Delayed gastric emptying (DGE) after pancreatic surgery: A suggested definition by the International Study Group of Pancreatic Surgery (ISGPS)

Hypothesis Experience with pancreatic resection for the last 10 years has resulted in new trends in patient characteristics and, for pancreaticoduodenectomy (PD), a decrease in the length of stay (LOS). This decrease is due in part to the implementation of case management and clinical pathways. Design Retrospective case series of patients undergoing pancreatic resection. Setting A university-affiliated, tertiary care referral center. Patients The study comprised 733 consecutive patients undergoing pancreatic resection for benign or malignant disease at the Massachusetts General Hospital in Boston from April 1990 to March 2000. Interventions Of the 733 pancreatic resections, 489 were PD; 190, distal pancreatectomy; 40, total pancreatectomy; and 14, middle-segment pancreatectomy. Main Outcome Measures Length of stay; occurrence of delayed gastric emptying, pancreatic fistula, reoperation, readmission, or other complications; mortality; and comparison of patients in 3 periods according to the implementation of case management (July 1995) and clinical pathways (September 1998). Results For PD, patients in group 1 (April 1990 to June 1995) were significantly younger (mean ± SD, 57 ± 15 years) than those in group 2 (July 1995 to August 1998; mean ± SD, 62 ± 13 years) and group 3 (September 1998 to October 2000; mean ± SD, 65 ± 13 years)( P P = .01), and the proportion of PD for chronic pancreatitis decreased from 23% to 10% ( P P P P P P P P = .06). Median LOS decreased from 9 days to 6. For total pancreatectomy, resections for cystic tumors increased from 18% to 43%. Median LOS decreased from 14.5 days to 11. For all resections, case volume increased from 4 resections per month in 1990 to 5.8 in 1995 and 12 in 2000 ( r = 0.83; P Conclusions Older patients are increasingly being selected for pancreatic resection. This reflects an increasing frequency of operations performed for cystic tumors and fewer for chronic pancreatitis. With the exception of delayed gastric emptying, complications and mortality have remained the same or decreased slightly during the past 10 years. However, there has been a significant decrease in LOS; this is the result of implementation of case management and clinical pathways, increasing case volume, decreasing incidence of delayed gastric emptying, and decreasing use of pylorus-preserving PD.

https://jamanetwork.com/journals/jamasurgery/articlepdf/391232/sne0006.pdf

Ten-Year Experience With 733 Pancreatic Resections: Changing Indications, Older Patients, and Decreasing Length of Hospitalization

From the Departments of Gastroenterology and Hepatology (D.L.C., E.A.J.R., K.H., M.J.B.), Surgery (D.J.G., M.A.B., O.R.B.), Radiology (Y.N., J.S., J.S.L.), and Clinical Epidemiology, Biostatistics, and Bioinformatics (M.G.W.D.), Academic Medical Center, Amsterdam. Address reprint requests to Dr. Cahen at the Department of Gastroenterology and Hepatology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands, or

https://www.nejm.org/doi/pdf/10.1056/NEJMoa060610

Endoscopic versus Surgical Drainage of the Pancreatic Duct in Chronic Pancreatitis

Chronic Pancreatitis: Challenges and Advances in Pathogenesis, Genetics, Diagnosis, and Therapy

Optimal digestion and absorption of nutrients requires a complex interaction among motor and secretory functions of the gastrointestinal tract. Digestion of macronutrients is a prerequisite for absorption and occurs mostly via enzymatic hydrolysis. In this context, pancreatic enzymes, in particular lipase, amylase, trypsin, and chymotrypsin, play the most important role but several brush border enzymes as well as other pancreatic and extrapancreatic enzymes also participate in macronutrient digestion. The crucial importance of pancreatic exocrine function is reflected by the detrimental malabsorption in patients with untreated pancreatic exocrine insufficiency, which is a typical complication of, for example, chronic pancreatitis.1–4

Comprehensive knowledge about the physiological pancreatic exocrine response to normal diets and to individual food components and about alterations in pancreatic exocrine insufficiency is necessary to administer a pancreatic enzyme preparation which imitates physiological conditions closely. Although many efforts have been made to substitute for pancreatic exocrine insufficiency by specially designed pancreatic enzyme preparations, these still have several disadvantages compared with physiological enzyme secretion. In particular lipid absorption is not completely normalised in most patients.5

As a basis for a better understanding of pancreatic exocrine function in health and disease this review will first summarise literature data on pancreatic exocrine response to a normal diet and to administration of individual food components in healthy humans. The next chapter will focus on pancreatic responses to a normal diet and to administration of individual food components in patients with pancreatic diseases, in particular chronic pancreatitits, but also in patients with other pancreatic and non-pancreatic diseases which are associated with intraluminal lack of pancreatic enzymes, for instance coeliac disease and diabetes mellitus. Other evidence of pancreatic involvement and dysfunction in these diseases will also be discussed, particularly if sufficient data on endogenously stimulated pancreatic secretion are lacking.

### 2.1 Introduction

The healthy human pancreas adopts …

https://gut.bmj.com/content/gutjnl/54/suppl_6/1.full.pdf

Human pancreatic exocrine response to nutrients in health and disease.

OBJECTIVE: To analyze the efficacy of extended drainage--that is, longitudinal pancreaticojejunostomy combined with local pancreatic head excision (LPJ-LPHE)-and pylorus-preserving pancreatoduodenectomy (PPPD) in terms of pain relief, control of complications arising from adjacent organs, and quality of life. SUMMARY BACKGROUND DATA: Based on the hypotheses of pain origin (ductal hypertension and perineural inflammatory infiltration), drainage and resection constitute the main principles of surgery for chronic pancreatitis. METHODS: Sixty-one patients were randomly allocated to either LPJ-LPHE (n = 31) or PPPD (n = 30). The interval between symptoms and surgery ranged from 12 months to 10 years (mean 5.1 years). In addition to routine pancreatic diagnostic workup, a multidimensional psychometric quality-of-life questionnaire and a pain score were used. Endocrine and exocrine functions were assessed in terms of oral glucose tolerance and serum concentrations of insulin, C-peptide, and HbA1c, as well as fecal chymotrypsin and pancreolauryl testing. During a median follow-up of 24 months (range 12 to 36), patients were reassessed in the outpatient clinic. RESULTS: One patient died of cardiovascular failure in the LPJ-LPHE group (3.2%); there were no deaths in the PPPD group. Overall, the rate of in-hospital complications was 19.4% in the LPJ-LPHE group and 53.3% in the PPPD group, including delayed gastric emptying in 9 of 30 patients (30%; p < 0.05). Complications of adjacent organs were definitively resolved in 93.5% in the LPJ-LPHE group and in 100% in the PPPD group. The pain score decreased by 94% after LPJ-LPHE and by 95% after PPPD. Global quality of life improved by 71% in the LPJ-LPHE group and by 43% in the PPPD group (p < 0.01). CONCLUSIONS: Both procedures are equally effective in terms of pain relief and definitive control of complications affecting adjacent organs, but extended drainage by LPJ-LPHE provides a better quality of life.

Extended drainage versus resection in surgery for chronic pancreatitis: a prospective randomized trial comparing the longitudinal pancreaticojejunostomy combined with local pancreatic head excision with the pylorus-preserving pancreatoduodenectomy.

OBJECTIVE: Two techniques of duodenum-preserving resection of the head of the pancreas were compared in a prospective, randomized trial. The technical feasibility and effects on quality of life were assessed. SUMMARY BACKGROUND DATA: Drainage and resection are the principles of surgery in chronic pancreatitis. The techniques of duodenum-preserving resection of the head of the pancreas as described by Berger and Frey combine both to different degrees. The efficacy of both procedures has not been compared thus far. METHODS: Forty-two patients were allocated randomly to either Beger's (n = 20) or Frey's (n = 22) group. In addition to routine pancreatic diagnostic work-up, a multidimensional psychometric quality-of-life questionnaire and and a pain score were used. Assessment of endocrine and exocrine function included oral glucose tolerance test, serum concentrations of insulin, C-peptide, and HbA1c, as well as fecal chymotrypsin and pancreolauryl test. The interval between symptoms and surgery ranged from 12 months to 12 years, with a mean of 5.7 years. The mean follow-up was 1.5 years. RESULTS: There was no mortality. Overall morbidity was 14% (20% Beger, 9% Frey). Complications from adjacent organs were resolved definitively in 94% (90% Beger, 100% Frey). A decrease of 95% and 94% of the pain score after Beger's and Frey's procedure, respectively, and an increase of 67% of the overall quality-of-life index in both groups were observed. Endocrine and exocrine function did not differ between both groups. CONCLUSIONS: Both techniques of duodenum-preserving resection of the head of the pancreas are equally safe and effective with regard to pain relief, improvement of quality of life, and definitive control of complications affecting adjacent organs. Neither procedure leads to further deterioration of endocrine and exocrine pancreatic function.

Duodenum-preserving resection of the head of the pancreas in chronic pancreatitis. A prospective, randomized trial.

Objective:
To report on the long-term follow-up of a randomized clinical trial comparing pancreatic head resection according to Beger and limited pancreatic head excision combined with longitudinal pancreatico-jejunostomy according to Frey for surgical treatment of chronic pancreatitis.

Long-term Follow-up of a Randomized Trial Comparing the Beger and Frey Procedures for Patients Suffering From Chronic Pancreatitis

Objective The technique of longitudinal V-shaped excision of the ventral pancreas for small duct chronic pancreatitis is presented and its efficacy in terms of pain relief and improvement of quality of life is evaluated. Summary background data Small duct chronic pancreatitis has been regarded as a classical indication for more or less extensive resection, in which the therapeutic success of pain relief is offset by the considerable risk of significant perioperative mortality and morbidity and the burden of substantial loss of pancreatic function. Methods Thirteen patients with severe pain who were diagnosed with small duct pancreatitis (defined as maximal Wirsungian ductal diameter of 2 mm) underwent longitudinal V-shaped excision of the ventral pancreas. In addition to routine pancreatic workup, a multidimensional psychometric quality-of-life questionnaire and a pain score were used. Assessment of exocrine and endocrine function included fecal chymotrypsin and the pancreolauryl test as well as oral glucose tolerance, serum concentrations of insulin, C-peptide, and hemoglobin A1c. The interval between symptoms and surgery ranged from 12 months to 10 years (mean, 5.4 years). Median follow-up was 30 months (range, 12-48 months). Results There were no deaths. Overall morbidity was 15.4%. In 92% of patients, complete relief of symptoms was obtained. Median pain score decreased by 95%. Physical status, working ability, and emotional and social functioning scores improved by 40%, 50%, 67%,, and 75%, respectively. Global quality-of-life index increased by 67%. Occupational rehabilitation was achieved in 69% of patients. Exocrine and endocrine pancreatic function was well preserved. Conclusions In small duct chronic pancreatitis, longitudinal V-shaped excision of the ventral pancreas is a safe and effective alternative to resection procedures. The new technique provides pain relief and improvement of quality of life, thus offering the benefit of a resection procedure without its burden.

Longitudinal V-shaped excision of the ventral pancreas for small duct disease in severe chronic pancreatitis: prospective evaluation of a new surgical procedure.

https://www.gastrojournal.org/article/S0016-5085(08)00344-2/pdf

T Kuechler

Papers

Extended drainage versus resection in surgery for chronic pancreatitis: a prospective randomized trial comparing the longitudinal pancreaticojejunostomy combined with local pancreatic head excision with the pylorus-preserving pancreatoduodenectomy.

Duodenum-preserving resection of the head of the pancreas in chronic pancreatitis. A prospective, randomized trial.

Long-term Follow-up of a Randomized Trial Comparing the Beger and Frey Procedures for Patients Suffering From Chronic Pancreatitis

Longitudinal V-shaped excision of the ventral pancreas for small duct disease in severe chronic pancreatitis: prospective evaluation of a new surgical procedure.

Resection vs Drainage in Treatment of Chronic Pancreatitis: Long-term Results of a Randomized Trial