**6.2 Duodenal obstruction**

442 New Advances in the Basic and Clinical Gastroenterology

there was evidence for significant benefit of DPPHR over PPPD in terms of morbidity (2 trials), pain relief (2 trials), quality of life (1 trial), endocrine function (1 trial ), exocrine function (1 trial) and weight gain (2 trials). In addition, 2 trials showed a benefit for DPPHR in terms of operating time while hospital stay and requirement for blood transfusion were improved in 1 trial each. A Cochrane review on short term outcomes concluded that there was benefit for DPPHR in respect of quality of life and professional rehabilitation, exocrine insufficiency, weight gain, hospital stay and intra-operative blood replacement. There was also a trend towards reduced post-operative diabetes (Diener MK Ann Surg 2008). However, in the 2 studies examining long term outcomes, it was seen that many of the short term clinical benefits described above were not maintained. Proposed reasons for this were study error related to the small population sizes studied and that pancreatic gland burn-out might be delayed by DPPHR (Muller MW Br J Surg 2008). Nevertheless, at 14 year follow up there remained a trend towards better endocrine function, while there was significant benefit in terms of appetite, subjective feeling of well being and mean period of employment after surgery for patients undergoing DPPHR(Muller MW Br J Surg 2008). Thus, while short term results favour DPPHR over PPPD in CP, long term results appear equivalent and

Only 2 randomized trials have compared different DPPHR procedures, with 1 trial undergoing long term follow up (table 2). The first trial compared the Beger and Frey procedures with no significant differences being found in the short term apart from a benefit for the Frey operation in terms of morbidity. After a median of 8.5 years, all variables had comparable outcomes while almost all patients were noted to be exocrine insufficient (Izbicki JR Ann Surg 1995; Strate T Ann Surg 2005). The second study compared the Beger and Berne procedures, suggesting a benefit for the Berne operation in terms of operation time and hospital stay. Results were analysed on intention to treat basis however, including 8 out of 32 (Beger procedure) and 6 out of 33 (Berne procedure) patients who had their operations altered for technical reasons. When patients were analysed per protocol ie only those who underwent their assigned procedure, only the difference in operating times

More extensive pancreatic resections such as total or near total distal pancreatectomy offer only short term relief and are associated with significant mortality and morbidity, often as a result of markedly reduced pancreatic function. They have largely been abandoned with their main role being as salvage procedures for complications relating to previous surgical interventions (including anastamotic leakage, pancreatic fistula and intractable pain

Surgery for the complications of CP should be individualized to cater to a patient's specific

Choledocho-duodenostomy or hepatico-jejunostomy using a Roux-en-Y loop are the preferred procedures to resolve isolated biliary obstruction although the former may result in enteric refux and a sump-like syndrome. Cholecysto-enterostomy has been associated

probably reflect the natural course of the disease.

following previous adequate resection or drainage surgery).

morphology and clinical presentation.

**6.1 Biliary obstruction** 

**6. Surgery for the complications of chronic pancreatitis** 

remained significant.

Surgical relief of obstruction related to a fibrotic stricture involves duodenal mobilization by Kocher's maneouvre with division of all fibrotic tissue. Should this be insufficient to restore patency, duodeno-duodenostomy or a gastro-jejunostomy may be considered, although the latter may be associated with biliary reflux. Where biliary obstruction co-exists in the presence of duodenal obstruction together with an inflammatory mass in the head, two options exist: PPPD or gastric bypass with a gastro-jejunostomy as part of the Roux drainage limb in a DPPHR.
