Endoscopical and/or surgical therapy of chronic pancreatitis

Department of SurgeryKlinikum rechts der IsarTechnische Universität München, Munich, Germany

Endoscopical and/or surgical

therapy of chronic pancreatitis

Helmut Friess

April 16th 2010

Department of SurgeryKlinikum rechts der IsarTechnische Universität München

Department of Surgery, Klinikum rechts der Isar, Technische Universität München

Department of SurgeryKlinikum rechts der IsarTechnische Universität MünchenChronic pancreatitis: 1990

therapyconservative

operative



therapyconservativeendoscopy (stent)

operative



therapyconservative

operative



Which is the best option?

Endotherapy or Surgery


Department of SurgeryKlinikum rechts der IsarTechnische Universität MünchenSurgery vs. Endotherapy

Dite et al., Endoscopy 2003

Prospective, randomised study: Surgery vs. Endotherapy in case of

painful obstructive CP

140 patients (72 randomised)

Surgery: 80% resection

20% drainage

Endotherapy: 52% sphincterotomy and stenting

23% concrement removal




Long term- pain relief:

Surgery - superior!

Pain managementPartial reliefComplete absenceNo success

Surgery vs. Endotherapy

P<0.05


Department of SurgeryKlinikum rechts der IsarTechnische Universität MünchenSurgery vs. Endotherapy

Long term- weight increase:

Surgery - superior!


Body WeightIncreaseDecreaseNo change

P<0.05



Surgery is superior to endotherapy in long term pain and body weight

control!

(Endotherapy as first-line therapy reasonable)


Surgery vs. Endotherapy


Department of SurgeryKlinikum rechts der IsarTechnische Universität MünchenSurgery versus Endotherapy

Cahen et al., New Engl. J. Med. 2007

Endoscopic versus surgical drainage of the

pancreatic duct in chronic pancreatitis

• 19 patients endoscopy• 20 patients pancreatico- jejunostomy

24 months follow-up




Surgery versus Endotherapy

Med

ian

Izbi

cki p

ain

scor

e

Follow-up

EndotherapyEndotherapy5151

SurgerySurgery2525

BeforeIntervention/

OperationHigh PS

Low PS

Lower Izbicki pain scores (25 vs. 51, p<0.001)


Department of SurgeryKlinikum rechts der IsarTechnische Universität MünchenSurgery versus Endotherapy


Surgery:• Lower Izbicki pain scores (25 vs. 51, p<0.001)

• 75% partial pain reduction (versus 32%, p=0.007)

• Better physical health summary scores (p=0.003)

• Less re-operations (3 versus 8, p<0.001)

Surgery is superior



Kahl et al., Am J Gastroenterol 2003

CP: Main bile duct stenosis: Endotherapy

61 patient with main bile duct stenosis

1 year stenting – 3 monthly stent changes

39 patients with calcifications 22 patients without calcifications

Success: 3/39 (8%) 13/22 (59%)

Failure: 36/39 (92%) 9/22 (41%)



If a patients needs an interventionsurgery is the treatment of choice

Surgery is superiorto endoscopic therapy!

Cahen et al., NEJM 2007Dite et al., Endoscopy 2003Kahl et al., Am J Gastroenterol 2003


Department of SurgeryKlinikum rechts der IsarTechnische Universität MünchenWhat is clinical reality

44-year old male patient, chron. pancreatitis since 2001

- long time alcohol abuse- common bile duct obstruction

since 2003: - several times/year stent changes- several stent closures- since 2007: portal thrombosis, varicosis- metal stent, then plastic stent in metal stent, laser therapy

- present: gastric outlet obstruction



Portal obstruction

varicosis1 23 4

Chronic pancreatitis – case report

Laparotomy, no resection possibleDouble bypass (bile, stomach)



• Ascites -> Ascites drainage, high dose furosemid/spironolacton -> removement of drainage

• Cholangitis (treated with antibiotics)

• Slow nutritional recovery

Postoperative course

Chronic pancreatitis – case report


Department of SurgeryKlinikum rechts der IsarTechnische Universität MünchenChronic pancreatitis – case report



Surgery is better than endoscopic therapy!

Cahen et al., NEJM 2007Dite et al., Endoscopy 2003

Which Operation???

Surgery versus Endoscopy


Department of SurgeryKlinikum rechts der IsarTechnische Universität MünchenChronic Pancreatitis

• pain• duodenal stenosis• common bile duct stenosis• obstruction main pancr. duct• obstruction of vessels • pseudocysts (symptomatic)• suspicion of malignancy

Indications for surgery surgical procedures

• drainage operations • resections - classical Kausch-Whipple - pylorus-pres. Whipple - duodenum-pres. pancreatic head

resection (Beger, Frey, Büchler) - longitudinal V-shape excision - segmentectomy - left resection

Kausch Whipple Beger


Department of SurgeryKlinikum rechts der IsarTechnische Universität MünchenEvidence-based surgery

chronic pancreatitis (randomized, controlled) studies

Klempa et al., Chirurg 1995 Whipple vs. DPPHRBüchler et al., Am. J. Surg. 1995 Whipple vs. DPPHRIzbicki et al., Ann. Surg. 1995 Frey vs. DPPHRIzbicki et al., Chirurg 1997 Frey vs. DPPHRStrate et al., Ann. Surg. 2005 Frey vs. DPPHRIzbicki et al., Ann. Surg. 1998 Whipple vs. FreyMakowiec et al., PancreasClub 2004 Whipple vs. DPPHR

organ preservationbetter

Pancreatic head resection



Long term results RCT: 7, 14 years follow-up

31 - Frey vs 30 - PPPD 20 – Beger vs 20 PPPD

Strate et al., Gastroenterology 2008Müller et al., Br J Surg 2008

Duodenum preserving versus WhippleDuodenum preserving versus Whipple

• Results short term:in favour of organ-preserving

• Results long term:Both procedures achieve: • adequate pain reduction• good quality of life• no difference in exo/endocrine function


Department of SurgeryKlinikum rechts der IsarTechnische Universität MünchenDuodenum-preserving pancreatic head

resection – optimal operation

Beger Operation Frey Operation

Beger et al., Chirurg 1982

Frey, Pancreas 1987

Gloor et al., Dig Surg 2001

Bern-Büchler/Farkas Operation



Longitudinal V-shape excisionIzbicki et al., Ann Surg 1998

Segmentectomy

Chronic pancreatitis – resection:Organ preserving operation technique



Long-term Follow-up After Organ-Preserving PancreaticHead Resection in Patients with Chronic Pancreatitis

Farkas G, Leindler L, Daroczi M, Farkas G Jr

J Gastrointest Surg 2008

Büchler/Farkas modification of the Beger/Frey Operation

Pain visual analog scaleFrequency of pain attacksPain medicationInability to workPain score

8275207563

1013 0 0 5.6 (p<0.001)

Preoperative Follow-up

ALL

(!)

Mean follow-up: 4.1 years

135 patients

Late mortality 3.7%



Pancreatic head excavation: A variation on the theme of duodenum-preserving pancreatic head resection

Andersen DK, Topazian MD

Arch Surg 2004

• 6 6 patientspatients• No mortalityNo mortality• NoNo s seriouserious complicationscomplications• OPOP time: time: 390 min 390 min• BlBlood loss: ood loss: 475 ml475 ml• HospitalisationHospitalisation: 6-8 : 6-8 daysdays




Müller et al. 2008, Am J Surg

Prospective study, 100 patients Büchler/Farkas between 2002 und 2006

Long-term follow-up

• 55% pain reduction

• 67% weight increase

• 22% development of insulin-dependent diabetes• No significant differences in QOL (compared to adult

control group or to Beger/Frey)




Prospective randomized controlled trial:65 patients: 32 - Beger, 33 – Büchler/Farkas

Köninger et al., Surgery 2008

Beger Büchler/Farkas




Köninger et al., Surgery 2008

Endpoints/results

Duration of surgery (min) 369+91 323+56 0.02

Quality of life scores (0-100)

EORTC QLQ-C30 65+25 71+22 0.37

EORTC QLQ-PAN26 64+24 76+16 0.03

Length of ICU stay 1 (0-2) 1 (0-3) 0.97

Length of hospital stay (days) 15 (8-47) 11 (8-39) 0.02

x

Beger Büchler/Farkas(n=32) (n=33)




Müller & Friess et al., Ann Surg 2006

Pancreatic head

Tumor

Resection

Pancreatic tail

Duodenum

Hepatic artery Splenic artery

Resection

17 patients: tumors23 patients: focal CP

Mortality: 2.5%

Heidelberg: 10/2001 – 08/2005

Segmentectomy

Chronic pancreatitis – organ preservation



40 patients: Whipple40 patients: Left resectionversus40 patients:

Segmentectomy

Blood lossHospitalisationMortalityMorbidity

comparable

OPOP of of choicechoice inin benign lesions benign lesions of p of pananccreareatic bodytic body!!

Müller & Friess et al., Ann Surg 2006

Segmentectomy – matched pairs

Less Diabetes mellitus*Better quality of life* *p<0.05



- Surgery is superior to endotherapy - Organ preserving OP techniques! (Beger, Frey, Büchler/Farkas, segmentectomy etc.)

- Low morbidity & mortality

- Preservation of function (exocrine, endocrine)

- Improvement of quality of life

Chronic pancreatitis Conclusion

Endoscopical and/or surgical therapy of chronic pancreatitis

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