Surgery and Chronic Pancreatitis
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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Cited by (33)
Pancreatic Trauma and Surgery
2014, Textbook of Gastrointestinal Radiology: Volumes 1-2, Fourth EditionSurgical outcomes after total pancreatectomy and islet cell autotransplantation in pediatric patients
2013, Surgery (United States)Citation Excerpt :Despite optimal medical management, almost half of these patients require subsequent operative intervention because of refractory abdominal pain.26 Traditional operative therapies for CP have consisted of main duct drainage procedures and/or limited gland resections for large duct disease.6,8-12 Unfortunately, a subset of these patients continue to have progressive disease and require further operative management.
Chronic Pancreatitis with Synchronous and Metachronous Malignancy: Three Unusual Cases and a Literature Review
2007, Journal of Surgical EducationCitation Excerpt :These cells are replaced by fibrous tissue and deposition of extracellular matrix.2 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.1 Today, earlier diagnosis of chronic pancreatitis by awareness, endoscopy and CT and nonoperative intervention for mild symptoms may delay the decline in secretory function and exocrine and endocrine malfunction.3
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
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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