The Liverpool duodenum-and spleen-preserving near-total pancreatectomy can provide long-term pain relief in patients with end-stage chronic pancreatitis
- 44 Downloads
Total pancreatectomy may improve symptoms in patients with severe end-stage chronic pancreatitis. This might be achieved whilst preserving both the duodenum- and spleen-(DPSPTP). Mature clinical outcomes of this approach are presented.
Single-centre prospective cohort study performed between September 1996 and May 2016. Demographic, clinical details, pain scores and employment status were prospectively recorded during clinic attendance.
Fifty-one patients (33 men, 18 women) with a median (interquartile range) age of 40.8 (35.3–49.4) years, a median weight of 69.8 (61.0–81.5) Kg and a median body mass index of 23.8 (21.5–27.8), underwent intended duodenum-and spleen-preserving near-total pancreatectomy for end-stage chronic pancreatitis. Aetiology was excess alcohol in 25, idiopathic (no mutation) in 15, idiopathic (SPINK-1/CFTR mutations) in two, hereditary (PRSS1 mutation) in seven and one each post-necrotising pancreatitis and obstructive pancreatic duct divisum in 1. The main indication for surgery was severe pain. Findings included parenchymal calcification in 79% and ductal calculi in 24%, a dilated main pancreatic duct in 57% and a dilated main bile duct in 17%, major vascular involvement in 27% and pancreato-peritoneal fistula in 2%. Postoperative complications occurred in 20 patients with two deaths. Median pain scores were 8 (7–8) preoperatively and 3 (0.25–5.75) at 5 years (p = 0.013). Opiate analgesic use was significantly reduced postoperatively (p = 0.048). Following surgery, 22 (63%) of 38 patients of working age re-entered employment compared with 12 (33%) working preoperatively (p = 0.016).
Duodenum-and spleen-preserving near-total pancreatectomy provided long-term relief in adult patients with intractable chronic pancreatitis pain, with improved employment prospects.
KeywordsChronic pancreatitis Total pancreatectomy Duodenum-preserving Spleen-preserving Total pancreatectomy Surgery Hereditary pancreatitis
We are grateful to the surgical team and specialist clinical nurses and other health care workers on the Pancreas Unit at the Royal Liverpool University Hospital for supporting this study.
A.R.G. Sheel: study concept and design, acquisition of data, analysis and interpretation of data, drafting of manuscript, critical review of manuscript. R.D. Baron: study concept and design, acquisition of data, analysis and interpretation of data, drafting of manuscript, critical review of manuscript. L.D. Dickerson: acquisition of data, critical review of manuscript. P. Ghaneh: acquisition of data, critical review of manuscript. F. Campbell: acquisition of data, analysis and interpretation of data, critical review of manuscript. M.G.T. Raraty: acquisition of data, critical review of manuscript. C.M. Halloran: acquisition of data, critical review of manuscript. J.P. Neoptolemos: study concept and design, acquisition of data, analysis and interpretation of data, drafting of manuscript, critical review of manuscript.
JPN was a Senior National Institute for Health Research Investigator during the course of the study (NF-SI-0512-10012).
Compliance with ethical standards
Conflict of interest
JPN has received research grants from NUCANA. ARGS has received research grants from the Royal College of Surgeons of England. RDB, PG and CMH have received research grants from Cancer Research UK. LDD, FC, MGTR and VY declare that that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
- 4.Yadav D, Hawes RH, Brand RE, Anderson MA, Money ME, Banks PA, Bishop MD, Baillie J, Sherman S, DiSario J, Burton FR, Gardner TB, Amann ST, Gelrud A, Lawrence C, Elinoff B, Greer JB, O'Connell M, Barmada MM, Slivka A, Whitcomb DC, North American Pancreatic Study Group (2009) Alcohol consumption, cigarette smoking, and the risk of recurrent acute and chronic pancreatitis. Arch Intern Med 169:1035–1045CrossRefGoogle Scholar
- 5.Threadgold J, Greenhalf W, Ellis I, Howes N, Lerch MM, Simon P, Jansen J, Charnley R, Laugier R, Frulloni L, Oláh A, Delhaye M, Ihse I, Schaffalitzky de Muckadell OB, Andrén-Sandberg A, Imrie CW, Martinek J, Gress TM, Mountford R, Whitcomb D, Neoptolemos JP (2002) The N34S mutation of SPINK1 (PSTI) is associated with a familial pattern of idiopathic chronic pancreatitis but does not cause the disease. Gut 50:675–681CrossRefGoogle Scholar
- 6.Howes N, Lerch MM, Greenhalf W, Stocken DD, Ellis I, Simon P, Truninger K, Ammann R, Cavallini G, Charnley RM, Uomo G, Delhaye M, Spicak J, Drumm B, Jansen J, Mountford R, Whitcomb DC, Neoptolemos JP, European Registry of Hereditary Pancreatitis and Pancreatic Cancer (EUROPAC) (2004) Clinical and genetic characteristics of hereditary pancreatitis in Europe. Clin Gastroenterol Hepatol 2:252–261CrossRefGoogle Scholar
- 8.Grocock CJ, Rebours V, Delhaye MN, Andrén-Sandberg A, Weiss FU, Mountford R, Harcus MJ, Niemczyck E, Vitone LJ, Dodd S, Jørgensen MT, Ammann RW, Schaffalitzky de Muckadell O, Butler JV, Burgess P, Kerr B, Charnley R, Sutton R, Raraty MG, Devière J, Whitcomb DC, Neoptolemos JP, Lévy P, Lerch MM, Greenhalf W, European Registry of Hereditary Pancreatitis and Pancreatic Cancer (2010) The variable phenotype of the p.A16V mutation of cationic trypsinogen (PRSS1) in pancreatitis families. Gut 59:357–363CrossRefGoogle Scholar
- 12.Drewes AM, Bouwense SAW, Campbell CM, Ceyhan GO, Delhaye M, Demir IE, Garg PK, van Goor H, Halloran C, Isaji S, Neoptolemos JP, Olesen SS, Palermo T, Pasricha PJ, Sheel A, Shimosegawa T, Szigethy E, Whitcomb DC, Yadav D, Working group for the International (IAP – APA – JPS – EPC) Consensus Guidelines for Chronic Pancreatitis (2017) Guidelines for the understanding and management of pain in chronic pancreatitis. Pancreatology 17:720–731CrossRefGoogle Scholar
- 16.Klaiber U, Alldinger I, Probst P, Bruckner T, Contin P, Köninger J, Hackert T, Büchler MW, Diener MK (2016) Duodenum-preserving pancreatic head resection: 10-year follow-up of a randomized controlled trial comparing the Beger procedure with the Berne modification. Surgery 160:127–135CrossRefGoogle Scholar
- 28.Ahmed Ali U, Nieuwenhuijs VB, van Eijck CH, Gooszen HG, van Dam R, Busch OR, Dijkgraaf MG, Mauritz FA, Jens S, Mast J, van Goor H, Boermeester MA, Dutch Pancreatitis Study Group (2012) Clinical outcome in relation to timing of surgery in chronic pancreatitis: a nomogram to predict pain relief. Arch Surg 147:925–932PubMedGoogle Scholar
- 33.Whitcomb DC, Shimosegawa T, Chari ST, Working Group for the International (IAP – APA – JPS – EPC) Consensus Guidelines for Chronic Pancreatitis 2018 et al International consensus statements on early chronic Pancreatitis. Recommendations from the working group for the international consensus guidelines for chronic pancreatitis in collaboration with The International Association of Pancreatology, American Pancreatic Association, Japan Pancreas Society, PancreasFest Working Group and European Pancreatic Club. Pancreatology 18(5):516–527CrossRefGoogle Scholar
- 34.Sheel ARG, Baron RD, Sarantitis I, Ramesh J, Ghaneh P, Raraty MGT, Yip V, Sutton R, Goulden MR, Campbell F, Farooq A, Healey P, Jackson R, Halloran CM, Neoptolemos JP (2018) The diagnostic value of Rosemont and Japanese diagnostic criteria for ‘indeterminate’, ‘suggestive’, ‘possible’ and ‘early’ chronic pancreatitis. Pancreatology 18(7):774–784CrossRefGoogle Scholar
- 35.Frøkjær JB, Akisik F, Farooq A, et al; Working group for the International (IAP – APA – JPS – EPC) Consensus Guidelines for Chronic Pancreatitis (2018) Guidelines for the diagnostic cross sectional imaging and severity scoring of chronic pancreatitis. Pancreatology 18(7):764–773CrossRefGoogle Scholar
- 37.Bellin MD, Prokhoda P, Hodges JS, Schwarzenberg SJ, Freeman ML, Dunn TB, Wilhelm JJ, Pruett TL, Kirchner VA, Beilman GJ, Chinnakotla S (2018) Age and disease duration impact outcomes of total pancreatectomy and islet autotransplant for PRSS1 hereditary pancreatitis. Pancreas 47(4):466–470CrossRefGoogle Scholar