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Beger and Frey Procedures for Treatment of Chronic Pancreatitis: Comparison of Outcomes at 16-Year Follow-Up

Beger and Frey Procedures for Treatment of Chronic Pancreatitis: Comparison of Outcomes at 16-Year Follow-Up
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   Accepted Manuscript Beger and Frey Procedures for Treatment of Chronic Pancreatitis: Comparison of Outcomes at 16-Year Follow-UpKai Bachmann, MD Lena Tomkoetter, MD Johannes Erbes, MD Bianca Hofmann, MDDaniel Perez, MD Yogesh Vashist, MD Maximilian Bockhorn, MD Jakob R. Izbicki,MD Oliver Mann, MDPII:S1072-7515(14)00281-6DOI:10.1016/j.jamcollsurg.2014.03.040Reference:ACS 7354To appear in: Journal of the American College of Surgeons  Received Date:30 October 2013Please cite this article as: Bachmann K, Tomkoetter L, Erbes J, Hofmann B, Perez D, Vashist Y,Bockhorn M, Izbicki JR, Mann O, Beger and Frey Procedures for Treatment of Chronic Pancreatitis:Comparison of Outcomes at 16-Year Follow-Up, Journal of the American College of Surgeons   (2014),doi: 10.1016/j.jamcollsurg.2014.03.040.This is a PDF file of an unedited manuscript that has been accepted for publication. As a service toour customers we are providing this early version of the manuscript. The manuscript will undergocopyediting, typesetting, and review of the resulting proof before it is published in its final form. Pleasenote that during the production process errors may be discovered which could affect the content, and alllegal disclaimers that apply to the journal pertain.  A CCEPTED MANUSCRIPT 1 1 Beger and Frey Procedures for Treatment of Chronic Pancreatitis: Comparison of Outcomes at 16-Year Follow-Up Kai Bachmann, MD, Lena Tomkoetter, MD, Johannes Erbes, MD, Bianca Hofmann, MD, Daniel Perez, MD, Yogesh Vashist, MD, Maximilian Bockhorn, MD, Jakob R. Izbicki, MD, Oliver Mann, MD, Department of General Visceral and Thoracic Surgery, University Hospital Hamburg Eppendorf, Hamburg, Germany Disclosure Information: Nothing to disclose. Correspondence address: Kai Bachmann, MD Department of General, Visceral and Thoracic Surgery University Medical Center Hamburg-Eppendorf Martinistrasse 52 20246 Hamburg Germany Phone +49-40-7410-57346 E-Mail: Running head: Beger vs Frey Procedures for Chronic Pancreatitis  A CCEPTED MANUSCRIPT 2 2 Abstract Background Chronic pancreatitis is a chronic inflammatory disorder characterized by progressive fibrosis of pancreatic tissue. The principal symptom is chronic pain resulting in reduced quality of life and inability to work. Short-term follow-up has shown that duodenum-preserving pancreatic head resections (DPPHRs) are superior in outcome to pancreatoduodenectomy. Therefore these organ-sparing procedures have gained wide acceptance. This trial was conducted to compare patient outcomes 16 years after treatment for chronic pancreatitis by means of the Beger or the Frey procedure. Study Design Seventy four patients suffering from chronic pancreatitis were randomly assigned to two treatment groups (Beger n=38) and Frey (n=36). The perioperative courses in the randomized controlled trial and the 8-year follow-up have been previously reported. All participating patients were contacted with a standardized, validated questionnaire to evaluate long-term survival, quality of life, pain, and exocrine and endocrine function. Results No significant differences between the two groups regarding quality of life, pain control, or other somatic parameters were detected after a median of 16 years postoperatively. Mortality was comparable after Beger and Frey procedures at 39% vs. 34%, respectively, with postoperative survivals of 13.0±1.1 years and 13.3±0.9 years, respectively (p=0.660). No statistically significant differences were found in rates of endocrine insufficiency (Beger 87% vs. Frey 86%; p=0.953) or exocrine insufficiency (Beger 77% vs. Frey 83%; p=0.655). Conclusions  A CCEPTED MANUSCRIPT 3 3Duodenum-preserving resections of the pancreatic head offered good and permanent pain relief and substantially increased quality of life in chronic pancreatitis. Overall a 16-year long-term follow-up found comparable outcomes for the Beger and Frey procedures.  A CCEPTED MANUSCRIPT 4 4 Introduction Chronic pancreatitis (CP) is a common inflammatory disease with a prevalence of 26.4 cases per 100,000 population. 1  It is characterized by the progressive fibrosis of pancreatic parenchyma. Alcohol consumption is the leading cause of CP in western countries (70%–90%), 2  followed by biliary lithiasis, autoimmune or individual genetic predisposition, and anatomic variants such as pancreas divisum. CP has an enormous personal and socioeconomic impact; the annual treatment costs are approximately $17,000 per patient 3  and, compared with a population without CP, life expectancy is shortened by 10–20 years and mortality is increased 3.6-fold. 3  The principal symptom is chronic pain resulting in reduced quality of life and inability to work. Despite improvements in conservative, interventional, and surgical procedures, the treatment of chronic pancreatitis remains challenging. 4,5  Since randomized controlled trials (RCTs) have shown that surgery is superior to endoscopic treatment, there is no doubt as to the need for surgical intervention in patients suffering from CP. 6-8  A wide variety of surgical interventions has been used in CP, ranging from simple drainage procedures to extensive resections, especially pancreatoduodenectomy. 9-13  However it has been shown that simple drainage procedures do not ensure sufficient pain relief in patients with enlargement of the pancreatic head. Therefore resection of the pancreatic head should be a central feature of any surgical procedure. On the other hand, the major disadvantage of pancreatoduodenectomy is that surrounding non-diseased organs such as the duodenum and the distal common bile duct are sacrificed, along with loss of continuity of the alimentary tract. Because of the complexity of the resection and reconstruction, the operation is technically demanding. Duodenum-preserving pancreatic head resections (DPPHRs) combine the advantages of both procedures: the “pacemaker” of the disease, the pancreatic head is subtotally resected and the continuity of the alimentary tract is preserved. 12  Duodenum-preserving resections were found
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