This document discusses chronic pancreatitis, including its definition, causes, symptoms, diagnostic tests, and surgical treatment options. It notes that chronic pancreatitis is characterized by irreversible morphological changes and permanent loss of pancreatic function. The main indications for surgery are intractable pain and complications. Surgical options include drainage procedures like longitudinal pancreaticojejunostomy or cyst-enterostomies, as well as resections like Whipple procedure or distal pancreatectomy. The goals of surgery are pain relief, control of complications, and improved quality of life. While surgery provides sustained pain relief in over 85% of patients, outcomes may be complicated by associated issues like portal hypertension.
2. Continuous inflammatory disease of pancreas
characterised by irreversible morphologic
changes [[irregular fibrosis, acinar and islet
cells loss,inflammatory infiltrates,stone
formation]]of both the parenchyma and
ducts;typically coupled with permanent loss of
function +/-pain
4. Alcohol;60-70% of all cases in developed
countries {6-12 yr history of 150-175 g/day}
Obstruction of pancratic duct;pancreas
divisum,post traumatic stricture,tumours
Cystic fibrosis[CFTR mutation]
Tropical pancreatitis
Autoimmune
Hypercalcemia
Hyperlipidemia
idiopathic
14. Pain relief
Control of complications
Preservation of exocrine and endocrine
functions
Social and occupational rehabilitation
Improvement of quality of life
15.
16.
17.
18. Large prospective surgical series;75-90%
success in pain relief and improvement in QOL
Pain relief with surgery vs medical Rx
:63vs43% at 10 yr
19. ‘……..seems unreasonable to adopt a
conservative approach in the hope that pain
relief will be obtained sometime in the future,at
which stage risk of narcotic addiction increses
and results of surgery are invarably poor.’
20.
21. Patients presented with complications;early
surgery
For pain relief
.early surgery [<4 yrs ]may delay progress
of exocrine/endocrine insufficiency[alc CP]
Ann surg 1999
.early surgery in NACP/trop CP improves
nutitrional status,weight gain,decrased insulin
requirement.
Controversies:how early what surgery:drainage or
resection?
22. Indicated for failure of medical management
Suspicion of malignancy
Drainage procedure
indicated in large duct disease
Resection-drainage procedure
indicated when there is inflammatory
mass
procedure of choice dictated by surgeon
experience and individualized to pt
23. 1954 Duval
distal pancreatectomy,spleenectomy,end to
end roux en Y pancreaticojejnostomy
1958 Puestow and Gillesby
longitudinal incision and invagination into
jejunal roux
1960 Partington and Rochelle
side to side longitudinal
anastomosis;preserve distal pancreas and
spleen;need dilated duct >6mm
24. Inflamed and enlarged pancreatic head
Requires resection
1.Whipple
2.Beger[duodenum preserving pancreatic
head resection]
3.Frey
31. Was developed for periampullary malignancy
More popular in the past 2 decades for CP also
due to advances in op technique,anesthesia and
perioprative mx
End to side PJ using 2 layer tech {vicryl/silk} duct-
to-full-thickness bowel
5 Fr pediatric feeding tube is used as a pancretic
stent
End to side choledochojejunostomy
2 layer GJ/DJ
Feeding jejunostomy
32.
33. Duodenum-sparing pancreatic head resection
C/I in suspected pancretic cancer
Portal vein freed,neck divided
Longitudinal pancreaticojejunostomy
Frozen section to rule out malignancy[5%]
34.
35. Coring of head of pancreas
Duodenum-sparing pancreatic head resection
and lateral pancreaticojejunostomy
Indicated for small duct disease
Technically easier then beger.
Local resection of pancreatic head relieves
CBD obustruction in 70% of cases
39. 1998,longitudinal V shaped excision of ventral
pancreas
Indicated for small duct pancreatitis
Author described 95% pain relief
40. Pathology predominantly limited to distal
portion of gland
Distal psedocyst,mass, SVT
Cut edge of gland oversewn
41.
42. Psedocyst complicates CP in 30% to 40% of
pts
Surgery indicated for pts with symtomatic
pseudocysts who are either not candidate or
have failed an initial attempt at
transampullary,transgastric,or transcutaneous
drainage
septated cyst with elevated fluid CEA and CA
15-3 levels treated by resection.[? Neoplasm]
43. Cyst-gastrostomy/duodenostomy
Roux-en-Y cyst-jejunostomy [simpler]
For small multiple cysts of pancreatic head-
Whipple proc
For cyst of pancreatic tail – distal
pancreatectomy
44. Surgical cyst-enterostomy is associated with
90-100% success
Success rates from cyst-duodenostomy-
100%,cyst-gastrostomy-90% and cyst-
jejunostomy-92%
Morbidity 9%-36%
Mortality 0%-1%
45.
46.
47. Last resort for pts with persistent or recurrent
pain following lesser proc
Requires autologous islet cell
autotransplantation
extended hospitalisation due to Poor diabetes
control
48.
49. Indicated in intractable pain abdomen due to
pancreatic and gastric carcinoma
Celiac ganglion block have transient effects,but
this neural ablation offers higher success rates
Thoracotomy is more invasive,VATS is less
invasive and offers more rapid recovery
50. All pts with recurrent pain abdomen
reevaluated with CTscan MRCP/ERCP,UGI
endoscopy.
For diffuse parenchymal disease-completion
pancreatectomy with or without islet cell
autotransplantation
For dilated duct-decmpressive surgery
For stricture-subtotal resection
52. Pain relief and quality of life issues are the
main concern in pts of chronic pancreatitis
undergoing treatment
Surgery is indicated for relief of intractable pain
and complications associated with CP
Failure of nonsurgical treatment and presence
of complications influence timing and need for
surgical intervention[[jury is still out:early surgery for
mild to moderate pain]]
53. Pain relief is sustained in NACP->85%
Duration of pain does not necessarily correlate
with surgical outcome
No consistent documentation of recovery of
pancreatic function following ductal drainage
Need for biliary bypass: frequent
Associted SVT/PHT makes surgery difficult
Late deaths occurs due to malignancy or
continued alcoholism