Nationwide Outcome of Tailored Surgery for Symptomatic Chronic Pancreatitis based on Pancreatic Morphology: Validation of the International guidelines

Charlotte L Van Veldhuisen; Charlotte A Leseman; Fleur E M De Rijk; E Nicole Dekker; Martine J Wellens; Nynke Michiels; Martijn W J Stommel; Christina Krikke; H Sijbrand Hofker; J Sven D Mieog; Stefan A Bouwense; Casper H Van Eijck; Bas Groot Koerkamp; Roel Haen; Marja A Boermeester; Olivier R Busch; Hjalmar C Van Santvoort; Marc G Besselink; Dutch Pancreatitis Study Group

doi:10.1097/SLA.0000000000006176

Nationwide Outcome of Tailored Surgery for Symptomatic Chronic Pancreatitis based on Pancreatic Morphology: Validation of the International guidelines

Ann Surg. 2023 Dec 13. doi: 10.1097/SLA.0000000000006176. Online ahead of print.

Authors

Charlotte L Van Veldhuisen^{1

2

3}, Charlotte A Leseman^{1

2}, Fleur E M De Rijk^{2

4}, E Nicole Dekker⁵, Martine J Wellens⁶, Nynke Michiels⁷, Martijn W J Stommel⁸, Christina Krikke⁹, H Sijbrand Hofker⁹, J Sven D Mieog⁷, Stefan A Bouwense¹⁰, Casper H Van Eijck⁴, Bas Groot Koerkamp⁴, Roel Haen⁴, Marja A Boermeester^{1

2}, Olivier R Busch^{1

2}, Hjalmar C Van Santvoort^{11

12}, Marc G Besselink^{1

2}; Dutch Pancreatitis Study Group

Affiliations

¹ Amsterdam UMC, location University of Amsterdam, Department of Surgery, Amsterdam.
² Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam.
³ Department of Research and Development, St. Antonius Hospital, Nieuwegein.
⁴ Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam.
⁵ Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center Rotterdam.
⁶ Department of Gastroenterology and Hepatology, Isala Hospital Zwolle.
⁷ Department of Surgery, Leiden University Medical Centre, Leiden.
⁸ Department of Surgery, Radboud University Medical Center, Nijmegen.
⁹ Departments of Surgery, University Medical Center Groningen, University of Groningen, Groningen.
¹⁰ Department of Surgery, Maastricht University Medical Center+, Maastricht.
¹¹ Department of Surgery, St. Antonius Hospital, Nieuwegein.
¹² Department of Surgery, University Medical Center Utrecht, Regional Academic Cancer Center Utrecht All: The Netherlands.

PMID: 38088187
DOI: 10.1097/SLA.0000000000006176

Abstract

Objective: To determine the nationwide use and outcome of tailored surgical treatment for symptomatic chronic pancreatitis (CP) as advised by recent guidelines.

Summary background data: Randomized trials have shown that surgery is superior to endoscopy in patients with symptomatic CP, although endoscopy remains popular Recent guidelines advice to "tailor surgery" based on pancreatic morphology meaning that the least extensive procedure should be selected based on pancreatic morphology. However, nationwide, and multicenter studies On tailored surgery for symptomatic CP are lacking.

Methods: Nationwide multicenter retrospective analysis of consecutive patients undergoing surgical treatment for symptomatic CP in all seven Dutch university medical centers (2010-2020). Outcomes included volume trend, major complications, 90-day mortality, postoperative opioid use and clinically relevant pain relief. Surgical treatment was tailored based on the size of the main pancreatic duct and pancreatic head (e.g. surgical drainage for a dilated pancreatic duct, and normal size pancreatic head).

Results: Overall, 381 patients underwent surgery for CP: 127 surgical drainage procedures ( 33%; mostly extended lateral pancreaticojejunostomy), 129 duodenum-preserving pancreatic head resections (DPPHR, 34%, mostly Frey), and 125 formal pancreatic resections (33%, mostly distal pancreatectomy). The annual surgical volume increased slightly (Pearson r=0.744). Mortality (90-day) occurred in 6 patients (2%), and was non-significantly lower after surgical drainage (0%, 3%, 2%; P =0.139). Major complications (12%, 24%, 26%; P =0.012), postoperative pancreatic fistula grade B/C (0%, 3%, 22%; P =0.038), surgical reintervention (4%, 16%, 12%; P =0.006), and endocrine insufficiency ( 14%, 21%, 43%; P <0.001) occurred less often after surgical drainage. After a median follow-up of 11 months [IQR 3-23] good rates of clinically relevant pain relief ( 83%, 69%, 80%; P =0.082) were observed and 81% of opioid users had stopped using (83%, 78%, 84%, P =0.496).

Conclusion: The use of surgery for symptomatic CP increased over the study period. Drainage procedures were associated with the best safety profile and excellent functional outcome, highlighting the importance of tailoring surgery based on pancreatic morphology.