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Background Surgery is the most effective treatment in patients with painful chronic pancreatitis and a dilated pancreatic duct. Studies reporting the outcomes of selected surgical approach according to the pancreatic head size in these patients are lacking. Method This was a retrospective, observational single-centre study of consecutive patients who underwent either a Frey procedure or extended lateral pancreaticojejunostomy (eLPJ) for pain due to chronic pancreatitis with a dilated main pancreatic duct (5 mm or more) between 2006 and 2017. A Frey procedure was used in patients with pancreatic head enlargement (40 mm or more) and eLPJ (full-length pancreaticojejunostomy, including transection of the gastroduodenal artery) in others. A biliodigestive bypass was added in the case of biliary obstruction. Results Overall, 140 of 220 patients met the eligibility criteria: 70 underwent a Frey procedure and 70 an eLPJ. Hepaticojejunostomy was added in 17.1 per cent of patients (Frey: 24.3 per cent; eLPJ: 10.0 per cent (P = 0.025)). Major morbidity occurred in 15.0 per cent of patients (Frey: 21.4 per cent; eLPJ: 8.6 per cent (P = 0.033)). After a median 7.8 years of follow-up, the mean (s.d.) decrease in Izbicki pain score was 33 (27) points (34 (28) points after a Frey procedure; 32 (26) points after an eLPJ). Pain relief was reported as ‘very much’ by 87.5 per cent of patients (Frey: 86.1 per cent; eLPJ: 88.9 per cent) and as ‘partial’ by 11.1 per cent (Frey: 13.8 per cent; eLPJ: 8.3 per cent). Conclusion Selective-use of either a Frey procedure or eLPJ in patients with symptomatic chronic pancreatitis was-associated with low morbidity and long-term pain relief. Adding a-biliodigestive bypass did not increase morbidity.

ObjectivePain in chronic pancreatitis is subdivided in a continuous or intermittent pattern, each thought to represent a different entity, requiring specific treatment. Because evidence is missing, we studied pain patterns in a prospective longitudinal nationwide study.Design1131 patients with chronic pancreatitis (fulfilling M-ANNHEIM criteria) were included between 2011 and 2018 in 30 Dutch hospitals. Patients with continuous or intermittent pain were compared for demographics, pain characteristics, quality of life (Short-Form 36), imaging findings, disease duration and treatment. Alternation of pain pattern and associated variables were longitudinally assessed using a multivariable multinomial logistic regression model.ResultsAt inclusion, 589 patients (52%) had continuous pain, 231 patients (20%) had intermittent pain and 311 patients (28%) had no pain. Patients with continuous pain had more severe pain, used more opioids and neuropathic pain medication, and had a lower quality of life. There were no differences between pain patterns for morphological findings on imaging, disease duration and treatment. During a median follow-up of 47 months, 552 of 905 patients (61%) alternated at least once between pain patterns. All alternations were associated with the Visual Analogue Scale pain intensity score and surgery was only associated with the change from pain to no pain.ConclusionContinuous and intermittent pain patterns in chronic pancreatitis do not seem to be the result of distinctly different pathophysiological entities. The subjectively reported character of pain is not related to imaging findings or disease duration. Pain patterns often change over time and are merely a feature of how severity of pain is experienced.

Importance: For patients with painful chronic pancreatitis, surgical treatment is postponed until medical and endoscopic treatment have failed. Observational studies have suggested that earlier surgery could mitigate disease progression, providing better pain control and preserving pancreatic function. Objective: To determine whether early surgery is more effective than the endoscopy-first approach in terms of clinical outcomes. Design, Setting, and Participants: The ESCAPE trial was an unblinded, multicenter, randomized clinical superiority trial involving 30 Dutch hospitals participating in the Dutch Pancreatitis Study Group. From April 2011 until September 2016, a total of 88 patients with chronic pancreatitis, a dilated main pancreatic duct, and who only recently started using prescribed opioids for severe pain (strong opioids for ≤2 months or weak opioids for ≤6 months) were included. The 18-month follow-up period ended in March 2018. Interventions: There were 44 patients randomized to the early surgery group who underwent pancreatic drainage surgery within 6 weeks after randomization and 44 patients randomized to the endoscopy-first approach group who underwent medical treatment, endoscopy including lithotripsy if needed, and surgery if needed. Main Outcomes and Measures: The primary outcome was pain, measured on the Izbicki pain score and integrated over 18 months (range, 0-100 [increasing score indicates more pain severity]). Secondary outcomes were pain relief at the end of follow-up; number of interventions, complications, hospital admissions; pancreatic function; quality of life (measured on the 36-Item Short Form Health Survey [SF-36]); and mortality. Results: Among 88 patients who were randomized (mean age, 52 years; 21 (24%) women), 85 (97%) completed the trial. During 18 months of follow-up, patients in the early surgery group had a lower Izbicki pain score than patients in the group randomized to receive the endoscopy-first approach group (37 vs 49; between-group difference, -12 points [95% CI, -22 to -2]; P =.02). Complete or partial pain relief at end of follow-up was achieved in 23 of 40 patients (58%) in the early surgery vs 16 of 41 (39%)in the endoscopy-first approach group (P =.10). The total number of interventions was lower in the early surgery group (median, 1 vs 3; P

Metafizikia, kimsingi, ni falsafa inayohusu uchunguzi wa chanzo cha fikra na maarifa kuhusu dhana mbalimbali hususan zile ambazo ni za kidhahania. Katika makala haya metafizikia ya kuwapo ni dhana maalumu inayohusiana na jinsi wanajamii wa Kimagharibi wanavyopania kuwa na kitovu mahususi ambacho kila kitu kingeibukia. Ni fikra inayohusishwa na mwanaudenguzi Mfaransa Jacques Derrida ambaye anaziona jamii hizi ziking’ang’ania kitovu hicho wanachokiona cha thamani na ambacho huenda kikawa Mungu, ukweli, mwanzo, au hata utu. Kitovu hiki kinachoenziwa na kuchukuliwa kuwa adili na wanajamii ndicho Derrida alichokiita logocentrism (nenofunge). Makala yanapendekeza kuwa jamii ya Waswahili nayo imejengeka katika fikra kama hii ambapo kila kitu kinawekwa katika kitovu maalumu, na hivyo basi metafizikia yao mahususi ya kuwapo. Makala yanafuatilia mbinu kuu ya kiudenguzi ya kuiweka wazi metafizikia ya kuwapo kwa kuzingatia ukinzani wa jozi za maneno katika methali maalumu za Waswahili. Ili kufikia lengo hilo, makala yamezamia kikoa mahususi cha methali za Waswahili kinachozungumzia ukinzani uliopo kati ya kuwapo/kutokuwapo na kubainisha jinsi metafizikia ya kuwapo, kama ilivyoendelezwa na Derrida, inavyoweza kueleweka. Sampuli ya methali 16 imetumiwa kwa kuzingatia kigezo cha kuzungumziwa ama kuwapo au kutokuwapo kwa sifa fulani. Kikoa hicho cha methali kinahusisha methali zinazoanza na mzizi wa kivumishi ‘–enye’ au zile zinazotaja kuwapo/kutokuwapo moja kwa moja. Hitimisho la makala haya ni kuwa kuwapo, sawa na kutokuwapo, mapenzi/chuki, wazee/vijana, wema/ubaya, wengi/wachache, mafundi/wanafunzi na jozi nyinginezo ambazo mara nyingi hutenganishwa na Waswahili zimebainishwa kama zinazoathiriana na kujengana kimaana – tofauti na fikra yetu kwamba zimeachana kama lilivyo jua na mbingu. Kwa sababu hiyo, methali za Waswahili zimejengeka katika fikra ya kiudenguzi inayohakiki utepetevu wa lugha na kutoimarika kwake kama msingi wa mawasiliano.