Journal of the Pancreas Open Access

Keywords

Chronic Pancreatitis, Alcoholic; Pancreatectomy; Pancreaticoduodenectomy; Pancreatic Neoplasms; Quality of Life

Abbreviations

EORTC QLQ-C30: European Organisation for Research and Treatment of Cancer-Quality of Life Questionnaire; FACTP: Functional Assessment of Cancer Therapy- Pancreas; GIQLI: Gastrointestinal Quality of Life Index; QoL: quality of life; SF-36: medical outcome study 36-Item Short-Form Health Survey; WHO: World Health Organization

Introduction

The World Health Organization (WHO) has defined the quality of life (QoL) as: "… an individual's perception of their position in life in the context of the culture and value system in which they live and in relation to their goals, expectations, standards and concerns. It is a broad-ranging concept affected in a complex way by the person's physical health, psychological state, level of independence, social relationships, and their relationship to salient features of their environment." [1]. This is a general definition because QoL, subjectively perceived by the patient, is becoming a major issue in the evaluation of any therapeutic intervention, mainly in patients with chronic or hard to cure diseases where the aim of the intervention is to keep patients either symptom-free and able to live in the community for a long time, or to reduce the discomfort caused by the disease. Even if chronic pancreatitis and pancreatic cancer are chronic and hard-to-cure diseases, the suggestion of WHO has been applied by clinical researchers only recently. In fact, together with the traditional evaluation of morbidity and mortality, and the assessment of exocrine and endocrine functions in patients with pancreatic disease, we should consider the perception of the health status of patients with benign [2, 3, 4] or malignant pancreatic diseases as a priority. If this is true for chronic disease treated medically, QoL becomes of particular interest in those patients who undergo surgical procedures for their pancreatic disease.

It is well-known that patients who undergo pancreatic surgery may develop several postprocedural complications mainly represented by diabetes and maldigestion which may affect their way of life [5].

The aim of this paper was to review the data existing in the English literature on the QoL in patients who undergo surgical resection of the head of or the entire pancreatic gland either for benign or for malignant diseases of the pancreatic gland.

Methods

A search was made on June 20^th, 2006 using three different data bases (MEDLINE, Web of Science and ScienceDirect) in order to select the data existing in the literature on QoL and pancreatic resection surgery published in full text only. Controlled terms only were searched: the Medical Subject Headings (MeSH) terms for MEDLINE, the Topic terms (TS) for Web of Science (WoS) and the Keywords for ScienceDirect. Seventy-four papers on MEDLINE, 122 on WoS, and 4 on ScienceDirect were found (Tables 1, 2, 3). In addition, one more article was identified in the reference data received in the same timeperiod from an e-mail alerting provider. Forty duplicate papers were found among the various databases; 37 of these were present in MEDLINE and WoS while, regarding the four papers found in the ScienceDirect database, two were present at same time in MEDLINE and one was present at same time in WoS. The fourth paper of the ScienceDirect database was in abstract form and was not included in the present study. One-hundred and sixty papers were found [6, 7, 8, 9,10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109,110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133, 134, 135, 136, 137, 138, 139, 140, 141, 142, 143, 144, 145, 146, 147, 148, 149, 150, 151, 152, 153, 154, 155, 156, 157, 158, 159, 160, 161, 162, 163, 164, 165] (Figure 1). Of these, 35 papers were excluded because they were review articles [6, 7, 8, 9,10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40] and two were letters to the editor not reporting original data [41, 42]. The remaining 123 original papers were considered for the purpose of this study. Of these 123 original papers, 11 were excluded because they reported data on nonpancreatic diseases (gastric cancer, cancer of the gallbladder, cancer of the common bile duct, caustic disease) [43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53]. Therefore, 112 studies satisfied the aim of our study; however, 27 papers described studies not utilizing any QoL questionnaire [54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80] and 37 papers reported data collected using non-validated QoL questionnaires [81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109,110, 111, 112, 113, 114, 115, 116, 117]. Thirty-five of the 48 remaining studies were not considered: 19 considered surgical procedures of pancreaticoduodenectomy or total pancreatectomy without distinction among chronic pancreatitis, pancreatic neoplasms, neoplasms of the papilla of Vater, or biliary tree neoplasms [118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133, 134, 135, 136]; seven papers reported non resective surgery or resective surgery of the tail of the pancreas [137, 138, 139, 140, 141, 142, 143]; seven papers reported data referring only to medical treatment of unresected patients [144, 145, 146, 147, 148, 149, 150]; finally, two papers [151, 152] did not distinguished among the various types of surgery. Therefore, only 13 papers were evaluated for the purpose of this study [153, 154, 155, 156, 157, 158, 159, 160, 161, 162, 163, 164, 165]; seven of these papers were present at the same time in two databases (MEDLINE and WoS) [153, 154, 155, 156, 157, 158, 159], two studies were present in the MEDLINE database only [160, 161], three in the WoS database only [162, 163, 164], and the remaining one was the one we received from an alerting e-mail [165].

Results

Of the 13 studies considered, two focused their interest on assessing the QoL as related to surgical procedures involving pancreatic neoplasms [160, 165] and 11 concerned surgical procedures in chronic pancreatitis patients [153, 154, 155, 156, 157, 158, 159, 161, 162, 163, 164].

Pancreatic Neoplasm

It is well-known that the QoL is worsen in patients with pancreatic cancer [166, 167], but an objective measure of the well-being in patients operated on for a pancreatic neoplasm is lacking. The only two studies performed on patients with pancreatic cancer are those of Farnell et al. [160] and Schniewind et al. [165]. Farnell et al. [160] utilized the Functional Assessment of Cancer Therapy-Pancreas (FACT-P) questionnaire which is made up of 37 items; the questionnaire was self-administered in 35 patients in order to investigate their quality of life before and four months after pancreatic resection. Ten patients underwent a Whipple procedure and 25 a Whipple procedure and extended lymph node excision. The authors did not find any difference in the QoL assessment between the two types of surgery. The study of Schniewind et al. [165] added some more information to the previous study of Farnell et al. [160]. These authors studied 91 patients resected for pancreatic adenocarcinoma before surgery, at discharge, and 3, 6, 12 and 24 months after the operation; the EORTC QLQ-C30 questionnaire was used for the study. At the time of discharge from the hospital, all functional scores had dropped below baseline. At 3 and 6 months after surgery, the scores were comparable to preoperative values. After 12 and 24 months, patients reported a slightly better QoL than before surgery. The only exception was in the scale role functioning, which improved at 24 months when compared to the value at discharge but did not reach the preoperative level. With patients who had R0 resection, similar outcomes were found in the EORTC QLQ-C30 functional scales between partial pancreaticoduodenectomy and pylorus preserving pancreaticoduodenectomy, even if patients who had pylorus preserving pancreaticoduodenectomy reported significantly more pain at 24 months after surgery. Moreover, patients who had an extended lymphadenectomy reported better QoL on the EORTC QLQ-C30 functional scales, but the symptom scales were worse in comparison to the patients who underwent a regional lymphadenectomy.

Chronic Pancreatitis

The questionnaires utilized by the various authors who assessed the QoL following surgical procedures in chronic pancreatitis patients are reported in Table 4. The questionnaires utilized were five: the SF-36, the EORTC QLQ-C30, the visual analog quality of life questionnaire, the Gastrointestinal Quality of Life Index (GIQLI), and the McGill Pain Questionnaire.

Table 5 shows the experimental designs of these 11 surgical studies and the respective results are reported in Table 6. At present, there are no comparative studies assessing the possibility that the various questionnaires utilized explored the same physical and mental domains. Furthermore, except for one study demonstrating that the QoL in surgical patients is worse as compared to a reference population [159], in the other studies [153, 154, 155, 156, 157, 158, 159, 161, 162, 163, 164], the authors aimed to demonstrate the superiority of one type of operation with respect to another, or to demonstrate that surgery is capable of improving the QoL as compared to the status evaluated prior to the surgery. The follow-up period for assessing QoL in these studies had a median of 37 months (range 18-104 months) and this timeinterval is probably too short to measure the impact of surgery on well-being over a longterm period. It is also difficult to compare QoL results between the various studies because of the differences in methodology, study design and patient characteristics. In this respect, more information comes from studies which evaluated mixed medicalsurgical populations of chronic pancreatitis patients with a long follow-up period; in these papers, patients who underwent various surgical procedures for chronic pancreatitis had a QoL similar to patients treated medically [4, 151, 152]. It is probably true that surgical procedures are able to briefly ameliorate the QoL of surgically treated patients but, thereafter, chronic pancreatitis per se tends to affect the well-being of these patients.

Conclusions

Presently, there are very few studies exploring the QoL in patients who undergo resection of the head of the pancreas or total pancreatectomy for benign and especially for malignant disease of the pancreas. Furthermore, more knowledge is necessary regarding the comparative behavior of the QoL between patients operated on for benign and for malignant pancreatic diseases; finally, there is a need for studies which compare the QoL of patients who have been operated on with the well-being of a reference population. In the meantime, the routinely assessment of QoL in operated patients is recommended both for patients affected by chronic pancreatitis and for those with pancreatic carcinoma in order to plan intensive medical and psychological support.

Conflict of interest The authors have no potential conflicts of interest

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