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Surgery for Chronic Pancreatitis: Indications, Which Surgery When, Results

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Surgery for Chronic Pancreatitis: Indications, Which Surgery When, Results Surgery for chronic pancreatitis: Indications, Which surgery when, Results Dr. Manish Madnani Resident DNB GI Surgery INDICATIONS FOR SURGERY IN CHRONIC PANCREATITIS Intractable pain (most common) Unsuccessful endoscopic management Suspicion of malignancy INDICATIONS FOR SURGERY IN CHRONIC PANCREATITIS Complications Pseudocyst Biliary obstruction Duodenal obstruction Colonic obstruction Gastrointestinal bleeding Pancreatic ascites Pancreatic carcinoma SURGICAL OPTIONS FOR PAIN Patient selection is as important as the choice of the operative procedure. The decision to undertake surgery should only be made when a full and thorough evaluation of the patient has been made. The patient must understand two important points. a) The risks of intervention and be aware that pain may not be relieved. b) Surgical intervention will not reverse the progressive loss of endocrine and exocrine pancreatic function. The type of operation depends on parenchymal and pancreatic ductal morphological changes of pancreas and can be divided into Pancreatic duct drainage Pancreatic resection procedures procedures Pure Drainage Operations Indications Surgical procedure of choice for isolated Cystojejunostomy pseudocysts Ductal dilation >7 mm without inflammatory Laterolateral pancreatojejunostomy mass Partington-Rochelle procedure Rare indications, replaced by other Caudal drainage/Puestow procedure procedures Resection Indications Procedures Pancreatic head Always include a ductal drainage resection Procedure of choice if inflammatory mass is in the head of the pancreas All techniques have comparable results Procedure of choice in suspected malignancy and in PD and PPPD irreversible duodenal stenosis DPPHR Techniques Indications DPPHR, Beger Procedures of choice if inflammatory mass in the head of the pancreas DPPHR, Bern Technically less difficult than Beger but equal in long-term outcome Patients with ductal obstruction in the head and tail and a smaller inflammatory mass DPPHR, Frey in the head of the pancreas V-shaped excision Small duct disease (diameter of pancreatic duct <3 mm) Pancreatic left resection Rare cases, such as isolated chronic pancreatitis in the tail (e.g., posttraumatic) Rare cases of large psudocysts in the tail Rare cases, such as isolated ductal stenosis in the body (e.g., posttraumatic) in Segmental resection patients without diabetes Total pancreatectomy Rare cases with severe changes in the entire pancreas and preexisting IDDM A) Lateral Pancreatico-Jejunostomy (Modified Puestow Procedure) It is generally recommended that the operation should only be performed in patients with pancreatic ducts larger than 7 mm in diameter. The most commonly performed drainage operation. The duct should be opened to within 1-2 cm. of splenic hilus and extended to the head of the gland and when necessary into the uncinate process. Intraoperative ultrasonography may be used to locate the duct. A) Lateral Pancreatico-Jejunostomy (Modified Puestow Procedure) Mucosa-to-mucosa apposition can be used as a one-layer continuous suture if the gland overlying the anterior aspect of the duct is thin. However, for most cases, anastomosis to the cut edge is performed when the duct is deeply embedded in an enlarged and inflamed pancreatic parenchyma. It is important to orientate the Roux limb so that its blind end is placed towards the tail of the pancreas, allowing the possibility of using the same limb for anastomosis to the biliary system. Pseudocysts can also be drained into the same Roux limb. A) Lateral Pancreatico-Jejunostomy (Modified Puestow Procedure) The morbidity and mortality rate <2% as minimal. There is almost no risk of diabetes because little if any pancreatic tissue resected. Pain is relieved in 85% of patient for the first several years. Most patients gain weight since they no longer experience pain with eating although the degree of malabsorption does not change. A) Lateral Pancreatico-Jejunostomy (Modified Puestow Procedure) Major drawback of this operation is that within 5 years, pain recurs in as many as 40 – 50% of patients. In a small number, this may be because of a stricture of the anastomosis. In most, it is probably associated with disease progression or the development of a complications. Recurrence of pain may also herald the appearance of pancreatic cancer. B) Frey Procedure: coring of the head of pancreas with lateral pancreatico-jejunostomy This operation indicated when the head of the pancreas is enlarged 3-4 cm or more in anterior-posterior diameter with dilated pancreatic duct. C) Sphincteroplasty Stenosis of the sphincter of oddi or pancreatic duct sphincter due to scaring from the passage of gallstones may result in: Obstruction of the pancreatic duct Chronic pain. Transduodenal sphinctroplasty with incision of the septum between the pancreatic duct and common bile duct appear to offer significant relief for patient with obstruction and inflammation isolated to this region. 2. PANCREATIC RESECTION PROCEDURES: In up to 30% of patients with chronic pancreatitis, the head of the gland will grossly enlarged by an inflammatory mass Often associated with bile duct stenosis and duodenal hold up. In these patients some form of pancreatic head resection is indicated even in the presence of gross pancreatic duct dilatation: Whipple operation Pylorus preserving pancreaticoduodenectomy Duodenal preserving resection of the head of pancreas (Beger Procedure) V Shape resection • Only very few patients come to medical attention with small duct disease (diameter of the pancreatic duct <3 mm) and no mass in the pancreatic head. In these cases, a V- shaped excision of the anterior aspect of the pancreas is a safe approach and offers effective pain management (Yekebas et al, 2006). Kausch Whipple Procedure • 1) the head of the pancreas is enlarged, often containing cysts and calcifications • 2) a previous endoscopic intervention or drainage procedure was ineffective • 3) a malignancy is present in the head of the gland. • Distinction between benign and malignant disease remains an unsolved dilemma in some patients (up to 6% to 8%) • PD and ppPD are safe and effective procedures in experienced hands, with an operative mortality of 2% to 5% and lasting pain relief in about 80% of patients (Büchler & Warshaw, 2008; Jimenez et al, 2000). • Poor postoperative digestive function has been reported, including gastric dumping, diarrhea, peptic ulcer, and dyspeptic complaints • In up to 20% of the patients with CP, the Kausch-Whipple resection results in diabetes mellitus and subsequently in increased late postoperative morbidity and mortality • Regarding quality of life, the ppPD provides better results than the classic PD, specifically with weight gain in around 90% of patients postoperatively • Gastric dumping, marginal ulceration, and bile-reflux gastritis can be reduced by preserving the pylorus & D1 • The operation leads to long-lasting pain relief in 85% to 95% of patients during the first 5 years postoperatively (Martin et al, 1996). • Delayed gastric emptying -30 to 50 % • Endo/exocrine insufficiency-45 % Pancreatic Resection Procedures A) Beger Procedure The operation is similar to the Frey Operation but the superior mesenteric/portal vein is exposed above and below the neck of the pancreas freed from posterior portion of the neck, and then the neck is divided, as done in a pancreaticoduodenectomy. The head of pancreas is then resected as done in the Frey Operation, preserving a shell of pancreas posteriorly. When the resection is complete, a pancreaticojejunostomy is done incorporating both the transected end of the distal pancreatic segment and the cavity resulting from the head resection. • Mortality < 1%, morbidity =15% • Greater weight gain, better glucose tolerance, and a higher insulin- secretion capacity (Büchler et al, 1995; Müller et al, 1997, 2008a). • 20% -new-onset diabetes mellitus. • Preserved endocrine function is seen in 39% • Silent disease in around 91% • 69% of the patients were professionally rehabilitated, 26% retired, and only 5% were still in the status of disease after DPPHR (Köninger et al, 2004). • DPPHR seems to be able to delay the natural course of CP. Bern Modification • Advantage in Portal hypertension • Probing of distal duct • Extension of anastomosis to tail or resection in 2-3 % (Strobel et al, 2009). Pancreatic Resection Procedure Good to excellent results are reported of resection procedure , in up to 90% of patients Although the postoperative incidence of diabetes in a patient who underwent a standard whipple resection is in excess of 50%. Up to 15% of patients continue to experience significant discomfort or pain and patient who continue to drink Alcohol have worse results than those who abstain. Pancreatic Resection Procedure B) Distal Pancreatectomy is the ideal surgical procedure for patients whose chronic pancreatitis is confined to the body or tail of the pancreas. This occurs in patients who develop a mid-duct stricture as a result of either necrotizing acute pancreatitis or trauma that injures the gland and duct as they cross the spine. Pain relief can be expected in as many as 90% of patients. • < 5% of all patients who have surgical interventions for CP may benefit from distal pancreatectomy. • with and without splenectomy • If no clear indication for splenectomy is present, such as perisplenic pseudocyst or inflammatory or fibrotic encasement of the splenic vessels, preservation of the spleen may be appropriate. • Drainage procedure should be reserved for patients with a dilated
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