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
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
- ↑ Society for Surgery of the Alimentary Tract (SSAT) (2004). "Operative treatment for chronic pancreatitis". Retrieved 2007-06-09.
- ↑ Ammann RW, Muellhaupt B (1999). "The natural history of pain in alcoholic chronic pancreatitis". Gastroenterology. 116 (5): 1132–40. PMID 10220505.
- ↑ 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.
- ↑ 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.
- ↑ PUESTOW CB, GILLESBY WJ (1958). "Retrograde surgical drainage of pancreas for chronic relapsing pancreatitis". AMA Arch Surg. 76 (6): 898–907. PMID 13532132.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Greenlee HB, Prinz RA, Aranha GV (1990). "Long-term results of side-to-side pancreaticojejunostomy". World J Surg. 14 (1): 70–6. PMID 2407040.
- ↑ 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.
- ↑ Bradley EL (1987). "Long-term results of pancreatojejunostomy in patients with chronic pancreatitis". Am. J. Surg. 153 (2): 207–13. PMID 3812895.
- ↑ Holmberg JT, Isaksson G, Ihse I (1985). "Long term results of pancreaticojejunostomy in chronic pancreatitis". Surg Gynecol Obstet. 160 (4): 339–46. PMID 2580360.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Frey CF, Smith GJ (1987). "Description and rationale of a new operation for chronic pancreatitis". Pancreas. 2 (6): 701–7. PMID 3438308.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 22.0 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.