Re: OPERATIVE TREATMENT FOR CHRONIC PANCREATITIS

December 29, 2001

Hi MARK

DO you have more info on the peuastow--also whippli partial whiplle

resection all thos optuons even

thankc debs

- In pancreatitis@y..., " Mark E. Armstrong " <casca@b...> wrote:

> 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

>

December 29, 2001

do you have any information about a calsified pancreas

--- debzdebznz wrote:

> Hi MARK

>

> DO you have more info on the peuastow--also whippli

> partial whiplle

> resection all thos optuons even

>

> thankc debs

>

> - In pancreatitis@y..., " Mark E. Armstrong "

> <casca@b...> wrote:

> > 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

> >

> > [Non-text portions of this message have been

> removed]

>

__________________________________________________

December 29, 2001

You can find that info at this page.

http://www.top5plus5.com/Pancreas/PROCEDURES/SURGICAL%20THERAPY.htm

Mark E. Armstrong

www.top5plus5.com

Oregon State Chapter Rep

Pancreatitis Association, International

Re: OPERATIVE TREATMENT FOR CHRONIC PANCREATITIS

> Hi MARK

>

> DO you have more info on the peuastow--also whippli partial whiplle

> resection all thos optuons even

>

> thankc debs

>

> - In pancreatitis@y..., " Mark E. Armstrong " <casca@b...> wrote:

> > 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

> >

December 29, 2001

The progression of chronic pancreatitis is not always predictable, but typically

the disease can be characterized by intractable abdominal pain, a state of

exhaustion resulting from lack of food and water, chronic depression, and often

chemical dependency. Although the malabsorption and diabetes associated with

chronic pancreatitis can be treated medically, intractable pain ultimately

becomes a major surgical indication in approximately one third of patients.

There is controversy over the role and timing of surgery in management of the

patient with chronic pancreatitis. Early intervention is recommended to prevent

irreversible functional impairment of the pancreas. Because the surgery is not

uniformly successful and there is a significant recurrence of symptoms, others

advocate expectant therapy.

There is no single surgical procedure uniformly recommended for all patients

with chronic pancreatitis. The surgical procedure is selected according to the

severity of pain, ductal morphology, the extent of parenchymal disease, and the

overall condition of the patient. The goal of surgery in chronic pancreatitis

patients is to relieve intractable pain while preserving endocrine and exocrine

functions of the pancreas. The results of surgical procedures are inconsistent

in their ability to control pain.

The longitudinal pancreaticojejunostomy or Puestow's procedure is the prototypic

drainage procedure for patients with marked dilation of the main pancreatic duct

(greater than 7-8 mm). An 8-10-cm segment of the pancreatic duct is unroofed and

intraductal concretions removed (Figure 22A). The jejunum is divided (Figure

22B) and the opened pancreatic duct is anastomosed to the jejunum (Figure 22C).

This allows adequate drainage to enter the jejunum. A jejunojejunostomy

reconnects the jejunum to restore continuity of the gastrointestinal tract

(Figure 22D). This procedure is successful in relieving pain in 70-80% of

patients in the short term. Pancreatic function remains good because there has

not been resection of the gland. It is a safe and effective surgery with low

morbidity and mortality.

[top]

Pancreaticoduodenectomy or Whipple resection has been recommended for treatment

of chronic pancreatitis primarily involving the head of the pancreas. The

procedure has a mortality rate of less than 5% and a 25-30% . Morbidity The

procedure is indicated for patients who have failed previous duct drainage

procedures, those with multiple small pseudocysts located in the head of the

pancreas and/or uncinate portions of the gland, those with symptomatic gastric

or biliary obstruction associated with extensive fibrosis or multiple

pseudocysts, and those with hemorrhage from inflammatory aneurysms involving

major peripancreatic vessels. Standard pancreaticoduodenectomy involves

resection of the head of the pancreas, duodenum, gallbladder, distal common bile

duct, and antrum. In chronic pancreatitis, preservation of the antrum and

proximal 1-2 cm of duodenum is a necessary modification in preserving the and

minimizing severe endocrine insufficiency. Pain relief is achieved in 60-80%

percent of patients in the first several years after surgery. (Figure 23).

[top]

The term distal pancreatectomy describes of variable amounts of the body and

tail of the pancreas. Partial pancreatic resection is recommended for patients

with diffuse (moderate to severe) parenchymal disease without ductal dilation

especially in the tail and body. Local resection of major pancreatic sites of

involvement may be sufficient for those patients with regional disease, whereas

a 95% distal resection is recommended for patients with diffuse disease.

Ninety-five percent distal pancreatectomy entails removal of the spleen and

almost all of the pancreas except for a thin rim of tissue within the " C " loop

of the duodenum. Splenic preservation is attempted but often fails because

dissection of splenic vessels from the chronically inflamed and scarred pancreas

is extremely difficult. This procedure provides pain relief for 75-80% of

patients and has a mortality rate less than 5 percent (Figure 24).