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Open Access 01-12-2023 | Chronic Pancreatitis | Research

Physiological stress level and screening for malnutrition as preoperative predictors of postoperative complications in pancreatic surgery: a retrospective study

Authors: Igor A. Kryvoruchko, Plamen Staikov, Valeriy V. Boyko, Massimo Sartelli, Yulia V. Ivanova, Andrij Honcharov, Svetlana Gramatiuk, Karine Sargsyan

Published in: BMC Surgery | Issue 1/2023

Abstract

Background

Assessment of ‘physiological stress levels’ and ‘nutritional status’ before surgery is important for predicting complications and indirect interventions on the pancreas. The aim of this study was to determine neutrophil–lymphocyte ratio (NLR) and nutritional risk index (NRI) indicators before surgery to predict 90-day complications and mortality in a cohort of patients with complicated chronic pancreatitis and cancer of the head of the pancreas.

Methods

We evaluated preoperative levels of NLR and NRI among 225 subjects treated at different centres located in three countries. Short-term outcomes included length of hospital stay, postoperative complications, and mortality at 90 days and were appreciated based on NLR and NRI. The level of physiological stress was divided according by the formulas: neutrophil–lymphocyte ratio (NLR) = (neutrophil count, %)/(lymphocyte count, %). The nutritional state of the patients was divided according to the INR: NRI = (1.519 × serum albumin, g/L) + (41.7 × present weight, kg / usual weight, kg)].

Results

All patients were operated. An analysis of the operations performed in three institutions demonstrated mortality in chronic pancreatitis and pancreatic pseudocysts in 1.4%, in chronic pancreatitis and the presence of an inflammatory mass mainly in the pancreatic head in 1.2%, and in cancer of the pancreatic head in 5.9%. The mean preoperative NLR was normal in 33.8% of the patients, the mild physiologic stress level was 54.7%, and the moderate was 11.5% before surgery. 10.2% of patients had a normal nutritional status, 20% had mild, 19.6% had moderate, and 50.2% had severe malnutrition. In a univariate analysis, at the cutoff of NLR ≥ 9.5 (AUC = 0.803) and the cutoff of NRI ≤ 98.5 (AUC = 0.801), increasing the risk of complications was observed (hazard ratio, 2.01; 95% CI, 1.247–3.250, p = 0.006), but at the cutoff of NRI ≤ 83.55 (AUC = 0.81), we observed a survival difference in operated patients (hazard ratio, 2.15; 95% CI, 1.334–3.477, p = 0.0025).

Conclusions

Our study demonstrated that NLR and NRI were predictors of postoperative complications, but only NRI was a predictor of 90-day mortality in patients after surgery.

Cupp M, Cariolou M, Tzoulaki I, Aune D, Evangelou E, Berlanga-Taylor AJ. Neutrophil to lymphocyte ratio and cancer prognosis: an umbrella review of systematic reviews and meta-analyses of observational studies. BMC Med. 2020;18(1):360. https://doi.org/10.1186/s12916-020-01817-1.CrossRefPubMedPubMedCentral

Kim S, Eliot M, Koestler DC, Wu W, Kelsey KT. Association of Neutrophil-to-Lymphocyte Ratio With Mortality and Cardiovascular Disease in the Jackson Heart Study and Modification by the Duffy Antigen Variant. JAMA Cardiol. 2018;3(6):455–62. https://doi.org/10.1001/jamacardio.2018.1042.CrossRefPubMedPubMedCentral

Yu H, Jiang L, Yao L, Gan C, Han X, Liu R, Su N. Predictive value of the neutrophil-to-lymphocyte ratio and hemoglobin in systemic lupus erythematosus. Exp Ther Med. 2018;16(2):1547–53. https://doi.org/10.3892/etm.2018.6309.CrossRefPubMedPubMedCentral

Russell CD, Parajuli A, Gale HJ, Bulteel NS, Schuetz P, de Jager CPC, Loonen AJM, Merekoulias GI, Baillie JK. The utility of peripheral blood leucocyte ratios as biomarkers in infectious diseases: A systematic review and meta-analysis. J Infect. 2019;78(5):339–48. https://doi.org/10.1016/j.jinf.2019.02.006.CrossRefPubMedPubMedCentral

Pascual-González Y, López-Sánchez M, Dorca J, Santos S. Defining the role of neutrophil-to-lymphocyte ratio in COPD: a systematic literature review. Int J Chron Obstruct Pulmon Dis. 2018;13:3651–62. https://doi.org/10.2147/COPD.S178068.CrossRefPubMedPubMedCentral

An Peilin, Zhou Xuan, Du Yue, Zhao Jiangang, Song Aili, Liu Huan, Ma Fei and Huang Guowei. Association of Neutrophil-Lymphocyte Ratio with Mild Cognitive Impairment in Elderly Chinese Adults: A Case-control Study, Current Alzheimer Research 2019; 16(14). https://doi.org/10.2174/1567205017666200103110521

D’Amico E, Zanghì A, Romano A, Sciandra M, Palumbo GAM, Patti F. The Neutrophil-to-Lymphocyte Ratio is Related to Disease Activity in Relapsing Remitting Multiple Sclerosis. Cells. 2019;8(10):1114. https://doi.org/10.3390/cells8101114.CrossRefPubMedPubMedCentral

Steiner J, Frodl T, Schiltz K, Dobrowolny H, Jacobs R, Fernandes BS, Guest PC, Meyer-Lotz G, Borucki K, Bahn S, Bogerts B, Falkai P, Bernstein HG. Innate Immune Cells and C-Reactive Protein in Acute First-Episode Psychosis and Schizophrenia: Relationship to Psychopathology and Treatment. Schizophr Bull. 2020;46(2):363–73. https://doi.org/10.1093/schbul/sbz068.CrossRefPubMed

Moutchia J, Pokharel P, Kerri A, McGaw K, Uchai S, Nji M, Goodman M. PLoS ONE. 2020;15(10):e0239802. https://doi.org/10.1371/journal.pone.0239802.CrossRefPubMedPubMedCentral

10.

Güell E, Martín-Fernandez M, De la Torre MC, Palomera E, Serra M, Martinez R, ManelSolsona M, Miró G, Vallès J, Fernández S, Cortés E, Ferrer V, Morales M, Yébenes JC, Almirall J. and Bermejo-Martin JFJ. Clin Med. 2019;8(5):754. https://doi.org/10.3390/jcm8050754.CrossRef

11.

Hajibandeh S, Hajibandeh S, Hobbs N, Mansour M. Neutrophil-to-lymphocyte ratio predicts acute appendicitis and distinguishes between complicated and uncomplicated appendicitis: A systematic review and meta-analysis. Am J Surg. 2020;219(1):154–63. https://doi.org/10.1016/j.amjsurg.2019.04.018.CrossRefPubMed

12.

Begic-Kapetanovic S, Avdagic N, Zaciragic A, Hasic S, Babic N, Hadzimuratovic A. Could the neutrophil-to-lymphocyte ratio serve as a marker in the diagnosis and prediction of acute appendicitis complications in children? Arch Med Sci. 2021;17(6):1672–8. https://doi.org/10.5114/aoms.2019.87697.CrossRefPubMed

13.

Murakami Y, Saito H, Shimizu S, Kono Y, Shishido Y, Miyatani K, Matsunaga T, Fukumoto Y, Fujiwara Y. Neutrophil–to–Lymphocyte Ratio as a Prognostic Indicator in Patients With Unresectable Gastric Cancer. Anticancer Res. 2019;39:2583–9. https://doi.org/10.21873/anticanres.13381.CrossRefPubMed

14.

Nora I, Shridhar R, Huston J, Meredith K. The accuracy of neutrophil to lymphocyte ratio and platelet to lymphocyte ratio as a marker for gastrointestinal malignancies. J Gastrointest Oncol. 2018;9(5):972–8. https://doi.org/10.21037/jgo.2018.08.05.CrossRefPubMedPubMedCentral

15.

Pointer DT, Roife D, Powers BD, Murimwa G, Elessawy S, Thompson ZJ, Schell MJ, Hodul PJ, Pimiento JM, Fleming JB, Malafa MP. Neutrophil to lymphocyte ratio, not platelet to lymphocyte or lymphocyte to monocyte ratio, is predictive of patient survival after resection of early-stage pancreatic ductal adenocarcinoma. BMC Cancer. 2020;20:750. https://doi.org/10.1186/s12885-020-07182-9.CrossRefPubMedPubMedCentral

16.

Nicolás-Ávila JÁ, Adrover JM, Hidalgo A. Neutrophils in homeostasis, immunity, and cancer. Immunity. 2017;46(1):15–28. https://doi.org/10.1016/j.immuni.2016.12.012.CrossRefPubMed

17.

Shaul ME, Fridlender ZG. Cancer related circulating and tumorassociated neutrophils – subtypes, sources and function. FEBS J. 2018;285(23):4316–42. https://doi.org/10.1111/febs.14524.CrossRefPubMed

18.

Bagante F, Tran TB, Postlewait LM, Maithel SK, Wang TS, Evans DB, Hatzaras I, Shenoy R, Phay JE, Keplinger K, Fields RC, Jin LX, Weber SM, Salem A, Sicklick JK, Gad S, Yopp AC, Mansour JC, Duh QY, Seiser N, Solorzano CC, Kiernan CM, Votanopoulos KI, Levine EA, Poultsides GA, Pawlik TM. Neutrophil-lymphocyte and platelet-lymphocyte ratio as predictors of disease specific survival after resection of adrenocortical carcinoma. J Surg Oncol. 2015;112(2):164–72. https://doi.org/10.1002/jso.23982.CrossRefPubMedPubMedCentral

19.

Liao LJ, Hsu WL, Wang CT, Lo WC, Cheng PW, Shueng PW, Hsieh CH, Chiu YL, Lin YC. Prognostic impact of pre-treatment neutrophil-to-lymphocyte ratio (NLR) in nasopharyngeal carcinoma: A retrospective study of 180 Taiwanese patients. Clin Otolaryngol. 2018;43(2):463–9. https://doi.org/10.1111/coa.12992.CrossRefPubMed

20.

Borazan E, Balik AA, Bozdag Z, Arık MK, Aytekin A, Yılmaz L, Elçi M, Başkonuş İ. Assessment of the relationship between neutrophil lymphocyte ratio and prognostic factors in non-metastatic colorectal cancer. Turk J Surg. 2017;33(3):185–9. https://doi.org/10.5152/turkjsurg.2017.3528.CrossRefPubMedPubMedCentral

21.

Wang YQ, Zhi QJ, Wang XY, Yue DS, Li K, Jiang RC. Prognostic value of combined platelet, fibrinogen, neutrophil to lymphocyte ratio and platelet to lymphocyte ratio in patients with lung adenosquamous cancer. Oncol Lett. 2017;14(4):4331–8. https://doi.org/10.3892/ol.2017.6660.CrossRefPubMedPubMedCentral

22.

Bennett S, Murphy CF, Fanning M, Reynolds JV, Doyle SL, Donohoe CL. The impact of Nutrition and Gastrointestinal Symptoms on Health-related Quality of Life in Survivorship after Oesophageal Cancer Surgery. Clin Nutr Open Sci. 2022;41:44–61. https://doi.org/10.1016/j.nutos.2021.11.005.CrossRef

23.

Gianotti L, Besselink MG, Sandini M, Hackert T, Conlon K, Gerritsen A, Griffin O, Fingerhut A, Probst P, Hilal MA, Marchegiani G, Nappo G, Zerbi A, Amodio A, Perinel J, Adham M, Raimondo M, Asbun HJ, Sato A, Takaori K, Shrikhande SV, Del Chiaro M, Bockhorn M, Izbicki JR, Dervenis C, Charnley RM, Martignoni ME, Friess H, de Pretis N, Radenkovic D, Montorsi M, Sarr MG, Vollmer CM, Frulloni L, Büchler MW, Bassi C. Nutritional support and therapy in pancreatic surgery: A position paper of the International Study Group on Pancreatic Surgery (ISGPS). Surgery. 2018;164(5):1035–48. https://doi.org/10.1016/j.surg.2018.05.040.CrossRefPubMed

24.

El Asmar A, Elie Ghabi E, Akl B, Malhab CA, Saber T, Eid S, Mahfouz E, Rahban H, El Rassi Z. Preoperative NLR and PLR are predictive of clinically relevant postoperative pancreatic fistula. Surgery in Practice and Science. 2022;10:100122. https://doi.org/10.1016/j.sipas.2022.100122.CrossRef

25.

Kim H, Jung W, Shin YC, Han IW, Byun Y, Lee HW, Heo JS, Choi DW, Lim C-S. The diagnostic and prognostic values of inflammatory markers in intraductal papillary mucinous neoplasm. HPB. 2021;23(10):1623–8.https://doi.org/10.1016/j.hpb.2021.04.001.CrossRefPubMed

26.

Shi N, Zhang X, Zhu Y, Deng L, Li L, Zhu P, Xia L, Jin T, Ward T, Sztamary P, Cai W, Yao L, Yang X, Lin Z, Jiang K, Guo J, Yang X, Singh VK, Sutton R, Lu N, Windsor JA, He W, Huang W, Xia Q. Predicting persistent organ failure on admission in patients with acute pancreatitis: development and validation of a mobile nomogram. HPB. 2022;24(1):1907–20. https://doi.org/10.1016/j.hpb.2022.05.1347.CrossRefPubMed

27.

PaProbst P, Fuchs J, Schoen MR, Polychronidis G, Forster T, Mehrabi A, Ulrich A, Knebel P, Hoffmann K. Nutritional risk in major abdominal surgery: NURIMAS Liver (DRKS00010923) – protocol of a prospective observational trial to evaluate the prognostic value of different nutritional scores in hepatic surgery. Int J Surg Protoc. 2017;6:5–10. https://doi.org/10.1016/j.isjp.2017.09.001.CrossRef

28.

Buettner S, Galjart B, van Vugt JLA, Bagante F, Alexandrescu S, Marques HP, Lamelas J, Aldrighetti L, Gamblin TC, Maithel SK, Pulitano C, Margonis GA, Weiss M, Bauer TW, Shen F, Poultsides GA, Marsh JW. IJzermans JNM, Groot Koerkamp B, Pawlik TM. Performance of prognostic scores and staging systems in predicting long-term survival outcomes after surgery for intrahepatic cholangiocarcinoma J Surg Oncol. 2017;116:1085–95. https://doi.org/10.1002/jso.24759.CrossRefPubMed

29.

Hyder O, Marques H, Pulitano C, Marsh JW, Alexandrescu S, Bauer TW, Gamblin TC, Sotiropoulos GC, Paul A, Barroso E, Clary BM, Aldrighetti L, Ferrone CR, Zhu AX, Popescu I, Gigot JF, Mentha G, Feng S, Pawlik TM. A nomogram to predict long-term survival after resection for intrahepatic cholangiocarcinoma: an Eastern and Western experience. JAMA Surg. 2014;149(5):432–8. https://doi.org/10.1001/jamasurg.2013.5168.CrossRefPubMed

30.

Templeton AJ, McNamara MG, Vera-Badillo FE, Aneja P, Ocaña A, Leibowitz-Amit R, Sonpavde G, Knox JJ, Tran B, Tannock IF, Amir E. Prognostic role of neutrophil-to-lymphocyte ratio in solid tumors: a systematic review and meta-analysis. J Natl Cancer Inst. 2014;106(6):dju124. https://doi.org/10.1093/jnci/dju124. PMID: 24875653.CrossRefPubMed

31.

Ergenç H, Ertürk Z, Eminler AT, Cinemre H. Diagnostic and Prognostic Value of Neutrophil/Lymphocyte Ratio and Platelet/Lymphocyte Ratios on Acute Pancreatitis Patients. OTJHS. 2022;7(1):80–5. https://doi.org/10.26453/otjhs.1022717.CrossRef

32.

Wang Y, Zhi Q, Wang X, Yue D, Li K, Jiang R. Prognostic value of combined platelet, fibrinogen, neutrophil to lymphocyte ratio and platelet to lymphocyte ratio in patients with lung adenosquamous cancer. Oncol Lett. 2017;14:4331–8. https://doi.org/10.3892/ol.2017.6660.CrossRefPubMedPubMedCentral

33.

Romano L, Giuliani A, Tomarelli C, Nervini A, Lazzarin G, Pessia B, Vicentini V, Carlei F, Schietroma M. Impact of Preoperative Neutrophil-Lymphocyte and Platelet-Lymphocyte Ratios on Long-Term Survival in Patients with Operable Pancreatic Ductal Adenocarcinoma. Med Princ Pract. 2022;31:586–94. https://doi.org/10.1159/000527360.CrossRefPubMedPubMedCentral

34.

Rivelsrud M, Paur I, Sygnestveit K, Nilsen RM, Tangvik RJ. Nutritional treatment is associated with longer survival in patients with pancreatic disease and concomitant risk of malnutrition. Clin Nutr. 2021;40(4):2128–37. https://doi.org/10.1016/j.clnu.2020.09.037.CrossRefPubMed

35.

Cañamares-Orbis P, García-Rayado G, Alfaro-Almajano E. Nutritional Support in Pancreatic Diseases. Nutrients. 2022;14:4570. https://doi.org/10.3390/nu14214570.CrossRefPubMedPubMedCentral

36.

Cong K, Chunwei G. Exploration of three different nutritional scores in predicting postoperative complications after pancreaticoduodenectomy. Nutr Hosp. 2022;39(1):101–10. https://doi.org/10.20960/nh.03740.CrossRefPubMed

37.

Yamamoto M, Kawaguchi Y, Ichida A, Matsumura M, Sakamoto Y, Arita J, Akamatsu N, Kaneko J, Kokudo N, Hasegawa K. Evaluation of preoperative nutritional variables to predict postoperative complications after pancreaticoduodenectomy. Nutrition. 2019;67–68:100006.CrossRef

38.

Zahorec R. Ratio of Neutrophil to Lymphocyte Counts-Rapid and Simple Parameter of Systemic Inflammation and Stress in Critically Ill. Bratisl Lek Listy. 2001;102(1):5–14.PubMed

39.

Yang AP, Liu JP, Tao WQ, Li HM. The diagnostic and predictive role of NLR, d-NLR and PLR in COVID-19 patients. Int Immunopharmacol. 2020;84:106504.CrossRefPubMedPubMedCentral

40.

Buzby GP, Williford WO, Peterson OL, Crosby LO, Page CP, Reinhardt GF, Mullen JL. A randomized clinical trial of total parenteral nutrition in malnourished surgical patients: the rationale and impact of previous clinical trials and pilot study on protocol design. Am J Clin Nutr. 1988;47(2 Suppl):357–65. https://doi.org/10.1093/ajcn/47.2.357.CrossRefPubMed

41.

Prasad N, Sinha A, Gupta A, Bhadauria D, Manjunath R, Kaul A, Sharma RK. Validity of nutrition risk index as a malnutrition screening tool compared with subjective global assessment in end-stage renal disease patients on peritoneal dialysis. Indian J Nephrol. 2016;26(1):27–32. https://doi.org/10.4103/0971-4065.158449.CrossRefPubMedPubMedCentral

42.

Brooke-Smith M, Figueras J, Ullah S, Rees M, Vauthey JN, Hugh TJ, Garden OJ, Fan ST, Crawford M, Makuuchi M, Yokoyama Y, Büchler M, Weitz J, Padbury R. Prospective evaluation of the International Study Group for Liver Surgery definition of bile leak after a liver resection and the role of routine operative drainage: an international multicentre study. HPB (Oxford). 2015;17(1):46–51. https://doi.org/10.1111/hpb.12322.CrossRefPubMed

43.

Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hila l M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, Del Chiaro M, Falconi M, Fernandez-Cruz L, Fernandez-Del Castillo C, Fingerhut A, Friess H, Gouma DJ, Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CR, Wolfgang CL, Yeo CJ, Salvia R, Buchler M. International Study Group on Pancreatic Surgery (ISGPS). The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery. 2017;161(3):584-591. https://doi.org/10.1016/j.surg.2016.11.014.

44.

Karim SAM, Abdulla KS, Abdulkarim QH, Rahim FH. The outcomes and complications of pancreaticoduodenectomy (Whipple procedure): Cross sectional study. Int J Surg. 2018;52:383–7. https://doi.org/10.1016/j.ijsu.2018.01.041.CrossRefPubMed

45.

Lubrano J, Bachelier P, Paye F, Le Treut YP, Chiche L, Sa-Cunha A, Turrini O, Menahem B, Launoy G, Delpero JR. Severe postoperative complications decrease overall and disease free survival in pancreatic ductal adenocarcinoma after pancreaticoduodenectomy. Eur J Surg Oncol. 2018;44(7):1078–82. https://doi.org/10.1016/j.ejso.2018.03.024.CrossRefPubMed

46.

Petrova E, Lapshyn H, Bausch D, D'Haese J, Werner J, Klier T, Nüssler NC, Gaedcke J, Ghadimi M, Uhl W, Belyaev O, Kantor O, Baker M, Keck T, Wellner UF. StuDoQ|Pancreas study group and members of StuDoQ|Pancreas registry of the German Society for General and Visceral Surgery (DGAV). Risk stratification for postoperative pancreatic fistula using the pancreatic surgery registry StuDoQ|Pancreas of the German Society for General and Visceral Surgery. Pancreatology. 2019 19(1):17-25 https://doi.org/10.1016/j.pan.2018.11.008.

47.

Keung EZ, Asare EA, Chiang YJ, Prakash LR, Rajkot N, Torres KE, Hunt KK, Feig BW, Cormier JN, Roland CL, Katz MHG, Lee JE, Tzeng CD. Postoperative pancreatic fistula after distal pancreatectomy for non-pancreas retroperitoneal tumor resection. Am J Surg. 2020;220(1):140–6. https://doi.org/10.1016/j.amjsurg.2019.11.026.CrossRefPubMed

48.

Andreou A, Aeschbacher P, Candinas D, Gloor B. The Impact of Patient Age ≥80 Years on Postoperative Outcomes and Treatment Costs Following Pancreatic Surgery. J Clin Med. 2021;10(4):696. https://doi.org/10.3390/jcm10040696.CrossRefPubMedPubMedCentral

49.

De Schryver N, Wittebole X, Hubert C, Gigot J-F, Laterre P-F, Castanares-Zapatero D. Early hyperlactatemia predicts pancreatic fistula after surgery. BMC Anesthesiol. 2015;15:109. https://doi.org/10.1186/s12871-015-0093-x.CrossRefPubMedPubMedCentral

50.

Lermite E, Sommacale D, Piardi T, Arnaud JP, Sauvanet A, Dejong CH, Pessaux P. Complications after pancreatic resection: diagnosis, prevention and management. Clin Res Hepatol Gastroenterol. 2013;37(3):230–9. https://doi.org/10.1016/j.clinre.2013.01.003.CrossRefPubMed

51.

van Genderen ME, Paauwe J, de Jonge J, van der Valk RJ, Lima A, Bakker J, van Bommel J. Clinical assessment of peripheral perfusion to predict postoperative complications after major abdominal surgery early: a prospective observational study in adults. Crit Care. 2014;18(3):R114. https://doi.org/10.1186/cc13905.CrossRefPubMedPubMedCentral

Title: Physiological stress level and screening for malnutrition as preoperative predictors of postoperative complications in pancreatic surgery: a retrospective study
Authors: Igor A. Kryvoruchko
Plamen Staikov
Valeriy V. Boyko
Massimo Sartelli
Yulia V. Ivanova
Andrij Honcharov
Svetlana Gramatiuk
Karine Sargsyan
Publication date: 01-12-2023
Publisher: BioMed Central
Keywords: Chronic Pancreatitis
Malnutrition
Pancreatic Surgery
Pancreatic Surgery
Published in: BMC Surgery / Issue 1/2023
Electronic ISSN: 1471-2482
DOI: https://doi.org/10.1186/s12893-023-02062-y

Mastering chronic pancreatitis pain: A multidisciplinary approach and practical solutions

Webinar | 06-02-2024 | 20:00 (CET)

Severe pain is the most common symptom of chronic pancreatitis. In this webinar, experts share the latest insights in pain management for chronic pancreatitis patients. Experts from a range of disciplines discuss pertinent cases and provide practical suggestions for use within clinical practice.

2024 ESC Congress

Springer Medicine

Physiological stress level and screening for malnutrition as preoperative predictors of postoperative complications in pancreatic surgery: a retrospective study

Abstract

Background

Methods

Results

Conclusions

Mastering chronic pancreatitis pain: A multidisciplinary approach and practical solutions

2024 ESC Congress

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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