Surgical Management of Chronic Pancreatitis

Surgical Management of Chronic Pancreatitis

Dr Happykumar Kagathara(M.S., Fellowship in Surgical Gastroenterology and Liver Transplantation)

Department of GI Surgery and Advanced Minimal Access Surgery

Nidhi Hospital, Ahmedabad

CME – IMA, Morbi: September, 2014

• Definition– One end of spectrum of inflammatory and

fibrosing conditions of the pancreas

– Progressive, permanent loss of exocrine and endocrine

– Irreversible morphologic changes

– Recurrent acute exacerbation or persistent painwww.nidhihospital.org

• Etiology– Alcohol (70%) – Idiopathic (Tropical) (20%)– Hypercalcemia– Recurrent acute severe pancreatitis– Hereditary and Genetics____– Obstructive causes_____

• Incidence– Indian scenario• 115-200 / 1,00,000 people• Idiopathic – Most common www.nidhihospital.org

PD obstruction

HTN of secondary PD

Parenchymal HTN

Stretch activated neural pathway

Chronic inflammation

Peripancreatic capsule fibrosis

Local blood flow impairment

Ischemic insult

www.nidhihospital.org

• Symptomatology– Abdominal pain (90%)• Episodic

• Exacerbated by eating

• “Burnout” period in late phase

–Weight loss• Avoidance of meals because of exacerbation of pain

• Malabsorption

– Exocrine insufficieny (4-30%)• Steatorrhoea

• Malabsorption www.nidhihospital.org

– Endocrine insufficiency• 90% parenchyma replaced by fibrosis

– Extrapancreatic complications• Biliary obstruction (3-30%), due to fibrosis of head of

pancreas

• Duodenal obstruction (2-12%)

• Splenic vein thrombosis (2%)

– Risk of pancreatic cancer


• Treatment strategy– Lifestyle modification

– Diet modification

– Pancreatic enzyme supplementation

– Pain control• Narcotics

• NSAID

• Anti-depresant

• Octreotide

• Celiac plexus nerve block


• Indication for surgery– Intractable abdominal pain

– Secondary complications of chronic pancreatitis (biliary stricture, duodenal stenosis, pseudocyst, and suspected pancreatic neoplasm)


• Objectives of surgical management– Pain relief

– Control of complications

– Preservation of exocrine and endocrine functions

– Social and occupational rehabilitation

– Improvement of quality of life www.nidhihospital.org

• Role of surgery in management of pain– 75-90% success in pain relief

– Pain relief with surgery vs medical treatment• 63 vs 43% @10 yr


– Timing of surgery• Non-surgical management as long as possible to avoid

surgical complications

• Better pain relief with early surgical drainage

• Decision regarding timing of surgery be individualized on a patient to patient basis.

• With failure of medical management, counsel regarding the risks and benefits of both modalities.


Surgery

Resection

Total Pancreatectomy

Whipples PD

Traverso PPPD

DPPHR

Beger

Bern

Distal Pancreatectomy

Decompression

Duval’s

Puestow’s

Partington’s

Hybrid – LR+ LPJ

Frey

Izbicki


• Hybrid procedures (LR+LPJ)– Indications• Dilated duct disease + Inflammation in head of pancres

– Complete pain relief in 92%


• Frey procedure (1987)– Duodenum-sparing resection of the pancreatic head + No

division of the neck of the pancreas + Longitudinal P-J of the dorsal duct

– Long-term pain relief and decrease opiate dependence


• Technical variations in Frey procedure– Izbicki procedure (1998)

» Known as “Hamburg modification”

» Inflammatory head mass + Small duct disease

» More extensive excavation of head + lateral decompressive pancreaticojejunostomy of the body and tail


• Drainage procedures– Indication• Isolated dilatation of the pancreatic duct >7mm or

“chain of lakes” appearance without an inflammatory mass in the head

• Generalized parenchymal involvement (no focal involvement)

• Recurrent or progressive segmental stenosis of the pancreatic duct


– Procedures• Duval’s procedure (1954)

– Drainage of the tail with a Roux-en-Y limb of jejunum

– Not effective for disease in the proximal pancreas


• Puestow’s procedure (Lateral P-J) (1958)– Longitudinal decompression of the body and tail of the

pancreas into a Roux limb of jejunum

– Initially described in conjunction with splenectomy and the distal pancreatectomy


• Partington’s lateral P-J (1960)– P-J without resection of the pancreatic tail

– Maximum pancreatic tissue preservation

– Recurrence of symptoms on long term due to incomplete decompression of MPD in head


• Resection procedures– Indications• Focal disease, confined to head of pancreas (except in

distal pancreatectomy)

• Suspicious malignant lesion

• Obstructive complication developed by fibrosis

• Non dilated duct

– Disadvantages• Endocrine insufficiency

• Exocrine insufficiencywww.nidhihospital.org

– Procedures• Whipples PD

– Resection of the head of the pancreas+distal CBD+distal stomach+duodenum +proximal jejunum

– Also treat bile duct stricture and duodenal obstruction


• Traverso’s pylorus preserving pancreaticoduodenectomy– Preservation of pylorus

– Improved QOL compare to Whipples’ pancreaticoduodenectomy


• Distal pancreatectomy– Isolated involvement of body and tail

– With or without splenectomy

– Stump closure by sutures or stapler application or by creating a Roux-en-Y pancreatojejunostomy

– Post-operative outcome is similar in both groups

– Drainage procedure should be reserved for patients with a dilated duct and/or a stricture in the pancreatic head


– Major portion of parenchyma remains untreated

– High risk of recurrence

– Requirement of completion pancreatectomy in 13%


• Total pancreatectomy– For persistence or recurrent pain

– Extended hospitalisation due to poor diabetes control

– Profound metabolic consequences in absence of islet transplantation

– Outcomes identicles with Whipple’s pancreaticoduodenectomy


• Beger’s duodenum preserving pancreatic head resection– Division of the neck overlying the confluence of the

splenic and superior mesenteric veins + Removal of the head of the pancreas, leaving a small rim of pancreatic tissue along the duodenum

– Maintain GI and biliary continuity

– Better long term outcomes


• Bern Modification of DPPHR– Pancreas is not divided at level of portal vein

– Useful in significant inflammation and PHTN

– Less intra-operative bleeding– Equal outcome compare to Beger’s procedure


• Comparison of results (PD vs Beger’s vs Frey)– Study of 43 patients by Klempa et al• DPPHR patients had a shorter hospital stay, greater

weight gain, less post operative diabetes, and exocrine dysfunction than standard Whipple patients

• Pain control was similar between two groupsKlempa I, Spatny M, Menzel J, et al. Chirurg.1995;66:350 –359


– Study of 40 patients by Buchler et al• DPPHR patients had better pain relief, glucose

tolerance, and weight gain compared with PPPD patients

Buchler MW, Friess H, Muller MW, et al. Am J Surg. 1995;169:65– 69; discussion 69 –70

– LR-LPJ and DPPHR compared with the PPPD• Shorter operation times

• Less intraoperative blood loss

• Less perioperative transfusion requirementsAspelund G, Topazian MD, Lee JH, et al.J Gastrointest Surg. 2005;9: 400 – 409

Koninger J, Seiler CM, Sauerland S, et al. Surgery. 2008;143:490 – 498.


– Study by Farkas et al examined 40 patients• Randomized to PPPD or organ-preserving pancreatic

head resection (OPPHR)

• OPPHR was associated with a shorter operating time, less post operative morbidity, shorter hospital stay, and better quality of life than PPPD.

• The degree of pain relief was equalFarkas G, Leindler L, Daroczi M, et al. Langenbecks Arch Surg. 2006;391:338 –342


• Role of minimal access surgery

• Conclusion– Pain relief and quality of life - main concern in

treatment of chronic pancreatitis

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

– Timing of surgery should be individualized on a patient to patient basis.


– Surgical options• Resection, Decompression procedures, Hybrid

procedures

– DPPHR and LR+LPJ are superior to resection in term of • Post-operative outcome, • Quality of life• Pain control, • Glucose tolerance• Weight gain• Shorter OT time• Less blood loss


– Bern’s DPPHR is technically simpler, as reflected by a significantly shorter operative time and a significantly shorter hospital stay

– It has broader acceptance in the future because of technical and economic advantages.


Surgical Management of Chronic Pancreatitis

Health & Medicine

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