ročník 3,1995 č.4

Editorial

  1. Prospective Rondomized Study Between Two Techniques of Duodenum Preserving Resection of the Head of the Pancreas in Chronic Pancreatitis *(1.part)

Abstrakta

  1. Arterializace vrátnicové žíly v prevenci a léčbě poshuntové jaterní encefalopatie
  2. Možnosti antimikrobiální léčby při hepatobiliárních a pankreatických operacích - Prospektivní randomizovaná studie

Editorial

Prospective Rondomized Study Between Two Techniques of Duodenum Preserving Resection of the Head of the Pancreas in Chronic Pancreatitis *

Izbicky JR1, Bloechle C1, Knoefel WT1, Limmer JC1, Kauchler T2, Seifert H3,
Department of Surgery1, Department of Medical Psychology2, Department of Surgical Endoscopy3
University of Hamburg, Hamburg, FRG

*This report represented an update of an article previously published in Annals of Surgery 221,1995:350-358

Summary

Objective:
Two techniques of duodenum preserving resection of the head of the pancreas were compared in a prospective randomized trial. The technical feasibility and effects on quality of life assessed.
Summary Background Data: Drainage and resection are the principles of surgery in chronic pancreatitis. The techniques of duodenum-preserving resection of the head of the pancreas as described by Beger and Frey combine both to different degrees. The efficacy of both procedures has so far not been compared.
Methods:
56 patients were randomly allocated to either Beger's (n=28) or Frey's (n=28) group. In addition to routine pancreatitis diagnostic work-up a multidimension psychometric quality-of-life questionnaire and a pain score were used. Assessment of endocrine and exocrine function included oral glucose tolerance test, serum concentrations of insulin, C-peptide, and HbA1c,as well as fecal chymotrypsin and pancreolauryl test. The interval between symptoms and surgery ranged from 12 months to 12 years with a mean of 5,3 years. The mean follow-up was 1,5 years.
Results:
There was no mortality. Overall morbidity was 27 % (32 % Beger, 21 % Frey). Complications from adjacent were organs were definitively resolved in 93 % (90 % Beger, 95 % Frey). A decrease of 95 % and 94 % of the pain score after Beger's and Frey's procedure, respectively, and an increase of 67 % of the overall quality-of-life index in both groups observed. Endocrine function did not differ between both groups.
Conclusions:
Both techniques of duodenum preserving resection of the head of the pancreas are equally safe and effective with regard to pain relief, improvement of quality of life, and definitive control of complications affective adjacent organs. Both producers do not lead to further deterioration of endocrine and exocrine pancreatis function.

Patients with chronic pancreatitis characterized by severe pain pose a therapeutic challenge (1). The impact of surgery in chronic pancreatitis has been discussed controversially (1,2).
Based on studies on the natural history of chronic pancreatitis it was hypothesized that eventually most patients will become pain free with progressive "burning out" of the organ (2). Therefore a conservative approach has been proposed. However, in a recently published study based on a larger population observed over a longer follow-up, pain alleviation did not occur in more than fifty percent of the patients while the disease progressed (3). Considering the compact of the impact of the "burning out" process on the patients and society, therapeutic conservatism may not to be the appropriate approach. Whether surgery is superior, and if so, which procedure, remains unclear.
In nearly one third of patients with chronic pancreatitis an inflammatory mass in the head of the pancreas develops frequently generating complications of adjacent organs, e.g. common bile duct stenosis and duodenal stenosis (4). In these patients partial pancreatoduodenectomy represents the most commonly employed operative procedure. The sacrifice of otherwise not disease organs, i.e. distal stomach, duodenum, and bile duct, is the major disadvantage of this procedure. Duodenum preserving resection of the head of the pancreas was introduced by Beger (5). This procedure includes subtotal resection of the pancreatic head sparing the stomach, duodenum, and common bile duct, while it reliably provides pain relief.
A modification of the Partington-Rochelle procedure, that also resect most of the pancreatic head, while it preserves the duodenum, has recently been promoted (6). This modifed duodenum preserving resection of the head of the pancreas is claimed to provide equally effective pain relief and control of pancreatitis associated complications, while it is considered to be technically easier. To compare both techniques of duodenum preserving resection of the head of the pancreas with regard to complete pain relief definitive control of organ complicatons arising from adjacent organs, and improvement of the patient's quality of life a prospective randomized study was devised.

Patients and methods

The protocol had been approved by the Ethics and Research Committee of the Hamburg Medical Association. Since January 1992 a consecutive series of 61 patients (46 males and 15 females) with chronic pancreatitis were randomly allocated to either Beger's or Frey's group.
Inclusion criteria were an inflammatory mass in the head of the pancreas ( more than 35 mm in diameter), severe recurrent pain attacks (at least one per month requiring opiates), history of pain attacks for at least one year, or coexisting complications from adjacent organs (e.g. common bile duct stenosis, duodenal stenosis).
Disease related exclusion criteria were chronic pancreatitis without involvement of the pancreatic head, pseudocysts without duct pathology, and portal vein thrombosis. Patient related exlusion criteria were myocardial infarction within six months, detection of a malignant pancreatic tumor and coexisting malignancy of other organs.
All patients were seen by a panel of gastroenterologists and surgeons which decided on the indications for surgery. During work-up and/or conservative treatment the patients had undergone a median of 5 ERCP's (range 1 to 19, excluding patients with duodenal stenosis). During a medical period of 14 weeks conservative treatment including endoscopic drainage and extracorporal shock wave lithotripsy (ESWL) had failed to provide pain relief in 44 patients. The remaining 17 patients primarily underwent surgery since conservative treatment modalities were considered inappropriate. Surgery was indicated because of recurrent intractable pain in all patients. Five out of the 61 patients were excluded after entry because an adenocarcinoma was found intraoperatively on frozen section analysis. In these patients surgery was delayed for 3 to 8 months due to conservative treatment including endoscopic drainage and/or ESWL.
The mean interval between symptoms and surgical intervention was 5,3 +/- 2,4 years. Etiology was alcohol overindulgence in 40 patients, blunt pancreatic trauma in one patient and iatrogenic in one patient. The latter had undergone endoscopic resection of papilary adenoma with subsequent scarring of the papilla prior to development of pancreatitis. In the remaining patients etiology remained unknown, and pancreatitis was consired to be of idiopathic origin. There was no significant difference between the two groups with regard to age, sex, and distribution of pathologic findings. All patients were reassessed in the outpatient clinic at six months intervals.

An inflammatory mass in the head of the pancreas was visualized in all patients. On sonography and CT scan the maximal diameter of the pancreatic head measured more than 50mm in 70 % of patients, varying from 41 to 126mm. In 7 patients, who presented with recurrent emesis, duodenal stenosis was endoscopically shown. After 4 weeks of total parenteral nutrition the duodenal obstruction had not ceased spontaneously as demonstrated by hypotonic duodenography. According to the Cambridge classification (7) ERP revealed pancreatic duct lesions attributed to stage I in 4, stage II in 17, and stage III in 24 patients. Due to duodenal stenosis ERCP could be performed in 11 patients. Thirty-five patients suffered from a common bile duct stenosis as indicated by ERC, sonography, and laboratory findings. In 14 patients angiography showed compression of the vein suggestive of segmental portal hypertension. Exocrine pancreatic function was assessed by estimation of fecal chymotrypsin concentration (normal more than 40 Ţg/g feces) (2) and the Pancreolauryl-test (normal more than 30 %, intermediate 20 to 30 %, pathologic less than 20 %) (8).
Endocrine pancreatic function was assessed by the need to treat diabetes mellitus with diet modification, oral hypoglycemic agents, or insulin. Furthermore fastenend serum insulin- (normal less than 10 ŢE/ml, pathologic more than 10 ŢE/ml) and C-peptide levels (normal less than 0,7-0,3 ng/ml, pathologic more than 3,0 ng/ml), as well as HbA1C concentrations (normal less than 4,5-6,0 %, pathologic more than 6,0 %) were detrmined. In all patients, that were not insulin-dependent, an oral glucose tolerance test (OGTT was performed and results were classified into normal, impaired OGTT, or diabetes mellitus according to the criteria set by the 1985 WHO Study Group on Diabetes Mellitus (9).
Pain intensity was estimated employing a recently suggested pain scoring system, which inclused a visual analog scale, frequency of pain attacks, analgesic medication, and the time of disease related inability to work (10).
In additon the European Organisation for Research and Treatment of Cancer (EORTC) quality-of-life questionnaire (11) was self assesed by the patients. It comprises different single and multi-trait scales on symptoms, physical status, working ability, emotional, cognitive, and social functioning, as well as a global quality of life scale .
The EORTC quality-of-life questionnaire had previously been validated for patients suffering from chronic pancreatitis (10).
Beger's and Frey's procedure were performed in 28 patients, each. Histopathologic examination of the resected specimen confirmed chronic pancreatitis in all patients.
2.část (číslo 96-1)


Abstrakta

Arterializace vrátnicové žíly v prevenci a léčbě poshuntové jaterní encefalopatie

Wiesner K
Chirurgické oddělení Okresní nemocnice ve Strakonicích
Přednosta: MUDr Wiesner K CSc

Souhrn

Autor popisuje své zkušenosti s tzv. arterializací vrátnicové žíly u 18 nemocných, kde byla provedena portosystémová spojka pro krvácející jícnové městky. Příčinou portální hypertenze ve všech případech byla jaterní cirhóza nebo fibróza. Mezi příčinami vzniku poshuntové jaterní encefalopatie staví na první místo změnu směru krevního proudu v portální žíle v důsledku portokavální spojky. Arterializace vrátnicové žíly je účinnou metodou k udržení prográdního proudění portální žílou a k zajištění perfuze jater potřebné pro normální detoxikační činnost jaterního parenchymu. Tam, kde detoxikační porucha typu jaterní encephalopatie následkem odklonu portální krve již vznikla, může arterializace obnovit porušené perfuzní poměry a bránit tak rozvoji jaterní poshuntové encefalopatie.
Klíčová slova: portální hypertenze - portosystémová spojka - postshuntová encefalopatie - arterializace portální žíly

Summary

Arterialisation of portal vein in the prophylaxis and treatment of postshunt encephalopathy
Wiesner K
The autor describes his experience with the portal vein "arterialisation", on 18 patients with esophageal variceal vein bleeding. The cause of portal hypertension was a liver cirrhosis or fibrosis in all cases. The main cause of postshunt liver encefalopathy is the change of blood flow direction in portal vein following portocaval shunt. The "arterialization" of portal vein stump is an effective method, to preserve prograde blood flow in liver portal vein system and so warrant the needful perfusion for normal detoxication. In case of a detoxication disorder, which is an effect of a change of the blood flow direction following portocaval shunt, "arterialisation" can restaure the perfusion and prevent the development of postshunt liver encephalopathy.
Key words: portal hypertension - portosystemic shunt - postshunt encephalopathy - arterialisation of portal vein

Možnosti antimikrobiální léčby při hepatobiliárních a pankreatických operacích - Prospektivní randomizovaná studie

Fried M,Pešková M, Růžička P
I.chirurgická klinika VFN, 1.LF UK,Praha
Přednosta: Prof MUDr Pešková M DrSc

Souhrn

Autoři uvádějí své zkušenosti z prospektivní randomizované studie účinků léčby kombinací pefloxacinu (Abaktalu) a klindamycinu (Klimicinu) s cefoxitinem u nemocných po chirurgických výkonech v oblasti hepatobiliární a pankreatické. Výsledky léčby u obou sledovaných skupin byly u více než 95% nemocných hodnoceny jako výborné, bez statisticky významných rozdílů. Autoři prokázali srovnatelnou účinnost kombinace pefloxacinu s klindamycinem s účinností cefoxitinu u nemocných po výše uvedených typech operačních výkonů, přitom však s nižšími ekonomickými náklady na léčbu a možností perorálního podávání těchto preparátů, jakmile to stav nemocných dovolí.
Klíčová slova: pefloxacin - klindamycin - cefoxitin - hepatobiliární operace

Summary

Fried M, Pešková M, Růžička M.
The possibilities of antimicrobe therapy in hepato-pancreato-biliary surgery. Prospective randomized study.
There is the authors° presentation of their experience from prospective randomize study about the effect of the antimicrobe therapy with pefloxacin and klindamicin with cefoxitin in patients after HPB surgery. The results of therapy in both groups of patients were in more then 95% excellent without statistical significant difference. The authors proved comparable effect of the combination of pefloxacin and klindamicin to cefoxitin with lower price on therapy and possibilities of peroral application.
Key words: pefloxacin - klindamycin - cefoxitin - hepatobiliary surgery