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Chronic Pancreatitis Pain Relieved by Surgery

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Chronic Pancreatitis Pain Relieved by Surgery 68 Gastroenterology I NTERNAL M EDICINE N EWS • April 15, 2006 Chronic Pancreatitis Perioperative Mortality Declines Pain Relieved by Surgery For Pancreatic Cancer Patients BY BETSY BATES most powerful independent variable linked Complete pancreatectomy was followed by the Los Angeles Bureau to mortality. Other negative predictors in- cluded advanced age, male gender, and, to autotransplantation of islet cells in 136 patients. S AN F RANCISCO — Perioperative a lesser degree, the year of the surgery. mortality associated with pancreatectomy “Could the decrease in mortality over BY BETSY BATES fined the procedure, eventually conclud- in pancreatic cancer patients is improving, time reflect a paradigm shift whereby a Los Angeles Bureau ing that complete pancreatectomy was Dr. James T. McPhee reported at a sym- higher percentage of pancreatic resec- preferable to near-total pancreatectomy posium sponsored by the American Soci- tions are being performed at high-volume S AN F RANCISCO — A majority of pa- or distal pancreatectomy, since patients ety of Clinical Oncology. surgical centers?” Dr. McPhee asked. tients with chronic pancreatitis experi- undergoing the latter procedures often re- In 1998, 7.7% of patients died before A look at total cases and potential con- enced pain relief and many were spared quired reoperation. leaving the hospital following pancreate- founders “lends some credence,” to that a lifetime of insulin-dependent diabetes The method of islet processing and in- ctomy for neoplasm. That figure dropped theory, he said. Certainly, more cancer pa- when total pancreatectomy was followed fusion also varied, with results repre- to 4.4% by 2003, according to a retro- tients are undergoing pancreatectomy at by autotransplantation of islet cells in a senting eight different distribution op- spective analysis of 6,024 patients tracked high-volume centers: 40% in 2003, com- University of Minnesota study. tions. The preferred approach is always a through the National Inpatient Sample, a pared with 32% in 1998. Dr. Tun Jie and Dr. David E. Suther- portal infusion, said Dr. Jie, but portal representative database of 994 hospitals in Furthermore, high-volume centers do land, both of the University of Minneso- pressure variability sometimes necessi- 37 states. not appear to be doing less complex cas- ta, Minneapolis, reported results of the tates the use of a kidney capsule or peri- “Pancreatic resection dual procedure in 136 patients at the an- toneal infusion. remains the only curative nual clinical congress of the American The mean operating time of 10 hours intervention for pancre- High-Volume Centers Report Lower College of Surgeons. Their retrospective included 2-4 hours for islet isolation in atic cancer,” noted Dr. In-Hospital Mortality After Pancreatectomy clinical review represents the largest col- some cases. (Today, infusion of islet cells McPhee, a surgeon at the lection of cases presented to date. is sometimes done post operatively.) The University of Massachu- High Volume 2% EWS An estimated 80,000 patients per year estimated blood loss was 1,500 cc. setts Memorial Medical (14 or more procedures a year) N suffer pancreatitis, at a cost of $63.8 mil- The mean length of hospital stay was Center in Worcester. Low Volume 8.3% EDICAL lion, Dr. Jie said. 22 days; however, some patients remained Mortality was consider- (1-3 procedures a year) M In some patients, the disease becomes hospitalized for an extended period only ably lower in hospitals chronic, resulting in intractable pain, for completion of metabolic studies. with a high volume of Note: Forty percent of procedures were performed at high- LOBAL malabsorption, and weight loss despite There were two deaths in the series, the difficult surgeries, Dr. volume centers. G interim surgical procedures such as dila- one due to sepsis following colon perfo- McPhee said at the sym- Source: 2003 data, Dr. McPhee LSEVIER tion of the pancreatic duct. For these pa- ration and one due to pulmonary em- posium. E tients, pain control often is achieved only bolism on postoperative day 2. By 2003, the in-hospital by total pancreatectomy, he explained. Complications among the 136 patients mortality rate at hospitals performing es, which could serve as a possible expla- However, the surgery propels patients included 42 infections, 12 bleeding epi- more than 13 pancreatectomies per year nation for the mortality disparity, he said. into diabetes by removing the gland that sodes requiring reoperation, and 6 biliary was 2%, down from 2.8% in 1998. That Although data were not available on makes insulin. complications. compared with 8.3% in 2003 and 14% in every patient’s race or socioeconomic Since 1977, the University of Minneso- Pediatric patients included in the series 1998 at low-volume hospitals, defined as status, two important potential con- ta has been using various techniques to “are the group doing the best,” Dr. Jie said. those performing fewer than four of the founders—age and gender—appeared isolate and process patients’ islet of Patient selection reflected referral pat- procedures a year. well balanced between high- and low-vol- Langerhans cells from their diseased pan- terns to the University of Minnesota and Perioperative mortality at centers that ume centers, Dr. McPhee and his associ- creases and transplant them back into the therefore a relatively low number of pa- did 4-13 cases per year fell into the ates found. patients following pancreatectomy. tients whose chronic pancreatitis was due midrange between the high- and low- The gastrointestinal cancer symposium Among 105 patients who completed a to alcohol abuse. volume hospitals. The overall in-hospital was also sponsored by the American Gas- pain questionnaire following the dual “I can tell you that alcoholic patients in mortality rate for all hospitals over the 6- troenterological Association, the Ameri- procedure, 68 reported complete resolu- our population actually have done the year period was 5.8%. can Society for Therapeutic Radiation tion of pain and another 22 said their pain worst. Part of that involves lifestyle [is- A multivariate regression analysis de- and Oncology, and the Society of Surgi- had lessened. Just 15 patients said their sues] such as trauma unrelated to the termined that surgical volume was the cal Oncology. ■ pain was unchanged, and none reported surgery itself, and not taking medical ad- worsened pain following pancreatectomy. vice as they should,” he continued. Insulin independence was achieved in Dr. Jeffrey B. Matthews, a University of patients who received the most pancreat- Cincinnati surgeon who has performed Declines in Memory, Attention Can Be ic islet cells, with a threshold of 2,000 islet numerous pancreatectomy/islet cell au- equivalents per kilogram required to pre- totransplants, raised the troubling issue of Signs of Advanced Liver Disease vent the need for regular insulin injections. patients in intractable visceral pain whose Of the 51 patients who did receive lengthy medical histories fail to docu- D ENVER — End-stage liver disease was The participants completed a cogni- 2,000 or more islet cells, 37 required only ment a clear history of pancreatitis. associated with significant deficits in tive assessment including the Repeatable intermittent insulin or none at all during Dr. Sutherland agreed that these pa- memory, abstract thought, sustained at- Battery for the Assessment of Neuropsy- long-term follow-up. tients pose a dilemma, but said that the tention, and executive function in a study chological Status (RBANS), which esti- The investigators found a clear link be- surgery is often their only option and not- of 104 adult patients, Tina Meyer, Ph.D., mates brain function in five different do- tween previous surgery and islet cell ed that they do well. reported in a poster presented at the an- mains: immediate memory, delayed yield. Patients with no previous pancre- Another thorny issue is narcotic-in- nual meeting of the American Psychoso- memory, visuospatial abilities, language, atic surgery had a mean yield of about duced hyperalgesia syndrome in patients matic Society. and attention. 4,000 islet equivalents per kilogram, com- treated for years with powerful painkillers “We want to enlighten the surgeons Overall, scores on the RBANS were be- pared with about 3,700 for patients with prior to the surgery. and primary care doctors that cognitive low average on the subtests of immedi- a previous pancreatic resection. Patients Dr. Sutherland said that although these decline can indicate serious liver prob- ate memory, visuospatial abilities, and at- with a history of a Puestow procedure patients get some relief from pancreatitis lems,” Dr. Meyer said in an interview. tention. After the investigators controlled (lateral pancreaticojejunostomy) had a pain, simple intestinal gas remains very She and her colleagues in the Transplant for education levels, higher MELD scores much lower mean yield, about 1,531 islet painful for them. Institute at the Henry Ford Health System were significantly associated with lower equivalents per kilogram. Malabsorption and maldigestion are in Detroit enrolled liver disease patients scores on the immediate memory and de- Because extensive surgery impacts common problems following the surgery, who met medical and psychosocial crite- layed memory subtests of RBANS, as islet cell yield, pancreatectomy and au- and Dr. Sutherland said he increasingly ria for a transplant. About half (51%) well as with lower scores on the Mini- totransplantation should be performed believes colectomy should be performed were male, 74% were white, and the av- Mental State Exam, the Shipley Institute early in the course of the disease, Dr. Jie in conjunction with total pancreatectomy erage age was 54 years. The patients’ av- of Living Scale, and the Trail-Making recommended. in patients who already have extreme erage score on the mean model for end- Test, parts A and B. Over the years, the surgical team re- colon dysfunction. ■ stage liver disease (MELD) was 11.3. —Heidi Splete.
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