Medical Complications of Pancreatic Resections

Ezio Gaia, Paola Salacone
Gastroenterology Unit, San Luigi Gonzaga Hospital. Orbassano (TO), Italy
Summary
The sequelae of pancreas surgery are
determined by the type of procedure, the
extent of the parenchymal resection and the
underlying disorder. In ductal carcinoma, the
outcome is heavily influenced by the disease
itself. Mortality rates are lower in centers
which perform the most operations.
In chronic pancreatitis, surgical management
is essentially therapeutic for complications
and palliative for the disease whose progress
is closely correlated with the sequelae.
Elective surgery does not appear to increase
the risk of diabetes whereas distal
pancreatectomy is an independent risk factor.
Parenchymal resection aggravates nutritional
deficiencies, such as low selenium, linoleic
acid, LDL and apolipoprotein B levels, and
thus increases the risk of atherogenesis.
Abstinence from alcohol is an indispensable
step towards the disappearance of
postoperative pain.
The sequelae of pancreas surgery are
determined by the type of procedure
(resective or derivative), the extent of the
parenchymal resection, and the underlying
disorder. The literature is rich in data
regarding the outcome of resection in the
management of neoplastic lesions. In ductal
carcinoma, the outcome is heavily influenced
by the disease itself. Morbidity associated
with resection of the pancreatic head is
relatively high (up to 60%), and there is no
statistically significant difference between
classic partial and pylorus-preserving
pancreaticoduodenectomy [1].
Numerous studies have reported a promising
increase in 5-year survival when ductal
carcinoma surgery is followed by radio-
therapy and chemotherapy [2, 3, 4]. It has also
been shown that mortality rates are lower in
centers which perform the most operations
[5]. In this connection, of course, it must be
borne in mind that specialized centers employ
more sophisticated means of diagnosis. They
are also furnished with appropriate intensive
care units and usually have access to more
abundant resources.
Chronic pancreatitis is a benign disorder.
Progressive, persistent destruction of the
pancreas may remain silent for years until the
onset of serious insufficiency or it may appear
in the form of irregular and painful acute
episodes or complications. The prime
indications for surgery are uncontrolled pain
or complications (e.g., pseudocysts).
Elimination of the cause of the disease
(alcohol,
obstruction,
autoimmunity)
improves or abolishes recrudescences, but
does not result in a cure. As has already been
stated, in fact, chronic pancreatitis progresses
to the point of insufficiency, which means
that surgical management is essentially
therapeutic for complications and palliative
for the disease.
Genes involved in trypsinogen instability are
thought to be responsible for pancreatitis [6,
7, 8, 9, 10]. Enhanced trypsinogen activation
in the exocrine cells may increase their

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apoptosis and turnover, and hence cause
exocrine insufficiency and parenchymal
fibrosis (painless pancreatitis), or massive
activation followed by recrudescence and
necrosis. The genetic substrate of other, more
numerous situations has not been determined
and environmental factors, such as alcohol
and a high-fat diet, are the only known
causes.
In a family described in a personal study [11],
a cationic trypsinogen mutation in exon 2
(V39A) was responsible for serious, clinically
silent pancreatitis which led to insufficiency
and required resective/derivative surgery due
to the appearance of a tumor or severe
complications.
Surgery is indicated in cases of chronic
pancreatitis for the resolution of
complications (especially intractable pain) or
when differentiation of tumors is uncertain.
Morbidity following resection of the
pancreatic head combined with longitudinal
pancreaticojejunostomy (Frey procedure) and
duodenum-preserving head resection (Beger
procedure) is 39% (compared with 48% for
other resections), with a 20% revision rate in
both cases [12, 13, 14].
Long-term mortality is 32% after both the
Frey and the Beger procedures [15]. Falconi
et al., however, achieved better results with
no mortality and significant reduction of pain
in a series of 40 patients operated on
according to Frey [16].
Abstinence from alcohol is an indispensable
step towards the disappearance of
postoperative pain [14]. The quality of life of
patients with pancreatitis is significantly
worse than that of the controls, mainly due to
pain [17]. Reason would suggest that
reduction of the parenchyma or better
drainage of the ducts would be sufficient to
reduce recrudescence. This has not yet been
established in controlled long-term trials.
The sequelae of surgery may aggravate the
clinical course (Table 1). The incidence of
diabetes after resection is closely correlated
with the surgical procedure: 25-40% after
Whipple; 8-15% after Frey; about 60% five
years after distal pancreatectomy due to the
greater concentration of islet cells in the tail.
Elective surgery does not appear to increase
the risk of diabetes, whereas distal
pancreatectomy is an independent risk factor.
Long-term postoperative mortality increases
if alcohol is not eliminated [15]. Alcohol and
diabetic decompensation are the main factors
responsible for high long-term postoperative
mortality [18].
Exocrine insufficiency is directly correlated
with the type of pancreatitis and serious
insufficiency is directly correlated with the
disappearance of pain ("burn out") [19]. The
incidence of exocrine deficiency ranges from
35% to 74% in function of the type of
resection [13]. These clinical considerations
must be borne in mind when weighing up the
efficacy of surgery as a remedy for pain in
chronic pancreatitis.
Resection also aggravates secondary
nutritional deficiencies, such as low selenium,
linoleic acid, LDL and apolipoprotein B
levels, and thus increases the risk of
atherogenesis. Cardiovascular complications
are frequent in chronic pancreatitis and are
further
aggravated
by
glycemic
decompensation [20, 21].
The enhanced risk of both extrapancreatic
[22] and pancreatic [23] neoplasias is an
important factor in the long-term management
of patients with chronic pancreatitis.
In hereditary forms due to cationic
trypsinogen gene mutations, its frequency is
50% at age 50 and 70% at age 65 and older
[24].
In conclusion, the sequelae of surgery are
closely correlated with the progress of chronic
pancreatitis. They primarily take the form of
exocrine
insufficiency,
nutritional
deficiencies, diabetes and its complications,
Table 1. Medical complications of chronic pancreatitis.
• Exocrine insufficiency
• Diabetes
• Autonomic neuropathy
• Intestinal malabsorption
• Intestinal bacterial pollution
• Atherosclerosis
• Bone changes
• Pancreatic carcinoma
• Extrapancreatic carcinoma
• Psychosis

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JOP. J Pancreas (Online) 2007; 8(1 Suppl.):114-117.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 8, No. 1 - January 2007. [ISSN 1590-8577]
116
altered lipid metabolism with an increased
risk of atherogenesis, and both
extrapancreatic and pancreatic carcinoma.
Keywords Diabetes Mellitus; Exocrine
Pancreatic Insufficiency; Pancreas /surgery;
Pancreatitis,
Chronic;
Postoperative
Complications
Conflict of interest The authors have no
potential conflicts of interest
Correspondence
Ezio Gaia
Gastroenterology Unit
A.S.O. San Luigi Gonzaga
Regione Gonzole 10
10043 Orbassano (TO)
Italy
Phone: +39-011.902.6600
Fax: +39-011.902.6256
E-mail: eziogaia@gmail.com
Document URL: http://www.joplink.net/prev/200701/26.html
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