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© Borgis - Postępy Nauk Medycznych s1/2012, s. 4-10
*Gyula Farkas, Laszlo Leindler, Gyula Farkas Jr.
12-letnie doświadczenie w resekcji głowy trzustki z oszczędzaniem dwunastnicy i trzustki (modyfikacja Buchler-Farkasa) w chirurgicznym leczeniu przewlekłego zapalenia trzustki u 180 chorych
12-year experience with duodenum and organ-preserving pancreatic head resection (Büchler-Farkas modification) in the surgical treatment of 180 patients with chronic pancreatitis
Department of Surgery, Faculty of Medicine, University of Szeged, Hungary
Head of Department: prof. Gyorgy Lazar, MD, PhD
Streszczenie
Wstęp. Przewlekłe zapalenie trzustki jest łagodnym, zapalnym procesem chorobowym odpowiedzialnym za powiększenie głowy trzustki, znaczne dolegliwości bólowe, postepującą utratę wagi ciała i istotne pogorszenie jakości życia (QoL).
Materiał i metody. W pracy przedstawiono kliniczne doświadczenie związane z wykonywaniem resekcji głowy trzustki z zachowaniem dwunastnicy i oszczędzaniem miąższu trzustki (duodenum and organ-preserving pancreatic head resection – DOPPHR) u 180 chorych w okresie 12 lat. Oceniano jakość życia (QoL) w okresie pooperacyjnym z wykorzystaniem metody EORTC QoL-C 30.
Wyniki. Średni czas operacji wynosił 165 minut. Nie obserwowano zgonów w okresie okołooperacyjnym. Z powodu powikłań pooperacyjnych (krwawienie z zespolenia i niedrożność jelit) zaistniała konieczność reperacji u trzech chorych. Średni czas pobytu w szpitalu wynosił 7-12 dni. Średni czas obserwacji pooperacyjnej wynosił 6,5 lat (0,5-12 lat). 12 chorych zmarło w odległym okresie po operacji, tzw. późna śmiertelność wyniosła 6,7%.
Uzyskano poprawę jakości życia u 89% operowanych. 150 chorych było bezobjawowych, a u 18 chorych objawy chorobowe były miernie nasilone. W okresie pooperacyjnym obserwowano średni przyrost wagi ciała około 13,2 kg (zakres od 4-30 kg). Pooperacyjna czynność endokrynna trzustki była porównywalna do czynności przedoperacyjnej.
Wnioski. 12-letni okres doświadczeń w wykonywaniu operacji DOPPHR wykazał, że technika ta jest bezpieczna i skuteczna w chirurgicznym leczeniu powikłanego przewlekłego zapalenia trzustki.
Summary
Introduction. Chronic pancreatitis (CP), a benign, inflammatory process, can cause enlargement of the pancreatic head, which is accompanied by severe pain and weight loss, and often leads to a significant reduction in the quality of life (QoL).
Material and methods. Our clinical experience relates to the results attained with duodenum and organ-preserving pancreatic head resection (DOPPHR) in 180 patients during a 12-year period. The QoL is assessed during the follow-up period by using EORTC QoL-C30.
Results. The mean operating time was l65 min. Three reoperations were required in consequence of anastomosis bleeding and small bowel obstruction, but no mortality was noted in the postoperative period. Duration of hospitalization ranged between 7 and 12 days. The mean follow-up time was 6.5 years (range 0.5-12.0). The late mortality rate was 6.7% (12 patients). The QoL improved in 89% of the cases. 150 of the patients became complaint-free, while 18 had moderate symptoms, and the weight increased by a median of 13.2 kg (range 4-30). The preoperative and postoperative endocrine functions remained in almost the same stage as preoperatively.
Conclusions. This 12-year experience clearly demonstrates that this DOPPHR technique is a safe and effective procedure, which should be preferred in the surgical treatment of the complications of CP.
Introduction
Chronic pancreatitis (CP) is a benign, inflammatory disease of the pancreas, which can cause enlargement of the pancreatic head with severe pain and weight loss and often reduces the quality of life (QoL) significantly. The enlarged inflamed head of the pancreas can lead to complications such as obstruction of the pancreatic duct, common bile duct stenosis and duodenal compression. These are all indications for surgical treatment: resection of the pancreatic head. The surgical treatment consists in different types of pancreatic head resection (1): pylorus-preserving pancreaticoduodenectomy (PPPD) (2), Beger’s duodenum-preserving pancreatic head resection (DPPHR) (3), and Frey’s longitudinal pancreaticojejunostomy combined with local pancreatic head excision (LPJ-LPHE) (4). PPPD and Beger’s DPPHR involve total and subtotal resection of the pancreatic head, respectively, which can be regarded as too invasive in cases of benign disease and do not adhere to the modern organ-preserving concept. Twelve years ago, therefore, a new duodenum and organ-preserving pancreatic head resection (DOPPHR) method was developed, which is essentially suitable for this purpose (5-8). Preliminary clinical results achieved with this operation, together with follow-up findings, were published recently (9-11). The present article reports on late follow-up (mean, 6.5 years [range 0.5-12.0]) results attained with our DOPPHR on 180 patients, including QoL parameters.

Material and methods
Since 1999, we have performed a DOPPHR to treat inflammatory tumours of the pancreatic head (median diameter 68 mm [range 45-132 mm], as assessed by helical CT scan) in 180 patients (133 men and 47 women; mean age: 48.4 yr. [range 27-68]). The preoperative morbidity involved frequent, sometimes severe abdominal pain, a significant loss in body weight in all patients, jaundice in 10 patients, duodenal obstruction in 16 patients and latent (LDM) and insulin-dependent diabetes mellitus (IDDM) in 33 and 29 patients, respectively. The mean interval between the appearance of the symptoms and the surgical intervention was 7.9 ± 2.6 yr. The aetiology was connected with chronic alcohol ingestion in 157 patients (87 per cent) and with biliary stone disease in 18 patients (10 per cent), and was unknown in 5 patients. The diagnosis of CP was confirmed by ERCP, MRCP, sonography and the CT scan. ERCP reveals that the diameter of the main pancreatic duct varied between 2 and 8 mm. In 10 icteric patients and in 21 patients without jaundice, the common bile duct was stenotic, due to inflammatory tumour compression with prestenotic dilatation, combined with high levels of alkaline phosphatase (range 956-1345 U/L). The CT scan demonstrated parenchyma calcification in 95 patients; 27 patients exhibited pseudocystic cavities, and 4 patients portal hypertension (tab. 1).
Table 1. Clinical characteristics of 160 patients undergoing DOPPHR*.
Age (yr, mean, range) 48.4 (27-68)
Sex ratio (male/female)133/47
Aetiology (per cent)
Alcohol ingestion
Biliary stone
Unknown

157 (87)
18 (10)
5 (3)
Duodenal obstruction (per cent)16 (8.9)
Head enlargement (per cent)
Pseudocystic cavity
180 (100)
27 (15)
Parenchymal calcification (per cent)95 (52.7)
Bile duct obstruction (per cent)
Jaundice
31 (17.2)
10 (5.6)
Portal hypertension (per cent)4 (2.2)
Pain intensity (per cent)
Weak
Moderate
Severe

10 (5.6)
135 (75)
35 (19.4)
Preoperative weight (kg, mean, range) 50.2 (42-66)
Diabetes mellitus (per cent)
None
Latent
Insulin-dependent

118 (65.5)
33 (18.4)
29 (16.1)
*Numbers of patients are shown, percentages given in parentheses.
Pancreatic functions were checked by means of stool elastase determination by a sandwich ELISA method (Pancreatic Elastase1®, ScheBo Biotech, Giessen, Germany) (12). The glucose tolerance test was applied to check the endocrine function. Blood glucose levels were measured by means of glucose oxidase assay 0, 30, 60, 90 and 120 min following administration of 75 g oral glucose.
Prophylactic antibiotic (ceftriaxone) was administered preoperatively, and in the early postoperative period all of the patients received standard supportive treatment, consisting of total parenteral nutrition for 4 days, a proton pump antagonist (pantoprazole), suppression of TNF synthesis (pentoxifylline) and octreotide medication (13). The oral nutrition was started on postoperative day 5.
Operative procedure
The surgical procedure involved a wide local resection of the inflammatory tumour in the region of the pancreatic head, and decompression of the organ and the intrapancreatic segment of the common bile duct if the prepapillary duct had become stenotic. The operative procedure started with the Kocher manoeuvre, partial dissection of the gastrocolic ligament for mobilization, and exploration of the head of the pancreas, without division and cutting of the pancreas over the portal vein. An intraoperative frozen section was performed for all patients; none of them revealed signs of malignancy. The following step of the operative procedure was ligation of the pancreaticoduodenal artery and the veins directed to the duodenum and to the superior mesenteric vein. The enlarged pancreatic head was excised in almost its entirety, leaving behind a bridge of pancreatic tissue about 10 mm wide, while a rim of pancreas (5 to 10 mm) remained beside the duodenum and on the upper margin of the pancreatic head. This wide excision gives a possibility for drainage of the pancreatic juice from the distal pancreas and for opening of the prepapillary obstructed common bile duct in icteric patients and in those with a stenotic common bile duct. The prestenotic dilated common bile duct was opened with an incision about 8-10 mm long, and the opened duct wall was sutured to the surrounding pancreatic tissue with interrupted Vicryl® 3/0 sutures. After careful haemostasis of the operative region, reconstruction, with drainage of the secretion from the remaining pancreas into the intestinal tract, took place through a jejunal Roux-en-Y loop, with the application of one-layer interrupted Vicryl® 2/0 sutures (7) (fig. 1.)

Fig. 1. The operation consists in a wide local resection of the inflammatory tumor in the region of the pancreatic head, without division and cutting of the pancreas over the portal vein. Reconstruction, with drainage of the secretion from the remaining pancreas into the intestinal tract, takes place through a jejunal Roux-en-Y loop. In icteric cases, prepapillary bile duct anastomosis is also performed with the jejunal loop.
Quality of life
The QoL and pain score before and after surgery were assessed by using the European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life Questionnaire (QLQ-C30) (14). The EORTC QLQ-C30 has been re-evaluated and demonstrated to be a valid and reliable with tool which to measure the QoL in patients with benign diseases such as CPl5. It comprises items relating to the physical status, the working ability, the emotional, cognitive and social functioning, and an overall QoL scale. Pain intensity was estimated by means of a pain-scoring system including a visual analogue scale, the frequency of pain attacks, the use of analgesic medication, and the duration of the inability to work. The overall pain score was given by the sum of the individual part-scores divided by 4. This questionnaire was prospectively assessed at two time points during the study: before the surgical procedure, and in the follow-up period, a mean of 6.5 years after the operation.
Statistical analysis
The details of the statistical analysis are presented in the manuscript as follows: The results on the parametric data are expressed as means ± standard deviation, and nonparametric data as medians. Statistical significance was estimated by using Student’s t test or the Wilcoxon rank test, as appropriate. The level of significance was set at P < 0·050.
Results
In 180 patients, the DOPPHR procedure was performed after the development of an inflammatory tumour of the pancreatic head. The intraoperative parameters and post surgical events are listed in table 2. The mean operation time was 165 min (range 120-230 min) and there was no indication for blood transfusion during the operations. In the postoperative period, three reoperations were required in consequence of anastomosis bleeding (2 patients) and small bowel obstruction (1 patient). Another 3 patients with anastomosis bleeding were treated conservatively, and 1 patient had pneumonia, but there was no septic complication, anastomosis insufficiency or other problem; the morbidity was therefore 3.9 per cent. There was no mortality in the postoperative period. In the 31 icteric and common bile duct stenotic patients (17.2 per cent), the liver functions normalized following the operation (serum bilirubin < 22 μmol/L, and alkaline phosphatase 232 ± 92 U/L; as compared with the preoperative data, the reduction was significant [P = 0·048]). The duration of hospitalization ranged between 7 and 12 days, by a mean of 8.5 days. The histological examinations confirmed fibrosis and calcification in 85 and 95 patients, respectively.
Table 2. Intraoperative parameters and early post surgical outcome after DOPPHR in 160 CP patients*.
Operative time (min, mean, range)165 (120-230)
Intrapancreatic bile duct anastomosis
(per cent)
31 (17.2)
Intraoperative blood transfusion31 (17.2)
Intraoperative blood transfusion0
Relaparotomy (per cent)
Anastomosis bleeding
Small bowel obstruction
3 (1.7)
2
1
Nonsurgical morbidity (per cent)
Bleeding treated conservatively
Pneumonia
4 (2.2)
3
1
Pancreatic fistula0
Wound infection0
Anastomosis leakage0
Abscesses or fluid collection0
Overall morbidity (per cent)7 (3.9)
Mortality (per cent)0 (0)
Post surgical hospital stay (day, mean, range)8.5 (7-12)
*Numbers of patients are shown, percentages given in parentheses.

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otrzymano: 2011-11-28
zaakceptowano do druku: 2012-06-04

Adres do korespondencji:
*Gyula Farkas
Department of Surgery Faculty of Medicine University of Szeged
P. O. Box 427, Szeged, H-6701, Hungary
tel.: +36 (62) 545-444, fax: +36 (62) 545-462
e-mail: fg@surg.szote.u-szeged.hu

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