Chronic pancreatitis surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

Surgery for Chronic Pancreatitis tends to be divided into two areas - resectional and drainage procedures.[1]

Surgery

 
 
 
 
 
 
 
Chronic pancreatitis causing intractable abdominal pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Dilated pancreatic duct
(>6-7mm)
 
 
 
 
 
 
 
Non dilated pancreatic duct
(<6-7mm)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fibrosis in the head of pancreas
Poor drainage
 
 
 
Head-dominant disease
 
Tail-dominant disease
 
 
Diffuse parenchymal involvement
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Lateral pancreaticojejunostomy
(Puestow procedure)
 
Lateral pancreaticojejunostomy with localized pancreatic head resection
(Frey procedure)
 
Classic pancreaticoduodenectomy
OR
pylorus-preserving pancreaticoduodenectomy
OR
Duodenum-preserving pancreatic head resection (Beger procedure)
 
Distal pancreatectomy
 
 
Total pancreatectomy with islet autotransplantation

Surgery for the pain management:

  • Surgery is usually considered when pain management fails with medical and endoscopic therapies.[2][3][4]
  • The goals of surgery are:
    • Effective pain relief
    • To reduce morbidity
    • To preserve long-term pancreatic function

1. Dilated pancreatic duct:

  • Obstructive pancreatopathy is the underlying pathology in patients with dilated pancreatic duct.
  • Patients are usually managed with drainage procedure that may or may not be accompanied with limited resection.

1.1 Lateral pancreaticojejunostomy (LPJ):

  • LPJ is the conventional surgical approach for pancreatic drainage.[5][6]
  • The procedure involves connecting the pancreatic duct to a Roux-en-Y jejunal limb for drainage.
  • Laparoscopic LPJ is the minimally invasive procedure with the success rate being directly proportional to the duct size.[7][8]
  • Complications such as intraoperative hemorrhage, postoperative hemorrhage and anastomotic leak are less common with this procedure.[6][9][10][11][12][13][14][15]

1.2  Lateral pancreaticojejunostomy with localized pancreatic head resection

  • This procedure involves opening the pancreatic duct into the head and uncinate process of pancreas.
  • It allows preservation of pancreatic parenchyma along the postero-lateral margins of pancreatic head and duodenum.[16][17][18][19][20][21][22]

2. Nondilated pancreatic duct

  • The diameter of the main pancreatic duct is small (<6 to 7 mm).
  • Patients are manages with pancreatic resection that can be partial or total.
    • Partial: Pancreaticoduodenectomy or distal pancreatectomy.
    • Total: Total pancreatectomy with islet autotransplantation.
2.1 Head-dominant disease 
  • Common techniques for pancreatic head resection include:
    • Classic pancreaticoduodenectomy (PD)
    • Pylorus-preserving PD (PPPD)
    • Duodenum-preserving pancreatic head resection (DPPHR)
  • Multiple trials have failed to prove any significant advantage of one technique over the other.[22][23][24][25][26][27]
  • The operative time and the length of stay after DPPHR was found to be shorter in trials.
2.1.1 Pancreaticoduodenectomy
  • Classic pancreaticoduodenectomy may cause significant pain relief in patients with chronic pancreatitis.[28][29][30][31]
  • PPPD is based on the idea of intact gastric emptying mechanism.[32]
  • PPPD is being used as a standard technique in modern pancreatic surgery but the nutritional advantages still need to be established.[33][34][35][36][37]
2.1.2 Duodenal-preserving pancreatic head resection

2.2 Tail-dominant disease

2.3 Diffuse parenchymal disease 

Surgery for the management of complications:

1. Duodenal stenosis 

2. Terminal biliary stenosis

3. Pancreatic pseudocysts

4. Gastric varices due to splenic vein occlusion

5. Fibrosing stenosis of the transverse colon

References

  1. ↑ Society for Surgery of the Alimentary Tract (SSAT) (2004). "Operative treatment for chronic pancreatitis". Retrieved 2007-06-09.
  2. ↑ Ammann RW, Muellhaupt B (1999). "The natural history of pain in alcoholic chronic pancreatitis". Gastroenterology. 116 (5): 1132–40. PMID 10220505.
  3. ↑ Ammann RW, Akovbiantz A, Largiader F, Schueler G (1984). "Course and outcome of chronic pancreatitis. Longitudinal study of a mixed medical-surgical series of 245 patients". Gastroenterology. 86 (5 Pt 1): 820–8. PMID 6706066.
  4. ↑ Layer P, Yamamoto H, Kalthoff L, Clain JE, Bakken LJ, DiMagno EP (1994). "The different courses of early- and late-onset idiopathic and alcoholic chronic pancreatitis". Gastroenterology. 107 (5): 1481–7. PMID 7926511.
  5. ↑ PUESTOW CB, GILLESBY WJ (1958). "Retrograde surgical drainage of pancreas for chronic relapsing pancreatitis". AMA Arch Surg. 76 (6): 898–907. PMID 13532132.
  6. ↑ 6.0 6.1 Nealon WH, Matin S (2001). "Analysis of surgical success in preventing recurrent acute exacerbations in chronic pancreatitis". Ann. Surg. 233 (6): 793–800. PMC 1421322. PMID 11371738.
  7. ↑ Tantia O, Jindal MK, Khanna S, Sen B (2004). "Laparoscopic lateral pancreaticojejunostomy: our experience of 17 cases". Surg Endosc. 18 (7): 1054–7. doi:10.1007/s00464-003-9210-x. PMID 15156382.
  8. ↑ Eid GM, Entabi F, Watson AR, Zuckerbraun BS, Wilson MA (2011). "Robotic-assisted laparoscopic side-to-side lateral pancreaticojejunostomy". J. Gastrointest. Surg. 15 (7): 1243. doi:10.1007/s11605-011-1495-9. PMID 21584825.
  9. ↑ Greenlee HB, Prinz RA, Aranha GV (1990). "Long-term results of side-to-side pancreaticojejunostomy". World J Surg. 14 (1): 70–6. PMID 2407040.
  10. ↑ Sato T, Miyashita E, Yamauchi H, Matsuno S (1986). "The role of surgical treatment for chronic pancreatitis". Ann. Surg. 203 (3): 266–71. PMC 1251088. PMID 2420294.
  11. ↑ Bradley EL (1987). "Long-term results of pancreatojejunostomy in patients with chronic pancreatitis". Am. J. Surg. 153 (2): 207–13. PMID 3812895.
  12. ↑ Holmberg JT, Isaksson G, Ihse I (1985). "Long term results of pancreaticojejunostomy in chronic pancreatitis". Surg Gynecol Obstet. 160 (4): 339–46. PMID 2580360.
  13. ↑ Sarles JC, Nacchiero M, Garani F, Salasc B (1982). "Surgical treatment of chronic pancreatitis. Report of 134 cases treated by resection or drainage". Am. J. Surg. 144 (3): 317–21. PMID 7114369.
  14. ↑ Adams DB, Ford MC, Anderson MC (1994). "Outcome after lateral pancreaticojejunostomy for chronic pancreatitis". Ann. Surg. 219 (5): 481–7, discussion 487–9. PMC 1243174. PMID 8185399.
  15. ↑ Schnelldorfer T, Lewin DN, Adams DB (2007). "Operative management of chronic pancreatitis: longterm results in 372 patients". J. Am. Coll. Surg. 204 (5): 1039–45, discussion 1045–7. doi:10.1016/j.jamcollsurg.2006.12.045. PMID 17481536.
  16. ↑ Frey CF, Smith GJ (1987). "Description and rationale of a new operation for chronic pancreatitis". Pancreas. 2 (6): 701–7. PMID 3438308.
  17. ↑ Frey CF, Amikura K (1994). "Local resection of the head of the pancreas combined with longitudinal pancreaticojejunostomy in the management of patients with chronic pancreatitis". Ann. Surg. 220 (4): 492–504, discussion 504–7. PMC 1234422. PMID 7524454.
  18. ↑ Keck T, Wellner UF, Riediger H, Adam U, Sick O, Hopt UT, Makowiec F (2010). "Long-term outcome after 92 duodenum-preserving pancreatic head resections for chronic pancreatitis: comparison of Beger and Frey procedures". J. Gastrointest. Surg. 14 (3): 549–56. doi:10.1007/s11605-009-1119-9. PMID 20033344.
  19. ↑ Negi S, Singh A, Chaudhary A (2010). "Pain relief after Frey's procedure for chronic pancreatitis". Br J Surg. 97 (7): 1087–95. doi:10.1002/bjs.7042. PMID 20632276.
  20. ↑ Pessaux P, Kianmanesh R, Regimbeau JM, Sastre B, Delcenserie R, Sielezneff I, Arnaud JP, Sauvanet A (2006). "Frey procedure in the treatment of chronic pancreatitis: short-term results". Pancreas. 33 (4): 354–8. doi:10.1097/01.mpa.0000236736.77359.3a. PMID 17079939.
  21. ↑ Gestic MA, Callejas-Neto F, Chaim EA, Utrini MP, Cazzo E, Pareja JC (2011). "Surgical treatment of chronic pancreatitis using Frey's procedure: a Brazilian 16-year single-centre experience". HPB (Oxford). 13 (4): 263–71. doi:10.1111/j.1477-2574.2010.00281.x. PMC 3081627. PMID 21418132.
  22. ↑ 22.0 22.1 Strate T, Taherpour Z, Bloechle C, Mann O, Bruhn JP, Schneider C, Kuechler T, Yekebas E, Izbicki JR (2005). "Long-term follow-up of a randomized trial comparing the beger and frey procedures for patients suffering from chronic pancreatitis". Ann. Surg. 241 (4): 591–8. PMC 1357062. PMID 15798460.
  23. ↑ Klempa I, Spatny M, Menzel J, Baca I, Nustede R, Stöckmann F, Arnold W (1995). "[Pancreatic function and quality of life after resection of the head of the pancreas in chronic pancreatitis. A prospective, randomized comparative study after duodenum preserving resection of the head of the pancreas versus Whipple's operation]". Chirurg (in German). 66 (4): 350–9. PMID 7634946.
  24. ↑ Büchler MW, Friess H, Müller MW, Wheatley AM, Beger HG (1995). "Randomized trial of duodenum-preserving pancreatic head resection versus pylorus-preserving Whipple in chronic pancreatitis". Am. J. Surg. 169 (1): 65–9, discussion 69–70. PMID 7818000.
  25. ↑ Farkas G, Leindler L, Daróczi M, Farkas G (2006). "Prospective randomised comparison of organ-preserving pancreatic head resection with pylorus-preserving pancreaticoduodenectomy". Langenbecks Arch Surg. 391 (4): 338–42. doi:10.1007/s00423-006-0051-7. PMID 16680474.
  26. ↑ Izbicki JR, Bloechle C, Knoefel WT, Kuechler T, Binmoeller KF, Broelsch CE (1995). "Duodenum-preserving resection of the head of the pancreas in chronic pancreatitis. A prospective, randomized trial". Ann. Surg. 221 (4): 350–8. PMC 1234583. PMID 7726670.
  27. ↑ Izbicki JR, Bloechle C, Broering DC, Knoefel WT, Kuechler T, Broelsch CE (1998). "Extended drainage versus resection in surgery for chronic pancreatitis: a prospective randomized trial comparing the longitudinal pancreaticojejunostomy combined with local pancreatic head excision with the pylorus-preserving pancreatoduodenectomy". Ann. Surg. 228 (6): 771–9. PMC 1191595. PMID 9860476.
  28. ↑ Sakorafas GH, Farnell MB, Nagorney DM, Sarr MG, Rowland CM (2000). "Pancreatoduodenectomy for chronic pancreatitis: long-term results in 105 patients". Arch Surg. 135 (5): 517–23, discussion 523–4. PMID 10807274.
  29. ↑ Jimenez RE, Fernandez-Del Castillo C, Rattner DW, Warshaw AL (2003). "Pylorus-preserving pancreaticoduodenectomy in the treatment of chronic pancreatitis". World J Surg. 27 (11): 1211–6. doi:10.1007/s00268-003-7240-0. PMID 14508610.
  30. ↑ Russell RC, Theis BA (2003). "Pancreatoduodenectomy in the treatment of chronic pancreatitis". World J Surg. 27 (11): 1203–10. doi:10.1007/s00268-003-7239-6. PMID 14534820.
  31. ↑ Vickers SM, Chan C, Heslin MJ, Bartolucci A, Aldrete JS (1999). "The role of pancreaticoduodenectomy in the treatment of severe chronic pancreatitis". Am Surg. 65 (12): 1108–11, discussion 1111–2. PMID 10597055.
  32. ↑ Traverso LW, Longmire WP (1978). "Preservation of the pylorus in pancreaticoduodenectomy". Surg Gynecol Obstet. 146 (6): 959–62. PMID 653575.
  33. ↑ Tran KT, Smeenk HG, van Eijck CH, Kazemier G, Hop WC, Greve JW, Terpstra OT, Zijlstra JA, Klinkert P, Jeekel H (2004). "Pylorus preserving pancreaticoduodenectomy versus standard Whipple procedure: a prospective, randomized, multicenter analysis of 170 patients with pancreatic and periampullary tumors". Ann. Surg. 240 (5): 738–45. PMC 1356476. PMID 15492552.
  34. ↑ Seiler CA, Wagner M, Bachmann T, Redaelli CA, Schmied B, Uhl W, Friess H, Büchler MW (2005). "Randomized clinical trial of pylorus-preserving duodenopancreatectomy versus classical Whipple resection-long term results". Br J Surg. 92 (5): 547–56. doi:10.1002/bjs.4881. PMID 15800958.
  35. ↑ Iqbal N, Lovegrove RE, Tilney HS, Abraham AT, Bhattacharya S, Tekkis PP, Kocher HM (2008). "A comparison of pancreaticoduodenectomy with pylorus preserving pancreaticoduodenectomy: a meta-analysis of 2822 patients". Eur J Surg Oncol. 34 (11): 1237–45. doi:10.1016/j.ejso.2007.12.004. PMID 18242943.
  36. ↑ Ohtsuka T, Yamaguchi K, Ohuchida J, Inoue K, Nagai E, Chijiiwa K, Tanaka M (2003). "Comparison of quality of life after pylorus-preserving pancreatoduodenectomy and Whipple resection". Hepatogastroenterology. 50 (51): 846–50. PMID 12828102.
  37. ↑ Beger HG, Krautzberger W, Bittner R, Büchler M, Limmer J (1985). "Duodenum-preserving resection of the head of the pancreas in patients with severe chronic pancreatitis". Surgery. 97 (4): 467–73. PMID 3983823.


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