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Langenbeck's Archives of Surgery

, Volume 404, Issue 7, pp 831–840 | Cite as

The Liverpool duodenum-and spleen-preserving near-total pancreatectomy can provide long-term pain relief in patients with end-stage chronic pancreatitis

  • A. R. G. Sheel
  • R. D. Baron
  • L. D. Dickerson
  • P. Ghaneh
  • F. Campbell
  • M. G. T. Raraty
  • V. Yip
  • C. M. Halloran
  • J. P. NeoptolemosEmail author
Original Article
  • 44 Downloads

Abstract

Purpose

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.

Methods

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.

Results

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).

Conclusion

Duodenum-and spleen-preserving near-total pancreatectomy provided long-term relief in adult patients with intractable chronic pancreatitis pain, with improved employment prospects.

Keywords

Chronic pancreatitis Total pancreatectomy Duodenum-preserving Spleen-preserving Total pancreatectomy Surgery Hereditary pancreatitis 

Notes

Acknowledgements

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.

Authors’ contributions

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.

Funding information

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.

Ethical approval

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.

References

  1. 1.
    Whitcomb DC, Frulloni L, Garg P, Greer JB, Schneider A, Yadav D, Shimosegawa T (2016) Chronic pancreatitis: an international draft consensus proposal for a new mechanistic definition. Pancreatology 16:218–224CrossRefGoogle Scholar
  2. 2.
    Etemad B, Whitcomb DC (2001) Chronic pancreatitis: diagnosis, classification, and new genetic developments. Gastroenterology 120:682–707CrossRefGoogle Scholar
  3. 3.
    Kleeff J, Whitcomb DC, Shimosegawa T et al (2017) Chronic pancreatitis. Nat Rev Dis Primers 3:17060CrossRefGoogle Scholar
  4. 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. 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. 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
  7. 7.
    Cohn JA, Neoptolemos JP, Feng J, Yan J, Jiang Z, Greenhalf W, McFaul C, Mountford R, Sommer SS (2005) Increased risk of idiopathic chronic pancreatitis in cystic fibrosis carriers. Hum Mutat 26:303–307CrossRefGoogle Scholar
  8. 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
  9. 9.
    Frokjaer JB, Akisik F, Farooq A et al (2018) Guidelines for the diagnostic cross sectional imaging and severity scoring of chronic pancreatitis. Pancreatology 18:764–773CrossRefGoogle Scholar
  10. 10.
    Lowenfels AB, Maisonneuve P, Cavallini G et al (1993) Pancreatitis and the risk of pancreatic cancer. International Pancreatitis Study Group. N Engl J Med 328:1433–1437CrossRefGoogle Scholar
  11. 11.
    van der Gaag NA, van Gulik TM, Busch OR et al (2012) Functional and medical outcomes after tailored surgery for pain due to chronic pancreatitis. Ann Surg 255:763–770CrossRefGoogle Scholar
  12. 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
  13. 13.
    Beger HG, Witte C, Krautzberger W, Bittner R (1980) Experiences with duodenum-sparing pancreas head resection in chronic pancreatitis. Chirurg 51:303–307PubMedGoogle Scholar
  14. 14.
    Beger HG, Schlosser W, Friess HM et al (1999) Duodenum-preserving head resection in chronic pancreatitis changes the natural course of the disease: a single-center 26-year experience. Ann Surg 230:512–519 discussion 519-523CrossRefGoogle Scholar
  15. 15.
    Frey CF, Smith GJ (1987) Description and rationale of a new operation for chronic pancreatitis. Pancreas 2:701–707CrossRefGoogle Scholar
  16. 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
  17. 17.
    Evans JD, Wilson PG, Carver C et al (1997) Outcome of surgery for chronic pancreatitis. Br J Surg 84:624–629CrossRefGoogle Scholar
  18. 18.
    Diener MK, Huttner FJ, Kieser M et al (2017) Partial pancreatoduodenectomy versus duodenum-preserving pancreatic head resection in chronic pancreatitis: the multicentre, randomised, controlled, double-blind ChroPac trial. Lancet 390:1027–1037CrossRefGoogle Scholar
  19. 19.
    Cooper MJ, Williamson RC, Benjamin IS, Carter DC, Cuschieri A, Linehan IP, Russell RC, Torrance HB (1987) Total pancreatectomy for chronic pancreatitis. Br J Surg 74:912–915CrossRefGoogle Scholar
  20. 20.
    Russell R (1995) Duodenum-preserving total pancreatectomy for chronic pancreatitis. J Hepato-Biliary-Pancreat Surg 2:45–51CrossRefGoogle Scholar
  21. 21.
    Wagner M, Z'Graggen K, Vagianos CE et al (2001) Pylorus-preserving total pancreatectomy. Early and late results. Dig Surg 18:188–195CrossRefGoogle Scholar
  22. 22.
    White SA, Sutton CD, Weymss-Holden S, Berry DP, Pollard C, Rees Y, Dennison AR (2000) The feasibility of spleen-preserving pancreatectomy for end-stage chronic pancreatitis. Am J Surg 179:294–297CrossRefGoogle Scholar
  23. 23.
    Alexakis N, Ghaneh P, Connor S, Raraty M, Sutton R, Neoptolemos JP (2003) Duodenum-and spleen-preserving total pancreatectomy for end-stage chronic pancreatitis. Br J Surg 90:1401–1408CrossRefGoogle Scholar
  24. 24.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213CrossRefGoogle Scholar
  25. 25.
    Issa Y, van Santvoort HC, van Goor H, Cahen DL, Bruno MJ, Boermeester MA (2013) Surgical and endoscopic treatment of pain in chronic pancreatitis: a multidisciplinary update. Dig Surg 30:35–50CrossRefGoogle Scholar
  26. 26.
    Alexakis N, Connor S, Ghaneh P, Raraty M, Lombard M, Smart H, Evans J, Hughes M, Garvey CJ, Goulden M, Parker C, Sutton R, Neoptolemos JP (2004) Influence of opioid use on surgical and long-term outcome after resection for chronic pancreatitis. Surgery 136:600–608CrossRefGoogle Scholar
  27. 27.
    Alexakis N, Sutton R, Raraty M, Connor S, Ghaneh P, Hughes ML, Garvey C, Evans JC, Neoptolemos JP (2004) Major resection for chronic pancreatitis in patients with vascular involvement is associated with increased postoperative mortality. Br J Surg 91:1020–1026CrossRefGoogle Scholar
  28. 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
  29. 29.
    Gall FP, Muhe E, Gebhardt C (1981) Results of partial and total pancreaticoduodenectomy in 117 patients with chronic pancreatitis. World J Surg 5:269–275CrossRefGoogle Scholar
  30. 30.
    Fleming WR, Williamson RC (1995) Role of total pancreatectomy in the treatment of patients with end-stage chronic pancreatitis. Br J Surg 82:1409–1412CrossRefGoogle Scholar
  31. 31.
    Garcea G, Weaver J, Phillips J, Pollard CA, Ilouz SC, Webb MA, Berry DP, Dennison AR (2009) Total pancreatectomy with and without islet cell transplantation for chronic pancreatitis: a series of 85 consecutive patients. Pancreas 38:1–7CrossRefGoogle Scholar
  32. 32.
    Holdsworth RJ, Irving AD, Cuschieri A (1991) Postsplenectomy sepsis and its mortality rate: actual versus perceived risks. Br J Surg 78:1031–1038CrossRefGoogle Scholar
  33. 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. 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. 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
  36. 36.
    Bellin MD, Beilman GJ, Sutherland DE et al (2019) How durable is total pancreatectomy and intraportal islet cell transplantation for treatment of chronic pancreatitis? J Am Coll Surg 228(4):329–339CrossRefGoogle Scholar
  37. 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

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Clinical Cancer Medicine, Institute of Translational MedicineThe University of LiverpoolLiverpoolUK
  2. 2.Department of Pancreato-Biliary SurgeryThe Royal Liverpool University HospitalLiverpoolUK
  3. 3.Department of HistopathologyThe Royal Liverpool University HospitalLiverpoolUK
  4. 4.The Royal London Hospital, WhitechapelLondonUK
  5. 5.Department of General, Visceral and Transplantation SurgeryUniversity of HeidelbergHeidelbergGermany

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