OPERATIVE TREATMENT FOR CHRONIC PANCREATITIS

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OPERATIVE TREATMENT FOR CHRONIC PANCREATITIS

INTRODUCTION

Chronic pancreatitis has an incidence in the United States of 5-10 per 100,000

population. It is most commonly associated with chronic alcohol use (75%).

Patients usually present with chronic pain, either persistent continuous pain or

postprandial pain. An anatomic abnormality should be evident in any patient

selected for operative treatment for pancreatic pain. Patients with chronic

pancreatitis may be at increased risk of developing pancreatic cancer.

SYMPTOMS AND DIAGNOSIS

Pain is the major disabling symptom in patients with chronic pancreatitis, often

leading to associated weight loss and/or narcotic dependency. Diabetes,

jaundice, and problems with digestion are also frequently seen.

CT scan, ultrasonography, MRCP, or ERCP usually makes the diagnosis of chronic

pancreatitis and its complications. Typical findings include a dilated

pancreatic duct ( " chain of lakes " ), pancreatic calcification, or pseudocyst.

Biliary or duodenal obstruction and evidence of portal hypertension may also be

present. It is difficult to distinguish between chronic pancreatitis and

pancreatic cancer, especially in patients without pancreatic calcification.

Marked elevation of serum CA 19-9 in a patient without jaundice is highly

suggestive of pancreatic cancer.

By clearly defining pancreatic and biliary ductal anatomy, ERCP and MRCP can

help to select patients who might benefit from surgery and to plan the most

appropriate operation. In patients with atypical gastrointestinal bleeding and

pancreatitis, angiography of the celiac and superior mesenteric arteries can

detect and embolize a pseudoaneurysm.

It is also important to establish a baseline of pancreatic exocrine and

endocrine function, nutritional status, pain severity, use of pain medication or

narcotics, employment status, and quality of life. Continued ingestion of

alcohol or narcotics should be addressed in either a medical or surgical

management plan.

TREATMENT

Patients with disabling abdominal pain, evidence of chronic pancreatitis, and

pancreatic ductal abnormalities are best managed by pseudocyst decompression,

ductal decompression (Puestow procedure), or resection. Biliary-enteric

decompression may also be required in patients with chronic pancreatitis and

bile duct obstruction. Although preservation of pancreatic tissue is desired to

maintain both exocrine and endocrine function, partial pancreatic resection

(such as distal pancreatectomy or the Whipple procedure) is at times the

preferred treatment. While alternative procedures such as endoscopic

sphincterotomy, short-term stent placement in the major pancreatic duct or

pancreatic pseudocyst, and extracorporeal shock wave lithotripsy for biliary

stones may provide short-term relief of symptoms; long-term results are as yet

unknown.

RISKS

Risks and complications associated with operation for chronic pancreatitis

include infection, bleeding, biliary and pancreatic anastomotic leaks, and

aggravation of existing acute pancreatitis, with a frequency in the range of

0.5% to 5%. While it varies with the procedure, the mortality rate of pancreatic

surgery is currently below 5% for major resections and even less for

non-resective decompressive operations.

EXPECTED OUTCOMES

Initial pain relief can be expected in 75-80% of patients and sustained in most

patients for 3-5 years. The incidence of postoperative diabetes and steatorrhea

(fatty stool) depends upon the amount of pancreatic tissue resected and the

disease status of the remaining gland. Among non-diabetic patients, 10-15% will

develop diabetes within 10 years due to the natural progression of associated

exocrine and endocrine insufficiency, which can be slowed in some patients by

abstinence from alcohol or by decompression of an obstructed main ductal system.

Successful relief of pain after operation is associated with weight gain in most

patients. Overall, the best outcomes occur in patients who are compliant with

pancreatic enzyme replacement and abstain from alcohol and narcotics use. The

average length of hospital stay after major pancreatic surgical procedures is

7-14 days. Hospital stay tends to be longer after pancreaticoduodenectomy than

after distal pancreatectomy or ductal decompression operations.

QUALIFICATIONS FOR PERFORMING SURGERY

Only surgeons who are certified or eligible for certification by the American

Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or

their equivalent should perform Pancreatic surgery. These surgeons have

undergone at least 5 years of surgical training after medical school. Pancreatic

surgery should preferably be performed by surgeons with special knowledge,

training and experience in the management of pancreatic disease.

Mark E. Armstrong

www.top5plus5.com

Oregon State Chapter Rep

Pancreatitis Association, International