chronic pancreatitis and surgica approach

1. Role and types of Surgery in
chronic pancreatitis

2. Introduction
• Chronic pancreatitis is defined as “Continuing
inflammatory disease of pancreas characterized by
irreversible morphologic changes that cause
abdominal pain and/or permanent impairement of
pancreatic function”

3. Etiology
• Toxic : Alcohol (50-60%), tobacco(25-30%),
Hypercalcemia, Uremia, Hyperlipidemia
• Idiopathic: Tropical calcific pancreatitis
• Genetic/hereditary: SPINK-1 mutation, CFTR,PRSS1
• Autoimmune/Immunologic: UC/Sjogren, viral
• Recurrent severe Acute Pancreatitis
• Obstructive causes:
– Benign pancreatic ductal obstruction (gallstones,
Pancreatic divisum), Stricture of PD after trauma/AP,
Malignant stricture

5. • Symptomatology
– Abdominal pain (90%)
• Episodic
• Exacerbated by eating
• “Burnout” period in late phase
– Weight loss
• Avoidance of meals because of exacerbation of pain
• Malabsorption
– Bloating discomfort
– Change in bowel habits

6. – Exocrine insufficieny (4-30%)
• Steatorrhoea
• Malabsorption
– 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

7. Management of chronic Pancreatitis
• Conservative Management
– Dietary modifications (Alcohol abstinence, Rich in
carbs, Medium chain TG, Vitamins)
– Pancreatic Exocrine enzyme Supplementation
– Insulin for type I Diabetes
– Treatment of Pain
• Medical management (NSAIDS/PCM, Opiods,
Antidepressant)
• Interventional procedures (Celiac plexus nerve block)

8. Endoscopic Management
• ESWL/Mechanical Lithotripsy
• Stenting
• Short lived patency i.e. need to change stent 2-4 monthly
• Occluded by calcified debris or protienaceous material
• Useful for
– Proximal stenosis without calcification or mass
– Pancreatic pseudocyst
– If not sufficiently effective after a year of treatment
or 2-3 failed endoscopy then referred to surgery

9. Surgical Treatment
• Two main concepts
1. Preservation of tissue via drainage
• Aim to protect against further loss of pancreatic
function
2. Pancreatic Resection
• For non dilated pancreatic ducts
• Pancreatic Head enlargements
• If pancreatic Carcinoma suspected in setting of CP

10. Indications for surgery
1. Intractable abdominal pain
2. Symptomatic local complications (biliary
stricture, duodenal stenosis, pseudocyst,
sinistral hypertension)
3. Unsuccessful endoscopic management
4. Suspicion of malignancy

11. Role of surgical management
– Pain relief
– Control of complications
– Preservation of exocrine and endocrine functions
– Social and occupational rehabilitation
– Improvement of quality of life

12. • 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

13. Surgical Procedures
A. Drainage procedure
– Duval’s Procedure
– Puestow (resection of pancreatic tail and LPJ)
– Modified Peustow or Partington Rochelle (Lateral
Pancreatojejunostomy(LPJ)

14. B. Resection Procedure
– Total Pancreatectomy and islet cell autotransplant
– Pancreatoduodenectomy (Classic Whipples,
Pylorus preserving PD)
– Distal pancreatectomy
C. Combined/Hybrid procedure
– DPPHR (Begers operation, Bern, Frey’s )
– Izbicki’s operation

16. 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

17. Duval’s procedure (1954)
–Drainage ofthe tail with a Roux-en-Y limb of jejunum
– Not effective for disease in the proximal pancreas
Distal pancreatectomy and
splenectomy with an end-to-end
pancreaticojejunostomy

18. Puestow’s Procedure (1958)
• Resection of pancreatic tail
• Longitudinal incision of pancreatic duct along
body of pancreas
• Anastomosis with Roux-en-Y loop of jejenum
(Lateral PJ)
• Splenectomy

19. Puestow’s Procedure(LPJ)
• Indication:
– Dilated ducts (at least 5-7mm) or multiple areas of
stricturing & dilatation throughout length
– Without associated inflammatory mass in head
– Obstructing intraductal stones
– Pancreatic Pseudocyst

20. Puestow’s Procedure
• Advantage:
– Allows for adequate decompression of dilated
pancreatic duct
– Minimizes morbidity , mortality of pancreatic resection
– Preservation of endocrine function
• Limitations:
– Neither feasible nor effcacious unless PD at least 5-7mm
– Inflammatory pancreatic head mass

21. Partington & Rochelle
(Modified Puestow)
• No resection of Pancreatic tail
• Lateral Pancreatico-jejunostomy

22. • Advantage of pure drainage procedure:
– Pain relief in 75-80% case in 5-10 years f/u
– Well preserved pancreatic function
• But, Recurrence of symptoms on long term due to
incomplete decompression of MPD in head
• So, replaced by procedure that combine resection
and drainage procedures

23. 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

24. Whipples PD
– Resection of the head of the
pancreas+distal CBD+distal
stomach+duodenum
+proximal jejunum
– Also treat bileduct stricture
and duodenal obstruction
– Done when there is suspicion of
tumor in pancreatic head

25. Traverso’s pylorus preserving
pancreaticoduodenectomy
• Preservation of pylorus
• Gastric dumping, marginal ulceration and bile
reflux gastritis reduced
• DGE (30-50%), Pancreatic Insufficiency

26. Distal pancreatectomy
– Isolated involvement of body and tail; suspicion of left sided
neoplasm
– 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

27. – Major portion of parenchyma remains untreated
– High risk of recurrence, Pancreatic insufficiency
– Requirement of completion pancreatectomy in 13%

28. Total pancreatectomy with islet
autotransplantation (TPIAT)
• Diffuse parenchymal disease
• Failure of other surgeries
• Includes resection of duodenum, distal bile
duct, spleen along with total pancreatectomy
– Care taken to preserve arterial blood supply (GDA,
splenic artery) for as long as possible to minimize
islet cell ischemia
– Islet cell harvesting
– Direct islet cell infusion into portal vein

29. Total pancreatectomy with islet
autotransplantation (TPIAT)
• 27 percent achieving insulin independence
• ~73% pts pain relief (narcotic independence)
Wilson et al; 2014

30. Duodenum Preserving Pancreatic Head Resection
(DPPHR)
• For benign lesion like CP, no reason to remove
organs adjacent to pancreas (except inability
to R/O malignancy )
• Advantage (compared to ppPD)
– Greater weight gain
– Better glucose tolerance (Higher insulin secretion)
– Low early and late mortality rate

31. Beger’s Procedure
• Divison of neck overlying confluence of splenic
and SMV + Removal of Head of pancreas leaving
small rim of pancreatic tissue along duodenum
• Roux-en-y jejunal loop
Anastomosed to
Pancreatic tail remnant &
Excavated head
• Technically demanding procedure

32. Berne Modification of DPPHR
–Pancreas is not divided at level of portal vein
–Useful in significant inflammation of head and Portal HTN
–Single anastomosis b/w jejunal loop & pancreatic
resection rim at head
–Equal outcome compare to Beger’s
But few required re-operation for
Ongoing pancreatitis

33. Frey’s Procedure
• Resection (Coring) in Pancreatic head is smaller
than Beger’s
• MPD is drained longitudinally for its full length
into pancreatic tail
• Reconstruction by single anastomosis between
Roux limb of jejenum & PD and head defect
(Lateral Pancreaticojejunostomy)

34. • Advantage
– Can also treat duct disease in pancreatic remnant
– Coring out pancreatic head appears to be safer than
resection when portal HTN or thrombosis present

35. Disadvantage: Rim of pancreatic tissue of pancreatic head
with active disease is left in place

37. IZBICKI PROCEDURE
• Longitudinal V shaped excision of
ventral pancreas
– Secondary & tertiary ducts
draining in to the Roux loop of
jejunum
– Done in small duct disease

38. • 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 groups
• Klempa I, Spatny M, Menzel J, et al. Chirurg.1995;66:350 –359

39. Biliary stricture a/w Chronic Pancreatitis
• Chronic scarring and fibrosis of head of
pancreas lead to external compression of
intrapancreatic part of CBD
– If cholangitis – Urgent ERCP + Temporary biliary
decompression
– In whom malignancy can’t be excluded – PD
– If malignancy excluded – Roux-en-Y HJ

40. Duodenal Stricture
• 1-2% develop duodenal stricture
• Needs initial stablization (Hydration,
nutritional support, NG decompression)
• Surgery : Gastrojejunostomy

41. Pseudocyst
• If Symptomatic:
– Endoscopic :: Cystogastrostomy or
cystoduodenostomy
– Surgery : Cystojejunostomy with Roux-en-Y
reconstruction

43. Take home message
– 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

44. – Patients with a dilated main pancreatic duct (≥6 to
7 mm) drainage procedure: lateral
pancreaticojejunostomy (LPJ) or Frey procedure
– With a nondilated main pancreatic duct and
inflammatory mass in head : DPPHR is less
invasive than PD and comparable long term
results

45. Refrences
1.Blumgart’s Surgery of Liver, Pancreas and
Biliary Tract; 6th edition
2. Fischer's Mastery of Surgery, 7th edition
3.Surgery in chronic pancreatitis: Indication, Timing
and procedures; Bouwense et al, Vis Med 2019