**7. Conclusion**

The pathophysiology of chronic pancreatitis is complex and as yet incompletely understood, confounding attempts at effective management strategies. The clinical picture is dominated by progressive pain which may become intractable and pancreatic endocrine and exocrine

The Surgical Management of Chronic Pancreatitis 445

[13] Bornman PC, Botha JF, Ramos JM et al. Guidelines for the diagnosis and treatment of

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[17] Braganza JM, Dormandy TL. Micronutrient therapy for chronic pancreatitis: rationale

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[19] Buchler MW, Friess H, Muller MW et al. Randomised trial of duodenum-preserving

[20] Büchler M, Weihe E, Friess H et al. Changes in peptidergic innervations in chronic

[21] Buechler MW, Friess H, Bittner R et al. Duodenum-preserving pancreatic head

[22] Cavallini G. Is chronic pancreatitis a primary disease of the pancreatic ducts. A new

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[25] Cook LJ, Musa OA, Case RM. Intracellular transport of pancreatic enzymes. Scand J

[26] D'Egidio A, Schein M. Pancreatic pseudocysts: a proposed classification and its

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pancreaticoduodenectomy. Langenbecks Arch Surg 2006; 391: 338-342 [31] Foster JR. Toxicology of the exocrine pancreas. In: Ballantyne B, Marrs T, Syversen T

without associated disease of the biliary or gastro-intestinal tract. Gastroenterology

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dysfunction which may severely impact on a patient's quality of life. Surgery aims to relieve ductal and tissue hypertension related to obstruction in the main and side branch ducts while also removing inflamed and fibrotic parenchymal tissue containing diseased nerve fibres. Duodenal preserving pancreatic head resections, usually combined with drainage of the main pancreatic duct, achieve both objectives with short and long term relief of pain in approximately 90% of patients at 5 year follow up. By preserving some parenchymal tissue these procedures attempt to limit pancreatic functional insufficiency. With acceptable morbidity and mortality figures, they have evolved as the surgical procedure of choice for the majority of patients with pain refractory to medical treatment. Surgery for complications of CP should be individualized while resection for neoplastic disease should be performed according to oncological principles, ensuring a clear margin of resection. More extensive resections should generally only be performed as salvage procedures for complications of previous surgery. Patients requiring surgery for chronic pancreatitis should be evaluated and treated by experienced surgeons in high volume centres utilizing a multi-disciplinary approach. Prior to undergoing surgery for pain, patients should have completed an adequate trial of medical therapy and been thoroughly counseled regarding the risks of surgery and its likely outcomes.

#### **8. References**


dysfunction which may severely impact on a patient's quality of life. Surgery aims to relieve ductal and tissue hypertension related to obstruction in the main and side branch ducts while also removing inflamed and fibrotic parenchymal tissue containing diseased nerve fibres. Duodenal preserving pancreatic head resections, usually combined with drainage of the main pancreatic duct, achieve both objectives with short and long term relief of pain in approximately 90% of patients at 5 year follow up. By preserving some parenchymal tissue these procedures attempt to limit pancreatic functional insufficiency. With acceptable morbidity and mortality figures, they have evolved as the surgical procedure of choice for the majority of patients with pain refractory to medical treatment. Surgery for complications of CP should be individualized while resection for neoplastic disease should be performed according to oncological principles, ensuring a clear margin of resection. More extensive resections should generally only be performed as salvage procedures for complications of previous surgery. Patients requiring surgery for chronic pancreatitis should be evaluated and treated by experienced surgeons in high volume centres utilizing a multi-disciplinary approach. Prior to undergoing surgery for pain, patients should have completed an adequate trial of medical therapy and been thoroughly counseled regarding the risks of

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**21** 

*Yoko Clinic Japan* 

**The Influence of Colonic Irrigation** 

It has been documented that the intestinal tract is inhabited by more than 1012 bacterial cells per gram of dry matter (Hayashi et al., 2002a; Langendijk et al., 1995; Suau et al., 1999), which is comprised of an estimated 400 to 500 bacterial species (Moor & Holdeman, 1974). The composition and activities of the indigenous intestinal microbiota are of paramount importance in human immunity, nutrition, and pathological processes, and therefore, the health of the individual (Van der Waaij et al., 1971). It is well established that the intestine is an important site of local immunity, and recent reports have suggested that it is a major site of extrathymic T cell differentiation (Cerf-Bensussan et al., 1985; Guy-Grand et al., 1991; Iiai eta al., 2002; Uchiyama-Tanaka, 2009). Numerous activated and quiescent lymphocytes are produced within gut-associated lymphatic tissues (GALT), such as Peyer's patches (Takahashi et al., 2005). Thus, it has been speculated that people who suffer from constipation and who harbor fecal residues in the intestine may have decreased local immune system function.

Colonic irrigations referred to as a colonics are a type of colonic hydrotherapy performed using an instrument in combination with abdominal massage, but without drugs or mechanical pressure. I previously reported that colonic irrigation may induce lymphocyte transmigration from GALT into the circulation, which may improve the functions of both the colon and immune system (Uchiyama-Tanaka, 2009). Colonic irrigation was developed about 40 years ago and no serious complications associated with its use have been reported. However, the impact of this method, which use a large amount of water, on the intestinal microbiota and serum electrolytes remains unknown. In this study, colonic irrigations were performed 3 times for each of the 10 subjects with no history of malignant or inflammatory

The procedures used in this study were in accordance with the guidelines of the Declaration of Helsinki for Human Experimentation, 2000 and all subjects provided informed consent. Ten outpatients from the Yoko Clinic (4 men and 6 women; mean age=38 ± 6 years; age range: 27–47 years) admitted to the hospital between April and May 2009 were enrolled in

this study. None of the subjects had cancer or any active inflammatory disease.

**1. Introduction** 

disease.

**2. Materials and methods 2.1 Study design and subjects** 

**on Human Intestinal Microbiota** 

Yoko Uchiyama-Tanaka

