliary Pancreat Sci 17:758–762PubMedCrossRefGoogle Scholar
  36. 36.
    Izbicki JR, Bloechle C, Knoefel WT et al (1995) Duodenum-preserving pancreatic head resection in chronic pancreatits. A prospective randomized trial. Am Surg 221:350–358Google Scholar
  37. 37.
    Farkas G, Leindler L, Daróczi M et al (2006) Prospective randomized comparison of organ-preserving pancreatic head resection with pylorus-preserving pancreaticoduodenectomy. Langenbecks Arch Surg 391:338–342PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  1. 1.Klinik für Allgemeine, Viszerale und TransplantationschirurgieUniversität HeidelbergHeidelbergDeutschland

Personalised recommendations