[Show abstract][Hide abstract] ABSTRACT: Limited surgical procedures for benign cystic neoplasms and endocrine tumours of the pancreas have the potential advantage of pancreatic tissue sparing compared to standard oncological resections.
Searching PubMed/MedLine, Embase and Cochrane Library identified 86 full papers: 25 reporting on enucleation (EN), 38 on central pancreatectomy (CP) and 23 on duodenum-preserving total/partial pancreatic head resection (DPPHRt/p). The results are based on analysis of data of 838, 912 and 431 patients for EN, CP and DPPHRt/s, respectively.
The indication for EN for cystic neoplasms and neuro-endocrine tumours to EN was 20.5 and 73 %; for CP 62.9 and 31 %; and for DPPHRt/p 69.6 and 10.2 %, respectively. The estimated mean tumour sizes were in EN-group 2.4 cm, in CP-group 2.9 cm and in DPPHRt/p-group 3.1 cm (DPPHRt/p vs EN, p = 0.035). Postoperative severe complications developed after EN, CP and DPPHRt/p in 9.6, 16.8 and 11.5 % of patients; pancreatic fistula in 36.7, 35.2 and 20.1 %; and reoperation was required in 4.7, 6.5 and 1.8 %, respectively. Hospital mortality after EN was 0.95 %; after CP 0.72 %; and after DPPHRt/p 0.49 %. Compared to EN and CP, DPPHRt/p exhibited significant lower frequency of reoperation (p = 0.029, p < 0.001) and lower rate of fistula (p < 0.001; p = 0.001).
EN, CP and DPPHRt/p applied for benign tumours are associated with low surgery-related early postoperative morbidity, a very low hospital mortality and the advantages of conservation of pancreatic functions. However, the level of evidence for EN and CP compared to standard oncological resections appears presently low. There is a high level of evidence from prospective controlled trials regarding the significant maintenance of exocrine and endocrine pancreatic functions after DPPHRt/p compared to pancreato-duodenectomy.
World Journal of Surgery 02/2015; DOI:10.1007/s00268-015-2976-x · 2.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
The recent evolution of limited local operative procedures for benign pancreatic lesions shifted surgical treatment options to the application of local techniques, although major resections of pancreatic head and left resection are still the standard.
To evaluate the level of evidence of tumour enucleation (EN), pancreatic middle segment resection (PMSR) and duodenum preserving total/subtotal pancreatic head resection (DPPHRt/s), we focus based on present knowledge on indication to surgical treatment evaluating the questions, when and how to operate.
Tumour enucleation is recommended for all symptomatic neuro-endocrine tumours with size up to 2 -3 cm and non-adherence to pancreatic main-ducts. EN has been applied predominantly in neuro-endocrine tumours and less frequently in cystic neoplasms. 20 % of enucleation are performed as minimal invasive laparascopic procedure. Surgery related severe post-operative complications with the need of re-intervention are observed in about 11 %, pancreatic fistula in 33 %. The major advantage of EN are low procedure related early post-operative morbidity and a very low hospital mortality. PMSR is applied in two thirds for symptomatic cystic neoplasm and in one third for neuro-endocrine tumours. The high level of 33 % pancreatic fistula and severe post-operative complications of 18 % is related to management of proximal pancreatic stump. DPPHRt/s is used in 70 % for symptomatic cystic neoplasms, for lesions with risk for malignancy and in less than 10 % for neuro-endocrine tumours. DPPHRt with segment resection of peripapillary duodenum and intra-pancreatic common bile duct has been applied in one third of patients and in two thirds by complete preservation of duodenum and common bile duct. The level of evidence for EN and PMSR is low because of retrospective data evaluation and absence of RCT results. For DPPHR, 7 prospective, controlled studies underline the advantages compared to partial pancreaticoduodenectomy.
The application of tumour enucleation, pancreatic middle segment resection and duodenum preserving subtotal or total pancreatic head resection are associated with low level surgery related early post-operative complications and a very low hospital mortality. The major advantage of the limited procedures is preservation of exo- and endocrine pancreatic functions.
[Show abstract][Hide abstract] ABSTRACT: Cystic neoplasms of the pancreas are being detected and surgically treated increasingly more frequently. Intraductal papillary mucinous neoplasms (IPMN) and mucinous cystic neoplasms (MCN) are primary benign lesions; however, the 5-year risk for malignant transformation has been estimated to be 63 % and 15 %, respectively. Surgical extirpation of a benign cystic tumor of the pancreas is a cancer preventive measure. The duodenum-preserving total pancreatic head resection technique (DPPHRt) is being used more frequently for cystic neoplasms of the pancreatic head. The complete resection of the pancreatic head can be applied as a duodenum-preserving technique or with segmental resection of the peripapillary duodenum. Borderline lesions, carcinoma in situ or T1N0 cancer of the papilla and the peripapillary common bile duct are also considered to be indications for segmental resection of the peripapillary duodenum. A literature search for cystic neoplastic lesions and DPPHRt revealed the most frequent indications to be IPMN, MCN and SCA lesions and 28 % suffered from a cystic neoplasm with carcinoma in situ or a peripapillary malignoma. The hospital mortality rate was 0.52 %. Compared to the Whipple type resection the DPPHRt exhibits significant benefits with respect to a low risk for early postoperative complications and a low hospital mortality rate of < 1 %. Exocrine and endocrine pancreatic functions after DPPHR are not impaired compared to the Whipple type resection.
Der Chirurg 02/2013; 84(5). DOI:10.1007/s00104-012-2423-6 · 0.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Laparoskopische Pankreasoperationen sind in Deutschland wenig verbreitet und werden nur in ca. 20Kliniken, allerdings zunehmend
praktiziert. Minimal-invasive Eingriffe an der Bauchspeicheldrüse setzen einen hohen laparoskopischen Erfahrungsschatz in
Kombination mit spezieller Erfahrung in der Pankreaschirurgie voraus.
Bei der Einführung gänzlich neuer Techniken in die Chirurgie, sei es konventionell oder minimal-invasiv, sind drei Prinzipien
obligat: Patientensicherheit, langfristig gleiche oder bessere Ergebnisse und vertretbare Kostenaspekte. Zur Evaluation dieser
Endpunkte wurde 2008 ein Register für laparoskopische Pankreaschirurgie mit Unterstützung der Deutschen Gesellschaft für Allgemeine
und Viszeralchirurgie begonnen.
Eine erste Konsensuskonferenz wurde im Mai 2011 im Klinikum Aalen mit Beiträgen aus 12 Kliniken, in denen bereits Erfahrung
in der Anwendung laparoskopischer Pankreasoperationen vorliegt, veranstaltet. Anhand der bisher berichteten Erfahrung mit
minimal-invasiven Eingriffen an der Bauchspeicheldrüse und den ausgiebigen Diskussionen wurde die Indikation zur laparokopischen
Operation diskutiert und in „geeignet“, „nicht geeignet“ oder „geeignet in besonderen Fällen“ klassifiziert. Die Konsensuskonferenz
führte zu dem Ergebnis einer Definition von Indikationen für laparoskopische Eingriffe an der Bauchspeicheldrüse. Die beteiligten
Kliniken haben verabredet, alle Patientendaten laparoskopischer Pankreasoperationen in ein gemeinsames Register einzubringen
und gemeinsam auszuwerten.
Laparoscopic pancreatic surgery is not common practice in Germany and is only carried out in approximately 20 clinics but
with an increasing trend. The reasons for this are manifold, such as the current selection of patients and both skills in
laparoscopic and pancreatic surgery are necessary to perform this operation safely. In 2008 a registry called „Laparoscopic
pancreatic surgery“ was implemented to collect enough data in Germany to find out whether the resection is safe, feasible
and beneficial for the patient.
For further development of new laparoscopic techniques new data is needed. A group of experts performing laparoscopic pancreatic
surgery in Germany supplied their data for the German registry for laparoscopic pancreatic resection and a consensus conference
about the indications became necessary. This consensus conference discussed in particular the indications for laparoscopic
pancreatic resection. A consensus was found by all members of the conference utilizing currently available evidence-based
It was suggested that all data of laparoscopic pancreatic surgery should be evaluated in the German Registry. A consensus
was made which diseases were either suitable for laparoscopic resection or not suitable or suitable in selected cases.
Der Chirurg 01/2012; 83(3):247-253. DOI:10.1007/s00104-011-2167-8 · 0.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic pancreatic surgery is not common practice in Germany and is only carried out in approximately 20 clinics but with an increasing trend. The reasons for this are manifold, such as the current selection of patients and both skills in laparoscopic and pancreatic surgery are necessary to perform this operation safely. In 2008 a registry called "Laparoscopic pancreatic surgery" was implemented to collect enough data in Germany to find out whether the resection is safe, feasible and beneficial for the patient.For further development of new laparoscopic techniques new data is needed. A group of experts performing laparoscopic pancreatic surgery in Germany supplied their data for the German registry for laparoscopic pancreatic resection and a consensus conference about the indications became necessary. This consensus conference discussed in particular the indications for laparoscopic pancreatic resection. A consensus was found by all members of the conference utilizing currently available evidence-based data.It was suggested that all data of laparoscopic pancreatic surgery should be evaluated in the German Registry. A consensus was made which diseases were either suitable for laparoscopic resection or not suitable or suitable in selected cases.
Der Chirurg 09/2011; 83(3):247-53. · 0.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: After the routine use of ether narcosis and surgical antisepsis, the evolution of surgery experienced fascinating and genuinely surgical technique-related advancements. Surgeons from Germany contributed strongly to the upturn of operative treatment in the second half of the nineteenth century. DISCUSSION: B. von Langenbeck inaugurated in 1852 an osteosynthese device in a patient with pseudoarthrosis. He is credited to be the very first in introducing the principle of fixateur externe. Th. Billroth performed in 1873 the first extirpation of the larynx in a patient with a malignant tumor. Postoperatively, the patient was cared with an artificial larynx. The first successful resection of the distal stomach inaugurated by Th. Billroth in 1881 was later called the Billroth II procedure. Rydygier from Kulm and Billroth from Wien are the first who successfully performed resection of the lower part of the stomach with anastomosis to the duodenum (Billroth I type of resection). In 1883, Th. Kocher from Bern reported 101 cases of thyroidectomy, the largest single-surgeon experience. L. Rehn from Frankfurt did in 1887 the first successful suturing of a beating heart to repair a large stab wound. A. Braun, Königsberg presented in 1892 his techniques of side-to-side anastomosis of the intestine to avoid a circular intestinal anastomosis. F. Sauerbruch from Breslau published in 1904 his thoracotomy chamber with space for two surgeons opening routine access to intrathoracic tissues protecting pulmonary ventilation during surgery. W. Kausch from Berlin reported in 1912 about three successful pancreatic head resections for peripapillary cancer. The first successful pancreatic head resection was performed in 1909 in a patient with a cancer of the papilla. The patient survived for a long term.
Langenbeck s Archives of Surgery 03/2010; 395 Suppl 1(S1):17-21. DOI:10.1007/s00423-010-0620-7 · 2.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: In February 1860, B. Langenbeck, Th. Billroth, and G. Gurlt certified in Berlin with the publisher A. Hirschwald the founding of Archiv für Klinische Chirurgie. The journal published extended reports about application of new and case-proven surgical procedures. Separate sections were dedicated to surgical casuistics and small surgical communications and report of surgical institutions from Germany, Austria, and Switzerland as well as annual statistical reports of hospitals. Beginning with the first issue, the Archive was an international journal with the focus on gastrointestinal, trauma, orthopedic, thyroid, and vascular surgery. A section Achievements and Progress in Surgery referred to published results in national and international medical and surgical journals. GERMAN SOCIETY OF SURGERY: Surgeons from Germany contributed strongly to the rise of operative treatment concepts in the second half of the nineteenth century by new surgical procedures, many of them published in the Archiv für Klinische Chirurgie. Since 1923, the German Society of Surgery took Archiv für Klinische Chirurgie as the official journal of the society. Beginning 1950, Langenbeck's published in a separate supplement the proceedings of the annual congress of the German Society of Surgery. A second supplement published since 1972 focused exclusively on reporting of research work presented in the section of Surgical Forum for Experimental and Clinical Surgery. AFTER THE WAR: After World War II, Langenbeck's Archiv für Chirurgie gained acceptance as the leading scientific surgical journal in Germany. Since 1998, the concept of Langenbeck's Archiv was completely changed to an English journal with the title Langenbeck's Archives of Surgery. In the last 12 years, Langenbeck's has turned to an international German-surgery-based electronic journal. Langenbeck's Archives of Surgery experienced an increasing international reputation; in 2001, only two non-American journals (British Journal of Surgery and Langenbeck's) belonged to the top ten journals in general and GI-tract surgery. The present impact factor (IF) of Langenbeck's Archives of Surgery is 1.829 (5-year IF). The decrease of subscriptions for the journal is compensated by an increase of electronic readers. The electronic supplementary material provided by the Springer Company is used to publish manuscripts in the section How-To-Do Surgery, combined with a video clip about surgical techniques. The focus of Langenbeck's is general, GI-tract, endocrine, and HBP surgery. CONCLUSION: Langenbeck's has continuously been published for 150 years and is considered to be the worldwide oldest scientific surgical journal. The English-language-based journal contributes increasingly to an international communication of surgical research and clinical surgeons from Germany.
Langenbeck s Archives of Surgery 03/2010; 395 Suppl 1:3-12. DOI:10.1007/s00423-010-0617-2 · 2.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: INTRODUCTION: For treatment of inflammatory and benign neoplastic lesions of the pancreatic head, a subtotal or total pancreatic head resection is a limited surgical procedure with the impact of replacing the application of a Whipple procedure. The objective of this work is to describe the technical modifications of subtotal and total pancreatic head resection for inflammatory and neoplastic lesions of the pancreas. The advantages of this limited surgical procedure are the preservation of the stomach, the duodenum and the extrahepatic biliary ducts for treatment of benign lesions of the pancreatic head, papilla, and intrapancreatic segment of the common bile duct. For chronic pancreatitis with an inflammatory mass complicated by compression of the common bile duct or causing multiple pancreatic main duct stenoses and dilatations, a subtotal pancreatic head resection results in a long-lasting pain control. Performing, in addition, a biliary anastomosis or a Partington Rochelle type of pancreatic main duct drainage, respectively, is a logic and simple extension of the procedure. The rationale for the application of duodenum-preserving total pancreatic head resection for cystic neoplastic lesions are complete exstirpation of the tumor and, as a consequence, interruption of carcinogenesis of the neoplasia preventing development of pancreatic cancer. Duodenum-preserving total head resection necessitates additional biliary and duodenal anastomoses. For mono-centric IPMN, MCN, and SCA tumors, located in the pancreatic head, total duodenum-preserving pancreatic head resection can be performed without hospital mortality and resurgery for recurrency. Based on controlled clinical trials, duodenum-preserving pancreatic head resection is superior to the Whipple-type resection with regard to lower postoperative morbidity, almost no delay of gastric emptying, preservation of the endocrine function, lower frequency of rehospitalization, early professional rehabilitation, and establishment of a predisease level of quality of life. CONCLUSION: The limited surgical procedures of subtotal or total pancreatic head resection are simple, safe, ensures free tumour margins and replace in the authors institution the application of a Whipple-type head resection.
Journal of Gastrointestinal Surgery 07/2008; 12(6):1127-32. DOI:10.1007/s11605-008-0472-4 · 2.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Chronic inflammatory processes induce oxidative stress and lipid peroxidation (LPO), hereby generating DNA-reactive aldehydes such as trans-4-hydroxy-2-nonenal (HNE). Etheno-modified DNA bases are inter alia generated by reaction of DNA with HNE. Using an immunoaffinity-(32)P-postlabeling method, the authors have investigated etheno-DNA adduct levels 1,N (6)-ethenodeoxyadenosine (epsilondA) and of 3,N (4)-ethenodeoxycytidine (epsilondC) in the pancreas of chronic pancreatitis patients and in the colon of patients with inflammatory bowel disease. Both epsilondA and epsilondC levels were found to be significantly, 3 and 28 times, respectively, elevated in the inflamed pancreatic tissue. In contrast, only epsilondC was found to be increased in affected colonic mucosa of Crohn's disease (19 times) and of ulcerative colitis patients (4 times) when compared to asymptomatic tissues. In all three cancer-prone diseases, the mean epsilondC-levels in tissues were five- to ninefold higher than those of epsilondA. Differential or impaired DNA repair pathways of these adducts, known to occur by two different glycosylases are implicated. K-ras in pancreatic tumors and K-ras and p53 in colon mucosa in long-standing inflammatory bowel disease are known to be highly mutated. The conclusion is that promutagenic etheno-DNA adducts are generated as a consequence of chronic inflammation, acting as a driving force to malignancy in cancer-prone inflammatory diseases.
[Show abstract][Hide abstract] ABSTRACT: In the future, new surgical techniques will only be introduced in clinical practice if evidence-based results--frequently the results of controlled clinical trials--are presented. Unlike any other medical discipline, surgeons provide their diagnostic and operative skills through the surgeons' hand and the use of technical equipment, which ranges from instruments and devices employed during operation to the use of surgical robots.
Analysing the fundaments of surgery on the turn of the century, there is only a little doubt about the increasing impact of data deriving from natural sciences on knowledge in medicine and management of diseases. The natural scientific method of detecting, measuring, and verifying facts is the methodological basis of surgery as well. The autonomy of the surgeon's clinical decision making is significantly restricted by the definition of guidelines. They shift the decision from a single patient to a collective panel. Patient safety and the efficiency of new treatment modalities compared with previous standards are the criteria for the judgement of innovative surgery today. The communication and interaction between surgeon-scientist and patients is guaranteed legally by written consensus. But beside of the high probability of benefit from therapy and written consensus, the surgeon-patient relation is determined by these factors: limitation of time for care of an individual patient, increase of time for administration and documentation, increase of bureaucratic barriers for medical research, and health cost constraints.
The medical mandate to cure a sick patient is an individual mandate to take action. Measures, numbers, and images are only preconditions for a surgeon's action in daily clinical work; they can never replace it. The call for an ethical imperative in scientific surgery that is dependent on technology is justified when the state of science and uncritical use of surgical skills and financial constraints have major impact on providing medical care.
Langenbeck s Archives of Surgery 05/2006; 391(2):143-8. DOI:10.1007/s00423-006-0039-3 · 2.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Surgical treatment of necrotizing pancreatitis (NP) has undergone considerable changes during the past 2 decades. In this study, we report our experience of necrosectomy and continuous closed lavage over the past 19 years in an attempt to define changes in patient characteristics and outcome at an academic referral center.
Among 1520 patients admitted with acute pancreatitis, 392 had NP, 285 of whom underwent operative treatment. The total series was evaluated separately for treatment period A (May 1982 until April 1993) and treatment period B (May 1993 until May 2001).
Intraoperative bacteriology revealed sterile necrosis in 145 and infected necrosis in 140 patients. Preoperative disease severity did not differ between the groups; however, the extent of pancreatic parenchymal necrosis was less in patients with sterile necrosis (P < .003). Postoperative complications were more frequent in infected necrosis (78%) than in sterile necrosis (61%) (P < .004), with mortality rates of 27% and 23%, respectively. The analysis of the 2 treatment periods revealed that during period B, there was a decrease in operatively treated patients with sterile necrosis (P < .0005). The preoperative systemic disease severity was significantly higher in these patients than in patients with infected necrosis.
Surgical treatment of NP by necrosectomy and closed lavage carries an overall mortality of 25%. Patients with sterile necrosis and early onset high disease severity may represent a distinct clinical entity in whom the optimal treatment strategy remains to be defined.
Surgery 08/2005; 138(1):28-39. DOI:10.1016/j.surg.2005.03.010 · 3.11 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Pancreas divisum (PD) represents a duct anomaly in the pancreatic head ducts, leading frequently leading to recurrent acute pancreatitis (rAP) or chronic pancreatitis (CP). Based on endoscopic retrograde cholangiopancreatography, pancreas divisum can be found in 1% to 6% of patients with pancreatitis. The correlation of this abnormality with pancreatic disease is an issue of continuing controversy. Because of the underlying duct anomalies and major pathomorphological changes in the pancreatic head, duodenum-preserving pancreatic head resection (DPPHR) offers an option for causal treatment. Thirty-six patients with pancreatitis caused by PD were treated surgically. Thirty patients suffered from CP, 6 from rAP. The mean duration of the disease was 47.5 and 49.8 months, respectively. The age at the time of surgery was 39.2 years in the CP group, and 27.6 years in the rAP group. Median hospitalization since diagnosis was 18.8 weeks for CP patients and 24.6 weeks for rAP patients. Previous procedures performed in these patients included endoscopic papillotomy (30%), duct stenting (14%), and surgical treatment (17%). The median preoperative pain score was 8 on a visual analog scale. According to the classification of pancreas divisum, 10 patients demonstrated a complete PD, 25 had a functionally incomplete PD, and 1 had a dorsal duct type. The pain status as well as the endocrine (oral glucose tolerance test) and exocrine (pancreolauryl test) function were evaluated preoperatively and early and late postoperatively with a median follow-up time of 39.3 months. There was no operative-related mortality. The follow-up was 100%; 4 patients died (1 from suicide, 1 from cardiac arrest, and 2 from cancer of the esophagus). Fifty percent of the patients were completely pain-free, 31% had a significant reduction of pain with a median pain score of 2 (P < 0.001). Six patients (5 CP, 1 rAP) had further attacks of acute pancreatitis with a need for hospitalization. DPPHR reduced pain and preserved the endocrine function in the majority of patients with pancreas divisum. Therefore, DPPHR is an alternative to other resective or drainage procedures after failure of interventional treatment.
Journal of Gastrointestinal Surgery 05/2005; 9(5):710-5. DOI:10.1016/j.gassur.2004.11.009 · 2.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Tumor desmoplasia is one of the representative histopathologic findings in ductal pancreatic adenocarcinoma. The aims of this study were to examine the cellular and molecular mechanisms of fibrogenesis associated with pancreatic adenocarcinomas.
Immunostainings were performed with human pancreatic adenocarcinomas (n = 27) and tumors induced in nude mice (n = 36) by subcutaneously injecting MiaPaCa2, Panc1, and SW850 with and without pancreatic stellate cells. Matrix-producing cells were isolated from pancreatic adenocarcinomas and compared with pancreatic stellate cells isolated from tissue of chronic pancreatitis. Paracrine stimulation of pancreatic stellate cells by carcinoma cells was studied regarding matrix synthesis (collagen and c-fibronectin on protein and messenger RNA level) and cell proliferation (bromodeoxyuridine incorporation).
High numbers of desmin and alpha-smooth muscle actin-positive cells were detected in 26 of 27 pancreatic adenocarcinomas. Intense fibronectin and collagen stainings were associated with these cells. By using cytofilament stainings, gene expression profiling, and morphological examinations, the matrix-producing cells obtained by the outgrowth method from pancreatic adenocarcinomas were identified as pancreatic stellate cells. Supernatants of MiaPaCa2, Panc1, and SW850 cells stimulated proliferation and collagen type I and c-fibronectin synthesis of cultured pancreatic stellate cells. Preincubation of the carcinoma cell supernatants with neutralizing antibodies against fibroblast growth factor 2, transforming growth factor beta 1, and platelet-derived growth factor significantly reduced the stimulatory effects. Subcutaneous injection of carcinoma cells and pancreatic stellate cells induced fast-growing subcutaneous fibrotic tumors in nude mice. Morphometric analysis of carcinoma cells (cytokeratin stainings) showed a high density of carcinoma cells in these tumors.
Pancreatic stellate cells strongly support tumor growth in the nude mouse model. The increased deposition of connective tissue in pancreatic carcinoma is the result of a paracrine stimulation of pancreatic stellate cells by carcinoma cells.
[Show abstract][Hide abstract] ABSTRACT: Severe acute pancreatitis is considered to be a subgroup of acute pancreatitis with the development of local and/or systemic complications. A significant correlation exists between the development of pancreatic necrosis, the frequency of bacterial contamination of necrosis and the evolution of systemic complications. Bacterial infection and the extent of necrosis are determinants for the outcome of severe acute pancreatitis. The late course of necrotizing pancreatitis is determined by bacterial infection of pancreatic and peripancreatic necroses. Mortality increases from 5-25% in patients with sterile necrosis to 15-28% when infection has occurred. The use of prophylactic antibiotics has been recommended in patients with necrotizing pancreatitis. Several controlled clinical trials demonstrated a significant reduction in pancreatic infections or a significant reduction of hospital mortality. However, the results of these clinical trials are controversial and not convincing. Recently, the largest randomized placebo-controlled, double-blind trial has been able to demonstrate that antibiotic prophylaxis with ciprofloxacin and metronidazole has no beneficial effects with regard to the reduction of pancreatic infection and the decrease of hospital mortality. The clinical data from this placebo-controlled trial do not support antibiotic prophylaxis in all patients with necrotizing pancreatitis, but in specific subgroups of patients with pancreatic necrosis and a complicated course.
[Show abstract][Hide abstract] ABSTRACT: Tissue and duct hypertension is considered as a major factor in the etiology of pain in patients with chronic pancreatitis (CP). Duct dilatation is a consequence of duct obstruction due to scars or duct stones. Nevertheless, the procedure of choice, drainage or resection, is still under discussion. We present long-term results of patients operated with duodenum-preserving pancreatic head resection (DPPHR) combined with a Partington-Rochelle duct drainage in cases of chronic pancreatitis with multiple stenosis and dilatation of the side ducts.
From April 1982 to September 2001, in 55 out of 538 patients with chronic pancreatitis, a DPPHR with additionally Partington-Rochelle duct drainage was performed (44 male, 11 female, mean age 45.8 years). Ninety-two percent of the patients suffered from alcoholic pancreatitis. Medical respective pain treatment for chronic pancreatitis was in median 64.5 months prior to surgery. The indications for surgery were in 87% pain, 59% of the patients had an inflammatory mass in the head of the pancreas, 36% a common bile duct stenosis and 5% a severe stenosis of the duodenum. The endocrine function (OGGT) was impaired in 79% of the patients preoperatively.
Hospital mortality was 0%, postoperative complications occurred in 11 patients. Follow-up: All except 2 patients were followed up in the outpatient clinic with the mean follow-up time of 69.7 months (8-105 months), the late mortality was 9%. Sixty-eight percent of the patients were completely free of pain, 29% had occasional pain, 3% suffered from a further attack of pancreatitis. Body weight increased in 79%, 58% were professionally rehabilitated. Late postoperative endocrine function was unchanged in 85% (improved in 5%, deteriorated in 10%).
The pain control in patients with multiple duct stenosis after duodenum-preserving pancreatic head resection with duct drainage leads to long-standing absence of pain and low recurrence rate of attacks of pancreatitis.