Chronic pancreatitis

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Chronic pancreatitis
THIS SLIDE WILL GO. Sahni WILL HAVE 9

• Surgery for pain
• Results and Quality of life

2
Sahni Surgery for pain results and quality of
life
Search strategy Pubmed

• Surgery Resectional
• Decompressive
• Combination
• Chronic pancreatitispainrelief surgery 291
  papers
• Chronic pancreatitissurgeryquality of life 121
  papers
• Abstracts reviewed if available
• Attempt to obtain full papers
• Select large series and randomized trials
• Three randomized trials 2 papers available

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Sahni Surgery for pain results and quality of
life
Randomized trials No 1 (1a)

• Begers (n38) and Freys (n36) procedure
• Duration of symptoms 5.1 (1-12) years
• Aetiology ? alcohol 30, idiopathic 10
• QOL and pain score assessed
• Endocrine function GTT, Insulin, C-peptide,
  HbA1C
• Exocrine function Faecal chymotrypsin,
  pancreolauryl
• Follow up 1-12 years, mean 30 months
• Izbicki et al. Ann Surg 1995221350-8 Chirurg
  199768369-77

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Sahni Surgery for pain results and quality of
life
Randomized trials No 2

• Freys (n31) and PPPD (n30) procedure
• Duration of symptoms 5.1 (1-10) years
• Aetiology alcohol 47, idiopathic 14
• QOL and pain score assessed
• Endocrine functio GTT, Insulin, C-peptide, HbA1C
• Exocrine function Faecal chymotrypsin,
  pancreolauryl
• Follow up 1-3 years, mean 24 months
• Izbicki et al. Ann Surg 1998228771-9

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Sahni Surgery for pain results and quality of
life
Randomized trials No 3

• DPPJ (n10) and PD (n8) procedure ?small duct
• DPPJ
• Less operative time and blood loss
• Complete pain relief
• Increase in body weight
• No steatorrhoea/diabetes
• Problems
• Abstract only
• Few details
• Duration of symptoms, aetiology, length of follow
  up
• Hwang et al. Hepatogastroenterology 200148270-2

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Sahni Surgery for pain results and quality of
life
Summary Randomized trials

• Small numbers
• Alcoholic aetiology
• Combined procedures better than resectional
  procedures
• Quality of life
• ? pain relief
• ? Drainage procedures

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Sahni Surgery for pain results and quality of
life
Large series

• 484 patients, Mayo Clinic, 20 years MPD lt7 mm
  65, Pain 95, ?mitosis 28, Cx 35, Aetiology
  ?alcohol high Resections (162) Drainage (322)
  Mean follow up 6.5 years
• Results Mortality 1.9 vs nil Morbidity 23 vs
  8
• Pain relief best after proximal resection 89
• Improvement in functional status 39 to 79
• Long term survival best after drainage
• Pancreatic Ca developed 3
• 255 patients, Johns Hopkins, 16 years Aetiology
  alcohol 43, idiopathic 38 Resections (62 PD,
  DP) Drainage (19 PJ)
• Results Mortality 1.9 Morbidity 35
• 89 alive at last follow up
• 5- 10-yr actuarial survivals 88 and 82
• Improved quality of life (47 assessed)
  overall, pain
• Decrease in use of narcotics 41 to 21
• Decrease in alcohol use 59 to 33
• Diabetes 12 to 41

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Sahni Surgery for pain results and quality of
life
Drainage series only

• 11 series, 20-100 patients, 2003
• 550 patients
• Pain main indication, Aetiology alcohol 0-100
• Results
• Mortality 0-7
• Late deaths 3-38
• Pain relief
• Good 30-79 Fair 6-46 Poor 2-39
• Few studies assessed endocrine and exocrine
  function
• Small group of patients with worsening status

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Sahni Surgery for pain results and quality of
life
Data AIIMS, Kerela

• AIIMS Data
• 92 patients had LPJ
• Pain main indication, Two-thirds no alcohol abuse
• Results Mortality 7 Late deaths 7
• Pain relief Good (Pain reliefgt 75) 79
• Fair (50) 12
• Poor (no relief) 8
• Data from Kerela
• Small duct disease 45
• Large duct disease 212
• LPJhead coring
• Results Median follow up gt30 months
• Pain relief 94 small vs. 91 large

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Sahni Surgery for pain results and quality of
life
Summary

• Procedure Pain morbidity Exo/endo Quality
  of relief function life
• Resectional Good Higher Worse Poorer
• Combination Good Less unchanged
• Drainage Good Less ?unchanged Better
• Pain relief
• Early (lt2 years) 90
• Late (gt2 years) 70-80
• ? Better with extended procedures
• Endocrine/exocrine dysfunction
• Less with drainage procedures
• 25-30 with resectional procedures