Presenter: Thomas Maatman MD | Indiana University Background: Operative management of chronic pancreatitis (CP) must be tailored to individual patient’s anatomy to achieve durable symptom relief. Incomplete drainage of an atrophic pancreatic tail is a common cause of symptom recurrence in patients undergoing drainage procedures. We have selectively applied limited distal pancreatectomy (DP) with duodenal-preserving pancreatic head resection (DPPHR) to patients with appropriate anatomy and hypothesized that this novel procedure provides durable therapy. Methods: Ten patients underwent DPPHR combined with limited DP between 2013-2018. Patient demographics, comorbidities, perioperative outcomes, and long-term CP-specific outcomes were recorded. Measurements of the pathology specimen determined pancreas tail volume. Chronic pancreatitis specific outcomes included endocrine/exocrine insufficiency, pain relief, and nutritional status. The amount of opioid pain medication was reported as daily morphine equivalents. Body mass index (BMI) and albumin were reported as surrogates for nutritional status. Descriptive statistics were applied. Continuous data are reported as means ± standard error of the mean. Results: Ten patients (8 females; age 49 ± 3 years) had etiology of idiopathic (n = 4), alcohol (n = 2), sequelae of severe acute pancreatitis (n = 1), hereditary (n = 1), autoimmune (n = 1), and pancreas divisum (n = 1). Operation was 57 ± 14 months after CP diagnosis. Patients had 6 ± 1 endoscopic procedures prior to operation. Mean operative time was 215 ± 11 minutes; estimated blood loss was 110 ± 28 mL. On average, 6 ± 1 cm of pancreatic tail was resected. Splenic preservation was possible in 7 patients. Postoperative LOS was 13 ± 2 days. Postoperative morbidity occurred in two patients; one grade B postoperative pancreatic fistula and one perforated duodenal ulcer. Readmission occurred in 5/10 patients at median time of 36 days (range, 16-78 days) postoperatively. Causes included abdominal pain (n = 2), small bowel obstruction (n = 1), intraabdominal abscess requiring antibiotic therapy (n = 1), and failure to thrive (n = 1). No perioperative mortality occurred. Overall, analgesic requirements and nutrition (measured by albumin) improved substantially (Figure 1). In addition, improvement in BMI (preoperative, 23.5 ± 1 kg/m2) was sustained at one- (23.7 ± 1 kg/m2), three- (25.6 ± 1 kg/m2), and five-years postoperatively (24.2 ± 1 kg/m2). At operation, 20% of patients required insulin; at five-year follow up this number was 25%. Eighty percent of patients were prescribed exocrine replacement preoperatively; all patients were on exocrine replacement at five-year follow up. During follow up (mean, 38 ± 7 months), one patient with hereditary CP underwent salvage total pancreatectomy with islet cell auto-transplantation 13 months postoperatively. Conclusion: In select chronic pancreatitis patients, including limited distal pancreatectomy with duodenal-preserving pancreatic head resection provides durable, long-term pain relief and improves nutritional parameters with minimal effect on pancreatic endocrine and exocrine function. This operation should be considered in select patients with appropriate anatomy.

Conventional techniques for biliary cannulation are unsuccessful in 5% to 10% of patients. Although precut needle-knife sphincterotomy (NKS) can improve the cannulation success rate, this technique has been associated with increased morbidity, particularly postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). Investigators examined the relationship between NKS and ERCP complications using data that were collected prospectively from two successive randomized ERCP trials involving 732 patients. PEP was …

The false-positive rate of endoscopic ultrasound fine-needle aspiration (EUS-FNA) cytology is thought not to exceed 1%. To test that assumption, Mayo Clinic researchers prospectively compared EUS-FNA cytology findings that were positive or suspicious for malignancy or neoplasm with findings from the diagnostic gold standard of surgical pathology. Only patients who proceeded directly to surgery without neoadjuvant therapy were included. Positive or suspicious FNA cytology in the absence …

One of the most common major complications of endoscopic retrograde cholangiopancreatography (ERCP) is post-ERCP pancreatitis (PEP). Several randomized

Surgical necrosectomy in patients with pancreatic necrosis has been associated with pancreaticocutaneous fistula formation. To determine whether percutaneous drainage followed immediately by endoscopic abscess drainage could prevent fistula formation and eliminate the need for surgical necrosectomy, investigators conducted a retrospective study involving 15 patients with organized pancreatic necrosis who underwent this combined-modality drainage technique at a single tertiary care center. Necromas occurred within 2 cm of the gastric or duodenal lumen in all patients and were located in the entire pancreas in …

Endoscopic retrograde cholangiopancreatography with sphincterotomy (ERCP/S) has traditionally been performed prior to laparoscopic cholecystectomy (LC) in patients with suspected choledocholithiasis. More recently, one-stage techniques — combination LC and laparoscopic common bile duct exploration (LC/LCBDE) — have been developed to treat these patients. In a randomized prospective trial, investigators compared the use of one-stage LC/LCBDE with two-stage ERCP/S + LC in patients with symptomatic gallstone disease and likely choledocholithiasis based on ≥1 of the following criteria: common bile duct diameter ≥6 mm …

Proposed risk factors related to the development of post–endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis include procedure-induced

An estimated 10% of adenocarcinomas of the pancreatic duct are inherited. Researchers sought to quantify risk for pancreatic cancer in families with

Prophylactic pancreatic duct (PD) stenting lowers the incidence of post–endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in

Approximately one third of all patients who undergo cholecystectomy have persistent pain after surgery. To determine whether bile microlithiasis might

Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP) and occurs in 20% to 30% of high-risk patients. Several animal studies have suggested that allopurinol, a xanthine oxidase inhibitor and an effective antioxidant with antiapoptotic effects, might prevent oxidative insult that triggers post-ERCP pancreatitis (PEP). However, two previously published studies in humans failed to show any benefit for allopurinol, whereas a third did show a significant reduction (JW Gastroenterol Jul 26 2005 and Gastrointest Endosc 2005; 62:245). Based on compelling animal data but inconsistent results from prior randomized trials in humans, researchers …

Performing endoscopic retrograde cholangiopancreatography (ERCP) with a standard duodenoscope in a patient with a surgically altered intestinal anatomy

When the pancreatic duct is completely transected, the portion of the pancreas that is upstream from the disruption (i.e., toward the tail) becomes

Sphincter of Oddi dysfunction (SOD) is a syndrome in which functional or structural abnormalities of the sphincter manifest as recurrent abdominal

The medical literature is inundated with studies that were designed to evaluate the efficacy of various methods (both pharmacologic and mechanical) for

Phospholipase A2 plays a critical role in the initial inflammatory cascade of acute pancreatitis. Nonsteroidal anti-inflammatory drugs (NSAIDs) are

Human epidermal growth-factor receptor type 1 (HER1/EGFR) is overexpressed in many pancreatic tumors and is associated with poor prognosis and accelerated disease progression. Researchers conducted an international randomized study of 569 patients to determine whether adding erlotinib (Tarceva), an oral HER1/EGFR tyrosine-kinase inhibitor, to gemcitabine (Gemzar) lengthens survival in patients with unresectable, locally advanced or metastatic pancreatic cancer. The enrolled groups were balanced well for demographics, performance status, extent of …