1. Tailored resective pancreatic surgery in chronic pancreatitis Weiss H, Brandstätter S, Biebl M, Mark W, Nehoda H, Lanthaler M, Nitsche U, Wildauer D, Aigner F, Öfner D, Margreiter R Dept Visceral, Transplant, and Thoracic Surgery Center of Operative Medicine - Medical University Innsbruck Jahrestagung der Tirolisch- Venezianisch- Lombardischen Chirurgenvereinigung gemeinsam mit der Società Triveneta di Chirurgia Convegno Annuale dell’Associazione Chirurgica Tirolo- Veneziana- Lombarda in Associazione con la Società Triveneta di Chirurgia Bozen-Bolzano, 21. 06. 2008

2. H. G. Weiss2/15 Pancreatic Resections in Chronic Pancreatitis Background Main indications for surgery: intractable pain suspicion of malignancy involvement of adjacent organs The goal of surgical treatment is to improve the quality of life of patients. Erythema ab igne

3. H. G. Weiss3/15 Pancreatic Resections in Chronic Pancreatitis Pain Leading symptom in 85% of patients with chronic pancreatitis Nerval impairment – neuritis, neurotransmitter-toxins Ischemia of parenchyma Increased intraductal pressure, hypertension Inflammatory mass Pseudocysts Compression/stenosis of ducts/duodenum Supportive treatment: Analgesic drugs, antidepressants, pancreatic enzymes, octreotide, antioxidants (selenium, Vit C,E, carotene, methionine) and endoscopy Nonoperative management to await the spontaneous resolution of pain by pancreatic “burn- out,” that hoped-for outcome never comes in at least half of the patients, and the wait may be intolerable and unjustifiable when more effective therapy exists. Supportive therapy Operative therapy

4. H. G. Weiss4/15 Pancreatic Resections in Chronic Pancreatitis Different strategies for pain relief (according to underlying mechanisms) Neuritis Neurotoxins Increased intraductal pressure Hypertension Inflammatory mass Compression/stenosis of ducts/duodenum Risk for cancer Complicated previous surgery Nerve blockade, thoracoscopic splanchnicectomy Maher Thoracoscopic splanchnicectomy for chronic pancreatitis pain. Surgery 1996 Cuschieri Bilateral endoscopic splanchnicectomy through a posterior thoracoscopic approach. J R Coll Surg Edinb 1994

5. H. G. Weiss5/15 Pancreatic Resections in Chronic Pancreatitis Different strategies for pain relief (according to underlying mechanisms) Neuritis Neurotoxins Increased intraductal pressure Hypertension Inflammatory mass Compression/stenosis of ducts/duodenum Risk for cancer Complicated previous surgery Nerve blockade, thoracoscopic splanchnicectomy Drainage procedures Mercadier Partington-Rochelle Rumpf-Pichlmayr

6. H. G. Weiss6/15 Pancreatic Resections in Chronic Pancreatitis Different strategies for pain relief (according to underlying mechanisms) Neuritis Neurotoxins Increased intraductal pressure Hypertension Inflammatory mass Compression/stenosis of ducts/duodenum Risk for cancer Complicated previous surgery Nerve blockade, thoracoscopic splanchnicectomy Drainage procedures Extended drainage procedures Resections (head, tail) Izbicki V-Excision DuVal Puestow-Gillesby Child

7. H. G. Weiss Pancreatic Resections in Chronic Pancreatitis Different strategies for pain relief (according to underlying mechanisms) Neuritis Neurotoxins Increased intraductal pressure Hypertension Inflammatory mass Compression/stenosis of ducts/duodenum Risk for cancer Complicated previous surgery Nerve blockade, thoracoscopic splanchnicectomy Drainage procedures Extended drainage procedures Resections (head, tail) Beger Extended Beger Frey Berne Izbicki V-Excision DuVal Puestow-Gillesby Child 6/15

8. H. G. Weiss Pancreatic Resections in Chronic Pancreatitis Different strategies for pain relief (according to underlying mechanisms) Neuritis Neurotoxins Increased intraductal pressure Hypertension Inflammatory mass Compression/stenosis of ducts/duodenum Risk for cancer Complicated previous surgery Nerve blockade, thoracoscopic splanchnicectomy Drainage procedures Extended drainage procedures Resections (head, tail) Beger Extended Beger Frey Berne Whipple Traverso-Longmire Izbicki V-Excision DuVal Puestow-Gillesby Child 6/15

9. H. G. Weiss Pancreatic Resections in Chronic Pancreatitis Different strategies for pain relief (according to underlying mechanisms) Neuritis Neurotoxins Increased intraductal pressure Hypertension Inflammatory mass Compression/stenosis of ducts/duodenum Risk for cancer Complicated previous surgery Nerve blockade, thoracoscopic splanchnicectomy Drainage procedures Extended drainage procedures Resections (head, tail) Total pancreatectomy 7/15

10. H. G. Weiss Pancreatic Resections in Chronic Pancreatitis Comparison of different surgical strategies Extended drainage procedures Beger Frey 8/15

11. H. G. Weiss Pancreatic Resections in Chronic Pancreatitis Comparison of different surgical strategies Extended drainage procedures Beger Frey Berne Hospital mortality rate 1% Surgical morbidity rate 16% Relaparotomy rate 6% Procedural time 295±7 min Intraoperative blood loss763±75 mL Postsurgical hospital stay 11.4 d Follow-up (41 m):pain improved in 55% weight increase in 67% de novo diabetes in 22% QOL similar to control population 9/15

12. H. G. Weiss Pancreatic Resections in Chronic Pancreatitis Comparison of different surgical strategies Resections (pancreatic head) vs. Extended drainage procedures Innsbruck 2003-06 N (patients) :23 Age (a) :52.8 ± 11.7 Gender:f:m = 1: 3.3 Suspicion of cancer: 9 (39.1%) Procedure: Kausch/Whipple (A): 13 (56.6%) DPPHR (B):10 (43.5%) No significant preoperative differences: p = 0.537 Results: Procedural time (min) : 439±92 (A) / 310±51(B) p=0.030 Hospital stay (d) : 21.7±11 (A) / 22.8±17 (B) p=0.533 Morbidity 39.1% p = 0.637 Anastomotic Compl:26.1% p = 0.197 Reoperations:17.4% 0 (A)/ 4 (B) p = 0.024 Recurrent pancreatitis: 17.4% p = 0.200 Mortality:0.0% Whipple 10/15

13. H. G. Weiss Pancreatic Resections in Chronic Pancreatitis Comparison of different surgical strategies Extended drainage procedures vs. Resections (pancreatic head) Beger Frey Büchler Randomized trial of duodenumpreserving pancreatic head resection versus pylorus-preserving Whipple in chronic pancreatitis. Am J Surg. 1995 Klempa Pancreatic function and quality of life after resection of the head of the pancreas in chronic pancreatitis. A prospective, randomized comparative study after duodenum preserving resection of the head of the pancreas versus Whipple’s operation. Chirurg. 1995 Farkas Prospective randomised comparison of organ-preserving pancreatic head resection with pyloruspreserving pancreaticoduodenectomy. Langenbecks Arch Surg. 2006 Izbicki Extended drainage versus resection in surgery for chronic pancreatitis: a prospective randomized trial comparing the longitudinal pancreaticojejunostomy combined with local pancreatic head excision with the pylorus-preserving pancreatoduodenectomy. Ann Surg. 1998 1284 articles 223 full papers 10 RCTs 4 no data mix 11/15

14. H. G. Weiss Pancreatic Resections in Chronic Pancreatitis Comparison of different surgical strategies Resections (pancreatic head) vs. Extended drainage procedures Beger Frey Pain relief p=0.46 Whipple Traverso-Longmire 12/15

15. H. G. Weiss Pancreatic Resections in Chronic Pancreatitis Comparison of different surgical strategies Resections (pancreatic head) vs. Extended drainage procedures Beger Frey Whipple Traverso-Longmire Morbidity p=0.22 12/15

16. H. G. Weiss Pancreatic Resections in Chronic Pancreatitis Comparison of different surgical strategies Resections (pancreatic head) vs. Extended drainage procedures Beger Frey Whipple Traverso-Longmire Blood replacement p=0.02 12/15

17. H. G. Weiss Pancreatic Resections in Chronic Pancreatitis Comparison of different surgical strategies Resections (pancreatic head) vs. Extended drainage procedures Beger Frey Whipple Traverso-Longmire Hospital stay p=0.0002 12/15

18. H. G. Weiss Pancreatic Resections in Chronic Pancreatitis Comparison of different surgical strategies Resections (pancreatic head) vs. Extended drainage procedures Beger Frey Whipple Traverso-Longmire New onset exocrine insufficiency p=0.008 12/15

19. H. G. Weiss2/10 Pancreatic Resections in Chronic Pancreatitis Comparison of different surgical strategies Resections (pancreatic head) vs. Extended drainage procedures Postop weight gain p=0.0006 Beger Frey Whipple Traverso-Longmire

20. H. G. Weiss Pancreatic Resections in Chronic Pancreatitis Comparison of different surgical strategies Resections (pancreatic head) vs. Extended drainage procedures Occupational rehabilitation p=0.01 Beger Frey Whipple Traverso-Longmire 12/15

21. H. G. Weiss Pancreatic Resections in Chronic Pancreatitis Comparison of different surgical strategies Resections (pancreatic head) vs. Extended drainage procedures Quality of life p=0.00001 Beger Frey Whipple Traverso-Longmire 12/15

22. H. G. Weiss Pancreatic Resections in Chronic Pancreatitis Comparison of different surgical strategies Resections (pancreatic head) vs. Extended drainage procedures Beger Frey Whipple Traverso-Longmire Pain relief Morbidity Blood replacement Operation time Pancreatic fistula Delayed gastric emptying Hospital stay Exocrine insufficiency Endocrine insufficiency Weight gain Occupational rehabilitation Quality of life 13/15

23. H. G. Weiss Pancreatic Resections in Chronic Pancreatitis Comparison of different surgical strategies Total pancreatectomy Hospital mortality rate 4.8% Surgical morbidity rate 35.5% Procedural time 380 min Splenectomy 67 % Portal vein resection 26 % Postsurgical hospital stay 11-29 d Matched-Pairs Analysis 14/15

24. H. G. Weiss Pancreatic Resections in Chronic Pancreatitis Comparison of different surgical strategies for pain relief Extended drainage procedures Resections (head, tail) Total pancreatectomy „Although evidence-based experience now exists to indicate what operation(s) to do and how to do it safely, the criteria for when and if to operate remain subject to the conflicting biases of surgeons, gastroenterologists, and other physicians.“ 15/15