INDICATIONS, SURGICAL TECHNIQUE AND OUTCOME OF THE DUODENUM-PRESERVING RESECTION OF THE HEAD OF THE PANCREAS

Twenty per cent of patients with chronic pancreatitis develop an inflammatory mass of the head of the pancreas leading to severe pain and/or stenosis of the pancreatic and common bile ducts. Until recently, the standard surgical operation for these patients was partial duodenopancreatectomy. To avoid disadvantages implied by the partial duodenopancreatectomy, the duodenum-preserving resection of the head of the pancreas (DPRHP) was introduced into clinical practice in 1972. The aim of this study was to re-evaluate and update the results, and the early and late postoperative complications of this surgical procedure. From May 1982 to October 1992, 268 patients suffering from chronic pancreatitis and inflammatory mass in the head of the pancreas were treated with DPRHP. The cause of chronic pancreatitis was chronic alcoholism in 82% and biliary diseases in 11% of the patients. The average time between onset of symptoms of pancreatitis and surgical treatment was 3.6 years. The main indication for surgical treatment was intractable pain (94% of the patients), stenosis of the pancreatic duct (60%), obstruction of the common bile duct (50%), and one-third of the patients exhibited a stenosis of the duodenum. Sixteen per cent of the patients suffered from clinically relevant stenosis of the major intestinal vessels. Glucose metabolism was impaired in 48% of the patients as assessed by oral glucose tolerance test. In these patients the inflammatory mass in the pancreatic head was resected preserving the gastric bowel, duodenum, and the extrahepatic biliary tree. The pancreatic secretary flow from the left pancreas into the upper intestinum was restored by interposition of the jejunal loop. In 17% of the patients with stenosis of the common bile duct, the subtotal resection of the pancreatic head was combined with decompression of the common bile duct at the peripapillary segment. The early postoperative complications were low (7%). Most frequently, patients developed a leakage of the pancreatic anastomosis. The early postoperative morality was to 1.07%; two patients suffered from irreversible sepsis after anastomosis insufficiency. Following a median follow-up period of three years of 199 patients, 77% were free from abdominal pain and 12% complained occasionally of abdominal pain attacks. Two-thirds of the patients had complete professional rehabilitation, 20% were in the state of limited or full retirement. The DPRHP had little impact on endocrine function. In 84% of the patients the pre- and postoperative glucose metabolism remained unchanged, in 11% of the patients the glucose metabolism deteriorated and in 5% it improved. Eleven of 210 patients died in the late postoperative phase (late postoperative mortality rate, 5.2%). Compared with partial duodenopancreatectomy, DPRHP is less radical, preserves more pancreatic tissue, leads to low early and late mortality, acceptable postoperative morbidity, and little impairment of endocrine function. Nevertheless, a high percentage of patients experience a long lasting relief from abdominal pain.