SURGERY IN CHRONIC PANCREATITIS

Resident of surgeryDr SNMC,JODHPUR

---Dr sumer 2013

definition

Continuous inflammatory disease of pancreas characterised by irreversible morphologic changes [[irregular fibrosis, acinar and islet cells loss,inflammatory infiltrates,stone formation]]of both the parenchyma and ducts;typically coupled with permanent loss of function +/-pain

prevalence

1. 10-15/100000 population in western countries

2. 114-200/100000 in southern india3. Typical age 35-55

CP Etiologies

Alcohol;60-70% of all cases in developed countries {6-12 yr history of 150-175 g/day}

Obstruction of pancratic duct;pancreas divisum,post traumatic stricture,tumours

Cystic fibrosis[CFTR mutation] Tropical pancreatitis Autoimmune Hypercalcemia Hyperlipidemia idiopathic

Symptomatic features

Exocrine insufficienc

yMaldigestion,diarrhea Weight loss

Endocrine insufficienc

yDiabetes mellitus

pain Varies with etiology

Diagnostic tests in CP

TESTS OF STRUCTURE

1.ERCP 2.EUS 3.MRI AND MRCP 4.CT scan 5.X ray abdomen 6.USG abdomen

TESTS OF FUNCTION 1.S. Glucose 2.S.Trypsinogen 3.Fecal elastase 4.Fecal chymotrypsin 5.Fecal fat[72 hr

collection] 6.Secretin pancreatic

stimulation test with duodenal intubation

X ray abd -calcification

EUS

Hyperechoic walls of duct Duct dilatation Stones in duct Parenchymal lobularity,strands and cysts

CECT-Homogenous enhancement of pancreas

MRCP-Dilated duct and intraductal debris

Management of CP

Medical therapy Endoscopic therapy Surgical options Nerve blocks

INDICATIONS FOR SURGERY

Pain –commonest indication[[[70-90%]]] Mass/suspicion of malignancy Biliary obstuction Duodenal stenosis Pseudocysts Internal pancreatic fistulae Vascular problems

AIMS OF SURGICAL TREATMENT

Pain relief Control of complications Preservation of exocrine and endocrine

functions Social and occupational rehabilitation Improvement of quality of life

Issues related to surgery

Problems;

Subjective Severity grading:often

arbitrary Pain scoring systems Natural history:alc cp

‘burn out theory’ Timing of surgery

Pain Mechanisms

Pancreatic duct hypertension{outflow obstruction}

‘Compartment syndrome’ Neural involvement Genetic factors

Pain scoring systems

Parameters assesed Intensity a.visual analog scale b.pain medication c.narcotic addiction Frequency Trials:>1 episode per month Duration most surgical series >1 yr Conseqences absence from work number of hospitalisations

Literature based evidence for surgery

Large prospective surgical series;75-90% success in pain relief and improvement in QOL

Pain relief with surgery vs medical Rx :63vs43% at 10 yr

The case for surgery………….

‘……..seems unreasonable to adopt a conservative approach in the hope that pain relief will be obtained sometime in the future,at which stage risk of narcotic addiction increses and results of surgery are invarably poor.’

Andrew

wershaw wershaw al

gastroenterology;1984

Surgical decision making

Anatomy of the disease 1.small duct disease 2.large duct disease 3.location of inflammatory mass Associated complications 1.biliary obstruction 2.duodenal stenosis 3.pseudocysts 4.GI bleeding / PHT 5.Malignancy Etiology

Timing of surgery

Patients presented with complications;early surgery

For pain relief .early surgery [<4 yrs ]may delay

progress of exocrine/endocrine insufficiency[alc CP]

Ann surg 1999 .early surgery in NACP/trop CP improves

nutitrional status,weight gain,decrased insulin requirement.

Controversies:how early what surgery:drainage or resection?

Surgical procedures in CP Indicated for failure of medical

management Suspicion of malignancy Drainage procedure indicated in large duct disease Resection-drainage procedure indicated when there is

inflammatory mass procedure of choice dictated by

surgeon experience and individualized to pt

Drainage procedures

1954 Duval distal

pancreatectomy,spleenectomy,end to end roux en Y pancreaticojejnostomy

1958 Puestow and Gillesby longitudinal incision and invagination

into jejunal roux 1960 Partington and Rochelle side to side longitudinal

anastomosis;preserve distal pancreas and spleen;need dilated duct >6mm

Combined resection-drainage procedure

Inflamed and enlarged pancreatic head Requires resection 1.Whipple 2.Beger[duodenum preserving

pancreatic head resection] 3.Frey

Lateral PJ [[Puestow]]

Click icon to add picture

Most commonly performed today

Two layered suturing

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PancreaticoduodenectomyWhipple procedure

Was developed for periampullary malignancy More popular in the past 2 decades for CP also

due to advances in op technique,anesthesia and perioprative mx

End to side PJ using 2 layer tech {vicryl/silk} duct-to-full-thickness bowel

5 Fr pediatric feeding tube is used as a pancretic stent

End to side choledochojejunostomy 2 layer GJ/DJ Feeding jejunostomy

Retroperitoneum after whipple specimen removed

Beger procedure

Duodenum-sparing pancreatic head resection

C/I in suspected pancretic cancer Portal vein freed,neck divided Longitudinal pancreaticojejunostomy Frozen section to rule out

malignancy[5%]

Freys procedure

Coring of head of pancreas Duodenum-sparing pancreatic head

resection and lateral pancreaticojejunostomy

Indicated for small duct disease Technically easier then beger. Local resection of pancreatic head

relieves CBD obustruction in 70% of cases

Beger vs Freys

Other procedures

Modifications of beger and freys proc

1998,longitudinal V shaped excision of ventral pancreas

Indicated for small duct pancreatitis Author described 95% pain relief

Distal pancreatectomy

Pathology predominantly limited to distal portion of gland

Distal psedocyst,mass, SVT Cut edge of gland oversewn

Laparascopic assisted distal pancreatectomy

Operations for pancreatic pseudocyst

Psedocyst complicates CP in 30% to 40% of pts

Surgery indicated for pts with symtomatic pseudocysts who are either not candidate or have failed an initial attempt at transampullary,transgastric,or transcutaneous drainage

septated cyst with elevated fluid CEA and CA 15-3 levels treated by resection.[? Neoplasm]

CONTd

Cyst-gastrostomy/duodenostomy Roux-en-Y cyst-jejunostomy [simpler] For small multiple cysts of pancreatic

head-Whipple proc For cyst of pancreatic tail – distal

pancreatectomy

CONTd

Surgical cyst-enterostomy is associated with 90-100% success

Success rates from cyst-duodenostomy-100%,cyst-gastrostomy-90% and cyst-jejunostomy-92%

Morbidity 9%-36% Mortality 0%-1%

Confirm location of psedocyst by aspiration

Cyst-jejunostomy

Total pancreatectomy

Last resort for pts with persistent or recurrent pain following lesser proc

Requires autologous islet cell autotransplantation

extended hospitalisation due to Poor diabetes control

Infusion of islets into the portal vein using 18 g angiocatheter

Video-assisted thoracoscopic splanchnicectomy

Indicated in intractable pain abdomen due to pancreatic and gastric carcinoma

Celiac ganglion block have transient effects,but this neural ablation offers higher success rates

Thoracotomy is more invasive,VATS is less invasive and offers more rapid recovery

Reoperative pancreatic surgery

All pts with recurrent pain abdomen reevaluated with CTscan MRCP/ERCP,UGI endoscopy.

For diffuse parenchymal disease-completion pancreatectomy with or without islet cell autotransplantation

For dilated duct-decmpressive surgery For stricture-subtotal resection

GI SURGERY AIIMS DATA

1995-2009 [[n=170]] Pain is the main indication 90% pain duration 1-30 yrs Biliary obstruction alone 10% NACP: 95 ; Alc CP ;75 DRAINAGE PROCEDURE …………….115 LPJ ………………………………….62 LPJ+BILIARY BYPASS …………….30 CYST-ENTEROSTOMIES …………23 RESECTIONS…………………………….19 WHIPPLES ………………………….11 WHIPPLES+LPJ …………………….3 DISTAL PANCREATECTOMY …….5

Summary and conclusion

Pain relief and quality of life issues are the main concern in pts of chronic pancreatitis undergoing treatment

Surgery is indicated for relief of intractable pain and complications associated with CP

Failure of nonsurgical treatment and presence of complications influence timing and need for surgical intervention[[jury is still out:early surgery for mild to moderate pain]]

CONTd

Pain relief is sustained in NACP->85% Duration of pain does not necessarily

correlate with surgical outcome No consistent documentation of recovery

of pancreatic function following ductal drainage

Need for biliary bypass: frequent Associted SVT/PHT makes surgery difficult Late deaths occurs due to malignancy or

continued alcoholism

THANKS