1 / 32

Endoscopical and/or surgical therapy of chronic pancreatitis

Department of Surgery Klinikum rechts der Isar Technische Universität München. Endoscopical and/or surgical therapy of chronic pancreatitis. April 16 th 2010. Helmut Friess. Chroni c p an c reatitis: 1990. c onservativ e operati ve. therap y. Chroni c p an c reatitis: 2000.

miranda-sweet
Download Presentation

Endoscopical and/or surgical therapy of chronic pancreatitis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Department of Surgery Klinikum rechts der Isar Technische Universität München Endoscopical and/or surgical therapy of chronic pancreatitis April 16th 2010 Helmut Friess

  2. Chronicpancreatitis: 1990 conservative operative therapy

  3. Chronicpancreatitis: 2000 conservative endoscopy (stent) operative therapy

  4. Chronicpancreatitis: 2010 conservative operative therapy

  5. Endotherapy or Surgery Which is the best option?

  6. Surgery vs. Endotherapy Prospective, randomisedstudy: Surgery vs. Endotherapy in case of painful obstructive CP 140 patients (72 randomised) Surgery: 80% resection 20% drainage Endotherapy: 52% sphincterotomyand stenting 23% concrement removal Dite et al., Endoscopy 2003

  7. Surgery vs. Endotherapy Pain management Partial relief Complete absence No success Long term- pain relief: Surgery - superior! P<0.05 Dite et al., Endoscopy 2003

  8. Surgery vs. Endotherapy Body Weight Increase Decrease No change Long term- weight increase: Surgery - superior! P<0.05 Dite et al., Endoscopy 2003

  9. Surgery vs. Endotherapy Surgery is superior to endotherapyin long term painand body weightcontrol! (Endotherapy as first-linetherapyreasonable) Dite et al., Endoscopy 2003

  10. Surgery versus Endotherapy • Endoscopic versus surgicaldrainage of the pancreatic duct in chronicpancreatitis • 19 patients endoscopy • 20 patientspancreatico- • jejunostomy • 24 monthsfollow-up Cahen et al., New Engl. J. Med. 2007

  11. Surgery versus Endotherapy Lower Izbicki pain scores (25 vs. 51, p<0.001) Before Intervention/ Operation High PS Endotherapy 51 Median Izbicki pain score Surgery 25 Low PS Follow-up Cahen et al., New Engl. J. Med. 2007

  12. Surgery versus Endotherapy • Surgery: • Lower Izbicki pain scores (25 vs. 51,p<0.001) • 75% partialpain reduction(versus 32%, p=0.007) • Better physical health summary scores (p=0.003) • Lessre-operations (3 versus 8, p<0.001) Surgery is superior Cahen et al., New Engl. J. Med. 2007

  13. CP: Main bile duct stenosis: Endotherapy 61 patient with main bile duct stenosis 1 yearstenting – 3 monthlystent changes 39 patients with calcifications22 patients without calcifications Success: 3/39 (8%) 13/22 (59%) Failure: 36/39 (92%) 9/22 (41%) Kahl et al., Am J Gastroenterol 2003

  14. Chronicpancreatitis: 2010 Surgery is superior toendoscopic therapy! Cahen et al., NEJM 2007 Dite et al., Endoscopy 2003 Kahl et al., Am J Gastroenterol 2003 If a patients needs an intervention surgery is the treatment of choice

  15. What is clinical reality • 44-year old male patient, chron. pancreatitissince 2001 • long time alcoholabuse • commonbileductobstruction • since 2003: - severaltimes/yearstentchanges • - severalstentclosures • - since 2007: portalthrombosis,varicosis • - metalstent, thenplasticstent in metalstent, lasertherapy • - present: gastricoutletobstruction

  16. Chronic pancreatitis – case report 2 1 4 3 varicosis Portal obstruction Laparotomy, no resection possibleDouble bypass (bile, stomach)

  17. Chronic pancreatitis – case report Postoperative course • Ascites -> Ascites drainage, high dose furosemid/spironolacton -> removement of drainage • Cholangitis (treated with antibiotics) • Slow nutritional recovery

  18. Chronic pancreatitis – case report

  19. Surgery versus Endoscopy Surgery is better than endoscopic therapy! Which Operation??? Cahen et al., NEJM 2007 Dite et al., Endoscopy 2003

  20. Chronic Pancreatitis 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 • pain • duodenal stenosis • common bile duct stenosis • obstruction main pancr. duct • obstruction of vessels • pseudocysts (symptomatic) • suspicion of malignancy Kausch Beger Whipple

  21. Evidence-basedsurgery chronic pancreatitis (randomized, controlled) studies Pancreatic head resection Klempa et al., Chirurg 1995 Whipple vs. DPPHR Büchler et al., Am. J. Surg. 1995 Whipple vs. DPPHR Izbicki et al., Ann. Surg. 1995 Frey vs. DPPHR Izbicki et al., Chirurg 1997 Frey vs. DPPHR Strate et al., Ann. Surg. 2005 Frey vs. DPPHR Izbicki et al., Ann. Surg. 1998 Whipple vs. Frey Makowiec et al., PancreasClub 2004 Whipple vs. DPPHR organ preservation better

  22. Duodenum preserving versus Whipple Long term results RCT: 7, 14 years follow-up 31 - Frey vs 30 - PPPD 20 – Beger vs 20 PPPD • Results short term: in favour of organ-preserving • Results long term: Bothprocedures achieve: • adequatepain reduction • good quality of life • no difference in exo/endocrine function Strate et al., Gastroenterology 2008 Müller et al., Br J Surg 2008

  23. Duodenum-preservingpancreatic head resection – optimal operation Beger Operation Frey Operation Frey, Pancreas 1987 Bern-Büchler/Farkas Operation Beger et al., Chirurg 1982 Gloor et al., Dig Surg 2001

  24. Chronic pancreatitis – resection: Organ preservingoperation technique Longitudinal V-shapeexcision Izbicki et al., Ann Surg 1998 Segmentectomy

  25. Büchler/Farkas modification of the Beger/Frey Operation Long-term Follow-up After Organ-Preserving Pancreatic Head Resection in Patients with Chronic Pancreatitis Farkas G, Leindler L, Daroczi M, Farkas G Jr J Gastrointest Surg 2008 135 patients Preoperative Follow-up 10 13 0 0 5.6 82 75 20 75 63 Pain visual analog scale Frequency of pain attacks Pain medication Inability to work Pain score ALL (!) (p<0.001) Mean follow-up: 4.1 years Late mortality 3.7%

  26. Büchler/Farkas modification of the Beger/Frey Operation Pancreatic head excavation: A variation on the theme of duodenum-preserving pancreatic head resection Andersen DK, Topazian MD Arch Surg 2004 • 6 patients • No mortality • No seriouscomplications • OP time: 390 min • Blood loss: 475 ml • Hospitalisation: 6-8 days

  27. Büchler/Farkas modification of the Beger/Frey Operation 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) Müller et al. 2008, Am J Surg

  28. Büchler/Farkas modification of the Beger/Frey Operation Prospective randomized controlled trial: 65 patients: 32 - Beger, 33 – Büchler/Farkas Beger Büchler/Farkas Köninger et al., Surgery 2008

  29. Büchler/Farkas modification of the Beger/Frey Operation Endpoints/results Beger Büchler/Farkas (n=32) (n=33) 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 Köninger et al., Surgery 2008

  30. Hepatic artery Splenic artery Pancreatic head Pancreatic tail Tumor Resection Resection Duodenum Chronic pancreatitis – organ preservation Segmentectomy Heidelberg: 10/2001 – 08/2005 17 patients: tumors 23 patients: focal CP Mortality: 2.5% Müller & Friess et al., Ann Surg 2006

  31. Segmentectomy – matched pairs 40 patients: Whipple 40 patients: Left resection 40 patients: Segmentectomy versus Blood loss Hospitalisation Mortality Morbidity comparable Less Diabetes mellitus* Better quality of life* *p<0.05 OPof choiceinbenignlesions of pancreatic body! Müller & Friess et al., Ann Surg 2006

  32. Chronic pancreatitis Conclusion • - Surgery is superior toendotherapy • - Organ preserving OP techniques! (Beger, Frey, Büchler/Farkas, segmentectomy etc.) • - Lowmorbidity & mortality • - Preservation of function(exocrine, endocrine) • - Improvement of quality of life

More Related