Journal Name: International Journal of Hepatobiliary … · Manuscript Accepted Early View Article Page 2 of 19 1 TYPE OF ARTICLE: ORIGINAL ARTICLE 2 3 TITLE: Head coring for chronic

Manuscript Accepted Early View Article

Page 1 of 19

Early View Article: Online published version of an accepted article before publication in the final form.

Journal Name: International Journal of Hepatobiliary and Pancreatic Diseases (IJHPD)

Type of Article: ORIGINAL ARTICLE

Title: Head coring for chronic calcific pancreatitis (CCP) without head mass - Short term outcome analysis

Authors: Rajamahendran Rajendran, Anbalagan Amudhan, Prabhakaran R, Benet

Duraisamy, Rajendran Vellaisamy, Kannan D, Chandramohan SM

doi: To be assigned

Received: 11th August 2014

Accepted: 10th September 2014

How to cite the article: Rajendran R, Amudhan A, Prabhakaran R, Duraisamy B, Vellaisamy R, Kannan D, Chandramohan SM. Head coring for chronic calcific pancreatitis (CCP) without head mass - Short term outcome analysis. International Journal of Hepatobiliary and Pancreatic Diseases (IJHPD). Forthcoming 2014.

Disclaimer: This manuscript has been accepted for publication. This is a pdf file of the Early View Article. The Early View Article is an online published version of an accepted article before publication in the final form. The proof of this manuscript will be sent to the authors for corrections after which this manuscript will undergo content check, copyediting/proofreading and content formatting to conform to journal’s requirements. Please note that during the above publication processes errors in content or presentation may be discovered which will be rectified during manuscript processing. These errors may affect the contents of this manuscript and final published version of this manuscript may be extensively different in content and layout than this Early View Article.


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TYPE OF ARTICLE: ORIGINAL ARTICLE 1

2

TITLE: Head coring for chronic calcific pancreatitis (CCP) without head mass - Short 3

term outcome analysis 4

5

AUTHORS: 6

Rajamahendran Rajendran1, Anbalagan Amudhan2, Prabhakaran R3, Benet 7

Duraisamy4, Rajendran Vellaisamy5, Kannan D6, Chandramohan SM7 8

9

AFFILIATIONS: 10

1Post Graduate in Surgical Gastroenterology, Institute of Surgical Gastroenterology, 11

Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, INDIA. Email ID: 12

[email protected] 13

2Assistant Professor in Surgical Gastroenterology, Institute of Surgical 14

Gastroenterology, Rajiv Gandhi Government General Hospital, Chennai, Tamil 15

Nadu, INDIA. Email ID: [email protected] 16







5Post graduate in Surgical Gastroenterology, Institute of Surgical Gastroenterology, 23

Rajiv Gandhi Government General hospital, Chennai, Tamil Nadu, INDIA. Email ID: 24


6Professor of Surgical Gastroenterology, Institute of Surgical Gastroenterology, Rajiv 26

Gandhi Government General Hospital, Chennai, Tamil Nadu, INDIA. Email ID: 27


7Director of Surgical Gastroenterology, Institute of Surgical Gastroenterology, Rajiv 29

Gandhi Government General Hospital, Chennai, Tamil Nadu, INDIA. Email ID: 30


32


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CORRESPONDING AUTHOR DETAILS 33

Dr. Rajamahendran Rajendran, 34

Madras Medical College, Institute of Surgical Gastroenterology, Rajiv Gandhi 35

Government General Hospital, Chennai, Tamil Nadu, INDIA. 36

Phone No: 09787387183/094444878183 37

Email ID: [email protected] 38

39

Short Running Title: Head coring for Chronic Calcific Pancreatitis without head 40

mass- Short term outcome analysis. 41

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Guarantor of Submission: The corresponding author is the guarantor of 43

submission. 44

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ABSTRACT 67

Aims: 68

Intolerable abdominal pain is the main cause which brings the patients with Chronic 69

Calcific Pancreatitis to the surgeon. As head is the pacemaker of pain in chronic 70

pancreatitis coring out the head even in the absence of inflammatory head mass 71

provides better pain relief. 72

73

Materials and Methods: 74

This retrospective cum prospective study analyzed the outcome of Frey procedure in 75

Chronic Calcific Pancreatitis patients without inflammatory head mass. Methods. For 76

the period between 2010 and 2013, 140 patients with chronic pancreatitis underwent 77

Frey procedure for intractable abdominal pain. Of them 80 patients without head 78

mass were included in the study. The mean follow-up was 6 months. Using Visual 79

analogue scale score pain was analyzed both preoperatively and postoperatively. 80

Endocrine and exocrine insufficiencies are also analyzed. 81

82

Results: 83

There was no 30-day mortality. Statistical analysis showed significant improvement 84

of Pain score. The improvement of Pain score in the patients without head mass is 85

comparable to the patients with head mass for whom Frey procedure was done. 86

Though there is improvement in Endocrine and exocrine insufficiency they are not 87

statistically significant as per Chi- Square test. 88

89

Conclusion: 90

This study shows that even in the patients with no head mass, the head coring 91

Pancreatico jejunostomy procedure described by Frey provides a better quality of life 92

and better pain relief with acceptable morbidity and nil mortality. Head coring 93

procedure can be therefore strongly recommended for pain relief even in pancreatitis 94

without head mass. 95


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Keywords: Chronic calcific pancreatitis, Non-head mass CCP, Head coring, Pain 96

score, Pancreatico Jejunostomy, Frey procedure. 97

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INTRODUCTION 130

Intolerable abdominal pain is the main cause which brings the patients with Chronic 131

Calcific Pancreatitis to the surgeon .There are many causes for the pain in Chronic 132

Pancreatitis which includes ductal hypertension [1], increased parenchymal 133

pressure, perineural inflammation [2] or as a complication of the disease. There are 134

various interventions available to relieve the pain in Chronic Calcific Pancreatitis like 135

conservative [3, 4] and surgical management [5]. Based on the morphology of the 136

gland resection [6] and drainage [7] are the two types of surgeries that are available. 137

Of the Chronic Pancreatitis cases, 18-50% of patients present with an inflammatory 138

head mass [6] and its resection was considered very essential to relieve the pain by 139

removing the ‘‘pacemaker of pain’’ [8]. In 1987, Frey et al. reported a novel technique 140

for patients with inflammatory head mass commonly known as Frey Procedure in 141

which local resection of the head of pancreas combined with longitudinal 142

pancreatico-jejunostomy (LR-LPJ) was done. It was found that this Frey procedure 143

provided excellent pain control in 90% of the patients with low mortality and morbidity 144

[9]. There are a sub group of patients who present with Chronic Calcific Pancreatitis 145

without head mass with or without a dilated duct. Routine practice in those patients is 146

to do Lateral Pancreatico jejunostomy known as Modified Puestow’s procedure. 147

Aim and Background: 148

Pancreatitis induced pain can be relieved adequately by removing the pacemaker, 149

draining the major and branch ducts sufficiently, removing the stones in the duct and 150

parenchyma around the head. The cored out tissue will be also available to rule out 151

malignancy in pancreas. This study enlightens that since the head is the “Pacemaker 152

of Pain” [10a,b] if we apply the same procedure of Head coring for the patients 153

without head mass there will be good pain control without added morbidity or 154

mortality. Frey Procedure was done in 80 patients who presented to us without 155

pancreatic head mass. Short term outcome analysis was done and results are 156

analyzed by the statistical variables. 157

158


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MATERIALS AND METHODS 159

Patients and Methods: 160

This is a combined prospective and retrospective study was done at Rajiv Gandhi 161

Government General Hospital by the Department of Surgical gastroenterology 162

between 2010 and 2013, 140 patients with chronic Calcific Pancreatitis underwent 163

Frey procedure for intractable abdominal pain. All patients had a detailed history and 164

clinical examination. The diagnostic workup includes measuring the Serum amylase, 165

Lipase, CA-19-9 and ultrasonography (USG), Upper GI endoscopy, Portal vein 166

Doppler, Computed tomographic scanning (CT), and magnetic resonance cholangio 167

pancreatography (MRCP). These patients presented to us with a typical history of 168

abdominal pain that is present in the epigastrium and radiating to the back. We 169

further evaluated and confirmed the diagnosis by looking at the pancreatic 170

calcification or dilatation of main pancreatic duct on imaging (US, CT scan, MRCP). 171

Head mass is defined by the presence of the mass in the head of pancreas with a 172

Antero posterior head diameter was more than 35 mm in CECT abdomen [11a,11b]. 173

Small or non-dilated duct is the name given if it measured 5 mm or less at neck [12]. 174

Main duct was considered as dilated if it measured greater than 7 mm in its maximal 175

diameter. Exocrine function of the pancreas was assessed by the presence or 176

absence of steatorrhea. Steatorrhea is defined as frequency of more than three 177

stools per day with nauseating smell and greasy consistency [13]. Pain was 178

assessed using Visual Analogue Scale (VAS) and frequency of pain attacks along 179

with analgesic requirement16. Surgery was offered to those patients who had Visual 180

analogue scale pain score more than 8. 181

Patient Exclusions: 182

Of the 140 cases of Chronic calcific pancreatitis those patients with head mass and 183

pseudocyst in the head are eliminated from the study. We also eliminated the 184

patients who failed to show alcohol abstinence. Patients who have completed at 185

least six months follow-up alone were included in the study. 186

In that way we selected only 80 patients who presented to us with Chronic Calcific 187

pancreatitis without head mass (CECT abdomen showing head of pancreas Antero 188

posterior diameter less than 35 mm) and had regular follow up for 6 months. 189

Surgical Procedure: 190


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The head coring procedure was performed exactly as described by Frey and Smith 191

[14]. The coring was done at the head of pancreas after lay opening the major duct. 192

The coring was continued without breaching the posterior pancreatic capsule. In 193

most cases we could identify the duct by aspiration method. Using Diathermy and 194

Harmonic scalpel the head and uncinate process of pancreas were cored out. The 195

amount of tissue cored was measured in grams. After perfect hemostasis, a loop of 196

jejunum brought in Roux En Y fashion to Pancreas and pancreatico jejunostomy 197

using a continuous 3’0 polyglactin in a single continuous layer. All the cored out 198

pancreatic tissue was sent for histopathological examination. Most patients were 199

discharged by 10th postoperative day after suture removal. 200

201

RESULTS 202

A total of 80 patients were analyzed. Of them 60 were male and 20 were female. The 203

age of the patients varies between 13 to 58 yrs. The mean age and SD is 37 +10.4 204

years (Figure 1). Regarding the etiology of chronic calcific pancreatitis, alcohol was 205

associated in 58 patients and 22 patients were considered to be tropical Calcific 206

pancreatitis. (Table 1). Of the various complications in this group (Figure 2): 10 207

presented with diabetes mellitus, 6 presented with exocrine insufficiency, Splenic 208

vein thrombosis with fundal varices was seen in 3 patients. Pseudocyst in the tail of 209

the pancreas was seen in 7 patients. Pancreatic ascites was present in 3 patients 210

and only two of them without head mass presented with jaundice. All the patients 211

underwent Contrast enhanced CECT to look for calcifications and head mass (Figure 212

3). MRCP was done in 2 patients who presented with jaundice (Wadsworth 213

syndrome) both of them had a tapering end of the distal CBD in the absence of head 214

mass( figure 4) . Upper GI scopy and portal venous Doppler was done for all 215

patients. Only three patients who has splenic vein thrombosis on portal vein doppler 216

had fundal varices on endoscopy and diagnosed as Sinistral Portal hypertension. All 217

the patients underwent Frey procedure as already described, amount of tissue cored 218

was measured in grams (Figure 5e) Average tissue coring done in the 80 patients is 219

3.8 grams. (Figures 5a,b,c,d,e) 220

Additional procedures like Distal pancreatectomy with splenectomy was done in 10 221

patients – 3 patients who had Sinistral portal hypertension, 7 patients who had 222


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pseudocyst in tail of pancreas. 6 patients who had small duct disease underwent 223

Izbikis ‘V’ shaped opening of the duct along with head coring. For the 2 patients who 224

had jaundice choledocho jejunostomy was done in 1 patient and the other patient 225

had relief of jaundice after coring (Table 2). All the other patients underwent single 226

layered Mucosa to mucosa Pancreatico jejunostomy using 3’0 Polypropylene 227

continuous sutures. (Figure 5.c and d) 228

No patient had major intra op complications. Mean blood loss is 150 ml. Mean 229

duration of surgery is 3 and half hours. There was no 30-day mortality. In this series 230

significant complications occurred in 10 patients. It included 3 with pulmonary 231

complications, 5 with wound infection, one had gastric outlet obstruction due to 232

Jejuno jejunal intussusception which was managed by laparotomy and one had 233

pancreatic leak which settled after 2 months by conservative management (Table 3). 234

The pulmonary complications that were mentioned include two patients with left lung 235

basal atelectasis and one patient with aspiration pneumonia. Atelectasis was treated 236

with Intravenous deriphylline, nebulization with bronchodilators and chest 237

physiotherapy. Aspiration pneumonitis was treated with Antibiotics and 238

bronchodilators. Wound Infection cases underwent Pus Culture and sensitivity and 239

appropriate antibiotics were added based on the antibiotic sensitivity. 4 cases had 240

Staphylococcus aureus positive in the culture test and one patient had E.Coli and 241

Kliebsiella grown in culture. One patient had jejuno jejunal intussusception at the 242

Jejuno jejunostomy site of anastomosis. The jejuno jejunostomy was done in that 243

case in an end to side fashion. The patient presented to us with history of pain 244

abdomen and vomiting after 2 months of surgery. When we did Gastrograffin study 245

we found that there is cut off at the level of upper jejunum with distension of 246

stomach. CECT abdomen showed the presence of intussusception. For that patient 247

we did relaparotomy and did disconnection of Jejuno jejunostomy. A new 248

anastomosis was done in a side to side fashion between the pancreatic limb of the 249

jejunum and afferent limb of jejunum. Biopsy of the cored tissue obtained in all cases 250

– Biopsy report came as chronic pancreatitis with only one patient showed evidence 251

of malignancy and she was referred to medical oncology for Gemcitabine based 252

Chemotherapy. The patient was under follow up with us for 6 months. He didn’t 253

develop any metastasis until 6 months. His CA 19-9 level after 6 months was 10. All 254


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patients were followed up for 6 months regularly in OP and register was maintained 255

about the pain score based on Visual Analogue Scale ( VAS )score, Diabetic control 256

(in terms of reduction in Hba1c and reduction in dose of insulin/OHA) or new onset 257

diabetes, weight gain and about exocrine insufficiency. 258

On follow up for 6 months period, 72 (90%) had complete pain relief and 8(10%) 259

patients on follow up found to have VAS score of 8. Coeliac plexus blockade was 260

given in the follow up period if they do not respond for analgesics for a period of two 261

months. Only those patients who had retractable pain after 2 months of analgesics 262

were selected for CECT guided Coeliac Plexus blockade. Of the 8 patients, only 6 263

needed coeliac plexus blockade and 2 patients were comfortable with analgesics. Of 264

the 10 patients with diabetes 4 (40%) of them improved in glycemic control with 265

reduction of Insulin dose and reduction in HBa1c after 3 months. Of the 6 patients 266

with steatorrhea 4 (66%) had improvement of symptoms. No patient developed new 267

diabetes or steatorrhea in the 6 month follow up period. About 54 patients (67.5%) 268

developed a weight gain of more than 5 kilograms in 6 months (Table 4) 269

Using Chi square test, the variables analyzed showed statistically significant p value 270

for pain relief and there is no statistical significance in the glycemic control and 271

steatorrhea( table 4) With the data obtained the mean and SD for pain score before 272

is 8.33+ 0.66 and the mean score and SD after surgery 1.14 + 0.47. Using paired t 273

test p value <0.0001, significant as per statisticians analysis (Table 5). 274

275

DISCUSSION 276

Surgical intervention for chronic pancreatitis is the most effective therapeutic option 277

for pain control and management of complications as per all studies. The main aim of 278

the surgical treatment of CP is to alleviate severe pancreatic pain and to manage 279

pancreatitis-related loco regional complications. Although lateral pancreatico 280

jejunostomy (Partingtons Rochalle) which had been practised over 3 decades, it is 281

clear that this is not a technique that solves all problems for patients with Chronic 282

pancreatitis. 283

Many of the patients who underwent LPJ had recurrence of pain, which was often 284

attributed to persistence or relapse of the disease in the pancreatic head. So the 285

symptomatic relief which was the demand by most of the patients were not met. It is 286


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only the symptomatic relief that we are aiming to achieve. The principle of Frey's 287

procedure is to decompress the branch ducts in the head of the pancreas, which is 288

considered to be the pacemaker of the disease ("controller of inflammation,") [20]. 289

The pancreatic head region is excised almost in its entirety, leaving behind a bridge of 290

pancreatic tissue about 1cm wide, while a rim of pancreas (5 to 10 mm) remains 291

beside the duodenum and on the upper margin of the pancreatic head [21,22]. The 292

pancreatic neck above the portal vein and superior mesenteric vein are left intact. 293

Regarding the post operative quality of life in terms of pain relief Frey procedure gives 294

much better life. Frey procedure is accepted as a ‘‘patient friendly’’ procedure with 295

zero mortality and a low morbidity rates [15].. Our mortality and morbidity is well 296

within the acceptable range as that of Frey procedure for Head mass Chronic 297

Calcific Pancreatitis (Table 6) 298

By doing surgery for chronic pancreatitis we aim at achieving the complete pain relief 299

and at the same time preserving the endocrine and exocrine function as much as 300

possible. As per the data, 70-80% of the patients with varying follow-up after this 301

procedure had good pain control [16,17]. A few patients having poor pain outcome 302

after surgery are multifactorial and may include inadequate drainage of head, 303

neuropathic changes and unrecognized cancer [18]. An incidence of 10-20% of 304

persistent recurrent symptoms has been reported following Frey procedure. A 305

significant improvement in diabetes and exocrine function is seen following the 306

decompression of the ductal system [19]. In our series we had improvement in both 307

endocrine and exocrine insufficiency though they are statistically not significant. 308

309

CONCLUSION 310

This study shows that the head coring Pancreatico jejunostomy procedure described 311

by Frey provides a better quality of life and better pain relief with acceptable 312

morbidity and nil mortality even in the patients with no head mass. Head coring 313

procedure can be therefore strongly recommended for pain relief even in pancreatitis 314

without head mass. Large scale RCTs must be done comparing the outcomes of LR-315

LPJ and LPJ alone for non-head mass Chronic Calcific Pancreatitis in future. 316

317

318


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CONFLICT OF INTEREST 319

Authors declare no conflict of interest 320

321

REFERENCES 322

1. Ebbehoj N, Svendsen LB, Madsen P. Pancreatic tissue pressure in chronic 323

obstructive pancreatitis. Scand J Gastroenterol 1984;19:1066-8. 324

2. Bockmann DE, Buchler M, Malfertheiner P, Beger HG. Analysis of nerves in 325

chronic pancreatitis. Gastroenterology 1988;94:1459-69. 326

3. Buechler MW, Binder M, Friess H. Role of somatostatin and its analogues in the 327

treatment of acute and chronic pancreatitis. Gut 1994;3:515-9. 328

4. Carr-Locke DL. Endoscopic procedures in the treatment of pancreatic pain. Acta 329

Chir Scand 1990;156:293-8. 330

5. Warshaw AL, Banks PA, Fernandez-del Castillo C. AGA technical review: 331

Treatment of pain in chronic pancreatitis. Gastroentrology 1998;115:765-76. 332

6. Traverso LW, Kozarek RA. Pancreaticoduodenectomy for chronic pancreatitis. 333

Ann surg 1999;236:429-36. 334

7. Bradley EL. Long-term results of pancreatojejunostomy in patients with chronic 335

pancreatitis. Am J Surg 1987;153:207-13. 336

8. Traverso LW. The surgical management of chronic pancreatitis: the Whipple 337

procedure. Adv Surg 1999;32:23-39. 338

9. Pessaux P, Kianmanesh R, Regimbeau JM. Frey procedure in the treatment of 339

chronic pancreatitis: short-term results. Pancreas 2006;33(4):354-8. 340

10a. Fischer Mastery of surgery 6th edition.page1401 Keith D.Lilemoe and Chad 341

G.Ball.(b) Shackelford’s Surgery of Alimentary tract- 7th Edition- Page 1138. Table 342

89-5 343

11a. Strate T, Taherpour Z, Bloechle C. Long term follow-up of a randomized trial 344

comparing the Beger and Frey procedures for patients suffering from chronic 345

pancreatitis. Ann Surg 2005;241:591-8. 346

11b. Factors affecting outcome after Frey procedure for chronic pancreatitis 347

:Anbalagan amudhan, tirupporur govindaswamy balachandar, Devy gounder 348

kannan, govindhasamy rajarathinam, Vellayudham vimalraj, shanmugasundaram 349

rajendran, 350


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Palanisamy ravichandran, satyanesan jeswanth & Rajagopal surendran, hpb 2008 351

12. Shrikande SV, Kleeff J, Friess H. Management of pain in small duct chronic 352

pancreatitis. J Gastrointest Surg 2006;10:227-33. 353

13. Rault A, Sacunha A, Klopfenstein D. Pancreaticojejunal anastomosis is 354

preferable to pancreaticogastrostomy after pancreaticoduodenectomy for long term 355

outcomes of pancreatic exocrine function. J Am Coll Surg 2005;201:239-44. 356

14. Frey CF, Smith GJ. Description and rationale of a new operation for chronic 357

pancreatitis. Pancreas 1987;2:701-7. 358

15. Izbicki JR, Bloeche C. Drainage operation as therapeutic principle of surgical 359

organ saving treatment of chronic pancreatitis. Chirurug 1997;68(9):865-73. 360

16. Frey CF, Amikura K. Local resection of the head of the pancreas combined with 361

longitudinal pancreaticojejunostomy in the management of patients with chronic 362


17. Keus E, van Laarhoven CJ, Eddes EH. Size of the pancreatic head as a 364

prognostic factor for the outcome of Beger’s procedure for painful chronic 365

pancreatitis. Br J Surg 2003;90(3):320-4. 366

18. Markowitz JS, Rattner DW, Warshaw AL. Failure of symptomatic relief after 367

pancreaticojejunal decompression for chronic pancreatitis. Strategies for salvage. 368

Arch surg 1994;129(4):374-9. 369

19. Nealon WH, Thompson JC. Progressive loss of pancreatic function in chronic 370

pancreatitis is delayed by main pancreatic duct decompression: a longitudinal 371

prospective analysis of the modified Puestow procedure. Ann Surg 1993;217:458-68. 372

20. Egawa S, Motoi F, Sakata N, et al. Assessment of Frey procedures : Japanese 373

experience. J Hepatobiliary Pancreat Sci 2010;17:745-751. 374

21. Frey CF, Smith GJ. Description and rationale of a new operation for chronic 375

pancreatitis. Pancreas 1987;2:701-707. 376

22. Frey CF, Amikura K. Local resection of the head of the pancreas combined with 377

longitudinal pancreaticojejunostomy in the management of patients with chronic 378


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TABLES 383

Table: 1: Etiology of Chronic Calcific Pancreatitis without Head mass. 384

Cause Number Percentage

Alcohol 58 72.5%

Tropical and others 22 27.5%

385

Table 2: Additional procedures performed. 386

Features Procedure Number of cases

(%)

Pseudocysts in tail of

pancreas

Frey+ Distal pancreatectomy and

splenectomy

7 (8.75%)

Sinistral portal hypertension Frey+ Distal Pancreatectomy and

splenectomy

3 (3.75%)

Wadsworth syndrome Choledocho jejunostomy 1 (1.25%)

Small Duct disease Izbikis with Head coring 6 (7.5%)

387

388

Table 3: Post operative complications. 389

Complications Number of patients (%)

Wound infection 5 (6.25%)

Pulmonary complication 3 (3.75%)

Jejuno jejunal intussusception 1 ( 1.25%)

Pancreatic fistula 1 (1.25%)

390

391

392

393

394

395

396

397


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Table 4: Follow Up. 398

S:No Variable Preop Post op Improvement

(%)

P value

1 Pain score ( >8) 80 (100%) 8(10%) 90% <0.00001

2 Diabetes mellitus

( reduction in Hba1c and

Insulin/OHA agents dose)

10 (100%) 6 (60%) 40% 0.29

3 Steatorrhea ( Increased stool

frequency >3 with oily nature)

6 (100%) 2 (44%) 66% 0.14

4 Weight gain >5 kg after 6

months

- 52 67.5% -

399

400

Table 5: Analysis of Pre op and Post op variables. 401

S:No Variables Pre op score Post op values P Value

1 Pain score 8.33+ 0.66 1.14 + 0.47 <0.00001

(significant)

402

403

Table 6: Various studies showing the outcome of Frey procedure. 404

Pain remission at end

of follow up (%)

Average follow

up( Months)

N

Frey and Amikura ( 1994) 86.7 37 50

Izbicki et al (1995) 89 17 22

Ho and Frey (2001) 88 38.4 75

Falconi et al (2006) 88.8 60 40

Pessaux et al ( 2006) 88 15 34

Egawa et al (2009) 100 46

Keck et al (2010) 62 43 50

Negi et al ( 2010) 75 76.8 60

405


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FIGURE LEGENDS 406

Figure 1: Age distribution of Chronic Calcific Pancreatitis without Head mass. 407

Figure 2: Complications of CCP without head mass. 408

Figure 3: CECT abdomen showing diffuse parenchymal calcification in head and 409

body. 410

Figure 4: MRCP showing Biliary stricture (Wadsworth syndrome). 411

Figure 5: Intraoperative pictures: (a) Removal of stones. (b) Head coring & opening of 412

duct. (c) Anastomosing the jejunum with pancreas. (d) Completed LR-LPJ. (e) 413

Removed stones and cored tissue being weighed. 414

415

FIGURES 416

417

Figure 1: Age distribution of Chronic Calcific Pancreatitis without Head mass. 418

419


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420

Figure 2: Complications of CCP without head mass. 421

422

423

Figure 3: CECT abdomen showing diffuse calcification in head and body. 424

425


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426

Figure 4: MRCP showing Biliary stricture (Wadsworth Syndrome). 427

428


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429

Figure 5: Intraoperative pictures: (a) Removal of stones. (b) Head coring & opening of 430

duct. (c) Anastomosing the jejunum with pancreas. (d) Completed LR-LPJ. (e) 431

Removed stones and cored tissue being weighed. 432

Documents

Journal Name: International Journal of Hepatobiliary … · Manuscript Accepted Early View Article Page 2 of 19 1 TYPE OF ARTICLE: ORIGINAL ARTICLE 2 3 TITLE: Head coring for chronic