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Duodenumerhaltende Pankreaskopfresektion bei chronischer Pankreatitis

Grenzen der Heidelberger Multicenter-ChroPac-Studie

Duodenum-preserving pancreatic head resection in chronic pancreatitis

Limitations of the Heidelberg multicenter ChroPac study

  • In der Diskussion
  • Published:
Der Chirurg Aims and scope Submit manuscript

An In der Diskussion to this article was published on 19 March 2018

Zusammenfassung

Die in Der Chirurg und The Lancet publizierten Daten nach einer Intention-to-treat-Analyse der Ergebnisse der Multicenter-ChroPac-Studie erlauben es nicht, die Empfehlung der Autoren zu unterstützen, die Whipple-Operation (PD) im Vergleich zur duodenumerhaltenden Pankreaskopfresektion (DEPKR) bei chronischer Pankreatitis (CP) vorzuziehen. Der Vergleich dreier unterschiedlicher Verfahren der DEPKR mit zwei verschiedenen PD-Operationen bewirkt eine erhebliche Heterogenität in der Zusammensetzung der Vergleichsgruppen. Nach der Randomisation wurden in der DEPKR-Gruppe 20 % der Patienten mit einem anderen Verfahren als duodenumerhaltende Kopfresektion operiert; in der PD-Gruppe sind es 13,5 %. Innerhalb der DEPKR-Gruppe wurde bei 83 % der DEPKR eine Coring-out-Technik angewandt und nur bei 17 % eine subtotale Kopfresektion. Eine erhebliche Heterogenität besteht auch im Vergleich der Verteilung der weit fortgeschrittenen chronischen Pankreatitis, die 90-mal in der DEPKR-Gruppe und 64-mal in der PD-Gruppe gelistet wurde. Die Feststellungen „CP-assoziierte Reoperation“ und „Rehospitalisation“ sind nicht durch Fakten belegt. Die Gleichwertigkeit von DEPKR und PD in Bezug auf postoperativ neu auftretenden Diabetes und exokrine Pankreasinsuffizienz beruht nicht auf gemessenen, sondern festgestellten Daten. Die Ergebnisse der bisher vorliegenden monozentrischen randomisierten kontrollierten Studien zum Vergleich DEPKR und PD bei chronischer Pankreatitis belegen die klinische Evidenz überzeugender als die ChroPac-Studie.

Abstract

The data published in Der Chirurg and The Lancet on the results of the multicenter ChroPac study comparing results of 115 patients in the duodenum-preserving pancreatic head resection (DPPHR) group with 111 patients in the pancreaticoduodenectomy (PD) group, recommend partial PD as the first line procedure for chronic pancreatitis (CP). This is based on the significantly higher frequency of rehospitalization assigned to CP in the DPPHR group and data derived from post hoc meta-analysis about higher frequency of reoperations in the DPPHR group. Based on the presented data of the intention-to-treat analysis it is difficult to support the authors’ recommendation of PD as the first line procedure for CP. The critical points are substantial heterogeneity of the different surgical procedures in the DPPHR group (20%) and PD group (13.5%) and a heterogeneity with respect to the number of patients with very advanced CP in the DPPHR group but not in the PD group. The data on the new onset of diabetes and endocrine insufficiency after surgery are not the result of measuring the preoperative and postoperative status of glucose metabolism and degree of exocrine dysfunction but are based on patient records. The advantages and/or disadvantages of the local parenchyma-sparing pancreatic head resection for CP compared to PD results of the published monocentric randomized controlled studies (RCT) more closely verify the clinical evidence than those of the ChroPac trial.

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Authors and Affiliations

  1. Allgemeine und Viszeralchirurgie, c/o Universität Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Deutschland

    H. G. Beger MD

  2. Institut für Epidemiologie und Medizinische Biometrie, Universität Ulm, Ulm, Deutschland

    B. Mayer PhD

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Correspondence to H. G. Beger MD.

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H. G. Beger und B. Mayer geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Beger, H.G., Mayer, B. Duodenumerhaltende Pankreaskopfresektion bei chronischer Pankreatitis. Chirurg 89, 392–396 (2018). https://doi.org/10.1007/s00104-018-0615-4

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  • DOI: https://doi.org/10.1007/s00104-018-0615-4

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