Chronic Pancreatitis
Chronic Pancreatitis
We have concerns with recommendations voiced again this year for total pancreatectomy treatment of chronic pancreatitis. Some patients undergoing total pancreatectomy in these studies may not have chronic pancreatitis because many patients have questionable causes for pancreatitis such as pancreas divisum and SOD, have clinical histories that are not convincing for chronic pancreatitis, are predominantly women (when there is an equal distribution among sexes or a predominance of men in most causes), and pancreatic tissue diagnostic proof of chronic pancreatitis is apparently lacking. To submit these usually young patients, even children, to total pancreatectomy and lifelong exocrine and endocrine insufficiency may not be justified, particularly if the diagnosis of total pancreatectomy is not ironclad and when outcomes are less than ideal.
One series of 409 patients who underwent total pancreatectomy included 53 children. Although the authors list criteria supporting the diagnosis of chronic pancreatitis before total pancreatectomy is done, it is unclear how many have definite tissue proof of chronic pancreatitis by histology, which would settle this issue. The authors claim total pancreatectomy reduces pain and prevents diabetes, but it is impossible to determine the effect of total pancreatectomy on clinical outcomes because data are presented on subsets of the 409 patients ranging from 268 for islet function to 207 for narcotic use and pain (Figures 3 and 4 of the article). Even these selected data reveal that preoperatively 92% are nondiabetic patients but postoperatively more than two-thirds use insulin and 41% continue narcotics at 2 years. No data are presented regarding EPI but certainly all have malabsorption postoperatively requiring PERT, which likely hampers glycemic control of diabetes. Likely, a significant proportion of these patients have central pain (perhaps originally resulting from painful chronic pancreatitis or from nonpancreatic causes) instead of visceral pain. In these patients it is unreasonable to perform total pancreatectomy, producing diabetes, malabsorption without relieving pain. Another potential concern is possible decreased long-term survival; overall 10-year survival is 81% and of children (ages 5–18 years old) it is 79%. To be certain of the benefit of total pancreatectomy on survival as well as outcomes for diabetes and pain requires a comparison with a population of chronic pancreatitis without total pancreatectomy and the general population.
Total Pancreatectomy
We have concerns with recommendations voiced again this year for total pancreatectomy treatment of chronic pancreatitis. Some patients undergoing total pancreatectomy in these studies may not have chronic pancreatitis because many patients have questionable causes for pancreatitis such as pancreas divisum and SOD, have clinical histories that are not convincing for chronic pancreatitis, are predominantly women (when there is an equal distribution among sexes or a predominance of men in most causes), and pancreatic tissue diagnostic proof of chronic pancreatitis is apparently lacking. To submit these usually young patients, even children, to total pancreatectomy and lifelong exocrine and endocrine insufficiency may not be justified, particularly if the diagnosis of total pancreatectomy is not ironclad and when outcomes are less than ideal.
One series of 409 patients who underwent total pancreatectomy included 53 children. Although the authors list criteria supporting the diagnosis of chronic pancreatitis before total pancreatectomy is done, it is unclear how many have definite tissue proof of chronic pancreatitis by histology, which would settle this issue. The authors claim total pancreatectomy reduces pain and prevents diabetes, but it is impossible to determine the effect of total pancreatectomy on clinical outcomes because data are presented on subsets of the 409 patients ranging from 268 for islet function to 207 for narcotic use and pain (Figures 3 and 4 of the article). Even these selected data reveal that preoperatively 92% are nondiabetic patients but postoperatively more than two-thirds use insulin and 41% continue narcotics at 2 years. No data are presented regarding EPI but certainly all have malabsorption postoperatively requiring PERT, which likely hampers glycemic control of diabetes. Likely, a significant proportion of these patients have central pain (perhaps originally resulting from painful chronic pancreatitis or from nonpancreatic causes) instead of visceral pain. In these patients it is unreasonable to perform total pancreatectomy, producing diabetes, malabsorption without relieving pain. Another potential concern is possible decreased long-term survival; overall 10-year survival is 81% and of children (ages 5–18 years old) it is 79%. To be certain of the benefit of total pancreatectomy on survival as well as outcomes for diabetes and pain requires a comparison with a population of chronic pancreatitis without total pancreatectomy and the general population.
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