Duodenum-preserving head resection versus pancreatico-duodenectomy for chronic pancreatitis of the head - A randomized controlled multicentre trial. ChroPac
Final Report Abstract
Surgical resection of the inflamed pancreatic head aims to relieve stenosis, pain, and reduced quality of life (QoL) in patients with chronic pancreatitis (CP). Basically, there are two resecting methods: the duodenum preserving pancreatic head resection (DPPHR) and the resection of the pancreatic head with removal of the duodenum (partial pancreatoduodenectomy). Both methods with their modifications are suitable to treat CP of the pancreatic head according to the current S3 guideline and have been used successfully for years. Monocenter studies with low numbers of patients have shown superiority of DPPHR compared to partial pancreatoduodenectomy with regard to short term QoL for patients with CP. ChroPac was the first randomized controlled multicenter trial to compare DPPHR with partial pancreatoduodenectomy regarding long-term QoL. No significant difference between the two techniques was shown for the primary endpoint, QoL, in this multicenter setting. Both techniques were capable to improve QoL two years after primary surgery compared to the patients’ preoperative situation. Duration of surgical intervention was significantly shorter with DPPHR, but rate of re-operation and inhouse treatment because of CP was significantly higher with this tissue preserving technique compared to partial pancreatoduodenectomy. Mortality and further secondary morbidity outcomes were comparable between the two techniques. When ChroPac trial was planned, patients with inflammatory enlargement of the pancreatic head due to chronic pancreatitis were commonly treated by surgical resection using one of the current techniques (partial pancreatectomy or duodenum preserving techniques according to Beger, Berne or Frey. By the time recruitment for ChroPac had started, a shift in treatment strategy was observed. Many patients were first seen by a gastroenterologist and treated conservatively (pain and anti-inflammatory medication, dietary measures), 71% had been treated by endoscopic procedures and 38% had undergone at least one stent placement in the pancreatic duct before they underwent surgical treatment. This led to lower recruitment rates than expected. Based on intraoperatively diagnosed pancreatic carcinoma in some of the patients, it can be concluded that partial pancreatoduodenectomy should be performed in patients in whom a carcinoma cannot be reliably ruled out. On the other hand, those patients who have compression or occlusion of the portal vein should receive a DPPHR. In all other cases, surgeons may continue to choose their preferred method of pancreatic head removal.
Publications
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ChroPac-trial: duodenum-preserving pancreatic head resection versus pancreatoduodenectomy for chronic pancreatitis. Trial protocol of a randomised controlled multicentre trial. Trials. 2010 Apr 29;11:47
Diener MK, Bruckner T, Contin P, Halloran C, Glanemann M, Schlitt HJ, Mössner J, Kieser M, Werner J, Büchler MW, Seiler CM
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Partial pancreatoduodenectomy versus duodenum-preserving pancreatic head resection in chronic pancreatitis: the multicentre, randomised, controlled, double-blind ChroPac trial. Lancet. 2017 Sep 9;390(10099):1027-1037
Diener MK, Hüttner FJ, Kieser M, Knebel P, Dörr-Harim C, Distler M, Grützmann R, Wittel UA, Schirren R, Hau HM, Kleespies A, Heidecke CD, Tomazic A, Halloran CM, Wilhelm TJ, Bahra M, Beckurts T, Börner T, Glanemann M, Steger U, Treitschke F, Staib L, Thelen K, Bruckner T, Mihaljevic AL, Werner J, Ulrich A, Hackert T, Büchler MW; ChroPac Trial Group
