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The First Surgical Clinic of the First Medical Faculty Charles University and General Faculty Hospital Prague made operations of the pancreas ever since 1971. In the work sooner or later all approaches to surgical treatment of pancreatitis were reflected. The authors present a brief review of results and their own experience since 1994 when duodenum sparing operations were introduced. Indications for surgical treatment were based on the diagnosis by US, CT and ERCP, in exceptional cases MR, after evaluation by a pancreatologist, roentgenologist and surgeon. The group of patients with chronic pancreatitis was extended by 15 patients from a group operated because of preoperative suspicion of a malignant pancreatic tumour not confirmed during and after surgery. In those Whipple's operation was performed. The same operation was performed in three patients with chronic pancreatitis with serious changes in the area of the head of the pancreas. In 111 patients a drainage and duodenum sparing operation was performed. Of these in 46x according to Neger, 9x according to Frey, 10x modification of these operations, 37x Partington-Rochelle's procedure. The authors did not record postoperative complications after the classical Beger operation and the hospital stay was on average by five days shorter as compared with the classical method of Whipple. When evaluating postoperative complaints and problems (pain, malnutrition, physical constitution and social position) the authors recorded equally favourable results as after non-complicated duodenopancreatectomy. They varied, depending on the patient s co-operation round 87% while after longitudinal drainage of the duct a satisfactory result was recorded in 78% of the operated patients. The authors consider Beger's operation logical because of the removal of the main tissue mass of the head of the pancreas, responsible for pain, complications caused by fibrosis in the area round the bile duct and duodenum, responsible for the deterioration of the compartment syndrome in the left half of the gland. Its result is destruction of the remainder of exocrine and endocrine tissue. Of 170 operated patients one patient with decompensated diabetes died. Based on their own experience the authors do not consider repeated re-operations an absolute contraindication of Beger's operation when conditions permit. A problem is, in their opinion, fibrosis in the vicinity of the pancreas and portal overpressure.
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PMID:[6 years' personal experience with duodenum-sparing procedures in chronic pancreatitis]. 1096 70

There are a number of indications for surgical intervention in chronic pancreatitis, but the most common is intractable pain. Many surgical procedures can be applied in the patient with chronic pain, and the variety of procedures reflects the fact that no single procedure is ideal for all patients. Duct drainage procedures are safe and have a significant response rate, but only about one third of patients experience long-lasting complete relief of pain. Procedures that combine resection and duct drainage are generally more effective, with long-term success rates in the 80% range. The development of the Frey and Beger procedures, two methods for pancreatic head resection that preserve the anatomy of the stomach, duodenum, and bile duct, represents an advance in surgical therapy of chronic pancreatitis. Total pancreatectomy with islet autotransplantation is a procedure that may be appropriate in certain subsets of patients. Thoracoscopic splanchnicectomy is a new, minimally invasive procedure, still in evaluation, which may become a very valuable method when the sole indication for surgery is intractable pain.
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PMID:Surgical options in the patient with chronic pancreatitis. 1098 Oct 16

The authors' approach to the overall surgical management of chronic pancreatitis is to treat complications, that is, pain and, less commonly, obstruction and bleeding. The authors' practice is to exhaust nearly all forms of nonsurgical intervention before suggesting a surgical approach. Nonresponders are then evaluated for severity of pain, interference of quality of life, and presence of chemical dependency. Appropriate candidates undergo imaging examinations to determine the primary site of disease, presence of pancreatic ductal dilatation, and associated peripancreatic complications. The surgical treatment approach involves classic lines of proximal resection (pylorus-preserving pancreaticoduodenectomy) for small duct disease and lateral pancreaticojejunal drainage for a dilated pancreatic duct. The authors have not yet routinely adopted the duodenum-preserving head resections of Beger and Frey, or thoracoscopic transthoracic splanchnicectomy, but they remain open-minded and avidly await good confirmatory, independent trials of these promising surgical interventions.
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PMID:Surgical management of chronic pancreatitis at the Mayo Clinic. 1139 31

During the past three decades, important advances in our understanding of the pathophysiology of chronic pancreatitis (CP), improved results of major pancreatic resections (including pancreatoduodenectomy), and integration of sophisticated diagnostic methods in clinical practice resulted in significant changes in our surgical approach to CP. Proximal pancreatectomy (including the pancreatoduodenectomy and the newer duodenum-preserving and common bile duct-preserving Beger and Frey procedures) achieved good results concerning pain relief (>80%) and quality of life in selected patients with head-dominant CP. Beger and Frey procedures were associated with lower early and late mortality and morbidity. However, when there is strong suspicion of an underlying malignancy, a pancreatoduodenectomy should be considered in surgically fit patients, as this is an adequate procedure for both CP and pancreatic cancer.
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PMID:Proximal pancreatectomy in the surgical management of chronic pancreatitis. 1174 50

Pancreaticojejunal anastomosis. Indication, technique and results. Pancreaticojejunal anastomoses are performed for the treatment of chronic pancreatitis and after resection of pancreatic carcinomas. In chronic pancreatitis by drainage procedures (Partington-Rochelle and Puestow-Gillesby) one can expect good long term results, if the diameter of the pancreatic duct is at least 1 cm and the length of the anastomosis 6 cm. The duodenumpreserving head resection (Beger or Frey) is a combination of resection and drainage and is significant in the therapy of inflammatory head processes. In the surgical treatment of pancreatic carcinomas pancreaticojejunostomies are applied after head resection (Whipple-, pyloruspreserving modification). The end-to-side mucosa-mucosa anastomosis offers the best results concerning postoperativ complications and mortality rates.
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PMID:[Pancreaticojejunal anastomosis. Indication, technique and results]. 1181 68

Surgeons frequently find pancreatic head mass when operating. The obvious difficulty is to make the correct preoperative differential diagnosis between chronic pancreatitis and pancreatic tumor. The first step is to reach a diagnosis, with some certainty, prior to the operation. The second step in the case of a tumor is the accurate staging and deciding whether or not it is resectable. On the one hand, time and cost must be considered; on the other hand, the therapy must be decided. Obtaining information about the characteristics of the pancreatic disease (nature, size, exact location) and establishing the tissue diagnosis preoperatively may simplify the decision to operate and the operation itself. In the case of chronic pancreatitis, the aim of the operation is to eliminate pain and other symptoms, while in the case of cancer, the purpose is to remove the malignant tissue. In most patients, it is possible to identify the disease on the basis of previous examinations together with preoperative diagnostic techniques such as exploration, palpation and fine-needle aspiration biopsy. Chronic pancreatic head mass should be operated upon with Beger s or Frey s procedure while pancreatic head tumors should be treated by means of head resection with the aim of preserving the pylorus or the Whipple procedure may be used. When the diagnosis is in doubt, a radical approach is thought to be best. Our conclusion is that there is no diagnostic method capable of making a definitive differential diagnosis as to the nature of the pancreatic head mass. Further study is required as to the extent to which differential diagnosis should be investigated.
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PMID:Pancreatic head mass: what can be done? Classification: the clinical point of view. 1185 62

We report herein a modification of the standard wirsungojejunostomy in patients with chronic pancreatitis, which includes concomitant duodenum-preserving resection of the head of the pancreas as described by Frey. This technique is safe and seems to provide more effective long-term pain relief than standard wirsungo-jejunal anastomosis.
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PMID:[Pancreatic head resection (Frey technique) and Wirsungo-jejunal anastomosis in the treatment of chronic pancreatitis]. 1249 44

Debilitating abdominal or back pain remains the most common indication for surgery in patients with chronic pancreatitis. The surgical approach to chronic pancreatitis should be individualized based on pancreatic and ductal anatomy, pain characteristics, baseline exocrine and endocrine function, and medical co-morbidity. No single approach is ideal for all patients with chronic pancreatitis. Pancreatic ductal drainage with pancreaticojejunostomy targets patients with a dilated pancreatic duct and produces good early postoperative pain relief; however, 30%-50% of patients experience recurrent symptoms at 5 years. Resection for chronic pancreatitis should be considered (1) when the main pancreatic duct is not dilated, (2) when the pancreatic head is enlarged, (3) when there is suspicion of a malignancy, or (4) when previous pancreaticojejunostomy has failed. Re-sectional strategies include pancreaticoduodenectomy, distal pancreatectomy, total pancreatectomy, duodenum-preserving pancreatic head resection (Beger procedure), or local resection of the pancreatic head with longitudinal pancreaticojejunostomy (Frey procedure). Superior results are obtained when the pancreatic head is resected, either completely (pancreaticoduodenectomy) or partially (Beger or Frey procedure). Although pylorus-preserving pancreaticoduodenectomy remains the gold standard resection procedure, there is evidence that newer operations, such as the Beger resection, may be as effective in regard to pain relief and better in respect to nutritional repletion and preservation of endocrine and exocrine function.
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PMID:Surgical treatment of chronic pancreatitis. 1265 98

The First Surgical Clinic of the First Medical Faculty of Charles University and General Faculty Hospital in Prague made operations of the pancreas ever since 1971. In the work sooner or later all approaches to surgical treatment pancreatitis were reflected. The authors present a brief review of results and their own experience since 1994 when duodenum-sparing operations were introduced. Indications for surgical treatment were based on the diagnosis by US, CT and ERCP, in exceptional case MR, after evaluation by a pancreatologist, roentgenologist and surgeon. The group of patients with chronic pancreatitis was extended by 21 patients from a group operated because of preoperative suspicion of a malignant pancreatic tumour not confirmed during and after surgery. In those Whipple's operation was preformed. The same operation was performed in three patients with chronic pancreatitis with serious changes in the area of the head of the pancreas. In 123 patients a drainage and duodenum sparing operation was preformed, of these in 57 according to Beger, 19 according to Frey, 37 Partington-Rochelle's procedure. The authors record two sepsis postoperative complications after the classical Beger operation and the hospital stay was on average by five days shorter as compared with the classical method of Whipple. When evaluating postoperative complaints and problems (pain, malnutrition, physical constitution and social position) the authors recorded equally favourable results as after non-complicated duodenopancreatectomy. They varied, depending on the patients co-operation round 84-87% while authors consider Beger's operation logical because of the removal of the main tissue mass of the head of the pancreas, responsible for pain, complications caused by fibrosis in the area round the bile duct and duodenum, responsible for the deteriation of the compartment syndrome in the left half of the gland. Its result is destruction of the remainder of exocrine and endocrine tissue. Of 187 operated patients one patient with decompensated diabetes died postoperatively. Based on their own experience the authors do not consider repeated re-operations an absolute contraindication of Beger's operation when conditions permit. A problem is, in their opinion, fibrosis in the vicinity of the pancreas and portal overpressure.
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PMID:[Choice of surgical procedure in operations for chronic pancreatitis--personal experience]. 1268 39

The etiology of pain in chronic pancreatitis may be ductal hypertension, increased parenchymal pressure, or neural damage. It is difficult to assess the severity of pain in this patient population, a problem made more challenging by the frequency of narcotic dependency. Therapeutic interventions developed to relieve the pain of chronic pancreatitis include denervation of the pancreas, decompression of the main duct of the pancreas, resection of part or all of the diseased pancreas, and reduction of pancreatic secretion. Operative intervention for patients with chronic pain is indicated when severe pain, complications of pain, or potential malignancy are present. The operations that consistently provide long-lasting pain relief all have in common resection of all or a portion of the head of the pancreas. Adverse effects on exocrine and endocrine function, nutrition, and quality of life are related to the amount of pancreas resected. The ideal procedure should be easy to perform, have a low morbidity and mortality rate, provide long-lasting pain relief, and not augment endocrine and exocrine insufficiency. No single operation fulfills this ideal. The local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy (LR-LPJ) proposed by Frey and the duodenum-preserving resection of the head of the pancreas (DPHR) proposed by Beger are discussed. The conceptualization, development, and technique of LR-LPJ are discussed, and comparisons of patient outcomes are made with the outcomes of other procedures for chronic pancreatitis.
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PMID:Comparison of local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy (frey procedure) and duodenum-preserving resection of the pancreatic head (beger procedure). 1453 21


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