Surgery and Chronic Pancreatitis

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Chronic pancreatitis is characterized by irreversible and continued destruction of pancreatic acinar and duct cells. These cells are replaced by fibrous tissue and deposition of extracellular matrix.15 Chronic pancreatitis is a spectrum of a disease that ranges from mild, with occasional attacks; to moderate, with frequent attacks and more irreversible glandular changes; to severe, with disabling sequelae, such as intractable pain, diabetes, and pancreatic insufficiency (Fig. 1). Until recently, surgeons were referred only patients with severe chronic pancreatitis who were malnourished, often abusers of alcohol or narcotics, and who had end-stage glandular disease. Pancreatic function did not improve after surgery, and improvement of pain and diminished frequency and severity of attacks were the sole determinant of a successful surgical procedure. Much has changed in the past decade. Today, earlier diagnosis of chronic pancreatitis by endoscopy and axial imaging and intervention for mild symptoms may delay the progressive changes in secretory function and exocrine and endocrine malfunction.40, 42

Objective complications of chronic pancreatitis warrant surgery; however, at present, these account for a minority of the procedures used to treat chronic pancreatitis. In contrast, the most common indications for surgery are the subjective complaints of intractability, interference with lifestyle, and pain. These issues create a dilemma in the selection of procedures and patients for treatment, akin to deciding jury awards for pain and suffering. In both, it is difficult to reach a wise judgment or a happy outcome.

This article reviews the current surgical treatment of chronic pancreatitis. Lessons learned from a 25-year experience are included to caution surgeons that unbridled enthusiasm is best replaced by tempered judgments.

The prevalence of chronic pancreatitis (as with pancreatic cancer) is low, at 8 to 10 cases per 100,000 population. Long-term consumption of alcohol is the cause of the disease in 75% of patients worldwide. Primary duct obstruction as a cause of chronic pancreatitis is present in only 5% of patients.42 Depending on hospital population and surgical referral practice, the causes of pancreatitis vary widely. Idiopathic pancreatitis, a diagnosis of exclusion, is more common in tertiary centers than in urban hospitals and accounts for nearly 40% of the cases referred to the author's institution. The cause of chronic pancreatitis is important only in preventing ongoing glandular insult by removing an exogenous stimulus, if identified. The choice of surgical procedure is dependent on anatomic findings and not on the cause.

Complications of chronic pancreatitis occur secondary to healing and fibrosis of the pancreas or deposition of inspissated proteinaceous material in the pancreatic duct, leading to duct obstruction and calculi. Tissue samples from patients undergoing pancreatic resection for chronic pancreatitis demonstrate an increased tissue level of connective tissue growth factor (CTGF; 25-fold) and transforming growth factor (TGF-B1; increased in 50% of chronic pancreatitis tissue samples). CTGF is a cysteine-rich peptide that belongs to a family of genes needed for the coordination of tissue repair.15 The overexpression of CTGF and TGF-B1 in chronic pancreatitis suggests that these proteins may contribute to the enhanced extracellular matrix synthesis, leading to fibrin and collagen deposition in chronic pancreatitis.15 As a result of pancreatic fibrosis, complications that develop include:

  • Bile duct obstruction (from cicatrix or a mass in the head of the pancreas)

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    Figure 4. An endoscopic retrograde cholangiopancreatography (ERCP) showing a dilated bile duct (BD) and pancreatic duct (PD).

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    Figure 5. The author's approach to all pancreatic surgery begins with an upper midline incision. The incision in this case was 3 inches long. (See also Color Plate 1, Fig. 1.)

  • Duodenal obstruction (from extrinsic compression of a fibrosed pancreas)

  • Gastric varices (from splenic vein entrapment and obstruction)

  • Obstruction of the pancreatic duct (from calculi, fibrotic parenchymal strictures, or duct strictures)

  • Pancreatic ascites (from a leaking pancreatic duct or pseudocyst)

  • Pancreatic pseudocyst formation (discussed elsewhere in this issue)

Section snippets

EVALUATION

The panoply of diagnostic imaging tests available to evaluate patients with malignancy of the pancreas has found equal application in chronic pancreatitis. These tests diagnose chronic pancreatitis in 60% to 80% of patients and demonstrate the duct and parenchymal changes necessary to determine which surgical procedures are feasible.2, 13, 20, 27, 36, 54 Pancreatic biopsy is the best way to establish a histologic diagnosis of chronic pancreatitis but is performed only as part of a surgical

GOALS OF SURGERY

It is important to emphasize what a surgical procedure can realistically accomplish in chronic pancreatitis. Surgery cannot cure the disease process. Surgery is indicated to palliate a complication of chronic pancreatitis and decrease the rate of irreversible changes, if possible. In choosing the surgical procedure, surgeons must consider the natural history of that complication and the perioperative risk. Indications for the surgical treatment of chronic pancreatitis include:

Bile duct obstruction

SELECTING THE SURGICAL PROCEDURE

Three anatomic factors—(1) the diameter of the pancreatic duct, (2) the location of the pancreatic duct obstruction (head, neck, body, or tail), and (3) the presence or absence of a focal mass in the pancreas—determine which surgical procedures are feasible. Determining when and if surgery is necessary is more complex. The outcome of surgery for chronic pancreatitis is very much dependent on patient selection. Patients whose indication for surgery is pain may be disappointed in the outcome

PAIN

Abdominal pain is the most common symptom of chronic pancreatitis and is present in 90% of these patients.22, 60 Several mechanisms of pain production in chronic pancreatitis have been suggested. Pain hypotheses include16, 18, 22, 24, 29, 30, 34:

  • Acute inflammation of the pancreas

  • Increased pressure within the pancreatic ductal system and parenchyma

  • Ischemia of the pancreatic parenchyma secondary to increased interstitial pressures

  • Overexpression of a particular protein (growth-associated

Bile Duct Strictures

Bile duct strictures and ERCP findings of intrapancreatic narrowing of the distal bile duct are present in 30% of patients with chronic pancreatitis (range, 2–45%).14, 31, 48, 55 Most bile duct strictures are asymptomatic, and the finding per se does not require intervention; however, intervention is necessary in 5% to 10% of patients. Complications of a bile duct stricture that may require therapy include jaundice, cholangitis, and increasing liver enzymes reflective of cholestasis. Endoscopic

LAPAROSCOPY

As technology and technique of laparoscopy continue to improve, its applications to pancreatic surgery have grown. Laparoscopic distal pancreatectomy and splenectomy and a laparoscopic longitudinal decompression of the pancreatic duct have been reported.11 The exact role of laparoscopy is evolving, and it will be exciting to follow the evolution of this modality. Cuschieri et al11 reported on five patients who underwent laparoscopic splenectomy and distal pancreatectomy for distal pancreatitis.

FAILED SURGICAL PROCEDURE

Surgical procedures for chronic pancreatitis fail for several reasons: (1) the disease progresses in the head or another area of the gland; (2) an anastomotic stricture develops that no longer decompresses an obstructed duct; and (3) when pain is the major problem, irrespective of the surgical procedure performed, the perception of pain and the pain pathway persists. Confirmatory evidence shows that, if bouts of pancreatitis recur and enzymes are elevated, the pancreas is the source. If pain

ALTERNATIVE THERAPY

When resection or duct decompression fails to relieve pain, denervating the pancreas by percutaneous or open techniques has been used. Splanchnicectomy may be done by thoracoscopy, laparoscopy, or percutaneous methods. Presently, this is a salvage procedure for pain relief when all else has failed. Maher et al33 reported on 19 patients treated by thoracoscopic splanchnicectomy. Eleven patients had complete relief of pain, 5 had major reduction in pain, and 3 no pain relief. Similar results were

RESULTS

The type of surgery performed varies with the operative findings and individual surgical experience with each procedure. Today, 30% to 50% of chronic pancreatitis patients undergo PDR, 14% to 30% undergo a drainage procedure, as many as 30% have a distal pancreatectomy, and 10% to 12% undergo complete pancreatectomy after previous resection. In the author's experience with the last 100 patients with chronic pancreatitis who were treated surgically, 50% had a longitudinal pancreaticojejunostomy,

SUMMARY

It is hoped that, in this millennium, chronic pancreatitis will be diagnosed earlier in the course of the disease process. Improved axial imaging of the pancreatic duct and pancreatic parenchyma will diminish the need for other invasive tests.

Surgical procedures are directed at pancreatic duct decompression or resection of the pancreas (head, body or tail) or, infrequently, total pancreatectomy. Pain relief in 75% to 90% is the general rule, with diabetes developing subsequently in as many as

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    Address reprint requests to Avram M. Cooperman, MD, Center for Pancreatic and Biliary Disease, Community Hospital at Dobbs Ferry, 128 Ashford Avenue, Dobbs Ferry, NY 10522

    *

    New York Medical College, Valhalla; the Institute for Liver, Biliary, and Pancreatic Surgery, Community Hospital at Dobbs Ferry, Dobbs Ferry; the Albert Einstein College of Medicine/Montefiore Medical Center, New York, New York; and the Howard University College of Medicine, Washington, DC

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