Clinical framework to guide operative decision making in disconnected left pancreatic remnant (DLPR) following acute or chronic pancreatitis

Murage, Kariuki P.; Ball, Chad G.; Zyromski, Nicholas J.; Nakeeb, Attila; Ocampo, Carlos; Sandrasegaran, Kumaresan; Howard, Thomas J.

doi:10.1016/j.surg.2010.07.039

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Volume 148, Issue 4 , Pages 847-857, October 2010

Clinical framework to guide operative decision making in disconnected left pancreatic remnant (DLPR) following acute or chronic pancreatitis

Presented at the 67th Annual Meeting of the Central Surgical Association, Chicago, Illinois, March 10–13, 2010.

Kariuki P. Murage, MD
- Departments of Surgery and Radiology, Indiana University School of Medicine, Indianapolis, IN
Chad G. Ball, MD
- Departments of Surgery and Radiology, Indiana University School of Medicine, Indianapolis, IN
Nicholas J. Zyromski, MD
- Departments of Surgery and Radiology, Indiana University School of Medicine, Indianapolis, IN
Attila Nakeeb, MD
- Departments of Surgery and Radiology, Indiana University School of Medicine, Indianapolis, IN
Carlos Ocampo, MD
- Department of Surgery, Hospital Cosme Argerich, Buenos Aires, Argentina
Kumaresan Sandrasegaran, MD
- Departments of Surgery and Radiology, Indiana University School of Medicine, Indianapolis, IN
Thomas J. Howard, MD
- Departments of Surgery and Radiology, Indiana University School of Medicine, Indianapolis, IN
- Reprint requests: Thomas J. Howard, MD, Emerson Hall No. 517, 545 Barnhill Drive, Indianapolis, IN 46202.

Accepted 15 July 2010. published online 27 August 2010.

Background

Disconnected left pancreatic remnant (DLPR) presents clinically as a pancreatic fistula, pseudocyst, or obstructive pancreatitis. Optimal operative treatment, either distal pancreatectomy (DP) or internal drainage (ID), remains unknown. This paper critically evaluates our operative experience in patients with DLPR.

Methods

A retrospective analysis of a consecutive case series from a single, high-volume institution was carried out. A total of 76 patients with radiographic-confirmed DLPR (computed tomography + endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography) who had operations between November 1995 and September 2008 were included. Pancreas preservation (the use of ID) was our default unless anatomic, physiologic, or technical factors precluded it. Follow-up to July 2009 was done (median follow-up, 22 months). Standard statistical methodology was used (P < .05 = statistical significance).

Results

The mean age of this cohort was 52 years (range, 18–85); 57% of the patients were male. A total of 59 (73%) had acute pancreatitis, whereas 17 (22%) had chronic pancreatitis. Presentation was pseudocyst in 53%, pancreatic fistula in 34%, and obstructive pancreatitis in 13%. Resection (DP) and drainage (ID) options were utilized equally for each clinical presentation as follows: pseudocyst, 60/40; pancreatic fistula, 50/50; or obstructive pancreatitis, 50/50. The strongest driver for DP (92%) was a small pancreatic remnant and splenic vein thrombosis. In contrast, large pancreatic remnants had ID 70% of the time. No differences in short- or long-term outcomes between DP or ID options were identified.

Conclusion

Using anatomic, physiologic, and technical factors to guide operative choice in DLPR, we report a 74% success rate with DP and an 82% success rate with ID at a median follow-up of 22 months. A pancreatic remnant size >6 cm favored ID options over resection.