Pancreaticoduodenectomy Versus Frey's Procedure for ... - Springer Link

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Yi-Yin Jan, and Miin-Fu Chen. Department of General Surgery, Chang Gung Memorial Hospital, 5 Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan. Abstract.

Surg Today (2007) 37:961–966 DOI 10.1007/s00595-007-3539-z

Pancreaticoduodenectomy Versus Frey’s Procedure for Chronic Pancreatitis: Preliminary Data on Outcome and Pancreatic Function Kun-Chun Chiang, Chun-Nan Yeh, Jun-Te Hsu, Han-Ming Chen, Huang-Yang Chen, Tsann-Long Hwang, Yi-Yin Jan, and Miin-Fu Chen Department of General Surgery, Chang Gung Memorial Hospital, 5 Fu-Hsing Street, Kwei-Shan, Taoyuan, Taiwan

Abstract Purpose. Several surgical treatments have been proposed for treating chronic pancreatitis (CP), including standard pancreaticoduodenectomy (PD), pyloruspreserving PD, Beger’s procedure, and Frey’s procedure; however, few studies have compared pre- and postoperative pancreatic function in patients undergoing surgery for CP. Methods. Between 1996 and 2003, 42 patients with CP underwent pancreatic head resection; as PD in 17 and as Frey’s procedure in 25. Frey’s procedure was chosen if the pancreatic duct was dilated more than 5 mm. We conducted this prospective, nonrandomized study to compare the pre- and postoperative status after PD or Frey’s procedure by evaluating pancreatic function and symptom relief. Results. The demographic features, surgical morbidity, and mortality were similar in the two groups. Pancreatic exocrine function improved, pain subsided, and complications of the adjacent organs resolved after surgery in both groups. Similar postoperative endocrine and exocrine functional results were observed in both groups. Frey’s procedure was associated with a significantly shorter hospital stay than PD (10.6 versus 15.4 days, respectively; (P < 0.0001)). Conclusion. There were no significant difference in operative time, surgical morbidity, or mortality rates between PD and Frey’s procedure. Both procedures were equally effective in terms of pain relief, improvement of pancreatic exocrine function, and control of complications affecting the adjacent organs; however, Frey’s procedure was associated with a significantly shorter hospital stay.

Reprint requests to: C.-N. Yeh Received: June 22, 2006 / Accepted: January 26, 2007

Key words Chronic pancreatitis · Pancreaticoduodenectomy · Frey’s procedure

Introduction Chronic pancreatitis (CP), a progressive inflammatory disease, is characterized by continuing morphologic and functional damage to both the exocrine and endocrine pancreas. In about 20% of patients with CP, an inflammatory mass develops in the head of the pancreas, which causes upper abdominal pain.1 Surgery is indicated for intractable pain, obstruction of the bile duct or duodenum, or if the condition is difficult to differentiate from pancreatic cancer.2 Standard pancreaticoduodenectomy (PD), or Whipple’s operation, is the standard procedure for headdominant CP,3 sacrificing the stomach, duodenum, and biliary tree,4 whereas the alternative pylorus-preserving PD (PPPD) sacrifices only the duodenum and the biliary tree.5 A less invasive procedure that allows preservation of healthy organs is crucial for treating benign diseases such as CP. Thus, procedures such as duodenum-preserving pancreatic head resection (Beger’s procedure)1 and local resection of the pancreatic head combined with longitudinal pancreaticojejunostomy (Frey’s procedure)6 have been propsed. These resections are extremely invasive, leading to fears that patients who survive may be debilitated by major gastrointestinal symptoms and pancreatic exocrine and endocrine insufficiency.5,7 However, few studies have compared pancreatic function pre- and postoperatively in patients undergoing surgery for CP. Evaluation of the effect of these operations has focused inevitably on pain relief. However, pancreatic exocrine and endocrine status and treatment requirements should be documented pre- and postoperatively to evaluate the surgery-induced deficits. Thus, we conducted a prospective, nonrandomized study to assess the pre- and postoperative status of patients

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K.-C. Chiang et al.: Surgery for Chronic Pancreatitis

Table 1. Demographic data and outcomes of 42 patients with chronic pancreatitis who underwent pancreaticoduodenectomy or Frey procedure

Gender (M : F) Age (years) Etiology Alcohol Biliary Others Operative indication Jaundice Duodenal obstruction Pain Pancreatic head mass Duration of symptoms (months) Operative time (min) Intraoperative bleeding (cc) Complication rates (%) Hospital stay (days) Mortality rates (%)

PD

Frey procedure

P

16 : 1 40.4 ± 15.1

20 : 5 39.7 ± 11.6

0.374 0.879 0.356

64.7% (11) 0 35.5% (6)

48% (12) 8% (2) 44% (11)

47.1% (8) 35.3% (6) 94.1% (16) 58.8% (10) 32.4 ± 24.2 296 ± 61 391 ± 284 11.8 15.4 ± 2.1 0

44% (11) 12% (3) 88% (22) 56% (14) 21.4 ± 10.5 302 ± 40 434 ± 274 20 10.6 ± 2.0 0

0.845 0.124 0.635 1.0 0.095 0.745 0.627 0.681 35 mm in diameter in the head of the pancreas. The surgical indications included intractable pain, jaundice, duodenal obstruction, a dilated ductal system with failed endoscopic treatment, and an inflammatory mass in the pancreatic head (Table 1). Either one of the two types of pancreatic head resection (PD or Frey) was performed for severe CP of the head of the pancreas combined with complications of adjacent organs or intractable abdominal pain. Frey’s procedure was performed only in patients with a dilated (>5 mm) main pancreatic duct. The diagnostic workup before surgery included abdominal ultrasonography, abdominal computed

Table 2. Pain score Points Frequency of pain attacks Daily Several times per week Several times per month Several times per year None Visual analog scale No pain Imaginative maximum of pain Analgesic medication (morphine-related analgesic potency) Morphine Bupremorphine Pethidine Tramadol Metamizole Acetaminophen Time of disease-related inability to work permanent

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