Surgical Management of Chronic Pancreatitis at the Mayo Clinic

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The surgical treatment of chronic pancreatitis is directed at managing complications that arise within and outside of the pancreas as a result of a chronic, fibrosing inflammatory process: pain, obstruction, hemorrhage (rare), infection, or malignancy. As surgeons, we treat and ameliorate the mechanical consequences of chronic pancreatitis; however, we rarely, if ever, provide a definitive resolution of the disease process itself.27 With this in mind, surgical treatment for pain, the more subjective, but most common, complication of chronic pancreatitis, is resorted to only after the less invasive, nonsurgical medical and interventional options have failed. Patients treated by surgical therapy represent a select group with more resistant symptomatology. This must be borne in mind when analyzing results of surgical intervention for pain. Similarly, surgical intervention is undertaken for treatment of chronic pain arising from pancreatitis largely for matters of quality of life, inability to work, and lifestyle. Although the concept of “burnout” of the disease1, 9 with resolution of the pain undoubtedly occurs, the time until spontaneous resolution may be years, and this offers no concomitant solace or relief to the patient. Also, because the primary disease process is not stopped or reversed postsurgically, surgical treatment might best be considered as a palliative intervention aimed at ameliorating the ongoing effects of chronic inflammation of the gland. In the context of this disease spectrum, recurrence or the development of further symptomatic complications should be expected.

This article addresses the authors' approach to the surgical management of chronic pancreatitis in a large, rural-based, specialty referral practice. The authors' institution has had a long-standing interest and recognized expertise in pancreatic surgery that has been cultivated and passed along through several generations of surgeons over the past 60 years.16 This article is based on an 18-year surgical experience treating 487 patients with documented, biopsy-proven chronic pancreatitis.20

Section snippets

PATHOPHYSIOLOGIC CONSIDERATIONS IN THE ETIOLOGY OF PAIN IN CHRONIC PANCREATITIS

Pain is the most common clinical presentation and primary indication for surgical intervention in chronic pancreatitis.20 The etiopathogenesis of pain seems to be multifactorial and complex. Two complementary theories offer a physiologic basis for surgical treatment in chronic pancreatitis: (1) the pancreatic compartment theory and (2) the neural inflammation theory.

PRESURGICAL EVALUATION

Many factors must be considered in the presurgical evaluation of patients with chronic pancreatitis, including not only the pancreatic and peripancreatic anatomy but also concomitant psychosocial concerns.

SURGICAL DECISION MAKING

The type of surgical approach suggested depends on a combination of anatomy (i.e., inflammatory mass, dominant disease, and a dilated pancreatic or bile duct), comorbidity, presence of chemical dependence, and psychosocial considerations. All of these variables are potentially important in the decision-making process. The types of surgical intervention available in the management of chronic pancreatitis include primary ductal drainage procedures, either formal anatomic pancreatic resections

SUMMARY

The authors' approach to the overall surgical management of chronic pancreatitis is to treat complications, that is, pain and, less commonly, obstruction and bleeding. The authors' practice is to exhaust nearly all forms of nonsurgical intervention before suggesting a surgical approach. Nonresponders are then evaluated for severity of pain, interference of quality of life, and presence of chemical dependency. Appropriate candidates undergo imaging examinations to determine the primary site of

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      2012, Shackelford's Surgery of the Alimentary Tract: Volume 1-2, Seventh Edition
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    Address reprint requests to Michael G. Sarr, MD. Gastroenterology Research Unit (AL 2-435). Mayo Clinic. 200 First Street SW. Rochester, MN 55905

    *

    Department of Surgery, Division of General and Gastroenterologic Surgery, Mayo Clinic, Rochester, Minnesota

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