Chronic Pancreatitis

Issues

• Diagnosis

• Natural course of the disease

• Treatment – Medical or Surgery or Endotherapy

• Surgery – Timing of Surgery Type of Surgery

• Recurrence of pain

Chronic Pancreatitis

Pathology : Progressive loss of exocrine & endocrine function. In late stage pancreas is enlarged & hard Ductal change – areas of stricture & dilatation Calcification – Intraductal & parenchymal

Pathogenic Mechanisms

Toxic and

metabolic

Idiopathic

GeneticHPCFTRSPINK -1

Autoimmune

RecurrentSAP

Obstructive

Oxidativestress

ToxicMetabolic

NecrosisFibrosis

SAPEHypothesis

Stone &DuctObstruction

Large Duct

ChronicPancreatitis

Cl. Featute – Pain, wt. Loss, diabetes, steatorrhoea

Clinical Presentation

Early onset _ Age < 35Late onset - Age > 35

Pain Characteristics of Chronic Pancreatitis

Type of Pain

Type A - Intermittent ,short duration, several episodes in a year

Type B - Continuous chronic pain Pseudocyst Obstructive pathology

Assessment: Pain severity

The needSelection of patients for surgery‘Objective’ documentation of pain reliefAssessment of treatment efficacyComparison of data

The “Tools”Pain scoring systems‘Quality of life’ assessment

Function scalesSymptom scales

Bloechle C et al, Pancreas 1995, Izbicki JR et al, Ann Surg 1998

Pain scoring systemsParameters assessed• Intensity

• Visual analog scale• Pain medication• Narcotic addiction

• Frequency• Trials: > 1 episode per month

• Duration• Most surgical series: > 1 year

• Consequences• absence from work• number of hospitalizations

Rai RR et al, Gastroenterol Jap 1988; Bloechle C et al, Pancreas 1995

The Izbicki pain score

A validated pain score specifically designed forchronic pancreatitis . It consists of four questions regarding • Frequency of pain• Intensity of pain (VAS score)• Use of analgesics• Disease-related inability to work

Based on these question a pain score can be calculated ranging from 0 (no pain) to 100 (severe, debilitating pain).

• Ductal Dilatation• Parenchymal Hypertension• Parenchymal Ischaemia• Neurohumoral inflammation• Obstruction of luminal structures

Aetiology of Pain in CP

Investigation - Exocrine function test

Direct Test InvasiveSecretin – Cerulein Test

Lundh Test

Fecal Test• Fecal Chymotrypsin test• Fecal Elastase 1 Test

Indirect Test• 24 hours Stool weight and Fecal fat

estimation• Pancreolauryl Test and PABA test• Breath Test – 13 C labeled substrate

Imaging Studies USG / MRCP/ ERCP/ CT/ EUS

CP with pancreas Divisum

MRCP in Chronic Pancreatitis

CP with CBD obstruction

CP with CBD Stone

MDCT Pancreatogram

MDCT

Ch Pancreatitis with Pseudocyst

Ch Pancreatitis and Carcinoma of Pancreas

Ch Pancreatitis with Pseudoaneurysm

Pancreatic Ascites

TreatmentMedical management – Nutrition Enzyme replacement Insulin Analgesics

Indication of surgery 1. Intractable pain 2. Complication – Obstruction – CBD, D2 Vascular involvement Panc. Cyst Presence of mass Pancreatic Ascites

Surgery for Chronic Pancreatitisa timeline

Date Author Procedure1946 Clagget Total Pancreatectomy

Whipple Pancreaticoduodenectomy1950 Richman and Colp Gastrectomy1954 Duval Caudal pancreaticojejunostomy1955 Bowers Choledochojejunostomy1956 Doubilet and

MulhollandSphincterotomy

1958 Puestow and Gillesby Lateral pancreaticojejunostomy1965 Fry and Child 95% Distal Pancreatectomy1978 Traverso and Longmire Pylorus-preserving “Whipple”1987 Frey and Smith Head resection and drainage1989 Beger et al Duodenum-preserving resection

Timing of Surgery

Early Vs Late

What is the appropriate type of Surgery ?

Surgery for Chronic pancreatitisA. Drainage procedure Longitudinal side to side Roux-en-Y pancreatojejunostomy (Modified Peustow or Partington Rochelle) B. Resection Procedure 1.Begers operation 2.Whipple’s Pancreatoduodenectomy 3.Distal pancreatectomy C. Combined procedure Frey’s operation Izbicki’s operation

Non operative Methods Endoscopic Therapy Caeliac ganglion block

LPJ – Partinhton- Rochelle

Frey’s Procedure

Berne Procedure – Modified DPPHR

Duval’s Procedure

Peustow-Gilesby Procedure

Beger’s Procedure - DPPHR

Izbicki’s procedure – Small duct Disease

Salvage or Redo Surgery after failure of Primary Surgery for pain relief

Drainage Surgery Resection Surgery

Resection Surgery Total Pancreatectomy

Thank You