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]
  • When compared with classic PD, retrospective studies on PPPD have shown:
    • Earlier return-to-work[34]
    • Better quality of life[36]
  • Laparoscopic PD and Robot-assisted laparoscopic PD are found to have following favorable outcomes when compared to open PD.[38][39][40][41][42]
    • Reasonable operative time (357 to 368 minutes)
    • Minimal blood loss(75 to 240 cc)
    • Decreased morbidity (26.7 to 42 percent)
    • Lower pancreatic fistula rates (6.7 to 18 percent)
2.1.2 Duodenal-preserving pancreatic head resection (DPPHR):
  • In 1980, Beger described duodenal-preserving pancreatic head resection (DPPHR) technique for chronic pancreatitis to decrease the morbidity of pancreatic head resection.[43][23][37][43][44][45]
  • It includes transaction of pancreatic neck
  • Followed by a subtotal resection of the pancreatic head
  • Pancreaticojejunostomy is then created by using a roux-en-Y limb of jejunum.

2.2 Tail-dominant disease

  • Distal pancreatectomy (DP) is usually done in[15][46][47][48][49][50][51]
    • Patients with chronic pancreatitis and disease localized to the left side of the pancreas.
    • Patients with a main pancreatic duct stricture in the neck or body.
    • DP with concomitant splenectomy may be used in patients having chronic pancreatitis associated with splenic vein thrombosis or severe inflammatory changes involving the splenic vessels.

2.3 Diffuse parenchymal disease:

  • Total pancreatectomy (TP) may be helpful for pain relief in patients with chronic pancreatitis with diffuse pancreatic involvement.
  • Total pancreatectomy (TP) includes:
    • Pancreatic and duodenal resection
    • Anastomosis of the stomach and bile duct with jejunal loop
  • Total pancreatectomy (TP) is effective in following cases:
    • Patients with diffuse small duct pancreatitis
    • Patients with genetic pancreatitis
    • Patients who have failed previous pancreatic surgeries of a lesser extent (salvage pancreatectomy)
  • Total pancreatectomy (TP) may result in brittle type 3c pancreatogenic diabetes.[52][53]
  • Total pancreatectomy with islet autotransplantation (TPIAT) is being used more commonly to decrease the morbidity resulting from total pancreatectomy (TP).[54]

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. ↑ 15.0 15.1 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. ↑ 23.0 23.1 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. ↑ 34.0 34.1 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. ↑ 36.0 36.1 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. ↑ 37.0 37.1 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.
  38. ↑ Palanivelu C, Rajan PS, Rangarajan M, Vaithiswaran V, Senthilnathan P, Parthasarathi R, Praveen Raj P (2009). "Evolution in techniques of laparoscopic pancreaticoduodenectomy: a decade long experience from a tertiary center". J Hepatobiliary Pancreat Surg. 16 (6): 731–40. doi:10.1007/s00534-009-0157-8. PMID 19652900.
  39. ↑ Kendrick ML, Cusati D (2010). "Total laparoscopic pancreaticoduodenectomy: feasibility and outcome in an early experience". Arch Surg. 145 (1): 19–23. doi:10.1001/archsurg.2009.243. PMID 20083750.
  40. ↑ Asbun HJ, Stauffer JA (2012). "Laparoscopic vs open pancreaticoduodenectomy: overall outcomes and severity of complications using the Accordion Severity Grading System". J. Am. Coll. Surg. 215 (6): 810–9. doi:10.1016/j.jamcollsurg.2012.08.006. PMID 22999327.
  41. ↑ Zureikat AH, Moser AJ, Boone BA, Bartlett DL, Zenati M, Zeh HJ (2013). "250 robotic pancreatic resections: safety and feasibility". Ann. Surg. 258 (4): 554–9, discussion 559–62. doi:10.1097/SLA.0b013e3182a4e87c. PMC 4619895. PMID 24002300.
  42. ↑ Zureikat AH, Postlewait LM, Liu Y, Gillespie TW, Weber SM, Abbott DE, Ahmad SA, Maithel SK, Hogg ME, Zenati M, Cho CS, Salem A, Xia B, Steve J, Nguyen TK, Keshava HB, Chalikonda S, Walsh RM, Talamonti MS, Stocker SJ, Bentrem DJ, Lumpkin S, Kim HJ, Zeh HJ, Kooby DA (2016). "A Multi-institutional Comparison of Perioperative Outcomes of Robotic and Open Pancreaticoduodenectomy". Ann. Surg. 264 (4): 640–9. doi:10.1097/SLA.0000000000001869. PMID 27433907.
  43. ↑ 43.0 43.1 Beger HG, Schlosser W, Friess HM, Büchler MW (1999). "Duodenum-preserving head resection in chronic pancreatitis changes the natural course of the disease: a single-center 26-year experience". Ann. Surg. 230 (4): 512–9, discussion 519–23. PMC 1420900. PMID 10522721.
  44. ↑ Beger HG, Büchler M, Bittner RR, Oettinger W, Roscher R (1989). "Duodenum-preserving resection of the head of the pancreas in severe chronic pancreatitis. Early and late results". Ann. Surg. 209 (3): 273–8. PMC 1493931. PMID 2923514.
  45. ↑ Büchler MW, Friess H, Bittner R, Roscher R, Krautzberger W, Müller MW, Malfertheiner P, Beger HG (1997). "Duodenum-preserving pancreatic head resection: Long-term results". J. Gastrointest. Surg. 1 (1): 13–9. PMID 9834325.
  46. ↑ Riediger H, Adam U, Fischer E, Keck T, Pfeffer F, Hopt UT, Makowiec F (2007). "Long-term outcome after resection for chronic pancreatitis in 224 patients". J. Gastrointest. Surg. 11 (8): 949–59, discussion 959–60. doi:10.1007/s11605-007-0155-6. PMID 17534689.
  47. ↑ Hutchins RR, Hart RS, Pacifico M, Bradley NJ, Williamson RC (2002). "Long-term results of distal pancreatectomy for chronic pancreatitis in 90 patients". Ann. Surg. 236 (5): 612–8. doi:10.1097/01.SLA.0000033039.70348.74. PMC 1422619. PMID 12409667.
  48. ↑ Schoenberg MH, Schlosser W, Rück W, Beger HG (1999). "Distal pancreatectomy in chronic pancreatitis". Dig Surg. 16 (2): 130–6. doi:10.1159/000018705. PMID 10207239.
  49. ↑ Sakorafas GH, Sarr MG, Rowland CM, Farnell MB (2001). "Postobstructive chronic pancreatitis: results with distal resection". Arch Surg. 136 (6): 643–8. PMID 11387000.
  50. ↑ Schnelldorfer T, Mauldin PD, Lewin DN, Adams DB (2007). "Distal pancreatectomy for chronic pancreatitis: risk factors for postoperative pancreatic fistula". J. Gastrointest. Surg. 11 (8): 991–7. doi:10.1007/s11605-007-0187-y. PMID 17508252.
  51. ↑ Diener MK, Seiler CM, Rossion I, Kleeff J, Glanemann M, Butturini G, Tomazic A, Bruns CJ, Busch OR, Farkas S, Belyaev O, Neoptolemos JP, Halloran C, Keck T, Niedergethmann M, Gellert K, Witzigmann H, Kollmar O, Langer P, Steger U, Neudecker J, Berrevoet F, Ganzera S, Heiss MM, Luntz SP, Bruckner T, Kieser M, Büchler MW (2011). "Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial". Lancet. 377 (9776): 1514–22. doi:10.1016/S0140-6736(11)60237-7. PMID 21529927.
  52. ↑ Gruessner RW, Sutherland DE, Dunn DL, Najarian JS, Jie T, Hering BJ, Gruessner AC (2004). "Transplant options for patients undergoing total pancreatectomy for chronic pancreatitis". J. Am. Coll. Surg. 198 (4): 559–67, discussion 568–9. doi:10.1016/j.jamcollsurg.2003.11.024. PMID 15051008.
  53. ↑ Dresler CM, Fortner JG, McDermott K, Bajorunas DR (1991). "Metabolic consequences of (regional) total pancreatectomy". Ann. Surg. 214 (2): 131–40. PMC 1358512. PMID 1867520.
  54. ↑ Sutherland DE, Matas AJ, Najarian JS (1978). "Pancreatic islet cell transplantation". Surg. Clin. North Am. 58 (2): 365–82. PMID 418514.


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